Danish version of the Tilburg Frailty Indicator – Translation, cross-cultural adaption and validity pretest by cognitive interviewing

Abstract

The Tilburg Frailty Indicator (TFI) is a self-administered questionnaire with a bio-psycho-social integrated approach that measures the degree of frailty in elderly persons. The TFI was developed in the Netherlands and tested in a population of elderly Dutch men and women. The aim of this study was to translate and culturally adapt the TFI to a Danish context, and to test face validity of the Danish version by cognitive interviewing. An internationally recognized procedure was applied as a basis for the translation process. The primary tasks were forward translation, reconciliation, back translation, harmonization and pretest. Pretest and review of the preliminary version by cognitive interviewing, were performed at a local community center and in an acute medical ward at the University Hospital in Aalborg, Denmark respectively. A large agreement regarding meaning of the items in the forward translation and reconciliation process was seen. Minor discrepancies were solved by consensus. Back translation revealed unclear wording in one matter. The harmonization committee agreed on a version for cognitive interviewing after revision of minor issues and thirty-four participants were interviewed. Two issues became evident and these were revised. The cognitive interviews and final lay-out resulted in minor adjustments as text type size, specific font, and lining for optimizing readability. In conclusion, we consider the TFI to be translated in such rigorous manner that the instrument can be further tested in clinical practice. The overall objective of the questionnaire being to identify frailty and improve the interventions relating to frail elderly persons in Denmark.

Introduction

Worldwide population aging has major consequences and implications for society as well as for the individual. Almost 35% of the European population is expected to be over 60 years in 2050 up from 22% in 2009 and the older population is in itself aging. In 2009 Denmark was ranked as number 11 in the world with respect to the percentage of the population above 60 years of age (United Nations, 2009).

An analysis of the Danish healthcare system by the Organization for Economic Co-operation and Development (OECD) outlines possible challenges as a consequence of the increasing number of elderly. These challenges include a growing number of frail elderly, and there is a need to find ways of meeting these challenges in a well-coordinated, safe and effective way in and between the primary and secondary healthcare sector (OECD, 2013).

Assessing frailty is important as frailty causes elderly persons to become vulnerable to adverse health outcomes such as disability, dependency, low quality of life, hospitalization, need for long-term care and death (Fried et al., 2001, Gobbens and van Assen, 2012, Gobbens et al., 2012b, Hubbard et al., 2010, Rockwood et al., 2005). Providing health professionals with a tool, making it possible to identify elderly with an increased risk of implications of frailty is therefore important. A feasible screening tool with an integral approach that identify frailty and predict adverse outcomes of frailty would provide a basis for improved individualized care and interventions in specific settings to prevent or minimize consequences. An integral approach is considered important as the attention to the individual as a whole otherwise will be jeopardized. This could potentially lead to fragmentation of care and subsequently to a reduction in the quality of care provided to frail elderly persons (Gobbens et al., 2010b, Gobbens et al., 2010d, Markle-Reid and Browne, 2003).

The term frailty was introduced in the late 1970s; at first a biomechanical and physical definition of frailty was dominating (Abellan van Kan et al., 2008, Gobbens et al., 2010b, Gobbens et al., 2010d). Recently a broader definition with a multidimensional integral perspective of frailty has commonly been accepted underlining, that not only a physical perspective is considered important in the life of elderly frail persons (Gobbens et al., 2010a, Gobbens et al., 2010c, Levers et al., 2006, Markle-Reid and Browne, 2003).

In 2010 Gobbens et al. defined frailty as a dynamic state affecting an individual who experiences losses in one or more domains of human functioning (physical, psychological, and social) that are caused by the influence of a range of variables and which increases the risk of adverse outcomes (Gobbens et al., 2010b, Gobbens et al., 2010d). On the basis of this definition the “Tilburg Frailty Indicator” (TFI) was constructed by Gobbens el al. at Tilburg University in the Netherlands (Gobbens et al., 2010a, Gobbens et al., 2010b, Gobbens et al., 2010b, Gobbens et al., 2010d). The construct contains important components of frailty based on research and expert opinions (Gobbens et al., 2010b, Gobbens et al., 2010d).

TFI is a self-administered questionnaire with a bio-psycho-social integrated approach, that measures frailty. TFI consists of two parts; part A measuring the determinants of frailty and part B measuring the components of frailty. Part A is used for early prevention in practice and for research. Part B is used to determine whether a state of frailty is present and in which domains the problems occur (Gobbens et al., 2010a, Gobbens et al., 2010c).

The feasibility of TFI is high; it takes maximum of 15 min to complete, health professionals can quickly calculate the degree of frailty and it is easy to use across different disciplines, wards, hospitals and sectors. TFI has shown promising results regarding reliability and validity (Gobbens et al., 2010b, Gobbens et al., 2010d), prediction of adverse outcomes (disability, healthcare utilization) and associations to quality of life (Gobbens and van Assen, 2012, Gobbens et al., 2012a). TFI was developed and validated for home dwelling elderly persons, but has been suggested by the developers as having potential applications in hospital or primary care settings as well (Gobbens and van Assen, 2012, Gobbens et al., 2012a, Gobbens et al., 2012b). The Dutch version of the TFI has been translated to English and Brazilian versions (Gobbens et al., 2010b, Gobbens et al., 2010d, Santiago et al., 2012).

There is a necessity for translating the Dutch version into Danish, even though an English version is available. The target group of this specific questionnaire is frail elderly citizens in the age group of 65+. This age group has no formalized education in English as this became mandatory from the 6th grade in 1958 and from the 5th grade in 1970. The majority of frail elderly citizens therefore are unable to read and understand English, to such a degree that they can answer a questionnaire in English.

TFI has been implemented in a number of healthcare organizations in the Netherlands. Experiences so far have been positive, and TFI has been described as a feasible instrument with a useful integral approach. Furthermore the use of TFI revealed frailty at an early stage making it possible to try to prevent or delay the adverse consequences of frailty (van Nordennen, Brants, Vanneste, & Arnold, 2011). TFI was recently utilized by The Netherlands Institute for Social Research in a report regarding frail older persons in the Netherlands (van Campen, 2011).

To our knowledge, no such integral screening tool has been tested nor implemented in clinical practice in a Danish context. The aim of this study therefore was to translate and undertake a cross-cultural adaptation of the TFI to a Danish context including a face validation of the TFI by using cognitive interviewing in both home dwelling and hospitalized elderly.