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

<b>Background/Objectives</b>: 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. <b>Methods:</b> 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. <b>Results:</b> PRISMA-6 showed a stronger correlation with the CFS (τ = 0.492) than PRISMA-7 (τ = 0.308, <i>z</i> = -10.2, <i>p</i> < 0.001). This effect was pronounced in men (<i>z</i> = -9.8, <i>p</i> < 0.001), whereas no difference was observed in women (<i>z</i> = 0.00, <i>p</i> = 1.000). PRISMA-6 reduced the frailty detection rate in men and was more closely aligned with the CFS. <b>Conclusions:</b> 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.