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. 2025 Apr 2;15(7):915.
doi: 10.3390/diagnostics15070915.

Sex Bias in Frailty Screening: A Cross-Sectional Analysis of PRISMA-7 and the Clinical Frailty Scale in Primary Care

Christian J Wiedermann  1 , Verena Barbieri  1 , Dietmar Ausserhofer  1 , Adolf Engl  1 , Giuliano Piccoliori  1 , Angelika Mahlknecht  1
Affiliations

Sex Bias in Frailty Screening: A Cross-Sectional Analysis of PRISMA-7 and the Clinical Frailty Scale in Primary Care

Christian J Wiedermann et al. Diagnostics (Basel). .

Abstract

Background/Objectives: Frailty screening is essential in primary care for the early identification of vulnerable older adults. PRISMA-7 is a widely used screening tool, but Item 2 ("Are you male?") introduces potential sex bias and overestimates frailty in men. PRISMA-6, a modified version that excludes Item 2, might provide a more equitable alternative. This study evaluates PRISMA-6's alignment with the Clinical Frailty Scale (CFS) and its impact on sex-specific frailty classification. Methods: A cross-sectional study was conducted in 142 general practices across South Tyrol, including 9190 general practice patients aged ≥75 years. Frailty was assessed using PRISMA-7, PRISMA-6, and the CFS. Correlations between tools were calculated using Kendall's Tau-b, whereas Fisher's z-test was used to compare differences in alignment. The frailty prevalence and odds ratios were stratified according to sex and age. Results: PRISMA-6 showed a stronger correlation with the CFS (τ = 0.492) than PRISMA-7 (τ = 0.308, z = -10.2, p < 0.001). This effect was pronounced in men (z = -9.8, p < 0.001), whereas no difference was observed in women (z = 0.00, p = 1.000). PRISMA-6 reduced the frailty detection rate in men and was more closely aligned with the CFS. Conclusions: PRISMA-6 demonstrated improved alignment with the CFS and reduced sex bias compared to PRISMA-7. However, its use as a screening tool for men requires prospective validation in diverse settings. PRISMA-6 shows promise as a reliable and equitable frailty screening tool and should be considered for use in future studies, particularly in primary care settings, while awaiting further prospective validation.

Keywords: Clinical Frailty Scale; PRISMA-6; PRISMA-7; frailty prevalence; frailty screening; frailty tools validation; older adults; primary care; sex bias.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
A flowchart of GP participation and patient inclusion in the frailty screening and assessment process.
Figure 2
Figure 2
The distribution of frailty scores by sex across three assessment tools. Stacked bar plots showing the distribution of scores for PRISMA-7, PRISMA-6, and the Clinical Frailty Scale (CFS) among 9190 general practice patients aged ≥75 years, stratified by sex. Frailty thresholds: PRISMA-7 and PRISMA-6: score ≥ 3; CFS: score ≥ 5.
Figure 3
Figure 3
Comparison of frailty detection rates by tools. CFS, Clinical Frailty Scale.
See this image and copyright information in PMC

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