Frailty is a geriatric syndrome that manifests as functional deterioration due to the systemic decline of physiological resources. It causes a heightened incidence of negative outcomes, such as hospitalization, disability and even mortality. Frailty in older adults is a major topic today in the field of aging. Recognition of its development could help detect and identify those at risk of negative outcomes and consequently help plan interventions and preventive care. Despite the importance of the topic, it has not been studied in Israel to date. This study from the Myers-JDC-Brookdale Institute examines the trajectory of frailty among older adults from 2008 to 2014 and the relation between frailty and the use of healthcare services and mortality. The study findings showed, for the first time in Israel, that changes in the state of frailty of older adults are common, and any deterioration increases the reliance on health services and the likelihood of mortality. Thus, it is important to broaden acquaintance with the topic and develop ways to diagnose and deal with frailty – from the level of policymakers to that of service providers and individual physicians. The findings are being widely disseminated to the health plans, national councils, and additional forums. The Ministry of Health has also recognized the importance of the topic and initiated a dialogue with professionals to find better ways of coping with frailty among older adults. The study was funded by Maccabi Institute for Health Services Research. For more information on this or other studies, visit us at http://brookdale.jdc.org.il or www.facebook.com/MJBInstitute.

1. Frailty among Older Adults
Netta Bentur  Shelley Sternberg  Jennifer Shuldiner
The study was funded by the Maccabi Institute for Health Services Research
RR-685-15

2. Frailty among Older Adults
Netta Bentur1
Shelley Sternberg2
Jennifer Shuldiner1
The study was funded by the Maccabi Institute for Health Services Research
1 Myers-JDC-Brookdale Institute
2 Maccabi Healthcare Services
Jerusalem January 2015

3. Editor: Raya Cohen
English translation: Evelyn Abel
Print Design and Production: Leslie Klineman
Myers-JDC-Brookdale Institute
P.O.B. 3886
Jerusalem 91037, Israel
Tel: (02) 655-7400
Fax: (02) 561-2391
Web site: www.jdc.org.il/brookdale

4. Related Myers-JDC-Brookdale Institute Publications
Bentur, N.; Sternberg, S. 2011. Comprehensive Geriatric Assessment Clinics in Israel.
RR-568-11 (Hebrew)
To order these publications, please contact the Myers-JDC-Brookdale Institute, P.O.B. 3886,
Jerusalem 91037; Tel: (02) 655-7400; Fax: (02) 561-2391; E-mail: brook@jdc.org.il
Reports are also available on the Institute website www.jdc.org.il/brookdale

5. i
Executive Summary
Background
Frailty is a geriatric syndrome that manifests as functional deterioration due to the systemic decline
of physiological resources. It causes a heightened incidence of negative outcomes such as
hospitalization, disability and even mortality. This decline gradually drains the body's reserves so
that even minor stressor events may produce significant health changes. Frailty in older adults is a
major topic today, engaging service providers and policymakers involved in the care of older
adults. One focus of interest is the trajectory of the development of frailty. If identified, it could
lead to the detection of groups of older adults who are at risk of fairly imminent negative outcomes,
which, in turn, could lead to the planning of interventions and care for them. Despite the importance
of the topic, to date it has not been studied in Israel.
To meet clinical and research requirements, approaches and tools have been developed around the
world to define and measure frailty. The Vulnerable Elders Survey (VES) is a common tool used
to detect risk of frailty and predict functional deterioration and mortality among older adults living
in the community. It takes into account age, self-appraisal of one's health, functional disabilities,
lifting ability in terms of load, fine motor skills, mobility, and the ability to perform tasks outside
the home. The measure ranges from 1 to 10 with the higher scores being a greater indication of
frailty. A score above 3 on the VES identifies about a third of the candidates for frailty, functional
decline, and mortality within two years of the examination in contrast to a score of 3 or less.
Study Goal
The study examines the course of frailty among older adults over six years, and the relationship
between frailty in 2008 and the use of health services in 2014, as well as between frailty and
mortality in this period.
Study Design
The study utilizes data from a 2008 survey of insurees aged 65+ in a large health plan. The survey
consisted of 608 older adults living in the community. The current study, conducted in 2014,
revisited those same people. Between 2008 and 2014, 183 (30%) of them passed away, and another
144 (24%) were omitted from the current study for the following reasons: their telephone lines had
been cut off (76 people, 13% – who were known to be among the living since they did not appear
in the Population Registry of the deceased); they refused to be interviewed (36, 6%); they had
moved to a nursing home (14, 2%); or other reasons (18, 3%).Of the 2008 target population, 281
people (46%) were ultimately included in the current study. The average age of the study population
in 2008 had been 79 (SD=6), 62% of them were women, 27% lived alone.
The study was conducted by telephone interviews, based on a closed, structured questionnaire, with
the older adults themselves. When it was not possible to interview the subject directly a relative

6. ii
was interviewed instead. Frailty was examined in the two studies by the VES measure. To examine
if, and to what extent, frailty had developed and progressed over the six-year period, we compared
the individual VES scores of the 281 older adults interviewed in both 2008 and 2014.
Findings
 In 2008, of the 608 people surveyed:
- 24% scored 3 or lower on the VES measure, i.e., they were not frail;
- 74% scored higher than 3, i.e., they were frail.
 Changes in the state of frailty between 2008 and 2014:
 In 2014 – among those who were not frail in 2008:
- 30% remained non-frail
- 39% became frail
- 14% passed away
- 17% were not located.
 In 2014 – among those who were frail in 2008:
- 1% were not frail (they might have had an acute illness in 2008 which affected the
degree of their frailty at the time)
- 37% were frail
- 36% had passed away
- 24% were not located.
Trajectory of Frailty
A comparison of the individual VES scores for the 281 people interviewed in 2008 and in 2014
showed that:
 19% were not frail in either survey
 22% were not frail in 2008 but had become frail by 2014
 22% were frail in both surveys to the same or a similar degree
 37% were frail in 2008 and frailer in 2014.
Use of Health Services, by Trajectory of Frailty
A multivariate analysis six years after the first study showed that:
 The chances of hospitalization in the previous year – of older adults who had become or
remained frail (whether or not the condition stayed stable or worsened) – were 3 times those
of older adults who had remained non-frail.

7. iii
 The chances of receiving homecare – of older adults who had become or remained frail
(whether or not the condition stayed stable or worsened) were 6 and 15 times, respectively,
those of older adults who had remained non-frail.
 The chances of having a personal caregiver – of older adults who had become frail, remained
frail, or become frailer – was 10 times, 17 times, and 31 times respectively that of older adults
who had remained non-frail.
Mortality, by Trajectory of Frailty
As mentioned above, 183 older adults (30%) of the 608 in the target population of the study had
passed away between 2008 and 2014. According to the bivariate analysis, among the deceased in
this period the rate of frail older adults had been higher than of the non-frail, and the rate of men –
higher than the rate of women, though no correlation was found with other demographic
characteristics. The Cox proportional ratio showed that 86% of the non-frail in 2008 were alive six
years later vs. 52% of the frail; the hazard ratio stood at 3.5 (CI 2.2-5.4).
Conclusions and Policy Directions
The study findings showed that changes in the condition of frailty among older adults are common,
and any deterioration that distances them from non-frailty increases both their reliance on health
services and their rate of mortality. It is thus important to confront this complex topic from the
level of policymakers to that of service providers and individual physicians. To do so:
a. The presentation of the topic should be expanded to policymakers in the medical system,
especially within the community, so that they may become acquainted with it, understand its
significance, importance and implications, and encourage its prominence. To this end, the
topic would benefit from its presentation at numerous forums and from discussion of its tools
and methods for the sake of sustainability.
b. Community physicians should make more effort to identify and deal with frailty. In particular,
steps should be taken to ensure that family doctors are familiar with the tools to identify frailty
and the means to approach and treat it.
c. It is important to present and raise the topic for discussion at forums of clinicians from various
professions caring for older adults, namely, orthopedics, neurology, rehabilitation, and even
intensive care, and to introduce them to simple, easy tools to check for frailty.
d. Consideration should be given to the use of VES, a validated, simple, easy tool to identify
frailty, and its institution among family doctors. This step should be taken in order to detect
frailty as early as possible and offer older adults interventions to cope with symptoms and
prevent deterioration.
The study was funded by the Maccabi Institute for Health Services Research.

8. iv
Acknowledgments
The study is based on data collected as part of a previous study conducted by the Myers-JDC-
Brookdale Institute (MJB) six years ago. We are indebted to our previous research partners,
especially to Johnathan Lemberger, for encouraging a deeper look at the same population of older
adults.
We are grateful to the readers of the different versions of the report for their valuable comments
and enlightening remarks.
Thanks, too, to our colleagues at MJB for their helpful advice and comments in the course of the
work. Thanks to Raya Cohen for her devoted editing, to Jenny Rosenfeld, director of the
publications unit, for her useful comments, Evelyn Abel for translation to English, Sue Bubis for
preparing the charts, and Leslie Klineman for producing the report.

9. Table of Contents
1. Introduction 1
1.1 Study Goals 2
2. Study Design 3
2.1 Study Population 3
2.2 Data Collection Methods 4
2.3 Research Variables 4
3. Findings 5
3.1 Population Characteristics 5
3.2 Mortality, by Frailty 8
3.3 Trajectory of Frailty 9
3.4 What Characterizes the Older Adults not Frail in 2008 11
3.5 Use of Health Services, by Trajectory of Frailty 12
3.6 Validity of Prediction for Using Health Services according to VES Measure 14
4. Discussion and Conclusions 16
List of Sources 20
List of Tables
Chapter 3: Findings
Table 1: Characteristics of Study Population in 2008 7
Table 2: Characteristics of Study Population in Division into Groups,
by Trajectory of Frailty 11
Table 3: Use of Health Services, by Trajectory of Frailty 12
Table 4: Use of Health Services, by Trajectory of Frailty – Logistic Regression Analysis 14
Table 5: Characteristics and Use of Health Services in 2014, by Frailty in 2008 15
Table 6: Use of Health Services in 2014, by State of Frailty in 2008 –
Logistic Regression Analysis 16
List of Figures
Chapter 2: Research Design
Figure 1: Target Population of Study 4
Chapter 3: Findings
Figure 2: Changes in the Condition of the Older Adults between 2008 and 2014 6
Figure 3: The Survival Curve for the Six Years, by VES Score in 2008 8
Figure 4: The Trajectory of Frailty from 2008 to 2014 10