Key messages
- Identify when a person has frailty or is at risk of having frailty, as their outcomes are poorer with minor illnesses such as infections.
- Screening and assessment for frailty should consider a person’s physical performance, nutritional status, cognition, mental health and health assets.
- Health assets are resources that individuals or communities have at their disposal, that protect against negative health outcomes and promote wellbeing.
Identifying frailty
Keep in mind that the terms ‘frail’ and ‘frailty’ may have negative connotations.
“One way to overcome this is to say that the older person ‘has frailty’, this approach reduces the use of ‘frailty’ as an adjective and makes it more like a diagnosis/syndrome.” (Geriatrician)
When screening and assessing for frailty, we should consider a person’s physical performance, nutritional status, cognition and mental health and be proactive in providing preventative and tailored care when the person is in hospital. It is also useful to understand the person's health assets and how these might act as protective factors. Health assets can include supportive family, community supports, social connections and economic independence.
In addition to following health service policy and procedures, the following actions can help us identify patients with or at risk of frailty.
Screening tools
There are very few validated tools that specifically screen for frailty. Recognising the importance of this emerging issue, the Failsafe Initiative is testing a new screening tool in UK acute hospital settings. The results of this study are yet to be published.
Some ways to determine the risk of frailty include:
- measuring walking speed: people aged 75 and over who have a walking speed of less than 0.8 m/s are at high risk of frailty1
- evaluating the presence of risk factors, including poor mobility, reduced strength, poor nutrition, delirium, falls, impaired cognition and low mood.
Assessment tools
Overview of frailty assessment scales
| Name of scale/approach | Components | Grading | How assessed? | Pros/Cons for clinical setting |
|---|---|---|---|---|
| Fried’s Frailty Phenotype approach2 | Performance on five variables:
| Robust: no problems Pre-frail: one or two problems Frail: three or more problems | Clinical performance-based measures | Pros: Widely used Cons: some floor effects |
| Frailty Index Rockwood-Mitnitski Deficit Accumulation model3 | Deficit count and proportion of potential deficits that a person has accumulated | Range: 0-1.0 less than 0.25 (robust/pre-frail) ≥ | Comprehensive Geriatric Assessment | Pros: robust indicator of frailty, precise grading Cons: Cumbersome in clinical setting |
| Clinical Frailty Scale5 | Single descriptor of a person’s level of frailty | Seven-point scale ranging from very fit to severely frail | Clinical judgement | Pros: Easy to use and implement Cons: subjective assessment, has only been validated for use by specialists |
| Edmonton Frail Scale6 | Descriptor of a person’s level of frailty based on 9 components:
| Five categories ranging from not frail to severe frailty | Self report, observation of function | Pros: can be administered by non-specialists Cons: time consuming in acute settings |
Adapted from Goldstein et al 20127
Fried’s Frailty Phenotype
This is the most common scale used to screen and assess for frailty. It measures deficits in the five domains:
- Weight loss (self-reported unintentional weight loss or decreased appetite)
- Exhaustion (self-reported energy levels)
- Physical activity (frequency of moderate intensity activity)
- Muscle strength (measured grip strength with dynamometer)
- Walking speed (self-reported slow speed or measured slow gait)2.
Frailty Index
The Frailty Index is calculated by counting the number of deficits out of a total list of potential deficits for that person3. For example, if an individual has 10 deficits from a total of 40, the index is 0.25. Scores of 0.2 and over are considered as approaching frailty. The Frailty Index is the best predictor of poor outcomes in older people in hospital4. It includes deficits such as osteoporosis, chronic illness, depression, anaemia and cognitive impairment. The more deficits a person has, the more likely they are to be frail.
Clinical Frailty Scale
The Clinical Frailty Scale5 classifies levels of frailty as follows:
- Very Fit– robust, active, energetic, well motivated and fit; these people commonly exercise regularly and are in the most fit group for their age
- Well - without active disease, but less fit than people in category 1
- Well, with treated comorbid disease – disease symptoms are well controlled compared with those in category 4
- Apparently vulnerable – although not frankly dependent, these people commonly complain of being “slowed up” or have disease symptoms
- Mildly frail – with limited dependence on others for instrumental activities of daily living, which includes meal preparation, ordinary housework, managing finances, using the phone, shopping, transportation
- Moderately frail – help is needed with both instrumental and non-instrumental activities of daily living which includes, mobility in bed, transferring on and chairs, toilets and into and out of bed, walking, dressing, eating, toilet use, personal hygiene, bathing
- Severely frail – completely dependent on others for the activities of daily living, or terminally ill
People in categories 4, 5 and 6 may not be as easily identified as being at risk of frailty.
This version of the Clinical Frailty Scale was extended in 2008 to include two more levels, a total of nine, and includes a comment about scoring frailty in people with dementia. This extended version is available for use in research and educational purposes only.
Edmonton Frail Scale
People with no training in geriatric assessment can use the Edmonton Frail Scale. It measures level of frailty through questions and activities related to cognition, general health, functional independence, social support, medication use, nutrition, mood, continence and functional performance.
1. Castell, M.-V., M. Sanchez, R. Julian, R. Queipo, S. Martin, and A. Otero, Frailty prevalence and slow walking speed in persons age 65 and older: implications for primary care. BMC Family Practice, 2013. 14(1): p. 86.
2. Fried, L.P., C.M. Tangen, J. Walston, A.B. Newman, C. Hirsch, J. Gottdiener, T. Seeman, R. Tracy, W.J. Kop, G. Burke, and M.A. McBurnie, Frailty in older adults: evidence for a phenotype. The journals of gerontology. Series A, Biological sciences and medical sciences, 2001. 56(3): p. M146-56.
3. Mitniski, A., X. Song, and K. Rockwood, The estimation of relative fitness and frailty in community-dwelling older adults using self-report data. The Journals of Gerontology Seris A: Biological Sciences and Medical Sciences, 2004. 59: p. M627-M632
4. Dent, E., I. Chapman, S. Howell, C. Piantadosi, and R. Visvanathan, Frailty and functional decline indices predict poor outcomes in hospitalised older people. Age and Ageing, 2014. 43(4): p. 477-484
5. Rockwood, K., X. Song, C. MacKnight, H. Bergman, D.B. Hogan, I. McDowell, and A. Mitnitski, A global clinical measure of fitness and frailty in elderly people. CMAJ, 2005. 173: p. 489-195.
6. Rolfson, D.B., S.R. Majumdar, R.T. Tsuyuki, A. Tahir, and K. Rockwood, Validity and reliability of the Edmonton Frail Scale. Age and Ageing, 2006. 35(5): p. 526-529
7. Goldstein, J.P., M.K. Andrew, and A. Travers, Frailty in older adults using pre-hospital care and the emergency department: a narrative review. Canadian Geriatrics Journal, 2012. 15.
Reviewed 05 October 2015