city4age frailty and mci risk model - european commission · this document – which is the first...

Project City4Age Grant Agreement #689731

D2.1 City4Age frailty and MCI risk model 1/71

Elderly-friendly city services for active and healthy ageing

City4Age frailty and MCI risk model

Deliverable ID D2.1

Version 1.0

Contractual delivery date 31/03/2016

This version delivery date 30/03/2016

Status1 Final

Dissemination level2 PU

Leading partner MMED

Contributors UNIPV

This project has received funding from the European Union’s Horizon 2020 research and innovation

programme under grant agreement No 689731

1 ToC (v# = 0.0), Draft (v# < 1.0), Final (v# = 1.0), Improvement (v# > 1.0)

2 PU: Public, CO: Confidential, only for members of the consortium (including the Commission Services)



History of changes

Version Date of issue Author(s) Description

1.0 30/03/2016 MMED, UNIPV Initial version



Table of contents

1 Executive summary .......................................................................................... 4

2 Introduction ...................................................................................................... 5

2.1 The case for City4Age unobtrusive behaviour monitoring ...................... 5

2.2 Measuring health.................................................................................. 8

2.3 Testbed cases ..................................................................................... 12

3 City4Age risk modelling ................................................................................. 15

4 MCI risk modelling ........................................................................................ 17

4.1 Brief introduction to MCI ................................................................... 17

4.2 The Lawton Instrumental Activities of Daily Living (IADL) Scale ....... 18

4.3 The OARS Multidimensional Functional Assessment Questionnaire .... 21

4.4 The Nottingham Extended Activities of Daily Living .......................... 23

4.5 The Direct Assessment of Functional Status ........................................ 26

4.6 The Mini–Mental state Examination ................................................... 29

4.7 The Short Test of Mental Status .......................................................... 31

4.8 The Montreal Cognitive Assessment ................................................... 33

4.9 Predicting MCI onset from gait speed analysis .................................... 37

5 Frailty risk modelling...................................................................................... 38

5.1 Brief introduction to frailty ................................................................. 38

5.2 Fried Frailty Index ............................................................................. 40

5.3 Study of Osteoporotic Fractures index................................................. 42

5.4 SHARE-FI ......................................................................................... 43

5.5 FRAIL scale ...................................................................................... 45

5.6 PRISMA-7......................................................................................... 46

5.7 Edmonton Frail Scale ......................................................................... 47

5.8 Tilburg Frailty Indicator ..................................................................... 49

5.9 Comprehensive Frailty Assessment Instrument.................................... 51

5.10 Groningen Frailty Indicator ................................................................ 54

5.11 The Sherbrooke Postal Questionnaire .................................................. 56

5.12 Frailty Index ...................................................................................... 57

6 Conclusions .................................................................................................... 59

7 Annex: list of Items ordered per category......................................................... 61



1 Executive summary

This document – which is the first version of deliverable D2.1 City4Age frailty and MCI risk model –

presents an initial attempt at outlining how risks of MCI and frailty onset can be assessed in the frame

of the City4Age project.

The work is based on an extensive review of current geriatrics knowledge, and it aims to propose

relevant measurement Instruments that are:

valid and reliable

able to predict the onset of critical health conditions in individuals (MCI and frailty

respectively)

linked to behavioural traits that can measured by sensors and other datasets available in the

city environment.

For each Instrument, an introduction, relevant literature references and a comprehensive description of

its structure (to identify which parts may be of interest to City4Age) are provided.

Overall, 8 Instruments for MCI and 11 instruments for frailty have been proposed, for a total of 226

Items.

The primary objective of this effort – at the current stage of the project – is to enable City4Age pilot

Partners to model the risk detection needs of their respective testbed scenarios, by connecting them

with Instruments and/or Items that have proven predictive value.

This, in turn, allows to base the pilots’ data collection strategy (e.g. sensing equipment, feature extraction, etc.) and behaviour reconstruction requirements (e.g. activity to be monitored) on a sound

and reliable foundation.

The quality of the modelling will then be assessed during the testbed experiments.

Several interesting insights are already discernible in this first version of this document, as for instance:

the importance of the Instrumental Activities of Daily Living, which (a) are significant for

both MCI and frailty prediction, (b) are directly described in behavioural terms, and (c)

have been demonstrated to be more sensitive to initial signs of frailty and MCI, when

compared with basic ADLs

the importance of gait, a behavioural characteristic that can potentially be extracted from

motions measures taken through the smartphone, which is crucial for early detection of

frailty and that has also been demonstrated, by some authors, to be linked to MCI risks

It has not escaped the attention of the City4Age Consortium that potentially new indicators can be devised “from scratch” by directly linking sensor data streams to ground truth regarding the onset of

frailty and MCI, without the “intermediation” of existing, recognized indicators. Although this direction cannot be easily pursued in City4Age, as it would require time and resources beyond those

available to the project, the approach proposed in this document will still provide relevant insights to

researchers (including Consortium Partners) that will be willing to take on this challenge in the future.

Next versions of this deliverable, due at months M21 and M27 respectively, will add extra content, in

particular thanks to new information that will be available after the analysis of testbed experiments:

assessment of the model Indicators’ and Items’ quality when used as a basis for unobtrusive

sensing in different urban contexts

relationship with the findings of other initiatives, in particular the European Innovation

Partnerships on Active and Healthy Ageing, and on Smart Cities and Communities

guidelines and recommendations directed to Social Services, for the application of the

City4Age risk detection model to specific needs of addressed elderly populations



2 Introduction

The overarching objective of the City4Age project is to demonstrate that smart cities can significantly

improve the early detection and mitigation of health risks (focusing in particular on Mild Cognitive Impairment and frailty) by harnessing the potential of new technologies for unobtrusive behavioural

sensing, which are more and more pervading urban life.

In order to achieve this objective, the first steps to be undertaken relate to the early risk detection

subsystem.

In particular, it is important to:

State the case for unobtrusive behaviour monitoring, comparing it to the methods currently

used in geriatrics to address MCI and frailty risk detection

Identify indicators from current, validated geriatrics knowledge, useful for measuring MCI

and frailty risk on the basis of behaviour and human activities monitoring

Link the issues above with the specific needs expressed by City4Age testbed cases, arising

in the different urban contexts represented by testbed cities.

The City4Age risk modelling effort – conducted in task T2.1 Modelling risks and resilience profiles and reported in this deliverable – aims at consolidating the output of the above mentioned elements

into a conceptual framework, to be used as a guidance in the design and implementation of the risk detection subsystem. Together with behavioural modelling – elaborated in task T2.2 Modelling

MCI/frailty related behaviours and reported in deliverable D2.2 – it constitutes the scientific base for

the work planned in the technical work-packages WP3 to WP6.

This section briefly introduces the rationale behind these elements and paves the way for the following

sections, that report on the risk modelling approach of City4Age.

2.1 The case for City4Age unobtrusive behaviour monitoring

It is well known, especially in geriatrics, that the early detection of risks relating to a specific health

condition improves the chances of enacting appropriate interventions that can halt or at least delay the

condition itself, with beneficial effects on both patients’ quality of life and costs of treatment3.

For instance, in the case of MCI, Petersen et al.4 emphasize the need for the clinician to detect the

earliest signs of cognitive impairment and highlight the importance of this quest. In fact, as MCI is

recognized as a possible precursor of AD, its early detection and subsequent intervention can help to

delay the onset of the disease. Considering, for instance, that an estimated 5.3 million Americans had Alzheimer's disease in 2015 and the overall cost of caring for these people is around $226 billion

5 (i.e.

more than $40,000 per patient per year) detecting and treating MCI such that the progression to AD

can be delayed by even a single year, would imply very important savings. In addition, this analysis

only considers the economic facet of the issue, which is easier to measure, but even more important is

the impact on the quality of life of elderlies and of their carers.

However, under current conditions, MCI detection is a challenge.

Earliest signs of MCI may consist, for instance, in some degree of forgetfulness, beyond what is

justified by normal aging. The forgetfulness may be apparent to those closest to the person but not to

the casual observer6. In fact, relying, as current practice, on self-reported detection of MCI signs and

symptoms (by the patient or by those around her/him) has several drawbacks:

3 Onder et al., Measures of physical performance and risk for progressive and catastrophic disability: Results

from the women’s health and aging study, Journals of Gerontology: Medical Sciences, 2005

4 Petersen et al., Practice parameter: early detection of dementia: mild cognitive impairment (an evidence based

review), Neurology, 2001

5 http://www.alz.org/facts/

6 Petersen, Mild Cognitive Impairment, The New England Journal of Medicine, 2011

http://www.neurology.org/content/56/9/1133.long

http://www.alz.org/facts/



It may not be easy to discriminate signs and symptoms of MCI insurgence from normal

effects of aging

Patients and their carer may not be knowledgeable about exactly which signs or symptoms

to look for

Some patients, especially older ones, may be subject to forms of denial against worsening

conditions (e.g. minimizing symptoms) to avoid care7.

Similar considerations apply to frailty8. Frailty has been shown to be directly correlated with high risk

for adverse health outcomes, such as falls or hospitalization, that increase care costs and decrease

quality of life. On the other hand, when detected early, possibly at the pre-frail stage, frailty can

potentially be prevented or treated. For this reason, the need to recognize frailty in a timely manner is

noted as one of the top priorities in both gerontology, general practice, and public health.

Several important technology developments, which appeared on the scene in the last decade, may offer

new ways to address this type of issues, and help to achieve a systematic health monitoring and early

health risk detection approach.

A paradigmatic example of these technologies is the modern smartphone which – packed with sensors that can capture many features, such as e.g. orientation, acceleration, location or voice, and equipped

with local computational power and an always-on network connection – can seamlessly interact with

other computer systems in order to conduct complex analysis on the generated data streams and infer

interesting aspects of human behaviour. The smartphone proliferation among users and its continuous

presence and usage, make it the ideal unobtrusive human activity data collection platform9.

In addition, smart cities environments offer extra opportunities, as ever more urban infrastructure is

deployed on the basis of technologies such as RFID cards (e.g. to check-in services), proximity devices

(e.g. BLE beacons for in-shop proximity detection), or intelligent meters of various kind (e.g. for

energy or water consumption)10

.

Prospects are also offered by “software sensors”, such as social network logging applications.

The endless possibilities arising from the combination of these technologies allow to measure, monitor

and analyse human behaviour in unprecedented ways.

With reference to the objectives of City4Age, and among many similar works that can be found in the

literature, Rantz et al. report on a simple yet paradigmatic case that shows what can be practically

achieved11

.

The authors installed an integrated sensors network in apartments of volunteer residents, hosted in an “aging in Place” retirement community that allows residents to remain in their apartments even if their

health deteriorates.

Among others, the sensors network included several passive infrared (PIR) motion detectors installed

in various locations, to detect presence in different rooms and to consequently infer specific activities.

In particular, the objective of the sensors network is to detect changes in activities that could be linked

to respective changes in health status, and to consequently offer relevant clinical interventions to help

residents age in place.

Alerts are generated and sent to clinicians whenever sensor activity (within definite daytime frames)

deviates from normal (in the particular example, the cut-off point was established at 4 standard

deviations from the mean of the previous 14 days, and it was chosen conservatively, to err on the side

of generating too many alerts rather than possibly missing a crucial one).

7 Trull et al., Ambulatory assessment, Annual Review of Clinical Psychology. 2013

8 Lucas et al., Frailty in the older adult: will you recognize the signs?, Nurse practitioner, 2014

9 Lathia et al., Smartphones for Large-Scale Behavior Change Interventions, IEEE Pervasive Computing, 2013

10 Hancke et al., The Role of Advanced Sensing in Smart Cities, Sensors, 2013

11 Rantz et al. Using Sensor Networks to Detect Urinary Tract Infections in Older Adults, IEEE 13th International

Conference on e-Health Networking, Applications and Services, 2011

http://www.mdpi.com/1424-8220/13/1/393



It is important to note that alerts are not diagnosis. In fact, whenever an alert is generated, the resident

is evaluated by a registered nurse, in order to check if the situation warrants more medical

investigation.

In this context, the authors report about several case studies related to the early detection of urinary

tract infections (UTI), a serious health threat for older women that, when treated too late, may lead to

kidney damage, system-wide infections or even death.

Since a common indicator of UTI observed by clinicians is urgency and frequent urination, particularly

at night, alerts based on increased nightly activity of the bathroom PIR motion detector have been used

to test residents for UTIs.

The authors show how, out of three case studies, two of them conducted to an effective early diagnosis

of UTI, which allowed a correspondingly early treatment and full recovery of the patient (the third one

being a false positive). If the diagnosis would have been delayed until the elderly person would have self-reported relevant symptoms to her GP or caregivers, the situation would have been much worse,

with a less certain and more costly outcome.

Although relatively simple and limited to the indoor environment, this example is paradigmatic of the

state-of-the-art in the field, and clarifies how unobtrusive and continuous behavioural sensing, paired

with an appropriate alerting mechanism, can concretely contribute to the improvement of health

management for elderly people and to the reduction of related care costs.

On this basis, it is possible to highlight some essential characteristics that should be also replicated in

the City4Age risk detection approach (refer to Figure 1 below):

Suitable data streams, coming from sensors and other datasets available in the smart city

environment, shall be linked to valid and reliable health status indicators, established in the

medical practice, that can be transposed in behavioural terms and used to address relevant health risks

The ultimate objective of the risk detection subsystem is to generate alerts, against which a

conventional medical investigation will possibly lead to diagnosis and intervention decisions

(in particular, it is out of scope for the system to automatically generate diagnosis). Alerts

can be augmented with additional information, collected from the data streams, digested and presented to clinicians through appropriate data dashboards, in order to support assessment

and decision making

A central element to consider in the design of the detection and alerting mechanism is the

achievement of the traditional maximization/balance among precision (reduce false positives) and sensitivity (reduce false negatives)

Figure 1. Risk detection subsystem in City4Age

City4Age Risk detection subsystem

Alerting mechanism Data dashboards

Visit (diagnosis, interventions)

Behaviour

Datasets

Health indicators



As previously mentioned, this approach has a direct impact and link with ROI estimation, as each true

positive represents actual savings made possible by the enactment of early medical interventions, while each false positive represent costs sustained for an additional, unnecessary medical investigation of a

healthy person (in City4Age, this analysis will be carried out as part of Task T8.2 Exploitation plan

and sustainability).

2.2 Measuring health

In order to implement the scheme illustrated in the previous section, a crucial element is the availability

of suitable health measurement indicators, that are:

valid and reliable

able to predict the onset of critical health conditions in individuals (for MCI and frailty, in

the case of City4Age)

linked to behavioural traits that can measured by sensors and other datasets available in the

city environment.

The effort to derive high quality health measurement indicators is longstanding one, that will probably

always continue.

In the last decades, many indicators of the health or well-being of individuals have been developed, in

order to address three ultimate aims12

:

Diagnosis of illness

Predict the need for care

Evaluate the outcomes of treatment

This is in agreement with the distinction made by Bombardier and Tugwell between the three purposes

of health measurement indicators: diagnostic, prognostic, and evaluative13

.

In particular, the second item – relating to the prognostic/predictive value of indicators – is the one of

interest to City4ge.

In this respect, it is also worth to note that several indicators have been validated for both concurrent

validity and predictive validity, depending on whether the focus is on current or future health status.

For instance, a questionnaire on hearing difficulties may be compared with the results coming from an audiometric test to assess its concurrent validity, or the same questionnaire may be compared with

future patient’s health outcomes, to assess its predictive validity.

In this promising context it is important to survey and analyse existing indicators, in order to identify

how they could meet City4Age requirements, and be used constitute the foundation of the project’s risk

detection model.

2.2.1 Structure of instruments

Defining health measurement indicators normally implies assembling a selection of elementary items,

that are intended to represent the specific aspects that are of interest.

Underlying each indicator is a model, that takes item values as input and – according to relevant algorithms derived through various techniques, such as machine learning, statistics modelling,

knowledge engineering, etc. – produces a final outcome that is the measure that was sought for.

Example of elementary items may be a measure on a specimen analysed in a laboratory, the flexion of

a limb observed by a physiotherapist, an estimate of working capacity assessed by a clinician, or a self-

reported behaviour obtained through a questionnaire response.

Items may in turn be grouped into specific categories or domains. For example, in the Mini-Mental State Examination indicator, the domain “Orientation to time” includes five questions, from broadest to

12 McDowell, Measuring Health: A Guide to Rating Scales and Questionnaires, Oxford University Press, 2006

13 Bombardier et al., Methodological framework to develop and select indices for clinical trials: statistical and

judgmental approaches, Journal of Rheumatology, 1982



most narrow, such “What year is this?”, “What season is this?”, “What month is this?”, “What is

today’s date?”, “What day of the week is this?”.

Sometimes, domains correspond to a single item, such as in the Lawton Instrumental Activities of Daily Living (IADL) Scale, where domains such as “shopping”, “ability to use the telephone”, “mode

of transportation”, directly correspond to eponymous items to be measured.

Ultimately, each item is associated with (a set of) values, among which the item measure, or score, is

drawn. Item scores then contribute – through application of the underlying model, as above mentioned

– to the generation of the instrument outcome score.

In current medical literature there is no uniform terminology to describe these notions, and several different terms – e.g. instruments, measures, measurement methods, indicators, scales, etc. – are used

more or less interchangeably, sometimes even indicating different concepts.

On the other hand, in City4Age modelling it is important to agree on some kind of formal definition of

the above ideas, upon which to base the subsequent design and implementation work.

For this reason, the specific schema illustrated in Figure 2 below is proposed.

Figure 2. Health measurement instruments strcture

In the figure, the following definitions apply:

Instrument: the overall measuring method, aimed at providing a final, comprehensive score

on a certain health entity

Category: a group of Items (see below) that contribute to the appraisal of a certain facet of

the measured health entity

Items: the actual, basic elements that will be measured to produce scores (see below).

Values: set of values associated to an Item. The Item’s measurement produces a specific

score, drawn from this set.

Model: the mathematical entity (algorithms and/or calculations) that allows to compute the

Instrument outcome score on the basis of the scores measured for single Items.

Examples of the application of these definitions to two established Instruments are illustrated in the

following table.

Category

Item Values

Instrument

1..*

1..* 1

Model 1

1..*



Instrument The Nottingham Extended Activities

of Daily Living

Fried Frailty Index

Example of

Category

Transportation Motility

Example of

Item

Question “Did you travel on public

transport?”

Test “time to walk 15 feet”

Example of

Score

“Not at all”, “With help”, “On your

own with help”, “On your own”

Number of seconds

Example of

(part of) Model

Count 1 if answer is “On your own with help” or “On your own”, 0

otherwise, sum to other item scores

Count 1 if threshold is exceeded (Note: threshold depends on sex and

height – not reported here to save space)

Table 1. Example of Instrument definitions

The above terminology has been devised with the ultimate aim of facilitating communication across

the interdisciplinary knowledge areas represented in the project, including geriatricians, behavioural scientists, information technology engineers, researchers, and data scientists. For this reason, some

trade-offs have been made, e.g. by using the term “Category” instead of the term “Domain”, often used

in geriatrics to denote groups of related items, because the term “Domain” has a strong but unrelated

connotation in the information technology field.

An important observation regards the meaning of the terms “score”, as used in the above definitions.

While in principle the outcome of measuring an Item (or the outcome of the overall Instrument) can

always be reduced to a numerical score, the following different types apply:

Nominal or categorical score: numbers are used just as labels for categories (e.g. 0 for false

and 1 for true, for a classifier outcome)

Ordinal score: in addition to the previous type, order is meaningful and represents growing

quantities (e.g. 1 = mild, 2 = moderate, 3 = strong)

Interval score: in addition to the previous type, difference among numbers is meaningful, i.e.

it exists the concept of unit of measure (e.g. temperature in oC)

Ratio score: in addition to the previous type, there is a meaningful zero point, so ratios

among scores are also meaningful (e.g. number of seconds to complete an action)

2.2.2 Instruments for City4Age

While the 1970s have been characterized by an intense proliferation of new Instruments and related

models, that were often created relatively hastily and sometimes with insufficient substantiation, the

more recent trend is to focus on a less wide number of high quality Instruments, making validation and

reliability assessment the priority.

Following this trend, the best strategy for City4Age is to also concentrate on a well-chosen set of Instruments, selected on the basis of the following characteristics, as suggested in the opening to this

subsection:

Predictive value for the conditions addressed by the project (MCI and frailty) and/or ability

of timely detect the onset of the condition

Measurability in behavioural terms (i.e. the model underlying the Instrument is linked to the

subject’s behaviour)

Feasibility of measurement through sensors/datasets readily available in a smart city, in the

timeframe expected for the project exploitation (as determined in Task T8.2 Exploitation

plan and sustainability)

These points deserve additional discussion.

Concerning measurability in behavioural terms, three approaches are possible (refer to Figure 3):

Use existing indicators, that rely on models directly linked to behaviours – Figure 3 (a) –

such as for instance the Lawton Instrumental Activities of Daily Living Scale, which



includes questions such as “Takes care of all shopping needs independently?”. In this case,

the City4Age behaviour reconstruction function shall detect the relevant behaviour (“Takes care of all shopping needs independently”) while the risk detection function should calculate

a relevant score and possibly generate an alert if, according to the model rules, a change is

detected (e.g. from “Takes care of all shopping needs independently” to “Shops

independently for small purchases”).

Use existing indicators, that rely on models that, although not directly linked to behaviours,

can be feasibly related to them – Figure 3 (b). For instance, the Fried Frailty Index includes

the test “time to walk 15 feet”. Although this is not directly a behaviour, the relevant input to

the underlying model (i.e. walking speed) can be related to behaviour, for example by monitoring walking speed through smartphone sensors.

Devise new geriatrics Instruments, based on new models that directly connect the sensors

and datasets information, gathered by the City4Age data collection subsystem, to a relevant

outcome score – Figure 3 (c).

The first and second approach will be the preferred ones in City4Age.

In fact, by relying on existing Instruments for the detection of MCI and frailty onset, already

established and accepted by geriatrics researchers and clinicians, the City4Age risk detection subsystem can count on their proven validity and reliability characteristics, as derived from decades of

geriatrics research and clinical practice.

Figure 3. Determining City4Age model

The third approach would be a relatively innovative one. In fact, it is worth to note that established Instruments have been conceived, validated and published at a time when the very mechanisms for data

collection considered by City4Age, based on new unobtrusive sensing technologies, where not

generally available to the research community. This brings the possibility that correspondingly new models, that directly relate sensor and dataset information to relevant outcome scores, could be

developed, and associated Instruments be assembled.

In fact, research in using unobtrusive sensing for direct health measurement is in its infancy, and few

studies in this direction have started to appear in the literature recently14

.

14 Ben-Zeev et al., Next-Generation Psychiatric Assessment: Using Smartphone Sensors to Monitor Behavior and

Mental Health, Psychiatric Rehabilitation Journal, 2015

Reconstruct

behaviour

Apply existing

Instrument

Sensors and

datasets Score

Reconstruct behaviour

Apply existing

Instrument

Sensors and

datasets Score

Apply new Instrument

Sensors and

datasets Score

Infer input for existing

Instrument

(a)

(b)

(c)



Although this approach is a very stimulating one, it would not be consistent with City4Age for two

reasons:

Models that directly link data features to MCI or frailty outcomes would be opaque to the

underlying behaviours and would fail to demonstrate the link between changes in behaviour, detected through unobtrusive sensing, and consequences of MCI and frailty, which is one of

the key objectives of the project

Currently proposed models are generally at the proof-of-concept stage and have not yet

achieved the level of validity and reliability assessment of established Instruments. On the

other hand, the effort and a timescale needed for defining, validating and assessing the reliability of these models would go far beyond those of City4Age.

Nonetheless, it is expected that the project experimentation at pilot sites will allow to gather important information and expertise about the relationship among behavioural sensing and MCI and frailty risk

detection, and this will in turn enable the generation of educated recommendations for researchers who are willing to undertake the above mentioned challenge in the near future. Moreover, several technical

achievements in City4Age (e.g. data collection subsystem, the human activity reconstruction

subsystem, the data analytics platform for risk detection, etc.) would also be a significant enabler for

this new line of investigation.

Finally, regarding technical feasibility, it should be noted that when selecting Instruments to include in the City4Age risk detection subsystem it is also necessary to understand if and how the inputs to the

underlying models can be reliably obtained from sensors and other city datasets information.

For instance (with reference to previous examples), it may be relatively easy to link an indicator like

the number of nightly visits to the bathroom to a dataset coming from a PIR motion detection, installed in the bathroom itself (like in the UTI early detection case), but it is quite a different story to

understand in a reliable way if a person is taking care of all her/his shopping needs or if she/he started

to shop only for small items (as in the case of the Lawton IADL scale application).

Seeking technical feasibility is the crucial task of City4Age work-packages WP3-WP5, while

reliability assessment will be carried out in WP7, at the six projects testbeds, in a diverse set of needs

and urban contexts.

2.3 Testbed cases

Although this document outlines a general model for risk detection in City4Age, which in principle

could be applied to every conceivable application instance, in the frame of the project the model will be tested at six specific instances, represented by the on-field experiments conducted at the project

testbeds.

These experiments will allow to derive relevant, hands-on expertise and insights that will be fed back

to the generic model in order to improve it.

This feedback loop will be implemented twice, and will be reported in versions 2 and 3 of this

document, planned for month M21 and month M27.

In this subsection we will briefly describe the context, the urban environment and the elderly population needs addressed by each pilot site, in order provide a general view of how each testbed

relates to the overall generic model and vice-versa.

2.3.1 Madrid testbed

The Madrid testbed has the following characteristics:

It addresses the needs of elderly citizens older than 80 years that are still living an active life

and moving independently

In particular, it will address mobility related needs, linked in particular to the usage of public

transportation across points of interest (e.g. home or day centre)

Proposed scenarios for risk detection include monitoring changes in transportation usage as a

means to detect forgetfulness or decreasing physical abilities



The targeted population is provided with smartphones and wristbands. The public API of the

transport system will be available, in order to provide additional context information about

transportation in the city

2.3.2 Singapore testbed

The Singapore testbed has the following characteristics:

It addresses the needs of elderly citizens older than 70 years, who are at risk of MCI or

frailty, living alone and attending neighbourhood Community Centres. Also addressed are

the needs of personal caregivers (family or others)

In particular, it will address the needs for older people in neighbourhoods to socialize at

Community Centres – in order to increase community spirit and resilience – and to move around safely

Proposed scenarios for risk detection include the implementation of tools for caregivers to

detect decreases in socializations, as sign of deteriorating health (based on existing

MCI/frailty indicators), and tracking position to ensure safety

The scenarios involve smart homes and various kind of wearables, including FPV

2.3.3 Montpellier testbed

The Montpellier testbed has the following characteristics:

It addresses the needs of elderly citizens over 65 years, who are at risk of MCI or frailty, that

live independently both at home and in the city; elderlies’ families are also involved

In particular, it will address the needs for resilience of older people, based on constant and

timely monitoring of activities at home and in the city, in order to react to changes that

signal health deterioration and offer supporting intervention, including by involving families

Proposed scenarios for risk detection include monitoring ADLs at home to gather signs that

can be precursor of MCI or frailty (e.g. depression, falls), and monitor city life (e.g.

participation in cultural events) to both ensure detection of health risks and monitoring of

personal safety. Note: it is proposed that Parkinson patients are selected among the pilot experiment participants as a “proxy” for patients at risk of MCI/frailty, because of stronger

predictability of health status evolution, in the limited timeframe of the project

The scenarios involve smart homes, various kind of wearables, and beacons

2.3.4 Athens testbed

The Athens testbed has the following characteristics:

It addresses elderly citizens that attend Friendship Clubs established in the city and managed

by the Municipality

In particular, it will address the needs of the Municipality to support vulnerable elderly

persons, particularly those hit by economic or social problems. This is to be addressed,

among other, by enacting Friendship Clubs as instruments for improving social support and

quality of life

Proposed scenarios for risk detection include monitoring attendance to Friendship Clubs and

participation to proposed activities, as they impact on quality of life and health status, as

well as tracking movement in the city with public transportation (also in relation to on

environmental conditions)

The scenarios involve the usage of various kind of wearables, and beacons

2.3.5 Birmingham testbed

The Birmingham testbed has the following characteristics:

It addresses the needs of elderly people living independently



In particular, it addresses the needs of these people for detecting MCI onset in order to

counteract it and live independently for longer, including through better use of their

environment both indoor and outdoor

2.3.6 Lecce testbed

The Lecce testbed has the following characteristics:

It addresses the needs of persons older than 70 years, that live alone in ownership homes, in

the neighbourhood of a typical small Mediterranean city. It will also involve the

Municipality social services as the principal actor with responsibility on the quality of life of

elderly in the local urban context

In particular, it will address the needs of elderly persons to maintain self-sufficiency and

avoid MCI or frailty risk while living in their neighbourhood. It also addresses the needs of

the Municipality social services to monitor elderly persons’ quality of life and ensuring that

the neighbourhood itself contribute to it (including offered services, even commercial activities)

Proposed scenarios for risk detection include monitoring routine activities conducted at both

the home level and the neighbourhood level (shopping, going to church, social centre, etc.)

The scenarios involve smart homes, various kind of wearables, and beacons



3 City4Age risk modelling

In the following two sections, relevant Instruments – respectively for MCI and frailty – that have been

selected to be included in the City4Age risk modelling are presented.

The selection has been conducted on the basis of the discussion and requirements expressed in section

2 above, including in particular:

capability of the Instrument to detect or predict the onset of MCI or frailty, respectively, as

documented in the literature

possibility to (partially) implement the Instrument through behavioural sensing

technical feasibility of the necessary unobtrusive human activity recognition

It is important to note that, with reference to the last two points, the selection presented here is rather liberal, preferring to include Instruments that may eventually reveal as unmeasurable through

behavioural sensing or technically unfeasible, rather than incurring the risk of leaving out good ones.

On this account, the analysis will be refined in the second and third versions of this document, that can

count on the availability of additional, important insights coming from the testbeds rounds of

experiments.

For each Instrument, we include:

an overall description, including its motivation, fundamental characteristics, and why it is

worth considering in City4Age

reference to literature, pointing to full information about the Instrument as well as to studies

that have addressed its predictive validity, as relevant

a synoptic view of the structure of the Instrument, along the definitions given in section 2. In

particular, for each Instrument, this view includes: o the list of Items

o for Items whose values correspond to potentially trackable behaviours, a full list of

those values

o the Category to which the Item belongs. As very similar Categories can be found being referenced across more than one Instrument, an effort has been made to

standardize Categories, as illustrated in Table 1Table 2.

Moreover, in order to allow future reference and tracking, each Item is given a unique ID,

which also identifies the Category and the Instrument to which it belongs.

It is expected that this information will provide a common understanding about the geriatrics risk indicators that can be used as a foundation for City4Age risk modelling, and be applied as the reference

material for the next phases of the project, aiming in particular at:

establishing the starting point for behaviour modelling, in particular for behaviours implied

in the proposed Instruments (e.g. mobility behaviours, shopping behaviours, finance

management behaviours, etc.)

establishing the basis for the implementation of the technical components that collect

unobtrusive datasets, reconstruct relevant human activities, and implement relevant behavioural monitoring

Code Categories Remarks

Co Communication Telephone and other communication

Sh Shopping

Fo Food Meal and/or food preparation

Ho Housekeeping

Ln Laundry

Tr Transportation Transportation beyond walking distance



Code Categories Remarks

Me Medication Ability to manage own medication

Fi Finances Ability to manage own finances

Cu Culture Cultural or entertainment activities

So Socialization

Ti Time Orientation to time

Sp Space Orientation to space

At Attention Attention and calculation

Mr Memory Recall (short-term verbal memory)

La Language

Vi Visuospatial Visuospatial/constructional praxis

Ab Abstraction

We Weight

Ex Exhaustion Exhaustion, fatigue, energy level

Mt Motility Slowness, ambulation, balance

Ac Activity Activity level

Wk Weakness

Dp Dependence Dependence/disabilities and social support

Mo Mood Mood or depression issues

He Health General health status, illnesses, sensory issues

Ad ADLs Activity of daily living (basic) in general

Ia IADLs Instrumental Activity of daily living in general

De Demographics

En Environment

Table 2. Items’ Categories in City4Age

It is worth to note that classification has not been always easy, and in some cases Items may rightly

address more than one Category. In these cases, an effort has been made to identify the main one and

assign the Item to that Category.

The overall classification effort is to be revised in subsequent versions of this document.



4 MCI risk modelling

4.1 Brief introduction to MCI

Mild cognitive impairment (MCI) represents an intermediate state of cognitive function between the

changes seen in aging and those fulfilling the criteria for dementia and often Alzheimer’s disease.

MCI is classified into two categories

amnestic MCI, which is characterized by memory impairments, that still do not meet the

criteria for dementia, while other areas (e.g. attention, language, executive function,

visuospatial skills) are not affected

non-amnestic MCI, which impacts non-memory related areas

Amnestic MCI is more common than anamnestic MCI and it has been related to the onset of AD. Non-amnestic MCI has been related to other kinds of dementia, not linked to AD, such as

frontotemporal lobar degeneration or dementia with Lewy bodies.

Prevalence of mild cognitive impairment ranges from 10 to 20% in persons older than 65 years of age.

For example, the Mayo Clinic Study of Aging, a prospective, population-based study of persons

without dementia who were between 70 and 89 years of age at enrolment, found a prevalence of

amnestic mild cognitive impairment of 11.1% and of non-amnestic mild cognitive impairment of 4.9%.

Given its role as a possible precursor of more severe forms dementia, MCI has recently received a lot

of attention in clinical practice as well as in research settings.

In fact, on one side, its detection can help to enact effective disease-delaying lifestyle interventions,

and, on the other side, being the earliest manifestation of cognitive disorders, it may also be important

in formulating research hypotheses.

Discriminating between MCI and normal aging can be a challenge. Slight forgetfulness, e.g.

misplacing objects and having difficulty recalling words, can be a normal effect of aging.

Amnestic MCI is characterized by a more prominent memory impairment. For example, patients may forget important information that they used to remember easily, such as appointments, telephone

conversations, or recent events of interest to them (e.g., sporting events), while all other aspects of

function are normally preserved.

The American Academy of Neurology recommends the following criteria for an MCI diagnosis:

self-reported memory problems, preferably confirmed by another person

greater-than-normal memory impairment, measured with standard tests

normal thinking and reasoning skills

no impairments in ADLs

Currently, there is no approved pharmacological intervention for MCI.

There is evidence of benefits from cognitive rehabilitation interventions (e.g. use of mnemonics,

association strategies, computer assisted training programs) for amnestic MCI patients15

.

Other recommended interventions include aerobic exercise, involvement in intellectually stimulating activities, and participation in social activities, given that these – even if not fully confirmed – might be

beneficial and pose little risk.

Following the criteria illustrated in section 3, the next several subsections present the most important,

Instruments which are currently used to predict or detect the onset of the MCI syndrome.

15 Jean et al., Cognitive intervention programs for individuals with mild cognitive impairment: systematic review

of the literature, The American journal of geriatric psychiatry, 2010



4.2 The Lawton Instrumental Activities of Daily Living (IADL) Scale

4.2.1 Overview

This Instrument has been devised in order to provide an assessment of the functional status in older

adults and deliver objective data to assist with targeting individualized care needs.

It guides the clinician to focus on the person’s baseline capabilities, facilitating early recognition of

changes, that may represent decline and/or need for additional medical check.

It is based on the assessment of a set of independent living skills, which are considered more complex

than the basic activities of daily living as measured by e.g. the Katz Index of ADLs.

For this reason, it can detect milder forms of cognitive impairment, with respect to basic ADLs. In

particular, studies have addressed its relationship with MCI assessment and its value in predicting

cognitive decline.

It is based on 8 domains of function. Persons are scored according to their highest level of functioning in each Category. A summary score ranges from 0 (low function, dependent) to 8 (high function,

independent).

The questionnaire has to be administered by a trained interviewer and collects self-reported

information.

The Instrument validity and reliability have been assessed in some studies, also by determining its

correlation with four other Instruments: Physical Classification (6-point rating of physical health), Mental Status Questionnaire (10-point test of orientation and memory), Behaviour and Adjustment

rating scales (4-6-point measure of intellectual, person, behavioural and social adjustment), and the

PSMS (6-item ADLs).

4.2.2 References

A complete description of the Instrument can be found at the ConsultGeri website of the

Hartford Institute for Geriatric Nursing, URL: https://consultgeri.org/try-this/general-

assessment/issue-23

A study addressing the usage of Instrumental Activities of Daily Living for assessing MCI

and for predicting future cognitive decline is described in the paper referred by the following

Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/22053873

4.2.3 Structure

ID Category Item Values

Co.Li.01 Communication Ability to Use Telephone Operates telephone on own initiative; looks up and dials

numbers /

Dials a few well-known

numbers /

Answers telephone, but does not

dial /

Does not use telephone at all

Sh.Li.02 Shopping Shopping Takes care of all shopping needs

independently /

Shops independently for small

purchases /

Needs to be accompanied on any

shopping trip /

Completely unable to shop

https://consultgeri.org/try-this/general-assessment/issue-23

https://consultgeri.org/try-this/general-assessment/issue-23

http://www.ncbi.nlm.nih.gov/pubmed/22053873




Fo.Li.03 Food Food Preparation Plans, prepares, and serves

adequate meals independently /

Prepares adequate meals if

supplied with ingredients. /

Heats and serves prepared meals

or prepares meals but does not

maintain adequate diet /

Needs to have meals prepared

and served

Ho.Li.04 Housekeeping Housekeeping Maintains house alone with occasion assistance (heavy

work) /

Performs light daily tasks such as

dishwashing, bed making /

Performs light daily tasks, but

cannot maintain acceptable level

of cleanliness /

Needs help with all home

maintenance tasks /

Does not participate in any

housekeeping tasks.

Ln.Li.05 Laundry Laundry Does personal laundry

completely /

Launders small items, rinses

socks, stockings, etc. /

All laundry must be done by

others

Tr.Li.06 Transportation Mode of Transportation Travels independently on public

transportation or drives own car /

Arranges own travel via taxi, but

does not otherwise use public

transportation /

Travels on public transportation

when assisted or accompanied by

another /

Travel limited to taxi or automobile with assistance of

another /

Does not travel at all

Me.Li.07 Medication Responsibility for Own

Medications

Is responsible for taking medication in correct dosages at

correct time /

Takes responsibility if

medication is prepared in

advance in separate dosages /

Is not capable of dispensing own

medication




Fi.Li.08 Ability to

Handle Finances

Ability to Handle Finances Manages financial matters independently (budgets, writes checks, pays rent and bills, goes

to bank); collects and keeps track

of income /

Manages day-to-day purchases, but needs help with banking,

major purchases, etc. /

Incapable of handling money



4.3 The OARS Multidimensional Functional Assessment Questionnaire

4.3.1 Overview

The OARS Multidimensional Functional Assessment Questionnaire (OMFAQ) has been designed at

the Duke Center for the Study of Aging and Human Development, as a tool for assessing individual functional status of older persons (including ability to carry out Activities of Daily Living), in order to

group together people of comparable functional status.

The questionnaire has to be administered by a trained interviewer and collects self-reported

information.

In this subsection we consider the part regarding the Instrumental Activities of Daily Living, which

includes questions from 56 to 62. This part has shown good validity and reliability, suggesting it is superior to many other Instruments. (Even if the recent trend is to do so, it is to be noted that the OARS

team counsels against using the ADL and IADL parts separately from the other questionnaire

components).

The Instrument has also been used as a screening tool and has been studied in assessing the correlation

among MCI and IADLs, also in view of improving prediction of the outcomes of MCI.

4.3.2 References

The main reference about the Instrument can be found on the site of the Duke Center for the

Study of Aging and Human Development, at the following URL:

http://www.geri.duke.edu/resources-a-links/141

A study on the association of the Instrument with MCI is referred by the following Pubmed

URL: http://www.ncbi.nlm.nih.gov/pubmed/22337146

4.3.3 Structure


Co.Oa.01 Communication Can you use the telephone? Without help, including looking

up numbers and dialling /

With some help (can answer

phone or dial operator in an

emergency, but need a special phone or help in getting the

number or dialling) /

Completely unable to use the

telephone

Tr.Oa.02 Transportation Can you get to places out of

walking distance?

Without help (drive your own car, or travel alone on buses, or

taxis) /

With some help (need someone to help you or go with you when

traveling) /

Unable to travel unless

emergency arrangements are

made for a specialized vehicle

like an ambulance

http://www.geri.duke.edu/resources-a-links/141





Sh.Oa.03 Shopping Can you go shopping for

groceries or clothes?

Without help (taking care of all shopping needs yourself, assuming you had

transportation) /

With some help (need someone

to go with you on all shopping

trips) /

Completely unable to do any

shopping

Fo.Oa.04 Food Can you prepare your own

meals?

Without help (plan and cook full

meals yourself) /

With some help (can prepare

some things but unable to cook

full meals yourself) /

Completely unable to prepare

any meals

Ho.Oa.05 Housekeeping Can you do your housework? Without help (can clean floors,

etc.) /

With some help (can do light housework but need help with

heavy work) /

Completely unable to do any

housework

Me.Oa.06 Medication Can you take your own

medicine?

Without help (in the right doses

at the right time) /

With some help (able to take

medicine if someone prepares it for you and/or reminds you to

take it) /

Completely unable to take your

medicines

Fi.Oa.07 Finances Can you handle your own

money?

Without help (write checks, pay

bills, etc.) /

With some help (manage day-to-

day buying but need help with

managing your check-book and

paying your bills) /

Completely unable to handle

money



4.4 The Nottingham Extended Activities of Daily Living

4.4.1 Overview

The Nottingham Extended Activities of Daily Living (NEADL) is a ranked assessment of daily living

scale that has been developed to assess activities which may be important to stroke patients who have

been discharged home.

However, its role has also been investigated in the transition from no cognitive impairment to mild

cognitive impairment (MCI) and dementia, in comparison to neuropsychological tests.

The questionnaire incorporates 22 ADL Items in four sections. Some of them regards basic ADLs, of

less use to City4Age, while others regard IADLs, that are more interesting. Subsection 4.4.3 below lists

all the Items, including ADLs.

Answers should reflect what has actually been done in the last few weeks. The questionnaire should be

intended as a record of activity rather than capability.

The questionnaire can be administered by an interviewer (including via telephone) or it can be self-

administered (e.g. via mail, as it has been initially designed as a postal questionnaire).

4.4.2 References

The paper that describes the Instrument can be found at the following URL: http://cre.sagepub.com/content/1/4/301.short

A study finding a powerful predictive value for the Instrument, comparable to that of

neuropsychological tests such as MMSE, MoCA, Addenbrooke cognitive assessment and

frontal assessment battery, can be found at the URL:

http://www.neurores.org/index.php/neurores/article/view/316

4.4.3 Structure


Mt.Ne.01 Motility Did you walk around outside? Not at all /

With help /

On your own with help /

On your own

Mt.Ne.02 Motility Did you climb stairs? Not at all /

With help /


On your own

Mt.Ne.03 Motility Did you get in and out of a car? Not at all /

With help /


On your own

Mt.Ne.04 Motility Did you walk over uneven

ground?

Not at all /

With help /


On your own

Mt.Ne.05 Motility Did you cross roads? Not at all /

With help /


On your own

Tr.Ne.06 Transportation Did you travel on public Not at all /

http://cre.sagepub.com/content/1/4/301.short

http://www.neurores.org/index.php/neurores/article/view/316




transport? With help /


On your own

Fo.Ne.07 Food Did you manage to feed

yourself?

Not at all /

With help /


On your own

Fo.Ne.08 Food Did you manage to make

yourself a hot drink?

Not at all /

With help /


On your own

Fo.Ne.09 Food Did you take hot drinks from one

room to another?

Not at all /

With help /


On your own

Ho.Ne.10 Housekeeping Did you do the washing up? Not at all /

With help /


On your own

Fo.Ne.11 Food Did you make yourself a hot

snack?

Not at all /

With help /


On your own

Fi.Ne.12 Finances Did you manage your own

money when out?

Not at all /

With help /


On your own

Ln.Ne.13 Laundry Did you wash small items of

clothing?

Not at all /

With help /


On your own

Ho.Ne.14 Housekeeping Did you do your own

housework?

Not at all /

With help /


On your own

Sh.Ne.15 Shopping Did you do your own shopping? Not at all /

With help /


On your own

Ln.Ne.16 Laundry Did you do a full clothes wash? Not at all /

With help /


On your own

Cu.Ne.17 Culture Did you read newspapers or Not at all /




books? With help /


On your own

Co.Ne.18 Communication Did you use the telephone? Not at all /

With help /


On your own

Cu.Ne.19 Culture Did you write letters? Not at all /

With help /


On your own

So.Ne.20 Socialization Did you go out socially? Not at all /

With help /


On your own

Ac.Ne.21 Activity Did you manage your own

garden?

Not at all /

With help /


On your own

Tr.Ne.22 Transportation Did you drive a car? Not at all /

With help /


On your own



4.5 The Direct Assessment of Functional Status

4.5.1 Overview

The Direct Assessment of Functional Status is a performance-based measure for evaluating a broad

spectrum of behaviours related to Instrumental Activities of Daily Living.

Although it has been designed and validated as tool for the assessment of the functional competencies of patients with dementia, rather than predicting cognitive degradation, the Instrument is included here

as a paradigmatic example of a performance-based method (i.e. method relying on direct observation

of subject’s behaviour in controlled settings) a practice that bear some resemblance to the City4Age

unobtrusive monitoring approach.

Items’ Categories are similar to other IADL related Instruments.

The Instrument needs to be administered by an expert team in appropriate settings.

It is worth to note that performance-based measures in general, and DAFS in particular, have been found to be better in detecting cognitive deficits, than self- or collateral report questionnaires, although

their broad application is limited by higher costs, as they are more time consuming, require space,

specialized equipment and expert examiners.

4.5.2 References

A paper describing the Instrument is referred by the following Pubmed URL:


A paper that shows DAFS higher sensitivity in detecting MCI, compared with self- or

collateral report questionnaire, is referred by the following Pubmed URL:

http://jgp.sagepub.com/content/27/4/253.short

A paper addressing the validity of the Instrument and also mentioning the current economic

and organizational limitations to performance-based methods (that can possibly be overcome

by the City4Age paradigm) is referred by the following Pubmed URL:


4.5.3 Structure


Ti.Da.01 Time The person is shown four different times (0300 h, 0800 h, 1030 h and 1215 h) using a large

model of a clock and is asked to

tell the time

Correct / Incorrect answer for

each item

Ti.Da.02 Time The person is asked to state the

date, the day, the month and the year.


each item

Co.Da.03 Communication The person is invited to dial the

operator, dial from a list of

telephone numbers, dial from oral presentation and dial from

written presentation.

Correct / Incorrect performance

for each item

Co.Da.04 Communication The person is observed on picking up the receiver, dialling,

hanging up and operating the

telephone in the correct

sequence.


for each item


http://jgp.sagepub.com/content/27/4/253.short





Co.Da.05 Communication The person is invited to fold a letter in half, put it in an

envelope, seal the envelope, put

on a stamp, address it (from a presented stimulus card) and add

a return address (the person’s

own current address, without a postal code).


for each item

Fi.Da.06 Finance The person is invited to identify

four different coins and three

notes


for each item

Fi.Da.07 Finance The person is invited to count

four amounts of money Correct / Incorrect performance

for each item

Sh.Da.08 Shopping Before the preparation of the letter (Co.Da.05), the examiner

instructs the person that in 10

min she/he will be going to a grocery store to select six items:

orange juice, spaghetti, cherry

jam, tuna fish, rice and

tomatoes. After 1 min to recall as many grocery items as

possible

Number of recalled items

Sh.Da.09 Shopping The person is taken to a simulated grocery store to pick

out the items from a total of 25

Number of recalled items

Sh.Da.10 Shopping The examiner then gives the

person a written grocery list (milk, crackers, eggs and

laundry detergent) and asks

them to select the four items and to hand them to the examiner

Correctly / Incorrectly picked

items

Fi.Da.11 Finance Given a note to pay for the

items, the person is invited to

make change

Change correctly / incorrectly

identified

Tr.Da.12 Transportation The examiner asks the person to

identify a driver's correct

response to 13 road signals

Correctly / Incorrectly identified

signals

Ad.Da.13 ADLs The person is taken to a bathroom and asked to take the

cap off a tube of toothpaste, put

toothpaste on a toothbrush, turn on the tap, brush teeth, dampen

washcloth, put soap on

washcloth, wash the face and

turn off the tap


for each item

Ad.Da.14 ADLs The person is invited to use a

hairbrush, put on a coat, button a

coat (three buttons), fasten a zip and tie shoelaces


for each item




Ad.Da.15 ADLs The person, sitting at a table, shows how she/he would cut a

steak, take a bite of it, eat soup

and pour water into a glass and drink it


for each item



4.6 The Mini–Mental state Examination

4.6.1 Overview

The mini–mental state examination (MMSE) is a 30-point questionnaire that is used extensively in

clinical and research settings to measure cognitive impairment. It was designed to give a practical

clinical assessment of change in cognitive status in geriatric inpatients.

It is also commonly used to screen for dementia, to estimate the severity and progression of cognitive

impairment and to follow the course of cognitive changes in an individual over time.

The Instrument has to be administered by a trained examiner.

Although one of the most frequently noted disadvantages of the MMSE relates to its lack of sensitivity

to MCI, we report it here because of its wider adoption and acceptance. Another disadvantage is that it

is affected by demographic factors, age and education being the most important.

Performance of specific MMSE domains as predictors of subsequent overall cognitive decline has been

object of study.

4.6.2 References

MMSE has been copyrighted by Psychological Assessment Resources (PAR). However,

their site (www.parinc.com) was down at the time of writing. A version of the MMSE questionnaire can be found on the British Columbia Ministry of Health website at the URL:

http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-

guidelines/cognitive-impairment#resources

A review of information regarding the psychometric properties and utility of the Mini-

Mental State Examination can be found in the paper referred by the following Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/1512391

Studies on the value of single MMSE domains in predicting decline over time can be found

at the following Pubmed URLs: http://www.ncbi.nlm.nih.gov/pubmed/19382130 and


4.6.3 Structure


Ti.Mm.01 Time The person is asked to state the year, season, month, date and

day of the week.


each element

Sp.Mm.02 Space The person is asked to state the country, province, city/town,

address (home: street address, in-facility: building name) and

location (home: room name, in-

facility: floor)


each element

Mr.Mm.03 Memory The examiner says “I am going to name three objects. When I am

finished, I want you to repeat them. Remember what they are

because I am going to ask you to

name them again in a few minutes.” The examiner says the

following words slowly at

1‐second intervals ‐ ball/ car/

man

Correct / Incorrect repetition for

each word

http://www.parinc.com/

http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/cognitive-impairment#resources

http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/cognitive-impairment#resources







At.Mm.04 Attention The examiner asks the person to spell the word WORLD. Now spell it backwards. (in

alternative, the interviewer

counting down from one hundred

by sevens)

Correct / Incorrect answer

(position of the first error)

Mr.Mm.05 Memory The examiner asks the person what were the three objects

she/he asked to remember?

Correctly / Incorrectly recalled

words

La.Mm.06 Language The examiner show a wristwatch and asks the person “What is this

called?”. Repeats with a pencil

Correctly / Incorrectly identified

items

La.Mm.07 Language The examiner asks the person to repeat this phrase “No ifs, ands

or buts.”

Correct / Incorrect repetition

La.Mm.08 Language The examiner asks the person to read the words on a page and

then do what it says. Then hand

the person the page with “CLOSE YOUR EYES” on it. If

the subject reads and does not

close their eyes, repeat up to three times. Score only if subject

closes eyes

Closing / Not closing eyes

La.Mm.09 Language The examiner hands the person a pencil and paper, then says

“Write any complete sentence on

that piece of paper”

Writing a sentence that make / does not make sense (ignore

spelling errors)

Vi.Mm.10 Visuospatial The examiner places a drawing (interlocking pentagons, i.e. two five-sided figures intersecting to

make a four-sided figure), eraser

and pencil in front of the person

and asks “Copy this drawing please.” (Allow multiple tries;

wait until person is finished and

hands it back.)

Drawing correctly / incorrectly

copied

La.Mm.11 Language The examiner asks the person if

she/he is right or left‐handed,

takes a piece of paper and hold it up in front of the person. Then

says “Take this paper in your

right/left hand [note: whichever

is non‐dominant], fold the paper

in half once with both hands and

put the paper down on the floor”.

Correct / incorrect performance

for each item



4.7 The Short Test of Mental Status

4.7.1 Overview

The Short Test of Mental Status (STMS) is a screening measure of cognition specifically developed for

use in dementia assessment and was intended to be more sensitive to problems of learning and mental

agility that may be seen in mild cognitive impairment (MCI).

In particular, STMS has been found to be better able than MMSE for predicting MCI.

The Instrument is to be administered by a trained examiner.

4.7.2 References

The Instrument is described in the paper referred by the following Pubmed URL:


A study that compares the STMS and MMSE in detecting or predicting MCI is referred by

the following Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/14676056

A study that identified STMS as the strongest predictor of MCI risk in NC subjects, among

several other considered demographic and clinical variables, is referred by the following

Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/25788555

4.7.3 Structure


Sp.Sm.01 Space The person is asked to state

name, address, current location (building), city state.


each item

Ti.Sm.02 Time The person is asked to state date

(day), month, year. Correct / Incorrect answer for

each item

At.Sm.03 Attention The following digit spans of increasing length are presented in

sequence to the person, asking

for repetition: 2-9-6-8-3, 5-7-1-9-

4-6, 2-1-5-9-3-6-2.

Length of correctly repeated

spans

Mr.Sm.04 Memory The examiner tell four unrelated words: “apple”, “Mr. Johnson”, “charity”, “tunnel”. The person is

requested to repeat all words.

Number of trial to repeat all four

words

At.Sm.05 Attention The examiner proposes 4 arithmetic operations to be

computed: 5x13, 65-7, 58/2,

29+11

Correctly / Incorrectly computed

operations

Ab.Sm.06 Abstraction The examiner proposes three pair of words and asks the person to state the abstract interpretation:

orange/banana, dog/horse,

table/bookcase (e.g. dog/horse =

animal)

Correctly / Incorrectly abstracted

interpretations

Vi.Sm.07 Visuospatial The examiner asks the person to

draw a clock face showing 11:15.

Clock face correctly / incorrectly

drawn

Vi.Sm.08 Visuospatial The examiner shows the person the drawing of a cube and asks to

copy it


copied







La.Sm.09 Language The examiner asks the person to provide three information element: “first president”,

“define an island”, “number of

weeks per year”

Correct/incorrect information

provided for each item

Mr.Sm.10 Memory The examiner asks the person to

recall the words from Mr.Sm.04

Correctly/incorrectly recalled

words



4.8 The Montreal Cognitive Assessment

4.8.1 Overview

The Montreal Cognitive Assessment (MoCA) is a 10-minute cognitive screening tool to assist first-line

physicians in detection of MCI as a clinical state that often progresses to dementia.

The MoCA has been assessed as a predictor of worsening cognitive conditions, e.g. in conversion from

MCI to Alzheimer’s disease.

The Instrument has to be administered by a trained examiner.

4.8.2 References

The Instrument is described in the paper found referred by the following Pubmed URL:


A study that assesses the usefulness of the Instrument in predicting conversion to AD is

referred by the following Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/24635004

4.8.3 Structure


Vi.Mo.01 Visuospatial The examiner instructs the subject: "Please draw a line,

going from a number to a letter

in ascending order. Begin here [point to (1)] and draw a line

from 1 then to A then to 2 and

so on. End here [point to (E)].".


each item

Vi.Mo.02 Visuospatial The examiner gives the following instructions, pointing

to the cube: “Copy this drawing

as accurately as you can, in the space below”.


copied

Vi.Mo.03 Visuospatial The examiner give the following

instructions: “Draw a clock. Put

in all the numbers and set the time to 10 past 11”.

Clock face correctly / incorrectly

drawn

La.Mo.04 Language The examiner points to three

animal figures (lion, rhino,

camel) in turn and says: “Tell me the name of this animal”.

Names correctly / incorrectly

repeated.






Mr.Mo.05 Memory The examiner reads a list of 5 words (face, velvet, church,

daisy, red) at a rate of one per

second, giving the following instructions: “This is a memory

test. I am going to read a list of

words that you will have to remember now and later on.

Listen carefully. When I am

through, tell me as many words

as you can remember. It doesn’t matter in what order you say

them”. When the subject

indicates that she/he has finished (has recalled all words), or can

recall no more words, the

examiner reads the list a second time with the following

instructions: “I am going to read

the same list for a second time.

Try to remember and tell me as many words as you can,

including words you said the

first time.”. At the end of the second trial, the examiner

informs the person that she/he

will be asked to recall these

words again”

Correct / Incorrect repetition for

each word

At.Mo.06 Attention The examiner gives the

following instruction: “I am

going to say some numbers and when I am through, repeat them

to me exactly as I said them”.

Then she/he reads the five

number sequence at a rate of one digit per second: 2-1-8-5-4.

Correctly / Incorrectly repeated

sequence


following instruction: “Now I am going to say some more

numbers, but when I am through

you must repeat them to me in

the backwards order.” Read the three number sequence at a rate

of one digit per second: 7-4-2

Correctly / Incorrectly repeated

sequence




At.Mo.08 Attention The examiner reads a list of letters (F B A C M N A A J K L

B A F A K D E A A A J A M O

F A A B) at a rate of one per second, after giving the

following instruction: “I am

going to read a sequence of letters. Every time I say the

letter A, tap your hand once. If I

say a different letter, do not tap

your hand”.

Correctly / Incorrectly tapped As


following instruction: “Now, I

will ask you to count by subtracting seven from 100, and

then, keep subtracting seven

from your answer until I tell you

to stop.”

Correct / Incorrect subtractions

La.Mo.10 Language The examiner gives the

following instructions: “I am

going to read you a sentence. Repeat it after me, exactly as I

say it [pause]: I only know that

John is the one to help today.”

Following the response, say: “Now I am going to read you

another sentence. Repeat it after

me, exactly as I say it [pause]: The cat always hid under the

couch when dogs were in the

room.”

Correct / Incorrect repetition

La.Mo.11 Language The examiner gives the following instruction: “Tell me

as many words as you can think

of that begin with a certain letter of the alphabet that I will tell

you in a moment. You can say

any kind of word you want,

except for proper nouns (like Bob or Boston), numbers, or

words that begin with the same

sound but have a different suffix, for example, love, lover,

loving. I will tell you to stop

after one minute. Are you ready? [Pause] Now, tell me as

many words as you can think of

that begin with the letter F.

[time for 60 sec]. Stop.”

Words generated




Ab.Mo.12 Abstraction The examiner asks the subject to explain what each pair of words

has in common, starting with the

example: “Tell me how an orange and a banana are alike”.

If the subject answers in a

concrete manner, then say only one additional time: “Tell me

another way in which those

items are alike”. If the subject

does not give the appropriate response (fruit), say, “Yes, and

they are also both fruit.” Do not

give any additional instructions or clarification. After the

practice trial, say: “Now, tell me

how a train and a bicycle are alike”. Following the response,

administer the second trial,

saying: “Now tell me how a

ruler and a watch are alike” Do not give any additional

instructions or prompts.

Correctly / Incorrectly abstracted

interpretations

Mr.Mo.13 Memory The examiner gives the

following instruction: “I read some words to you earlier,

which I asked you to remember.

Tell me as many of those words as you can remember.”

Correctly / Incorrectly recalled

words

Ti.Mo.14 Time The examiner gives the

following instructions: “Tell me

the date today”. If the subject does not give a complete

answer, then prompt accordingly

by saying: “Tell me the [year, month, exact date, and day of

the week].”


each element

Sp.Mo.15 Space Then the examiner says: “Now,

tell me the name of this place, and which city it is in.”


each element



4.9 Predicting MCI onset from gait speed analysis

4.9.1 Overview

Although not actually an established Instrument used in research or clinical settings, we would like to

present here a significant result that is representative of new directions that can be potentially pursued.

We refer to the study of Buracchio et al. (see References subsection below) that assesses how gait

speed can be used as predictor of MCI onset.

Subjects for the study were 204 healthy seniors (58% women) from the Oregon Brain Aging Study,

who have been evaluated for up to 20 years with annual neurologic, neuropsychological and motor

examinations.

The authors found that rates of change with aging of gait speed were significantly different between

MCI converters and non-converters (p<0.001).

Change points occurred approximately 14 years prior to MCI onset in men and approximately 6 years

for women.

As gait speed can be measured in a relatively easy and unobtrusive way through a smartphone, this

result is significant for City4Age. In fact, research work aimed at devising unobtrusive classifier

systems based on this model have recently appeared in the literature (see References subsection below).

Authors have also analysed tapping speed and found it significantly different between MCI converters

and non-converters both in the dominant hand (p<0.003) and non-dominant hand (p<0.001). However, in this case, change points occurred after the onset of MCI, and thus the feature could not be used for

prediction.

4.9.2 References

The relevant paper from Buracchio er al. is referred by the following Pubmed URL:


A study that applies the Buracchio et al.s’ model to build an appropriate classifier, based on

datastreams coming from motion sensors placed in a smart home, is referred by the

following Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/25585407

4.9.3 Structure


Mt.Gm.01 Motility Time in seconds to walk from a starting point to a marker 15 feet

away, turn, and back at a normal

casual gait for a total of 30 feet

(9.14 meters).

Decrease of 0.013m/s/yr in all

subjects /

Decrease of 0.023m/s/yr in men

who are MCI converters, at 14.2

yr prior to MCI diagnosis /

Decrease of 0.025m/s/yr in

women who are MCI converters,

at 6.0 yr prior to MCI diagnosis





5 Frailty risk modelling

5.1 Brief introduction to frailty

Frailty is a geriatric syndrome of decreased reserve and resistance to stressors, resulting from

cumulative declines across multiple physiologic systems, causing increased vulnerability to adverse

outcomes16

.

People living with frailty are more at risk of dramatic health outcomes after apparent minor events, like

for instance an infection or a new medication. These outcomes include falls, disability,

institutionalization, hospitalization or even mortality.

On the other hand, frail people may be relatively low users of health care services, and be little known

to their GP, until they undergo a major health decline, possibly as a result of a marginal episode.

There is evidence that older people may not recognize themselves as living with frailty and do not

accept to be considered as ‘frail’, a term that is heavily associated with vulnerability and dependence17

.

There are two broad models of frailty.

the Phenotype model, based on a group of patient characteristics (unintentional weight loss,

reduced muscle strength, reduced gait speed, self-reported exhaustion and low energy

expenditure) which, if present, can predict poorer outcomes

the Cumulative Deficit model, that assumes an accumulation of deficits (ranging from

symptoms e.g. loss of hearing or low mood, through signs such as tremor, through to various

diseases such as dementia) which can occur with ageing and which combine to increase the

‘frailty index’ which in turn will increase the risk of an adverse outcome

Usually, three ordered frailty levels are identified: frail, pre-frail and robust (non-frail).

In City4Age, the ‘pre-frail’ level is an important one, as it has been referred to in the literature as a state of less ‘inevitability’ that may be more amenable to interventions than the frail state

18. In fact, frailty

may be preventable and early detection and interventions can minimize transitions from the pre-frail

(and pre-disabled) to the frail state, reduce the chance of adverse outcomes, and reduce healthcare

costs19

.

The prevalence of frailty in community-dwelling older Europeans (65 years and older) varies between

5.8% and 27.3%. In addition, between 34.6% and 50.9% are classified as ‘pre-frail’20

.

Current recommendations to detect frailty need include:

periodic social service assessment

review after referral for community intervention

primary care review when interacting with older people

assessment from home carers

assessment by ambulance crew, when called e.g. for a fall or other urgent matter

In terms of prevention, unhealthy behaviours that are implicated include:

insufficient physical activity, particularly resistance and aerobic exercise, which is beneficial

in preventing and treating the physical performance component of frailty

poor diet, particularly in terms of suboptimal protein/total calorie intake and vitamin D

insufficiency

16 Fried et al., Frailty in Older Adults: Evidence for a Phenotype, Journal of Gerontology, 2001

17 British Geriatrics Society, Fit for frailty (Report), 2014

18 Gill et al., Transitions between frailty states among community living older persons, Archives of internal

medicine, 2006

19 Morley et al., Frailty consensus: a call to action, Journal of the American Medical Directors Association, 2013

20 Santos-Eggiman et al., Prevalence of frailty in middle-aged and older community-dwelling Europeans living in

10 countries, The journals of gerontology. Series A, Biological sciences and medical sciences, 2009



In relation to this, the Action Group A3 of the European Innovation Partnership on Active and Healthy Ageing has specific areas related to Food and Nutrition and to Physical Activity that investigate how these aspects can be addressed in order to promote frailty prevention and to enact related multi-modal

interventions.

Following the criteria illustrated in section 3, the next several subsections present the most important,

currently used Instruments aimed at predicting or detecting the onset of the frailty syndrome.



5.2 Fried Frailty Index

5.2.1 Overview

The Fried Frailty Index (FFI) is a landmark Instrument that has been conceived as a phenotype

framework for defining frailty and it is one of the most popular and widespread.

It encompasses the assessment of five dimensions that are hypothesized to reflect systems the impaired regulation of which underlies the syndrome: unintentional weight loss, exhaustion, muscle weakness,

slowness while walking, and low levels of activity.

Corresponding to these dimensions are five specific Items indicating adverse functioning, which are

implemented using a combination of self-reported and performance-based measures.

The instrument classifies people as

‘frail’, when three or more Items are found positive

‘pre-frail’, when one or two Items are found positive

‘non-frail’, when no Items are found positive

5.2.2 References

The seminal study of Fried et al. that defined FFI is referred by the following Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/11253156; the same study also offers concurrent and

predictive validity for the Instrument, based on data from the Cardiovascular Health Study

A paper that confirmed FFI validity with data from the Women's Health and Aging Studies

is referred by the following Pubmed URL: https://www.ncbi.nlm.nih.gov/pubmed/16567375

5.2.3 Structure


We.Fi.01 Weight The person lost >10 pounds unintentionally last year

True / False

Ex.Fi.02 Exhaustion The person felt that everything

she/he did was an effort in last

week

Rarely or none of the time (<1

day) /

Some or little of the time (1 to 2 days) /

Moderate amount of the time (3

to 4 days) / Most of the time

Ex.Fi.03 Exhaustion The person felt that she/he could

not get going in last week

Rarely or none of the time (<1

day) /

Some or little of the time (1 to 2 days) /

Moderate amount of the time (3

to 4 days) / Most of the time

Mt.Fi.04 Motility Time to walk 15 feet (4.57

meters) Number of seconds beyond/not

beyond thresholds:

For men with height <= 173 cm:

7 secs /

For men with height > 173 cm: 6

secs /

For men with height <= 173cm:

7 secs /

For men with height > 173cm: 6

secs


https://www.ncbi.nlm.nih.gov/pubmed/16567375




Ac.Fi.05 Activity Physical expenditure on activity scale per week on 18 items

(Walking for exercise,

moderately strenuous household chores, mowing or raking the

lawn, gardening, hiking,

jogging, biking, exercise cycle, dancing, aerobics, bowling, golf,

singles or doubles tennis,

racquetball, calisthenics,

swimming. To compute kcals expended per week, use the

formula: kcal/week = [activity-

specific MET (kcal/kg × hour) ] × [duration per session (min) /

60 min] × [body weight (kg)] ×

[number of sessions in the last 2 wk / 2] × [number of months per

year activity was done])

kCal beyond / not beyond

threshold of 270 kCal

Wk.Fi.06 Weakness Grip strength (average of 3

trials, dominant hand, measured with Jamar hand dynamometer)

Kg beyond/not beyond

thresholds:

For men, BMI <= 24: 29 kg /

For men, BMI 24.1-26: 30 kg /

For men, BMI 26.1-28: 30 kg /

For men, BMI > 28: 32 kg /

For women, BMI <= 23: 17kg /

For women, BMI 23.1-26: 17.3

kg /

For women, BMI 26.1-29: 18 kg

/

For women, BMI > 29: 21 kg



5.3 Study of Osteoporotic Fractures index

5.3.1 Overview

The Study of Osteoporotic Fractures index (SOF index) is an attempt to propose a simpler alternative

to the FFI Instrument, easier to use in the clinical practice.

It has been developed in the frame of the Study of Osteoporotic Fractures, within a cohort of 6701

women 69 years or older, and its predictive validity has been compared with that of the FFI Instrument.

It uses 3 components: weight loss, the subject's inability to rise from a chair 5 times without using her

arms, and reduced energy level.

Other studies have subsequently extended validation to additional cohorts, including men.

SOF index can classify people as ‘robust’ (no Item is found positive), ‘pre-frail’ (one Item is found

positive), or ‘frail’ (two or more Items are found positive)

5.3.2 References

The paper that describes the development of the SOF index Instrument and the comparison

of its predictive validity with that of the FFI Instrument, is referred by the following Pubmed

URL: http://www.ncbi.nlm.nih.gov/pubmed/18299493

A paper that further validates the SOF index and compares it with FFI in a diverse elderly

community-dwelling sample of men and women is referred by the following Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/19682112

A study aiming at determining the ability of the SOF index criteria to predict adverse health

outcomes at a one-year follow-up in a sample of older outpatients in Italy is referred by the


5.3.3 Structure


We.So.01 Weight Weight loss (irrespective of

intent to lose weight) of 5% or more in a 2 years period

True / False

Mt.So.02 Motility Subject's inability to rise from a

chair 5 times without using her arms

True / False

Ex.So.03 Exhaustion Do you feel full of energy? Yes / No






5.4 SHARE-FI

5.4.1 Overview

SHARE-FI (SHARE Frailty Instrument) is an Instrument based in the on the Survey of Health, Ageing

and Retirement in Europe (SHARE).

SHARE-FI represents an attempt to operationalise the FFI Instrument in a very large European

population-based sample, offering an alternative to FFI in the European context.

To develop the Instrument, SHARE-FI authors selected the five SHARE variables that, in their view,

were the closest to FFI’s Items. On the other hand, their selection was not without significant

departures from FFI and thus SHARE-FI has been validated on its own.

The ultimate goal of the Instrument is to provide European community practitioners with a simple and

valid tool that addresses people over the age of 50.

The SHARE-FI Instrument is publicly available as an HTML/Javascript downloadable calculator21

.

5.4.2 References

The main study that defines SHARE-FI can be found at the following Pubmed URL:

http://www.ncbi.nlm.nih.gov/pubmed/20731877. The paper also assesses the validity of the

Instrument in predicting mortality

A paper that provides further prospective validation of SHARE-FI, with a focus on

disability, is referred by the following Pubmed URL:


A study that shows that SHARE-FI predicts mortality similarly to a more complex frailty

Instruments based on Comprehensive Geriatrics Assessment (CGA) is referred by the


5.4.3 Structure


Ex.Sh.01 Exhaustion In the last month, have you had too little energy to do the things

you wanted to do?

Yes / No

We.Sh.02 Weight What has your appetite been like?

Diminution in desire for food

and/or eating less than usual /

No change in desire for food

and/or eating the same as usual /

Increase in desire for food and/or

eating more than usual.

Wk.Sh.03 Weakness Grip strength (highest among

four measures, two for each

hand, taken with a

dynamometer)

Kg (continuous measure)

Mt.Sh.04 Motility Because of a health or physical

problem, do you have any

difficulty walking 100 metres? (Exclude any difficulties that

you expect to last less than three

months)

Yes / No

21 http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-10-57




http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-10-57




Mt.Sh.05 Motility Because of a health or physical problem, do you have any

difficulty climbing one flight of

stairs without resting? (Exclude any difficulties that you expect

to last less than three months)

Yes / No

Ac.Sh.06 Activity How often do you engage in

activities that require a low or moderate level of energy such as

gardening, cleaning the car, or

doing a walk?

Hardly ever, or never /

One to three times a month /

Once a week /

More than once a week.



5.5 FRAIL scale

This 5-Items Instrument has been demonstrated as an excellent screening test for clinicians that need to

identify frail persons at risk of developing disability, declining in health functioning and mortality.

The FRAIL scale has been developed with the intent of providing an Instrument that does not requires

face-to-face examination, and could thus result in more efficient identification of the syndrome, that

could be accomplished by telephone or through self-administered forms. These features are aimed at

earlier recognition and treatment by practitioners.

5.5.1 References

The International Academy of Nutrition, Health, and Aging proposed the FRAIL scale in the

following papers: http://www.ncbi.nlm.nih.gov/pubmed/18165842 and


Another study that shows that the Instrument can predict future disability before the person

becomes disabled, is referred by the following Pubmed URL:


5.5.2 Structure


Ex.Fr.01 Exhaustion How much of the time during

the past 4 weeks did you feel tired?

Rarely or none of the time /

Some or little of the time / Moderate amount of the time /

Most of the time

Mt.Fr.02 Motility By yourself and not using aids,

do you have any difficulty walking up 10 steps without

resting?

Yes / No

Mt.Fr.03 Motility By yourself and not using aids, do you have any difficulty

walking several hundred yards?

Yes / No

He.Fr..04 Health Did a doctor ever tell you that

you have [illness]? [where illness is: hypertension,

diabetes, cancer (other than a

minor skin cancer), chronic lung disease, heart attack, congestive

heart failure, angina, asthma,

arthritis, stroke, and kidney

disease

Number < 5

Number >= 5

We.Fr.05 Weight How much do you weigh with

your clothes on but without

shoes? One year ago in (MO,

YR), how much did you weigh without your shoes and with

your clothes on?

Decrease > 5% /

Decrease < 5%






5.6 PRISMA-7

The PRISMA-7 is a seven-Item, self-completion questionnaire Instrument.

It is intended to be used as a postal questionnaire, or for people who are too unwell to undertake the 4

metre walking speed test.

One point is scored for each of its seven questions and a score of 3 points or more is considered to

identify frailty.

As other similar endeavours, it has been conceived as a cost-effective tool to assess large number of

people, with good sensitivity and specificity. It aims to preview moderate to severe disabilities and may

be less efficient in detecting milder ones. In fact, it is used more as a case finding Instrument (current

state: prevalent cases) rather than a screening one (predicting incident cases).

5.6.1 References

A paper that illustrates how PRISMA-7 was conceived and validated is referred by the


A paper that compares PRISMA-7 properties with those of four other Instruments is referred

by the following Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/23108163

5.6.2 Structure


De.Pr.01 Demographics Are you more than 85 years? Yes / No

De.Pr.02 Demographics Are you male? Yes / No

He.Pr.03 Health In general, do you have any health problems that require you

to limit your activities?

Yes / No

Dp.Pr.04 Dependence Do you need someone to help you on a regular basis?

Yes / No

He.Pr.05 Health In general, do you have any

health problems that require you

to stay at home?

Yes / No

Dp.Pr.06 Dependence In case of need, can you count

on someone close to you? Yes / No

Mt.Pr.07 Motility Do you regularly use a stick,

walker or wheelchair to get about?

Yes / No





5.7 Edmonton Frail Scale

5.7.1 Overview

The Edmonton Frail Scale (EFS) is intended as a simple valid measure of frailty, covering multiple

important Categories, with scores ranging from 0 (not frail) to 17 (very frail).

The EFS does not depend on formal medical training to administer, requires less than 5 minutes of the patient’s time, and it has been shown to be a valid measure of frailty compared with the clinical

impression of geriatric specialists after their more comprehensive assessment.

5.7.2 References

The paper that defines and validates the EFS Instrument is referred by the following Pubmed

URL http://www.ncbi.nlm.nih.gov/pubmed/16757522

A study that further validates EFS demonstrating that it is associated with increasing

comorbidity, hospital lengths of stay, lower use of invasive procedures, and increased

mortality in a known high-risk population (elderly patients with ACS) is referred by Pubmed

URL http://www.ncbi.nlm.nih.gov/pubmed/24183299

5.7.3 Structure


Vi.Ed.01 Visuospatial Clock diagram: Place the numbers in the correct positions

then place the hands to indicate

a time of “10 after 11”

No errors /

Minor spacing errors /

Other errors.

He.Ed.02 Health Hospital admissions in past year 0 /

1-2. /

>=2.

He.Ed.03 Health General health description Excellent, very good, or good /

Fair /

Poor.

Ia.Ed.04 IADLs Requires assistance with

activities such as meal

preparation, shopping, transportation, dialling

telephone, housekeeping,

laundry, managing money,

taking medications

0-1 /

2-4 /

5-8.

Dp.Ed.05 Dependence Availability of individuals who

are willing and able to support

patient needs

Always /

Sometimes /

Never.

He.Ed.06 Health Five or more different

prescription medications on a regular basis

Yes / No

Me.Ed.07 Medication Forgetfulness about taking

prescription medications Yes / No

We.Ed.08 Weight Weight loss Yes / No

Mo.Ed.09 Mood Reported feelings of sadness or

depression Yes / No

He.Ed.10 Health Unexpected urinary

incontinence Yes / No






Mt.Ed.11 Motility Patient begins by sitting in a chair with back and arms

resting, then stands up and

walks approximately 3 m, and returns to the chair and sits

down

0-10s /

11s-20s /

>= 20s



5.8 Tilburg Frailty Indicator

5.8.1 Overview

As most frailty assessments Instruments are dominated by biomedical indicators, the Tilburg Frailty

Indicator (TFI) was developed in order to extend this view, and to consider frailty from a live course perspective, expressing relationships between life-course determinants, diseases, frailty and adverse

outcomes.

Based on this model, TFI addresses the measurement of frailty in community-dwelling older persons,

along three domains: physical, psychological and social.

TFI has been shown to have good predictive validity for quality of life and adverse outcomes such as

disability and receiving personal care, nursing, and informal care.

5.8.2 References

The TFI Instrument can be found on the website of the Tilburg University, at the URL

https://www.tilburguniversity.edu/upload/ac3c1079-6188-4bea-b4af-

8f552c07a1d2_tfieng.pdf

A study that assesses the reliability and validity of the TFI Instrument is referred by the


5.8.3 Structure


He.Ti.01 Health Do you feel physically healthy? Yes / No

We.Ti.02 Weight Have you lost a lot of weight

recently without wishing to do so? (‘a lot’ is: 6 kg or more

during the last six months, or 3

kg or more during the last month)

Yes / No

Mt.Ti.03 Motility Do you experience problems in

your daily life due to difficulty

in walking?

Yes / No

Mt.Ti.04 Motility Do you experience problems in

your daily life due to difficulty

maintaining your balance?

Yes / No

He.Ti.05 Health Do you experience problems in your daily life due to poor

hearing?

Yes / No

He.Ti.06 Health Do you experience problems in your daily life due to poor

vision?

Yes / No

Wk.Ti.07 Weakness Do you experience problems in

your daily life due to lack of strength in your hands?

Yes / No

Ex.Ti.08 Exhaustion Do you experience problems in

your daily life due to physical

tiredness?

Yes / No

Mr.Ti.09 Memory Do you have problems with

your memory? Yes / Sometimes / No

Mo.Ti.10 Mood Have you felt down during the

last month? Yes / Sometimes / No

https://www.tilburguniversity.edu/upload/ac3c1079-6188-4bea-b4af-8f552c07a1d2_tfieng.pdf

https://www.tilburguniversity.edu/upload/ac3c1079-6188-4bea-b4af-8f552c07a1d2_tfieng.pdf





Mo.Ti.11 Mood Have you felt nervous or anxious during the last month?

Yes / Sometimes / No

Mo.Ti.12 Mood Are you able to cope with

problems well? Yes / No

Dp.Ti.13 Dependence Do you live alone? Yes / No

Dp.Ti.14 Dependence Do you sometimes miss having

people around you? Yes / Sometimes / No

Dp.Ti.15 Dependence Do you receive enough support

from other people? Yes / No



5.9 Comprehensive Frailty Assessment Instrument

5.9.1 Overview

The Comprehensive Frailty Assessment Instrument (CFAI) aims to broaden the body of knowledge

regarding the concept of frailty by introducing a multidimensional, self-administrated instrument

capturing 4 domains of frailty: physical, psychological, social and environmental.

In particular, CFAI was the first Instrument to include the environmental Category in the assessment of

frailty. It was developed on the basis of the TFI Instrument, that already added psychological and social

measurement to the traditional physical measurement.

The relationship of an aging individual with her/his spatial context is assumed to be essential and to

contribute to an aging individual’s quality of life. For instance, as authors report, evidence suggests that the proximity of amenities and services may promote health either directly or indirectly through the

possibilities they provide for people to live healthy lives.

5.9.2 References

The paper that describes the development and initial assessment of the CFAI Instrument is

referred by the following Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/23608069

A study that assesses the validity of the CFAI Instrument in comparison with the TFI

instrument is referred by the following URL:

http://www.europeangeriaticmedicine.com/article/S1878-7649(13)00045-4/abstract

5.9.3 Structure


Ac.Cf.01 Activity Indicate how long you have

been hampered by your health status in performing less

demanding activities like

carrying shopping bags

Not at all \

3 months or less \

More than 3 months

Mt.Cf.02 Motility Indicate how long you have

been hampered by your health

status in walking up a hill/stairs

Not at all \

3 months or less \

More than 3 months


been hampered by your health status in bending or lifting

Not at all \

3 months or less \

More than 3 months


been hampered by your health

status in going for a walk

Not at all \

3 months or less \

More than 3 months

Mo.Cf.05 Mood To what extent do you agree

with the statement “Feeling unhappy”

Completely disagree /

Disagree /

Neither agree nor disagree /

Agree /

Completely agree.

Mo.Cf.06 Mood To what extent do you agree with the statement “Losing self-

confidence”


Disagree /


Agree /

Completely agree.


http://www.europeangeriaticmedicine.com/article/S1878-7649(13)00045-4/abstract




Mo.Cf.07 Mood To what extent do you agree with the statement “Unable to

cope with problems”


Disagree /


Agree /

Completely agree.


with the statement “Feeling

pressure”


Disagree /


Agree /

Completely agree.

Mo.Cf.09 Mood To what extent do you agree with the statement “Feeling

worth nothing anymore”


Disagree /


Agree /

Completely agree.


with the statement “I experience

a general sense of emptiness”


Disagree /


Agree /

Completely agree.


with the statement “I miss having people around me”


Disagree /


Agree /

Completely agree.

Mo.Cf.12 Mood To what extent do you agree with the statement “I often feel

rejected”


Disagree /


Agree /

Completely agree.

Dp.Cf.13 Dependence There are plenty of people I can

lean on when I have problems Yes / No

Dp.Cf.14 Dependence There are many people I can trust completely

Yes / No

Dp.Cf.15 Dependence There are enough people I feel

close to Yes / No

Dp.Cf.16 Dependence How many persons can you rely on among partner, son and

daughter-in-law? (Social support

network 1)

Number of persons

Dp.Cf.17 Dependence How many persons can you rely on among daughter, son-in-law

and grandchildren? (Social

support network 2)

Number of persons




Dp.Cf.18 Dependence How many persons can you rely on among brother or sister (-in-

law), family, neighbours and

friends? (Social support network 3)

Number of persons

En.Cf.19 Environment My house is in a bad condition Yes / No

En.Cf.20 Environment My house is not comfortable Yes / No

En.Cf.21 Environment It is difficult to heath my house Yes / No

En.Cf.22 Environment There is insufficient comfort in

my house Yes / No

En.Cf.23 Environment I do not like the neighbourhood Yes / No



5.10 Groningen Frailty Indicator

5.10.1 Overview

The Groningen Frailty Indicator (GFI) has been developed to identify frailty of home-dwelling as well

as institutionalized elderly people. It comprises both a professional and a self-assessed version.

The GFI is widely used in clinical practice (i.e., geriatric centres, nursing homes, emergency departments, traumatology, pulmonology, rheumatology, and surgical medicine), in outpatient settings,

and in clinical studies.

To obtain the self-reported version (presented here), the professional version of the GFI was modified

from a patient-orientated questionnaire (with Items such as “Has the patient recently felt downhearted

or sad?”) to an individual-oriented questionnaire (with Items such as “Have you recently felt

downhearted or sad?”) and, as a consequence, the formulations of all Items were adapted.

5.10.2 Reference

The paper that illustrates the development and initial test of the GFI Instrument can be found

at the University of Groningen website: http://www.rug.nl/research/portal/publications/measuring-frailty(f91ecfcc-18e0-481f-84a7-

1230d62e032c).html

A couple of studies that address the predictive validity of GFI (and conclude that, for the

self-reported version, more work is needed) can be found at the following Pubmed URLs:

http://www.ncbi.nlm.nih.gov/pubmed/20353611 and http://www.ncbi.nlm.nih.gov/pubmed/22579590

5.10.3 Structure


Sh.Gr.01 Shopping Are you able to carry out

shopping single-handedly and

without any help?

Yes / No

Mt.Gr.02 Motility Are you able to carry out

walking around outside (around

the house or to the neighbours)

single-handedly and without any help?

Yes / No

Ad.Gr.03 ADLs Are you able to carry out

dressing and undressing single-handedly and without any help?

Yes / No

Ad.Gr.04 ADLs Are you able to carry out going

to the toilet single-handedly and

without any help?

Yes / No

He.Gr.05 Health What mark do you give yourself

for physical fitness? Yes / No

He.Gr.06 Health Do you experience problems in

daily life due to poor vision? Yes / No

He.Gr.07 Health Do you experience problems in

daily life due to being hard of

hearing?

Yes / No

We.Gr.08 Weight During the last 6 months have you lost a lot of weight

unwillingly? (3 kg in 1 month or

6 kg in 2 months)

Yes / No

http://www.rug.nl/research/portal/publications/measuring-frailty(f91ecfcc-18e0-481f-84a7-1230d62e032c).html

http://www.rug.nl/research/portal/publications/measuring-frailty(f91ecfcc-18e0-481f-84a7-1230d62e032c).html






He.Gr.09 Health Do you take 4 or more different types of medicine?

Yes / No

Mr.Gr.10 Memory Do you have any complaints

about your memory? Yes / No

Mo.Gr.11 Mood Do you sometimes experience emptiness around yourself?

Yes / No

Mo.Gr.12 Mood Do you sometimes miss people

around yourself? Yes / No

Mo.Gr.13 Mood Do you sometimes feel

abandoned? Yes / No

Mo.Gr.14 Mood Have you recently felt

downhearted or sad? Yes / No

Mo.Gr.15 Mood Have you recently felt nervous

or anxious? Yes / No



5.11 The Sherbrooke Postal Questionnaire

5.11.1 Overview

The Sherbrooke Postal Questionnaire is a simple six-Items Instruments, suitable for postal

administration, that has been developed in order to enact effective programmes of assessment and surveillance in a context of secondary prevention. The Items’ Categories cover the physical (four

Items), social support (one Item), and cognitive (one Item) domains of functioning.

The authors found it valid for screening elderly individuals at risk for functional decline, although

another study, comparing it with the GFI and TFI Instruments, suggests that further research is needed.

5.11.2 References

The paper that illustrates the development of the SPQ Instruments, also assessing its

predictive validity, can be found at the following Pubmed URL:


The SPQ Instrument has been compared to the GFI and TFI instruments in the study referred

by the following Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/20353611

5.11.3 Structure


Dp.Sb.01 Dependence Do you live alone? Yes / No

He.Sb.02 Health Do you take more than three

different medications every day? Yes / No

Mt.Sb.03 Motility Do you regularly use a cane, a walker or a wheelchair to move

about?

Yes / No

He.Sb.04 Health Do you see well? Yes / No

He.Sb.05 Health Do you hear well? Yes / No

Mr.Sb.06 Memory Do you have problems with your memory?

Yes / No





5.12 Frailty Index

5.12.1 Overview

The Frailty Index is presented here as an example of the Cumulative Deficit model.

We present the version discussed by Mitnitski et al. in the paper referred to in the Reference subsection

below.

It is composed by 40 Items that represents corresponding relevant health deficits (e.g. symptoms, health attitudes, illnesses, and impaired function), the accumulation of which is assumed to represent

the frailty of the subject.

5.12.2 References

The development of the Instrument here presented is illustrated in the paper referred by the

following Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/15215283; the paper also offer predictive validation of the Instrument, by demonstrating the association between it

and mortality

5.12.3 Structure


He.Fx.01 Health Eyesight 5 levels Likert scale

He.Fx.02 Health Hearing 5 levels Likert scale

Ad.Fx.03 ADLs Help to eat 3 levels Likert scale

Ad.Fx.04 ADLs Help to dress and undress 3 levels Likert scale

Ad.Fx.05 ADLs Ability to take care of

appearance 3 levels Likert scale

Mt.Fx.06 Motility Help to walk 3 levels Likert scale

Mt.Fx.07 Motility Help to get in and out of bed 3 levels Likert scale

Ad.Fx.08 ADLs Help to take a bath or shower 3 levels Likert scale

Ad.Fx.09 ADLs Help to go to the bathroom 3 levels Likert scale

Co.Fx.10 Communication Help to use the telephone 3 levels Likert scale

Tr.Fx..11 Transportation Help to get to place out of walking distance

3 levels Likert scale

Sh.Fx.12 Shopping Help in shopping 3 levels Likert scale

Fo.Fx.13 Food Help to prepare own meals 3 levels Likert scale

Ho.Fx.14 Housekeeping Help to do housework 3 levels Likert scale

Me.Fx.15 Medication Ability to take medicine 3 levels Likert scale

Fi.Fx.16 Finances Ability to handle own money 3 levels Likert scale

He.Fx.17 Health Self-rating of health 5 levels Likert scale

He.Fx.18 Health Troubles prevent normal

activities 3 levels Likert scale

Dp.Fx.19 Dependence Living alone Yes / No

He.Fx.20 Health Having a cough Yes / No

Ex.Fx.21 Exhaustion Feeling tired Yes / No

He.Fx.22 Health Nose stuffed up or sneezing Yes / No

He.Fx.23 Health High blood pressure Yes / No





He.Fx.24 Health Heart and circulation problems Yes / No

He.Fx.25 Health Stroke or effects of stroke Yes / No

He.Fx.26 Health Arthritis or rheumatism Yes / No

He.Fx.27 Health Parkinson’s disease Yes / No

He.Fx.28 Health Eye trouble Yes / No

He.Fx.29 Health Ear trouble Yes / No

He.Fx.30 Health Dental problems Yes / No

He.Fx.31 Health Chest problems Yes / No

He.Fx.32 Health Trouble with stomach Yes / No

He.Fx.33 Health Kidney trouble Yes / No

He.Fx.34 Health Losing control of bladder Yes / No

He.Fx.35 Health Losing control of bowels Yes / No

He.Fx.36 Health Diabetes Yes / No

He.Fx.37 Health Trouble with feet or ankles Yes / No

He.Fx.38 Health Trouble with nerves Yes / No

He.Fx.39 Health Skin problems Yes / No

He.Fx.40 Health Fractures Yes / No



6 Conclusions

The purpose of this deliverable is to support (jointly with deliverable D2.2 MCI/Frailty related

behaviours models) the work to be conducted in technical work-packages WP3-WP6, so that it is based

on a sound scientific basis, grounded on current geriatrics knowledge and practice.

To this end, the previous sections presented:

The case for unobtrusive behavioural sensing, as a way to improve the current procedures

used to assess the risks of frailty and MCI onset, and of progression toward worsening conditions

The general structure of relevant health measurement Instruments, that should form the basis

of the City4Age risk detection subsystem

A first proposal toward the definition of a City4Age risk model, consisting of two lists of

Instruments – respectively, for MCI and for frailty – that are characterized by useful

properties: o They have been assessed as valid and reliable by geriatrics research

o They have the ability to detect and/or predict the onset of the condition

o Their Items (or at least part of them) can be transposed into behavioural terms, in order to be measured by the City4Age behavioural sensing system

This material is expected to be used in the next phases of the project as follows:

Instruments’ structure shall be matched against the needs of each Project testbed, in order to

generate initial hypothesis about which Instruments and Items best address those needs and

can consequently be used as the basis for risk detection at the testbed site (for MCI, for

frailty or for both, according to specific pilot scenarios)

Technical feasibility of measuring relevant Items with the sensors and technologies to be

developed within WP3 shall be assessed (this implies harmonization with findings reported in deliverable D3.1 Requirements and specification of the personal data capturing system)

Relevant features linked to the Items shall be extracted from the measures obtained by the

data collection subsystem, in order to be used as input for the behaviour reconstruction and

analysis algorithms to be developed within WP4 and WP5. This includes the design of the alert generation mechanism and of dashboard UIs, as illustrated in section 2 above.

As an example of application of this process, we mention the work of Akl et al.22

where the authors – having selected gait speed as an Instrument able to predict MCI onset

23 (see also subsection 4.9) –

designed an appropriate motion sensor layout (sensors placed on the ceiling of an apartment, approximately 61 cm apart in areas such as a hallway or a corridor, with restricted field view of ±4°) in

order to measure walking speed. From this measure relevant features were then extracted, and used to

build classifiers able to detect MCI risks (two classifiers were tested, based respectively on Support

Vector Machines and Random Forests).

The overall appreciation of the Instruments listed in sections 4 and 5 above, and its comparison with

testbed needs, allows to derive interesting insights, as for instance:

Instrumental Activity of Daily Living are a very interesting concept, that forms the basis of

several Instruments. In MCI detection it has been shown to have a predicting power similar

to that of more sensitive psychometrics tests such as STMS. IADLs are also present in some

frailty indicators.

Since the IADL concept is directly related to behavioural properties, it seems particularly

suitable for application in City4Age. For instance, IADLs in the Transportation Category

may be of special interest to the Madrid testbed, that addresses bus transportation.

22 Akl et al., Autonomous unobtrusive detection of mild cognitive impairment in older adults, IEEE transactions

on bio-medical engineering, 2015

23 Buracchio at al., The trajectory of gait speed preceding mild cognitive impairment, Archives of neurology,

2010



Some of the IADLs Instruments are admittedly not easy to monitor from a technical point of

view (e.g. understanding if a person goes to shopping trips autonomously or accompanied by

someone). However, more conservative hypothesis can be investigated: for instance, the Lawton, NEADL and OARS Instruments all agree that stopping to go out for shopping is in

any case a negative change of behaviour. Thus, for instance, a feature simply based on the

activation of relevant beacons in shops of a given neighbourhood may still be a significant

indicator. A similar method can be applied in other cases, as for instance measuring trips to the bank for the Finance Category. This kind of Items can be useful, for instance, in the

Lecce testbed, that addresses needs of elderlies living in a neighbourhood.

Gait speed seems to be another important Item that enters several frailty as well as MCI

Instruments. Acceleration and location detection features that can be extracted from smartphone sensors make this Item particularly interesting

Although in several cases Instruments’ authors advise against using Items separately, most

Instruments’ models do in fact sum single Items’ scores up, in order to compute the overall

Instrument score. In other words, in these cases each Item contributes individually and independently to the final assessment. That means that, with due attention, a sort of

“mix-and-match” approach to Item selection, at feature extraction stage, is worth

experimenting.

In connection with the point above, and regarding frailty, it is also worth noting that many

Instruments, when summing up contributions from single Items, establish two different cut-off points: (a) a point beyond which the person is considered to have frailty, and (b) a

lower point, at which the person is considered to be in a ‘pre-frail’ state. This ‘pre-frail’ state

is considered by many authors an important precursor of the ‘frail’ state, particularly suited for enacting early interventions that still have a good chance to avoid the transition to full

frailty

6.1.1 Next versions

As above mentioned, the Instruments presented in this version of the deliverable are to be considered a

first try at creating a City4Age risk modelling.

After the Project’s testbeds experimental runs, based on features generated through these models, new

information will be available to revise the Instruments’ list and make it more specific to City4Age

objectives, by adding for instance:

An assessment of the Indicators’ and Items’ predictive value when specifically used as a

basis for unobtrusive sensing

Guidelines and recommendations for Instruments and Items’ application to specific usage

scenarios, including considerations about feasibility and cost

In addition, the next versions of the deliverable will also add additional content that explores other

directions of risk modelling:

Relationship with the findings of the European Innovation Partnership on Active and

Healthy Ageing, Action Group A3 on “Prevention of functional decline and frailty”, in

particular comparing the City4Age risk modelling approach with Action Group’s A3 best

practices.

Relationship with the European Innovation Partnership on Smart Cities and Communities,

in particular to assess the latest development in smart cities and their “data generating”

potential, in order to identify possible new ways to address Instruments and Items from the

City4Age risk model

Guidelines and recommendations directed to Social Services, aimed at proposing different

modes for deploying appropriate risk detection approaches, based on the needs and the

characteristics of a given urban context.



7 Annex: list of Items ordered per category

The following table lists all 226 Items currently included in the City4Age risk modelling, ordered per

Category.

A version of this table in spreadsheet format is also made available to Partners, in order to make it

easier to rearrange it along other dimensions, or to slice and dice it in other ways.

Condition ID Category Item

MCI Ab.Mo.12 Abstraction The examiner asks the subject to explain what each pair of words has in common, starting with the

example: “Tell me how an orange and a banana are alike”. If the subject answers in a concrete manner,

then say only one additional time: “Tell me another

way in which those items are alike”. If the subject

does not give the appropriate response (fruit), say, “Yes, and they are also both fruit.” Do not give any

additional instructions or clarification. After the

practice trial, say: “Now, tell me how a train and a bicycle are alike”. Following the response,

administer the second trial, saying: “Now tell me

how a ruler and a watch are alike” Do not give any

additional instructions or prompts.

MCI Ab.Sm.06 Abstraction The examiner proposes three pair of words and asks the person to state the abstract interpretation: orange/banana, dog/horse, table/bookcase (e.g.

dog/horse = animal)

Frailty Ac.Cf.01 Activity Indicate how long you have been hampered by your health status in performing less demanding

activities like carrying shopping bags

Frailty Ac.Fi.05 Activity Physical expenditure on activity scale per week on 18 items (Walking for exercise, moderately

strenuous household chores, mowing or raking the lawn, gardening, hiking, jogging, biking, exercise

cycle, dancing, aerobics, bowling, golf, singles or

doubles tennis, racquetball, calisthenics, swimming.

To compute kcals expended per week, use the formula: kcal/week = [activity-specific MET

(kcal/kg × hour) ] × [duration per session (min) / 60

min] × [body weight (kg)] × [number of sessions in the last 2 wk / 2] × [number of months per year

activity was done])

MCI Ac.Ne.21 Activity Did you manage your own garden?

Frailty Ac.Sh.06 Activity How often do you engage in activities that require a low or moderate level of energy such as gardening,

cleaning the car, or doing a walk?

MCI Ad.Da.13 ADLs The person is taken to a bathroom and asked to take the cap off a tube of toothpaste, put toothpaste on a toothbrush, turn on the tap, brush teeth, dampen

washcloth, put soap on washcloth, wash the face

and turn off the tap




MCI Ad.Da.14 ADLs The person is invited to use a hairbrush, put on a coat, button a coat (three buttons), fasten a zip and

tie shoelaces

MCI Ad.Da.15 ADLs The person, sitting at a table, shows how she/he would cut a steak, take a bite of it, eat soup and

pour water into a glass and drink it

Frailty Ad.Fx.03 ADLs Help to eat

Frailty Ad.Fx.04 ADLs Help to dress and undress

Frailty Ad.Fx.05 ADLs Ability to take care of appearance

Frailty Ad.Fx.08 ADLs Help to take a bath or shower

Frailty Ad.Fx.09 ADLs Help to go to the bathroom

Frailty Ad.Gr.03 ADLs Are you able to carry out dressing and undressing

single-handedly and without any help?

Frailty Ad.Gr.04 ADLs Are you able to carry out going to the toilet single-

handedly and without any help?

MCI At.Mm.04 Attention The examiner asks the person to spell the word WORLD. Now spell it backwards. (in alternative,

the interviewer counting down from one hundred by

sevens)

MCI At.Mo.06 Attention The examiner gives the following instruction: “I am going to say some numbers and when I am through,

repeat them to me exactly as I said them”. Then

she/he reads the five number sequence at a rate of

one digit per second: 2-1-8-5-4.

MCI At.Mo.07 Attention The examiner gives the following instruction: “Now I am going to say some more numbers, but when I am through you must repeat them to me in

the backwards order.” Read the three number

sequence at a rate of one digit per second: 7-4-2

MCI At.Mo.08 Attention The examiner reads a list of letters (F B A C M N A A J K L B A F A K D E A A A J A M O F A A B)

at a rate of one per second, after giving the following instruction: “I am going to read a

sequence of letters. Every time I say the letter A,

tap your hand once. If I say a different letter, do not

tap your hand”.

MCI At.Mo.09 Attention The examiner gives the following instruction: “Now, I will ask you to count by subtracting seven from 100, and then, keep subtracting seven from

your answer until I tell you to stop.”

MCI At.Sm.03 Attention The following digit spans of increasing length are presented in sequence to the person, asking for

repetition: 2-9-6-8-3, 5-7-1-9-4-6, 2-1-5-9-3-6-2.

MCI At.Sm.05 Attention The examiner proposes 4 arithmetic operations to

be computed: 5x13, 65-7, 58/2, 29+11




MCI Co.Da.03 Communication The person is invited to dial the operator, dial from a list of telephone numbers, dial from oral

presentation and dial from written presentation.

MCI Co.Da.04 Communication The person is observed on picking up the receiver, dialling, hanging up and operating the telephone in

the correct sequence.

MCI Co.Da.05 Communication The person is invited to fold a letter in half, put it in an envelope, seal the envelope, put on a stamp,

address it (from a presented stimulus card) and add

a return address (the person’s own current address,

without a postal code).

Frailty Co.Fx.10 Communication Help to use the telephone

MCI Co.Li.01 Communication Ability to Use Telephone

MCI Co.Ne.18 Communication Did you use the telephone?

MCI Co.Oa.01 Communication Can you use the telephone?

MCI Cu.Ne.17 Culture Did you read newspapers or books?

MCI Cu.Ne.19 Culture Did you write letters?

Frailty De.Pr.01 Demographics Are you more than 85 years?

Frailty De.Pr.02 Demographics Are you male?

Frailty Dp.Cf.13 Dependence There are plenty of people I can lean on when I

have problems

Frailty Dp.Cf.14 Dependence There are many people I can trust completely

Frailty Dp.Cf.15 Dependence There are enough people I feel close to

Frailty Dp.Cf.16 Dependence How many persons can you rely on among partner, son and daughter-in-law? (Social support network

1)

Frailty Dp.Cf.17 Dependence How many persons can you rely on among daughter, son-in-law and grandchildren? (Social

support network 2)

Frailty Dp.Cf.18 Dependence How many persons can you rely on among brother or sister (-in-law), family, neighbours and friends?

(Social support network 3)

Frailty Dp.Ed.05 Dependence Availability of individuals who are willing and able

to support patient needs

Frailty Dp.Fx.19 Dependence Living alone

Frailty Dp.Pr.04 Dependence Do you need someone to help you on a regular

basis?

Frailty Dp.Pr.06 Dependence In case of need, can you count on someone close to

you?

Frailty Dp.Sb.01 Dependence Do you live alone?

Frailty Dp.Ti.13 Dependence Do you live alone?

Frailty Dp.Ti.14 Dependence Do you sometimes miss having people around you?

Frailty Dp.Ti.15 Dependence Do you receive enough support from other people?

Frailty En.Cf.19 Environment My house is in a bad condition




Frailty En.Cf.20 Environment My house is not comfortable

Frailty En.Cf.21 Environment It is difficult to heath my house

Frailty En.Cf.22 Environment There is insufficient comfort in my house

Frailty En.Cf.23 Environment I do not like the neighbourhood

Frailty Ex.Fi.02 Exhaustion The person felt that everything she/he did was an

effort in last week

Frailty Ex.Fi.03 Exhaustion The person felt that she/he could not get going in

last week

Frailty Ex.Fr.01 Exhaustion How much of the time during the past 4 weeks did

you feel tired?

Frailty Ex.Fx.21 Exhaustion Feeling tired

Frailty Ex.Sh.01 Exhaustion In the last month, have you had too little energy to

do the things you wanted to do?

Frailty Ex.So.03 Exhaustion Do you feel full of energy?

Frailty Ex.Ti.08 Exhaustion Do you experience problems in your daily life due

to physical tiredness?

MCI Fi.Da.06 Finance The person is invited to identify four different coins

and three notes

MCI Fi.Da.07 Finance The person is invited to count four amounts of

money

MCI Fi.Da.11 Finance Given a note to pay for the items, the person is

invited to make change

Frailty Fi.Fx.16 Finances Ability to handle own money

MCI Fi.Li.08 Finances Ability to Handle Finances

MCI Fi.Ne.12 Finances Did you manage your own money when out?

MCI Fi.Oa.07 Finances Can you handle your own money?

Frailty Fo.Fx.13 Food Help to prepare own meals

MCI Fo.Li.03 Food Food Preparation

MCI Fo.Ne.07 Food Did you manage to feed yourself?

MCI Fo.Ne.08 Food Did you manage to make yourself a hot drink?

MCI Fo.Ne.09 Food Did you take hot drinks from one room to another?

MCI Fo.Ne.11 Food Did you make yourself a hot snack?

MCI Fo.Oa.04 Food Can you prepare your own meals?

Frailty He.Ed.02 Health Hospital admissions in past year

Frailty He.Ed.03 Health General health description

Frailty He.Ed.06 Health Five or more different prescription medications on a

regular basis

Frailty He.Ed.10 Health Unexpected urinary incontinence

Frailty He.Fr..04 Health Did a doctor ever tell you that you have [illness]? [where illness is: hypertension, diabetes, cancer

(other than a minor skin cancer), chronic lung disease, heart attack, congestive heart failure,

angina, asthma, arthritis, stroke, and kidney disease




Frailty He.Fx.01 Health Eyesight

Frailty He.Fx.02 Health Hearing

Frailty He.Fx.17 Health Self-rating of health

Frailty He.Fx.18 Health Troubles prevent normal activities

Frailty He.Fx.20 Health Having a cough

Frailty He.Fx.22 Health Nose stuffed up or sneezing

Frailty He.Fx.23 Health High blood pressure

Frailty He.Fx.24 Health Heart and circulation problems

Frailty He.Fx.25 Health Stroke or effects of stroke

Frailty He.Fx.26 Health Arthritis or rheumatism

Frailty He.Fx.27 Health Parkinson’s disease

Frailty He.Fx.28 Health Eye trouble

Frailty He.Fx.29 Health Ear trouble

Frailty He.Fx.30 Health Dental problems

Frailty He.Fx.31 Health Chest problems

Frailty He.Fx.32 Health Trouble with stomach

Frailty He.Fx.33 Health Kidney trouble

Frailty He.Fx.34 Health Losing control of bladder

Frailty He.Fx.35 Health Losing control of bowels

Frailty He.Fx.36 Health Diabetes

Frailty He.Fx.37 Health Trouble with feet or ankles

Frailty He.Fx.38 Health Trouble with nerves

Frailty He.Fx.39 Health Skin problems

Frailty He.Fx.40 Health Fractures

Frailty He.Gr.05 Health What mark do you give yourself for physical

fitness?

Frailty He.Gr.06 Health Do you experience problems in daily life due to

poor vision?

Frailty He.Gr.07 Health Do you experience problems in daily life due to

being hard of hearing?

Frailty He.Gr.09 Health Do you take 4 or more different types of medicine?

Frailty He.Pr.03 Health In general, do you have any health problems that

require you to limit your activities?

Frailty He.Pr.05 Health In general, do you have any health problems that

require you to stay at home?

Frailty He.Sb.02 Health Do you take more than three different medications

every day?

Frailty He.Sb.04 Health Do you see well?

Frailty He.Sb.05 Health Do you hear well?

Frailty He.Ti.01 Health Do you feel physically healthy?




Frailty He.Ti.05 Health Do you experience problems in your daily life due

to poor hearing?

Frailty He.Ti.06 Health Do you experience problems in your daily life due

to poor vision?

Frailty Ho.Fx.14 Housekeeping Help to do housework

MCI Ho.Li.04 Housekeeping Housekeeping

MCI Ho.Ne.10 Housekeeping Did you do the washing up?

MCI Ho.Ne.14 Housekeeping Did you do your own housework?

MCI Ho.Oa.05 Housekeeping Can you do your housework?

Frailty Ia.Ed.04 IADLs Requires assistance with activities such as meal preparation, shopping, transportation, dialling

telephone, housekeeping, laundry, managing

money, taking medications

MCI La.Mm.06 Language The examiner show a wristwatch and asks the

person “What is this called?”. Repeats with a pencil

MCI La.Mm.07 Language The examiner asks the person to repeat this phrase

“No ifs, ands or buts.”

MCI La.Mm.08 Language The examiner asks the person to read the words on a page and then do what it says. Then hand the

person the page with “CLOSE YOUR EYES” on it. If the subject reads and does not close their eyes,

repeat up to three times. Score only if subject closes

eyes

MCI La.Mm.09 Language The examiner hands the person a pencil and paper, then says “Write any complete sentence on that

piece of paper”

MCI La.Mm.11 Language The examiner asks the person if she/he is right or

left‐handed, takes a piece of paper and hold it up in

front of the person. Then says “Take this paper in your right/left hand [note: whichever is

non‐dominant], fold the paper in half once with

both hands and put the paper down on the floor”.

MCI La.Mo.04 Language The examiner points to three animal figures (lion, rhino, camel) in turn and says: “Tell me the name of

this animal”.

MCI La.Mo.10 Language The examiner gives the following instructions: “I am going to read you a sentence. Repeat it after me, exactly as I say it [pause]: I only know that John is

the one to help today.” Following the response, say:

“Now I am going to read you another sentence.

Repeat it after me, exactly as I say it [pause]: The cat always hid under the couch when dogs were in

the room.”




MCI La.Mo.11 Language The examiner gives the following instruction: “Tell me as many words as you can think of that begin with a certain letter of the alphabet that I will tell

you in a moment. You can say any kind of word

you want, except for proper nouns (like Bob or Boston), numbers, or words that begin with the

same sound but have a different suffix, for example,

love, lover, loving. I will tell you to stop after one minute. Are you ready? [Pause] Now, tell me as

many words as you can think of that begin with the

letter F. [time for 60 sec]. Stop.”

MCI La.Sm.09 Language The examiner asks the person to provide three information element: “first president”, “define an

island”, “number of weeks per year”

MCI Ln.Li.05 Laundry Laundry

MCI Ln.Ne.13 Laundry Did you wash small items of clothing?

MCI Ln.Ne.16 Laundry Did you do a full clothes wash?

Frailty Me.Ed.07 Medication Forgetfulness about taking prescription medications

Frailty Me.Fx.15 Medication Ability to take medicine

MCI Me.Li.07 Medication Responsibility for Own Medications

MCI Me.Oa.06 Medication Can you take your own medicine?

Frailty Mo.Cf.05 Mood To what extent do you agree with the statement

“Feeling unhappy”


“Losing self-confidence”


“Unable to cope with problems”


“Feeling pressure”


“Feeling worth nothing anymore”

Frailty Mo.Cf.10 Mood To what extent do you agree with the statement “I

experience a general sense of emptiness”


miss having people around me”


often feel rejected”

Frailty Mo.Ed.09 Mood Reported feelings of sadness or depression

Frailty Mo.Gr.11 Mood Do you sometimes experience emptiness around

yourself?

Frailty Mo.Gr.12 Mood Do you sometimes miss people around yourself?

Frailty Mo.Gr.13 Mood Do you sometimes feel abandoned?

Frailty Mo.Gr.14 Mood Have you recently felt downhearted or sad?

Frailty Mo.Gr.15 Mood Have you recently felt nervous or anxious?

Frailty Mo.Ti.10 Mood Have you felt down during the last month?




Frailty Mo.Ti.11 Mood Have you felt nervous or anxious during the last

month?

Frailty Mo.Ti.12 Mood Are you able to cope with problems well?

Frailty Mr.Gr.10 Memory Do you have any complaints about your memory?

MCI Mr.Mm.03 Memory The examiner says “I am going to name three objects. When I am finished, I want you to repeat them. Remember what they are because I am going

to ask you to name them again in a few minutes.”

The examiner says the following words slowly at

1‐second intervals ‐ ball/ car/ man

MCI Mr.Mm.05 Memory The examiner asks the person what were the three

objects she/he asked to remember?

MCI Mr.Mo.05 Memory The examiner reads a list of 5 words (face, velvet, church, daisy, red) at a rate of one per second, giving the following instructions: “This is a

memory test. I am going to read a list of words that

you will have to remember now and later on. Listen

carefully. When I am through, tell me as many words as you can remember. It doesn’t matter in

what order you say them”. When the subject

indicates that she/he has finished (has recalled all words), or can recall no more words, the examiner

reads the list a second time with the following

instructions: “I am going to read the same list for a

second time. Try to remember and tell me as many words as you can, including words you said the first

time.”. At the end of the second trial, the examiner

informs the person that she/he will be asked to

recall these words again”

MCI Mr.Mo.13 Memory The examiner gives the following instruction: “I

read some words to you earlier, which I asked you to remember. Tell me as many of those words as

you can remember.”

Frailty Mr.Sb.06 Memory Do you have problems with your memory?

MCI Mr.Sm.04 Memory The examiner tells four unrelated words: “apple”,

“Mr. Johnson”, “charity”, “tunnel”. The person is

requested to repeat all words.

MCI Mr.Sm.10 Memory The examiner asks the person to recall the words

from Mr.Sm.04

Frailty Mr.Ti.09 Memory Do you have problems with your memory?

Frailty Mt.Cf.02 Motility Indicate how long you have been hampered by your

health status in walking up a hill/stairs


health status in bending or lifting


health status in going for a walk




Frailty Mt.Ed.11 Motility Patient begins by sitting in a chair with back and arms resting, then stands up and walks approximately 3 m, and returns to the chair and sits

down

Frailty Mt.Fi.04 Motility Time to walk 15 feet (4.57 meters)

Frailty Mt.Fr.02 Motility By yourself and not using aids, do you have any

difficulty walking up 10 steps without resting?

Frailty Mt.Fr.03 Motility By yourself and not using aids, do you have any

difficulty walking several hundred yards?

Frailty Mt.Fx.06 Motility Help to walk

Frailty Mt.Fx.07 Motility Help to get in and out of bed

MCI Mt.Gm.01 Motility Time in seconds to walk from a starting point to a marker 15 feet away, turn, and back at a normal

casual gait for a total of 30 feet (9.14 meters).

Frailty Mt.Gr.02 Motility Are you able to carry out walking around outside (around the house or to the neighbours) single-

handedly and without any help?

MCI Mt.Ne.01 Motility Did you walk around outside?

MCI Mt.Ne.02 Motility Did you climb stairs?

MCI Mt.Ne.03 Motility Did you get in and out of a car?

MCI Mt.Ne.04 Motility Did you walk over uneven ground?

MCI Mt.Ne.05 Motility Did you cross roads?

Frailty Mt.Pr.07 Motility Do you regularly use a stick, walker or wheelchair

to get about?

Frailty Mt.Sb.03 Motility Do you regularly use a cane, a walker or a

wheelchair to move about?

Frailty Mt.Sh.04 Motility Because of a health or physical problem, do you have any difficulty walking 100 metres? (Exclude

any difficulties that you expect to last less than

three months)

Frailty Mt.Sh.05 Motility Because of a health or physical problem, do you have any difficulty climbing one flight of stairs without resting? (Exclude any difficulties that you

expect to last less than three months)

Frailty Mt.So.02 Motility Subject's inability to rise from a chair 5 times

without using her arms

Frailty Mt.Ti.03 Motility Do you experience problems in your daily life due

to difficulty in walking?

Frailty Mt.Ti.04 Motility Do you experience problems in your daily life due

to difficulty maintaining your balance?

MCI Sh.Da.08 Shopping Before the preparation of the letter (Co.Da.05), the examiner instructs the person that in 10 min she/he will be going to a grocery store to select six items:

orange juice, spaghetti, cherry jam, tuna fish, rice

and tomatoes. After 1 min to recall as many grocery

items as possible




MCI Sh.Da.09 Shopping The person is taken to a simulated grocery store to

pick out the items from a total of 25

MCI Sh.Da.10 Shopping The examiner then gives the person a written grocery list (milk, crackers, eggs and laundry detergent) and asks them to select the four items

and to hand them to the examiner

Frailty Sh.Fx.12 Shopping Help in shopping

Frailty Sh.Gr.01 Shopping Are you able to carry out shopping single-handedly

and without any help?

MCI Sh.Li.02 Shopping Shopping

MCI Sh.Ne.15 Shopping Did you do your own shopping?

MCI Sh.Oa.03 Shopping Can you go shopping for groceries or clothes?

MCI So.Ne.20 Socialization Did you go out socially?

MCI Sp.Mm.02 Space The person is asked to state the country, province, city/town, address (home: street address, in-facility: building name) and location (home: room name, in-

facility: floor)

MCI Sp.Mo.15 Space Then the examiner says: “Now, tell me the name of

this place, and which city it is in.”

MCI Sp.Sm.01 Space The person is asked to state name, address, current

location (building), city state.

MCI Ti.Da.01 Time The person is shown four different times (0300 h, 0800 h, 1030 h and 1215 h) using a large model of a

clock and is asked to tell the time

MCI Ti.Da.02 Time The person is asked to state the date, the day, the

month and the year.

MCI Ti.Mm.01 Time The person is asked to state the year, season,

month, date and day of the week.

MCI Ti.Mo.14 Time The examiner gives the following instructions: “Tell me the date today”. If the subject does not give a complete answer, then prompt accordingly

by saying: “Tell me the [year, month, exact date,

and day of the week].”

MCI Ti.Sm.02 Time The person is asked to state date (day), month, year.

MCI Tr.Da.12 Transport The examiner asks the person to identify a driver's

correct response to 13 road signals

Frailty Tr.Fx..11 Transportation Help to get to place out of walking distance

MCI Tr.Li.06 Transportation Mode of Transportation

MCI Tr.Ne.06 Transportation Did you travel on public transport?

MCI Tr.Ne.22 Transportation Did you drive a car?

MCI Tr.Oa.02 Transportation Can you get to places out of walking distance?

Frailty Vi.Ed.01 Visuospatial Clock diagram: Place the numbers in the correct positions then place the hands to indicate a time of

“10 after 11”




MCI Vi.Mm.10 Visuospatial The examiner places a drawing (interlocking pentagons, i.e. two five-sided figures intersecting to make a four-sided figure), eraser and pencil in front

of the person and asks “Copy this drawing please.”

(Allow multiple tries; wait until person is finished

and hands it back.)

MCI Vi.Mo.01 Visuospatial The examiner instructs the subject: "Please draw a line, going from a number to a letter in ascending order. Begin here [point to (1)] and draw a line

from 1 then to A then to 2 and so on. End here

[point to (E)].".

MCI Vi.Mo.02 Visuospatial The examiner gives the following instructions, pointing to the cube: “Copy this drawing as

accurately as you can, in the space below”.

MCI Vi.Mo.03 Visuospatial The examiner gives the following instructions: “Draw a clock. Put in all the numbers and set the

time to 10 past 11”.

MCI Vi.Sm.07 Visuospatial The examiner asks the person to draw a clock face

showing 11:15.

MCI Vi.Sm.08 Visuospatial The examiner shows the person the drawing of a

cube and asks to copy it

Frailty We.Ed.08 Weight Weight loss

Frailty We.Fi.01 Weight The person lost >10 pounds unintentionally last

year

Frailty We.Fr.05 Weight How much do you weigh with your clothes on but without shoes? One year ago in (MO, YR), how

much did you weigh without your shoes and with

your clothes on?

Frailty We.Gr.08 Weight During the last 6 months have you lost a lot of weight unwillingly? (3 kg in 1 month or 6 kg in 2

months)

Frailty We.Sh.02 Weight What has your appetite been like?

Frailty We.So.01 Weight Weight loss (irrespective of intent to lose weight) of

5% or more in a 2 year period

Frailty We.Ti.02 Weight Have you lost a lot of weight recently without

wishing to do so? (‘a lot’ is: 6 kg or more during the last six months, or 3 kg or more during the last

month)

Frailty Wk.Fi.06 Weakness Grip strength (average of 3 trials, dominant hand,

measured with Jamar hand dynamometer)

Frailty Wk.Sh.03 Weakness Grip strength (highest among four measures, two

for each hand, taken with a dynamometer)

Frailty Wk.Ti.07 Weakness Do you experience problems in your daily life due

to lack of strength in your hands?

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