Population ageing is a global phenomenon, with the number of persons aged 60 and above rising from 200 million in 1950 to 1 billion by 2020, and 2 billion by 2050 (1). Improved healthcare, lower mortality rates, improved socioeconomic development and lower fertility rates have contributed to this achievement (1). In the midst of this unprecedented demographic shift, low and middle-income countries such as Malaysia are ageing much faster than developed countries, with significant implications for health and social care planning and delivery (2).

Malaysia is expected to become an aged nation by 2030, with 15% of the population aged 60 or older (3). As the population ages, the prevalence of age-related conditions such as frailty will rise, making it critical that the healthcare system evolves to better meet the health needs of this growing population group (1,4).

Frailty is a state of vulnerability caused by cumulative physiological decline over a lifetime, which increases the risk of developing adverse health outcomes such as falls, disability, hospitalisation, institutionalisation, and death following a stressor (5). Frailty prevalence among Malaysian community-dwelling older adults is estimated to be between 5.7% and 9.4% (6,7).

Frailty, however is reversible and interventions such as exercise and nutrition can help reduce its incidence or impact (8). Therefore, early detection of frailty is critical and we previously proposed that frailty screening programmes be implemented in Malaysia through government-funded primary care services.

The two most used frailty definitions are the phenotypic approach of Fried et al (9) and the frailty index of Rockwood and Mitnitski (10). Frailty is defined by the Fried phenotype as having three or more of the following five characteristics: weak grip strength, slow walking speed, weariness, low physical activity, and accidental weight loss, however Rockwood and Mitnitski utilise the number of «deficits» to calculate a frailty index. These procedures, however, are impractical for identifying frailty in primary care since they are time consuming and involve physical performance measurements.

There are several time efficient and validated screening tools recommended for identifying frailty in older adults in primary care, including the FRAIL scale, the Clinical Frailty Scale (CFS), the Vulnerable Elders Survey-13 (VES-13), the Kihon checklist (KCL), and the Study of Osteoporotic Fractures (SOF) (11). However, these tools have several limitations. The FRAIL and the SOF scales identify frailty with only a small number of symptoms (12,13) The KCL and the VES-13, assesses multiple health domains and are more comprehensive, but still leave out some important elements such as polypharmacy, continence, pain, vision, and hearing (14,15). Despite its pictorial design, the CFS requires clinical judgement because it was designed to summarise a comprehensive assessment (16).

The Pictorial Fit Frail Scale (PFFS) is a novel frailty screening tool developed by Theou and Rockwood that comprehensively assesses across 14 health domains (17). The PFFS is reliable when administered by patients, caregivers, and the healthcare professionals in various clinical settings (18–21). Because the PFFS is pictorial in nature, it overcomes language and health literacy barriers; thus, it is suited for Malaysia’s multi-ethnic and multi-lingual population, where poor health literacy is high (22,23). The PFFS was translated into the Malay language, giving rise to the PFFS-M (Pictorial Fit Frail Scale- Malay version) (24). The reliability and validity of the PFFS-M were established for use with older Malaysians attending publicly funded primary care clinics and cut-offs (i.e. score 6 and above) were also determined to identify frailty when the frailty index was used as the reference method (18) The next step was to investigate the association between the PFFS-M and adverse health outcomes, which had not previously been studied in the primary care setting.

The goal of this study was therefore to determine the association of the PFFS-M across all frailty levels and adverse outcomes defined as death or the presence of either falls, disability, hospitalisation, or nursing home placement.