Archives of Gerontology and Geriatrics 90 (2020) 104128

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Archives of Gerontology and Geriatrics

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Psychometric analysis of the Arabic (Saudi) Tilburg Frailty Indicator among T

Saudi community-dwelling older adults
Bader A. Alqahtani*, Walid Kamal Abdelbasset, Aqeel M. Alenazi
Department of Health and Rehabilitation Sciences, Prince Sattam Bin Abdulaziz University, Saudi Arabia

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Frailty is a common geriatric syndrome that can be screened using validated questionnaires. A
Frailty commonly used assessment is the Tilburg Frailty Indicator (TFI), containing fifteen self-reported questions about
Saudi components of frailty, with scores ranging from zero to fifteen (higher scores representing increased frailty and a
Arabic Tilburg frailty indicator cutoff score of greater than five used to diagnose frailty). Despite its widespread use, the TFI is not commonly
Elderly
used in Arabic-speaking countries, and there is an overall lack of Arabic-translated questionnaires to adequately
detect and measure frailty for older adults in Saudi Arabia.
Objectives: To translate and cross-culturally adapt the Tilburg Frailty Indicator (TFI) specifically for use with the
Saudi population, and to examine reliability and construct validity among adults in senior-living facilities in
Saudi Arabia.
Methods: A total of 84 community-dwelling older adults were enrolled (mean age = 72 ± 4.7 years). The
translation and cross-cultural adaptation of the TFI from English to Arabic was performed using standardized
guidelines. Test–retest reliability and internal consistency were examined in two visits, spaced one-week apart.
Construct validity of the TFI against other measurements related to frailty was examined. The physical domain
for TFI was validated against the Short Physical Performance Battery (SPPB), the timed Up and Go Test (TUG),
and gait speed (as part of the SPPB). The psychological domains were validated against the Patient Health
Questionnaire, and the social domains were validated against the social domain scores from the WHOQOL-BREF.
Results: The internal consistency of the TFI with the overall KR-20 was 0.70. For the domain scores KR-20 was
0.68 for the physical, 0.57 for the psychological, and 0.42 for the social. The KR-20 after deletion of each item
correlations ranged from 0.66 to 0.72. For the test-retest reliability with one-week interval, the ICC was 0.86 (95
% CI = 0.67–0.94). The Arabic TFI showed statistically significant association with other measurements related
to frailty.
Conclusion: This study found that the translated Arabic (Saudi) TFI is a valid and reliable instrument in assessing
the frailty among Saudi community-dwelling older adults. Our results suggest that the use of this Arabic-
translated TFI for clinical screening of frailty in any primary health setting may aid continued understanding for
the validity of this instrument and help provide a quantitative diagnostic tool for the prevention and treatment of
frailty.

1. Introduction
Within the next decade, the geriatric population in Saudi Arabia is
expected to grow significantly. The United Nations estimated that
roughly five percent of the population in Saudi Arabia will be sixty or
older in 2017; by 2050, these projections are expected to rise up to 22.9
% (United Nations, 2017b). This drastic increase in the number of older
adults poses challenges to the healthcare system due to the high pre-
valence of chronic conditions within this population that require close
monitoring and constant care, such as diabetes, arthritis and
cardiovascular disease. Aging has been associated with the deteriora-
tion of cardiac, sensory, musculoskeletal and cognitive functions
(Gangavati et al., 2011; Lord, 2006; Segev-Jacubovski et al., 2011).
Additionally, older adults are at higher risk of frailty, which has been
linked to functional disability, increased risk of falls, vulnerability to
adverse events, and premature admission to nursing care facilities
(Cawthon et al., 2007; Ensrud et al., 2007; Ferrucci et al., 2004). Due to
the increasing geriatric population and their risk for frailty, it is im-
perative to address the shortcomings of both diagnosis and treatment of
frailty for older adults in Saudi Arabia (United Nations, 2017a).

⁎
Corresponding author at: Prince Sattam Bin Abdulaziz University, Al-Kharj, 11942, Saudi Arabia.
E-mail address: ba.alqahtani@psau.edu.sa (B.A. Alqahtani).

https://doi.org/10.1016/j.archger.2020.104128
Received 3 February 2020; Received in revised form 24 May 2020; Accepted 25 May 2020
Available online 29 May 2020
0167-4943/ © 2020 Elsevier B.V. All rights reserved.
B.A. Alqahtani, et al.
Frailty is perceived as a geriatric clinical syndrome and is defined as
an excessive vulnerability to external stressors (Abellan Van Kan et al.,
2008; Abellan van Kan et al., 2009). Furthermore, a growing number of
studies have indicated frailty as a major health condition for older
adults (Clegg, Young, Iliffe, Rikkert, & Rockwood, 2013; Rockwood
et al., 2004). In a recent systematic review studying the prevalence of
frailty in low and middle-income countries, it was reported that a di-
agnosis of frailty was featured in 4% among of older adults in China, 13
% of older adults in Tanzania, 51 % of older adults in Cuba, and up to
72 % of older adults in Brazil (Siriwardhana, Hardoon, Rait,
Weerasinghe, & Walters, 2018).
Fortunately, frailty is viewed as a dynamic geriatric syndrome,
meaning that the symptoms of frailty may be alleviated through ap-
propriate intervention strategies (Kidd et al., 2019). However, without
proper intervention, older adults are at risk of developing frailty, be-
coming progressively frailer, and having increased susceptibility for
disability (Liu & Fielding, 2011). Therefore addressing frailty through
early detection using reliable instruments is imperative to reducing the
burden of frailty for both older adults and the healthcare system in
Saudi Arabia.
Although extensive work on frailty has been conducted in several
countries around the world, frailty has been understudied for the ger-
iatric population in Saudi Arabia. Numerous instruments have been
established to assess frailty, including the Cardiovascular Health Study
Frailty Screening Measure, the FRAIL scale, the Tilburg Frailty Indicator
(TFI), and the Frailty Scale Study of Osteoporotic Fractures. Despite
these scales being developed and widely used by English-speaking
countries, the only scale validated for use in Arabic for the geriatric
population in Saudi Arabia is the FRAIL scale (Alqahtani & Nasser,
2019). The FRAIL scale, however, overlooks two important aspects of
frailty, namely the psychological and social domains associated with
frailty. An alternative instrument for the assessment of frailty is the
Tilburg Frailty Indicator, which has been shown to be a suitable frailty
instrument for use in primary care settings according to a recent sys-
tematic review (Pialoux, Goyard, & Lesourd, 2012). The TFI has been
validated and translated into different languages, but through a review
of published literature, it appears to have limited use in Arabic. Our
study found only one instance where the TFI was translated and cross-
culturally adapt into Jordanian Arabic (Hayajneh, 2019). However, that
study contained several limitations including validation using only self-
reported, quality-of-life physical domains and not validating their
modified TFI against other metrics of physical capacity. Apart from that
study, there are no other published records for the use of TFI in Arabic,
and the TFI has not been translated, culturally-adapted, and fully-va-
lidated for use in Saudi Arabia. Therefore, this study sought to design
and validate a version of the TFI for use in Saudi Arabia. The aims of
this study were to translate the TFI into Arabic, cross-culturally adapt
the TFI for use specifically for assessing the geriatric population in
Saudi Arabia, examine the test-retest reliability of this modified as-
sessment, and test construct validity among Saudi community-dwelling
older adults in Saudi Arabia.
2. Subjects and methods
This is a cross-sectional research study with study sample of older
adults aged 65 years and older who were visiting the outpatient clinic at
Prince Sattam Bin Abdulaziz University Hospital in Saudi Arabia, were
recruited to take part in this study. The recruitment for this study took
place from April 2019 to November 2019. Subjects were included if
they were 65 years of age or older, and able to walk independently. The
only exclusion criteria was if subjects were unable to communicate to
answer questions. Prior to enrolling in this project, all subjects have
given their written informed consent. An IRB approval was obtained
from the ethical committee at Prince Sattam Bin Abdulaziz University.
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Archives of Gerontology and Geriatrics 90 (2020) 104128
2.1. Sample size
The current sample size of 84 subjects was larger than the suggested
minimum sample size in the literature, which is a minimum of five
subjects per item (Onwuegbuzie & Collins, 2007; Streiner & Norman,
2008).
2.2. Frailty instrument (TFI)
The TFI is made up of 15 self-reported questions. The scale covers
three different domains including eight questions about physical do-
main, four questions on psychological domain, and three items about
social domain. The total score ranged from 0 to 15, with higher score
indicate more frailty. A cutoff score of ≥ 5 was used to diagnose frailty
(Gobbens, van Assen, Luijkx, Wijnen-Sponselee, & Schols, 2010). A full
description of the questions can be found in the original study
(Gobbens, van Assen et al., 2010).
2.3. Translation and cross-cultural adaptation process
The translation and cross-cultural adaptation process was per-
formed base on the Beaton guidelines (Beaton, Bombardier, Guillemin,
& Ferraz, 2000). The process incorporated the following phases: for-
ward translation from English into Arabic, synthesis of the translation,
backward translation from Arabic into English, expert committee con-
sensus, and testing the pre-final version Fig. 1.
First, two bilingual professional Arabic native speakers performed a
forward translation of the TFI from English into Arabic. One translator
was aware of the concepts that was investigated in the TFI, and the
second translator was not a health professional. Two different Arabic
versions were produced. Second, a panel of experts assessed the two
Arabic versions and created a reconciled translated version.
Subsequently, two other bilingual professional translators who had no
knowledge of the original instrument translated the reconciled Arabic
version backwards into the original language. Two independent English
translations were produced. Then, an expert panel (including qualified
language interpreter, geriatric and geriatric physical therapist) re-
viewed the backward translated English version. The consensus be-
tween a panel of experts was made to make sure that the linguistic,
logical and experiential equivalents were achieved. Finally, the pre-
approval version the TFI was assessed on a subsample of older adults
(n = 20) for questionnaire clarity and comprehension. The final version
was approved to be used in this study.
2.4. Psychometric measurements
First, the internal consistency was evaluated by the correlation be-
tween each item on the scale of the Arabic TFI and the total score.
Second, test–retest reliability for Arabic TFI was examined in two dif-
ferent visits with one-week apart (Leppink & Pérez-Fuster, 2017). Third,
convergent and divergent validity of the TFI against other measure-
ments related to frailty. The physical domain of the TFI was validated
against the Short Physical Performance Battery (SPPB), (Guralnik et al.,
1994) the timed Up and Go Test (TUG) (Podsiadlo & Richardson, 1991)
to assess the function of the lower extremity, and gait speed (as part of
the SPPB). In addition, Grip strength which was asses by a digital hand
dynamometer (JAMAR PLUS+®). Subjects performed two trials after
one practice trial, using the dominant hand. The average of the two
trials was included in the analysis. The Psychological domain in the TFI
was validated against the Arabic Patient Health Questionnaire (PHQ-9)
(AlHadi et al., 2017). The Arabic Patient Health Questionnaire (PHQ-9)
is an assessment tool used to examine depression symptoms in primary
health care (AlHadi et al., 2017). The Arabic PHQ-9 shows very good
reliability with Cronbach’s alpha of 0.86 (AlHadi et al., 2017). The
physical domain was validated against The social domain in the TFI was
validated against the social part of the World Health Organization
B.A. Alqahtani, et al.
Fig. 1. Flowchart of the cross-cultural adaptation process.
Quality of Life Brief (WHOQOL-BREF). The social domain in the
WHOQOL-BREF consists of three items asking about social relations,
and has been found to have excellent reliability (Ohaeri & Awadalla,
2009). A trained physical therapy student has collected these mea-
surements.
2.5. Statistical analysis
Data were analyzed using Stata version 15.1 (Stata Corp, College
Station, TX). The Intraclass correlation coefficients (ICC) and 95 %
confidence intervals (95 % CI) were computed to assess the test-retest
reliability. The internal consistency of the TFI was evaluated by ex-
amining the item-total correlations and the Kuder–Richardson formula
(KR-20). In addition, construct validity (convergent and divergent) of
the TFI against the SPPB, TUG test, the Arabic PHQ-9, Grip strength,
and the Arabic WHOQOL-BREF was assessed using the Spearman’s
correlation coefficients. Significance level was set at alpha = 0.05 for
all analysis.
3. Results
A total of 84 community-dwelling Saudi older adults were recruited
to be part in this study. The average age of the study sample was
72 ± 4.7. Seventy-three percent (61/84) of the subjects were male
(Table 1). The TFI was translated and adapted to be used in Saudi older
adults. In the final Arabic version of TFI there was no need to change
any items. Using the TFI, 28 % of the study sample were frail (Fig. 2).
3.1. Reliability
The internal consistency of the TFI with the overall KR-20 was 0.70.
For the domain scores KR-20 was 0.68 for the physical, 0.57 for the
psychological, and 0.42 for the social. The KR-20 after deletion of each
item correlations ranged from 0.66 to 0.72, Table 2. For the test-retest
reliability with one-week interval, the ICC was 0.86 (95 %
3
Archives of Gerontology and Geriatrics 90 (2020) 104128
CI = 0.67–0.94) indicating very good reliability.
3.2. Construct validity (convergent and divergent)
Convergent validity results showed a significant correlation be-
tween all matching tools with the TFI total score and physical domain
only. The Arabic TFI was significantly and negatively associated with
SPPB, gait speed, grip strength, and WHOQOL-BREF. The physical do-
main score showed the highest correlations with WHOQOL-BREF,
SPPB, and TUG, suggesting a good convergent validity. In addition, a
significant positive association was found as expected between the
Arabic TFI and TUG, and the Arabic PHQ-9. The strongest correlation
was observed between the psychological domain and the Arabic PHQ-9
(Spearman = 0.512), and for the social domain was with WHOQOL-
BREF (Spearman = −0.483). Both the psychological and social do-
mains of the TFI were significantly correlated as expected with the
Arabic PHQ-9 and WHOQOL-BREF, respectively, which indicate good
convergent validity. Divergent validity was also demonstrated as the
correlation of domains with matching tools was higher than with tools
associated with other domains. For example, a weak and non-sig-
nificant correlation was noticed between psychological and social do-
mains of the TFI and other unrelated measurements (Table 3).
4. Discussion
The purpose of this study was to translate and cross-culturally adapt
the TFI to the Saudi population, and to assess the questionnaire’s psy-
chometric properties. The TFIs are linked to frailty as a dynamic con-
dition, which includes physical frailty, social frailty, psychologic frailty,
and total frailty (Gobbens, Luijkx, Wijnen-Sponselee, & Schols, 2010).
The user-friendly nature of the TFI, as a questionnaire that can be
completed efficiently in fifteen minutes (or less) and without a direct
interview, is another advantage (Gobbens, Van Assen, Luijkx, & Schols,
2012). Prior studies indicate that most instruments measure only phy-
sical frailty (e.g., the Frailty Scale). However, frailty is a
B.A. Alqahtani, et al. Archives of Gerontology and Geriatrics 90 (2020) 104128

Table 1 The adopted construct of frailty in Saudi Arabia is perceived in a

Participants’ demographic and clinical characteristics (n = 84). similar way to other countries, including common variables that are
Variable n (%) considered in health assessments of older adults in Saudi Arabia
(Abellan Van Kan et al., 2008; Teixeira, 2008). This study’s sample was
Age, mean (SD) 72 (4.7) assessed based on the physical, psychological, and social components of
Sex, n (%)
an Arabic language version of the TFI questionnaire, thereby enabling
Men 61 (73)
Women 23 (27)
an analysis of frailty in Saudi community-dwelling older adults. This
Nationality (Saudi) 84 (100) questionnaire is distinguished by satisfactory internal consistency,
Level of education concept validity, and reliability. The findings regarding the internal
No formal education 7 (8.3) consistency of the Arabic TFI using the mean of KR-20 indicated that,
Primary school 43 (51.2)
after deleting each item, the KR-20 ranged from 0.66 to 0.72. This result
Middle school or more 34 (40.5)
Marital status, n (%) is reliable when compared to the Brazilian (Santiago, Luz, Mattos,
Single 8 (9.5) Gobbens, & van Assen, 2013) and the original Dutch versions of the TFI
Married 76 (90.5) (0.78 and 0.79 respectively) (Gobbens, van Assen et al., 2010).
Monthly household income
The findings showed that the TFI is a valid instrument for assessing
€600 or less. (SAR 2472 or less) 3 (3.6)
€601 - €900 (SAR 2476-3708) 4 (4.8)
frailty. Validity for TFI was examined using validated outcome mea-
€901 - €1200 (SAR 3712-4944) 7 (8.3) sures for physical, psychological and social domains. Validity outcomes
€1201 - €1500 (SAR 4948- 6180) 9 (10.7) were convergent between total score of TFI and the physical domain
€1501 - €1800 (SAR 6184-7416) 11 (13.1) indicating a decrease of physical performance with frailty and increase
€1801 - €2100. (SAR 7420-8652) 23 (27.4)
of TUG and PHQ-9. The unique version of TFI approved that psycho-
€2101 or more (SAR 8656 or more) 27 (32.1)
Lifestyle, logical and social domains have a low internal consistency because of
Healthy 53 (63.1) the low number of items (Gobbens, Luijkx et al., 2010). The current
Not healthy, not unhealthy 21 (25) study findings reflect a high correlation between components of psy-
Unhealthy 10 (11.9) chological TFI domain and PHQ-9, while this is not demonstrated in the
Life events, % of yes
Death of a loved one 26 (30.9)
social TFI domain which is highly correlated with WHOQOL-BREF.
Serious illness yourself 8 (9.5) The current study shows a good construct validity, which means
Serious illness in a loved one 11(13.1) that each individual domain of the TFI was significantly correlated as
Ending of an important relationship 10 (11.9) expected with well-established related measurements. The correlation
Traffic accident 8 (9.5)
coefficients were higher as the measure become more relevant to the
Crime 3 (3.6)
Satisfactory environment, % of yes 76 (90.1) specific domain of the TFI, and become weaker and non-significant with
≥2 self-reported chronic conditions those not related to the TFI domains. These results demonstrate both
Yes 63 (75) convergent and divergent validity of the TFI domains. Convergent va-
No 21(25) lidity was significantly correlated with all corresponding measures for
Grip strength, mean (SD) 19.3 (5.6)
SPPB total, mean (SD) 8.8 (2.4)
the TFI total score and physical domain only. However, psychological
TUG, mean (SD) 12.5 (5.8) and social domains were not significantly correlated with all corre-
PHQ-9, mean (SD) 16.37 (5.2) sponding measures. Comparing the TFI psychological domain scores
WHOQOL-BREF, mean (SD) with other assessments, our study found a statistically significant cor-
Physical 60.3 (11.4)
relation between the TFI psychological domain score and the Arabic
Psychological 63.6 (12.01)
Social 72.8 (11.6) PHQ-9. This could reflect the specificity for the domain and the cor-
Environmental 67.4 (10.8) responding measure. Although, more than half of our sample (56 %)
have responded “no” to the two components of the social TFI domain
SAR: Saudi Riyal, SPPB: Short Physical Performance Battery, TUG: Timed (questions 13 and 14), the social domain was correlated with
Up and Go. WHOQOL-BREF, suggesting that the items were in a good fit with the
social measure (WHOQOL-BREF). These findings were consistent with
previous studies that converted the TFI to Italian and Spanish (Mulasso,
Roppolo, Gobbens, & Rabaglietti, 2016; Vrotsou et al., 2018). On the
other hand, the divergent validity of both psychological and social
domains was good as both domains correlated as expected more
strongly with the related measurements i.e. the Arabic PHQ-9 and
WHOQOL-BREF, respectively.
Based on a recent systematic review, the prevalence of frailty
ranged from 4% to 51 % among community-dwelling older adults in
different populations (Siriwardhana et al., 2018). Previous literature
has stated that around 40 % of the aged population is experiencing
frailty (Slaets, 2006), whereas around 28 % of our sample were clas-
sified as frail.
Fig. 2. The prevalence of frailty in the study sample. The high rate of the worthy acceptance and understanding of the
scale items indicate that the adapted TFI may be a useful instrument in
the assessment of the elder Saudi. However, it is necessary to continue
multicomponent condition that includes physical, psychological, and
testing the translated TFI produced by this study to ensure that it ac-
social domains, each of which must be measured. The TFI clearly in-
curately captures frailty for older adults in Saudi Arabia. While this
dicates the components that belong to these domains, and in the present
study did not replace or adapt any items of the TFI when it was
study, the questionnaire was translated into the Arabic language and
translated into Arabic. The Arabic TFI could indicate good under-
validated. This study extends previous research in proposing a scale
standing by participants and easy to administer.
that can measure physical, psychological, and social frailty in Saudi
The current study outcomes should be explained in the context of
Arabia, including other Arabic-speaking communities.
important strengths. This study assessed the test-retest reliability and

4
B.A. Alqahtani, et al. Archives of Gerontology and Geriatrics 90 (2020) 104128

Table 2
Internal consistency of the Arabic version of the TFI corrected item correlations for TFI items.
Variable Corrected item total correlation KR-20 if item deleted

Physical components
1.‫ﻫﻞ ﺗﺸﻌﺮ ﺑﺼﺤﺔ ﺟﻴﺪﺓ؟‬ 0.45 0.68
(Do you feel physically healthy?)
2.‫ﻫﻞ ﻓﻘﺪﺕ ﻭﺯﻧﺎ ﻛﺒﻴﺮﺍ ﰲ ﺍﻵﻭﻧﺔ ﺍﻷﺧﻴﺮﺓ ﺩﻭﻥ ﺍﻟﺮﻏﺒﺔ ﰲ ﺍﻟﻘﻴﺎﻡ ﺑﺬﻟﻚ؟‬ 0.10 0.70
(Have you lost a lot of weight recently without wishing to do so?)
3.‫ﻫﻞ ﺗﻮﺍﺟﻪ ﻣﺸﺎﰻ ﰲ ﺣﻴﺎﺗﻚ ﺍﻟﻴﻮﻣﻴﺔ ﺑﺴﺒﺐ ﺻﻌﻮﺑﺔ ﰲ ﺍﳌﴚ؟‬ 0.43 0.69
(Do you experience problems in your daily life due to difficulty in walking?)
4.‫ﻫﻞ ﺗﻮﺍﺟﻪ ﻣﺸﺎﰻ ﰲ ﺣﻴﺎﺗﻚ ﺍﻟﻴﻮﻣﻴﺔ ﺑﺴﺒﺐ ﺻﻌﻮﺑﺔ ﺍﳊﻔﺎﻅ ﻋﲆ ﺗﻮﺍﺯﻧﻚ؟‬ 0.39 0.71
(Do you experience problems in your daily life due to difficulty maintaining your balance?)
5. ‫ﻫﻞ ﺗﻮﺍﺟﻪ ﻣﺸﺎﰻ ﰲ ﺣﻴﺎﺗﻚ ﺍﻟﻴﻮﻣﻴﺔ ﺑﺴﺒﺐ ﺿﻌﻒ ﺍﻟﳧﻊ؟‬ 0.27 0.72
)Do you experience problems in your daily life due to poor hearing?(
6. ‫ﻫﻞ ﺗﻮﺍﺟﻪ ﻣﺸﺎﰻ ﰲ ﺣﻴﺎﺗﻚ ﺍﻟﻴﻮﻣﻴﺔ ﺑﺴﺒﺐ ﺿﻌﻒ ﺍﻟﻨﻈﺮ؟‬ 0.18 0.70
(Do you experience problems in your daily life due to poor vision?)
7. ‫ﻫﻞ ﺗﻮﺍﺟﻪ ﻣﺸﺎﰻ ﰲ ﺣﻴﺎﺗﻚ ﺍﻟﻴﻮﻣﻴﺔ ﺑﺴﺒﺐ ﻧﻘﺺ ﺍﻟﻘﻮﺓ ﰲ ﻳﺪﻳﻚ؟‬ 0.42 0.67
(Do you experience problems in your daily life due to lack of strength in your hands?)
8. ‫ﻫﻞ ﺗﻮﺍﺟﻪ ﻣﺸﺎﰻ ﰲ ﺣﻴﺎﺗﻚ ﺍﻟﻴﻮﻣﻴﺔ ﺑﺴﺒﺐ ﺍﻟﺘﻌﺐ ﺍﻟﺒﺪﱐ؟‬ 0.40 0.72
(Do you experience problems in your daily life due to physical tiredness?)
Psychological components
9‫ﻫﻞ ﻟﺪﻳﻚ ﻣﺸﺎﰻ ﰲ ﺍﻟﺬﺍﻛﺮﺓ؟‬ 0.37 0.68
Do you have problems with your memory?
10. ‫ﻫﻞ ﺷﻌﺮﺕ ﺑﺎﻹﺣﺒﺎﻁ ﺧﻼﻝ ﺍﻟﳪﺮ ﺍﳌﺎﴈ؟‬ 0.39 0.69
(Have you felt down during the last month?)
11. ‫ﻫﻞ ﺷﻌﺮﺕ ﺑﺎﻟﺘﻮﺗﺮ ﺃﻭ ﺍﻟﻘﻠﻖ ﺧﻼﻝ ﺍﻟﳪﺮ ﺍﳌﺎﴈ؟‬ 0.20 0.70
(Have you felt nervous or anxious during the last month?)
12.‫ﻫﻞ ﺃﻧﺖ ﻗﺎﺩﺭ ﻋﲆ ﻣﻮﺍﺟﻬﺔ ﺍﳌﺸﺎﰻ ﺑﺸﲁ ﺟﻴﺪ؟‬ 0.47 0.66
(Are you able to cope with problems well?)
Social components
13.‫ﻫﻞ ﺗﻌﻴﺶ ﲟﻔﺮﺩﻙ؟‬ 0.26 0.70
(Do you live alone?)
14.‫ﻫﻞ ﺗﻔﺘﻘﺪ ﻭﺟﻮﺩ ﺃﴯﺎﺹ ﻣﻦ ﺣﻮﻟﻚ ﺃﺣﻴﺎﻧﴼ؟‬ 0.21 0.71
(Do you sometimes miss having people around you?)
15. ‫ﲻﺎ ﰷﻓﻴ ًﺎ ﻣﻦ ﺃﴯﺎﺹ ﺁﺧﺮﻳﻦ؟‬ ً ‫ﻫﻞ ﺗﺘﻠﱾ ﺩ‬ 0.28 0.69
(Do you receive enough support from other people?)

Internal consistency of the total scale KR-20 = 0.70.

the validity of the translated TFI on a population of community-
dwelling older adults in Saudi Arabia. The TFI total score and separate
scores for physical, psychological, and social domains were compared
to scores from well-established and validated instruments such as the
SPPB, the TUG, grip strength test, and the Arabic PHQ-9.
The main study limitation is despite the KR-20 is widely used to
assess the internal consistency of the physiological studies, this test
value suggests several concerns (Dunn, Baguley, & Brunsden, 2014). A
major limitation of this study includes the use of a single geographic
area which may affect the generalizability of our results, especially
given that Arabic-translated items may have slight differences across
regions with different Arabic accents. Another limitation is the lack of
standardized measures of frailty, which limits comparative measures
needed to assess the validity of our translated-TFI. Future work for this
study should implement this assessment on a larger population of older
adults spread throughout Saudi Arabia to limit the possible effects of
testing bias. Additionally, a future study is needed to perform item
factor analysis to explore more about the interrelationship between
each domain questions of the TFI. Finally, more work assessing the
relation between the TFI scores and other health measures such as
metrics related to disability, healthcare utilization, morbidity, and
mortality, may elucidate the accuracy of our translated instrument.
5. Conclusion
The results of this study suggest that the translated Arabic TFI
created by this study and intended for use in assessing frailty among
Saudi community-dwelling older adults, is valid and reliable when
compared to scores from validated measures of frailty. Our results
suggest that the use of this Arabic-translated TFI for clinical screening
of frailty in any primary health setting may aid continued under-
standing for the validity of this instrument and help provide a quanti-
tative diagnostic tool for the prevention and treatment of frailty.
Source of funding
This project was supported by the deanship of scientific research at
Prince Sattam bin Abdulaziz University under the project # 2018/03/
9367.

Table 3
Correlations between the Arabic version of the TFI and other frailty-related measurements (n=84).
TFI score P TFI physical P TFI psychological P TFI social P

SPPB −0.381 0.009 −0.392 < 0.001 −0.203 0.325 −0.122 0.175
TUG 0.375 0.012 0.384 0.043 0.237 0.233 0.073 0.413
Gait speed −0.344 < 0.001 −0.371 0.036 −0.132 0.287 −0.112 0.126
Grip strength −0.324 0.006 −0.301 < 0.001 −0.201 0.117 −0.110 0.122
The Arabic PHQ-9 0.451 < 0.001 0.325 < 0.001 0.512 0.004 0.143 0.182
WHOQOL-BREF −0.564 < 0.001 −0.421 < 0.001 −0.151 0.197 −0.483 0.003

SPPB: S hort Physical Performance Battery, TUG: Timed Up and Go. Bold font indicates significant at p < 0.05.

5
B.A. Alqahtani, et al. Archives of Gerontology and Geriatrics 90 (2020) 104128

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