In a frail individual, an apparently small insult (e.g. new medication, minor illness/surgery) results in a disproportionate change in health; from independent to dependent, mobile to immobile, postural stability to falling, lucid to delirious.
Frailty is measured because it is a better predictor of adverse health outcomes than chronological age alone. It is associated with hip fracture, disability, hospitalisation and mortality independent of other health behaviours, pre-existing disability and comorbidity. Poorer postoperative surgical outcomes are also correlated with frailty.
How to measure frailty?
Previously the ‘eye-ball test’ was used to subjectively identify adults as ‘frail’ or ‘not frail’. Today, two broad approaches are recognised – a phenotypic and a cumulative deficit model – from which multiple frailty tools have been developed.
How to decide which one to use?
This depends on the clinical setting and purpose of measuring frailty. Some tools are better suited to research settings, or require a trained administrator, while others can be easily self-completed by the patient or carer. Three tools worth highlighting are the F.R.A.I.L Scale, the Edmonton Frailty Scale (EFS), and the Clinical Frailty Scale (Table 1).
Recognising frailty helps clinicians identify individuals at risk of complications related to the disease and/or intervention being considered. This can guide decision making (e.g. considering an invasive procedure or medication). Frailty, rather than chronological age, can be used to weigh up the advantages and disadvantages of treatments, allowing patients and families to make more informed decisions.
Identifying a frail individual can lead to consideration about what can be done to optimise their health status. Given frailty is a multidimensional syndrome, management usually involves a multidisciplinary team.
Consideration of referral to a geriatrician-led team to undertake comprehensive geriatric assessment (CGA) can help to identify and optimise frailty and/or avoid futile interventions based on risk-benefit assessment.
Comprehensive geriatric assessment that leads to therapeutic intervention can optimise the likelihood of improved clinical outcomes, including returning home, minimising cognitive and functional decline and lower hospital mortality.
Review polypharmacy and consider deprescribing in frail individuals, who may not live long enough to experience the benefits of certain medications.
Consider prescribing an individualised exercise program, as physical activity can improve mobility and functioning among frail older adults. Although specific nutrition interventions have not been established in preventing or treating frailty, diet and nutrition should be evaluated because higher protein intake has been associated with lower risk of incident frailty.
Frailty is associated with alcohol, smoking, and obesity so ongoing attention to these factors is important.
- Frailty is associated with adverse outcomes at an individual and population level.
- Several validated tools are available to screen and detect frailty.
- Use an individualised, holistic and multidisciplinary approach to management.
ED: The author acknowledges the input of Dr Charles Inderjeeth in the preparation of this article.
References available on request.
Questions? Contact the editor.
Author competing interests: nil relevant disclosures.
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Table 1 Assessment tools
|F.R.A.I.L Scale||Edmonton Frailty Score||Clinical Frailty Scale|
|Description||5 item questionnaire that assesses key components of frailty:|
1. Fatigue (‘F’)
2. Resistance (‘R’)
3. Ambulation (‘A’)
4. Illnesses (‘I’)
5. Loss (‘L’) of weight
|9 item questionnaire that assesses these Domains:||Pictorial representation of frailty based on clinical judgement, intended to be used after a comprehensive clinical assessment.|
|1. Functional independence.|
2. General health status.
|6. Social support.|
9. Functional performance.
|Advantages||§ Patient can self-complete.|
§ No special training or equipment required.
|§ Validated for use by non-geriatricians.|
§ Physical and non-physical domains assessed.
|§ Predictive of death and institutionalisation if used with a CGA.|
|Disadvantages||§ Focus on physical components of frailty.||§ Patient can’t self-complete.||§ Less valid if performed by non-trained staff without clinical assessment.|