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Frailty screening and assessment tools

Frailty has implications for individuals, clinical practice and public health, and as the population of older adults rises across the world it is recognised as a growing health burden1.

Frailty is not an inevitable part of ageing though and can also be a variable part of ageing. It is therefore important to identify when a person is frail, or is at risk of becoming frail, through use of evidence-based tools.

Frailty is known to be associated with increased falls and poor mobility, hospitalisations, admission to residential care and mortality, as well as poor quality of life, depression, cognitive decline and reported loneliness1-4.

Screening and assessment for frailty should consider a person’s physical performance, nutritional status, cognition, mental health and health supports, such as resources that protect against negative health outcomes and promote wellbeing.

Following identification, evidence-based interventions and management should be underpinned by a shared decision-making approach.

We have focused on five of the most referenced screening and assessment tools, with further details below.

FRAIL scale

Estimated time: < 10 min
Five question tool directed at components of the Cardiovascular Health Study Frailty Index and one at the Rockwood Mitnitski Frailty Index.

Classification or scoring

5-item scale

  • Fatigue
  • Resistance
  • Ambulation
  • Illnesses
  • Loss of weight

Clinical settings

  • Hospital acute care
  • Outpatient clinical setting
  • Community / general practice

Assessment process

Self reported, yes or no answers. If person is in hospital, assess as how person was at two weeks prior.

  • Special equipment is not required
  • Assessor training is not required
  • Valid and reliable
  • Outcome prediction is good

Pros and cons

  • pro Is quick and easy to use
  • pro Simple questionnaire consisting of five self-reported yes or no items
  • pro Patient can self-complete
  • pro Does not require special equipment or measurements
  • pro Identifies factors contributing to frailty
  • pro Results indicate appropriate intervention, e.g. if patient or carer reports fatigue then screen for depression; if resistance or ambulation refer for physical activity or resistance training; weight loss refer to dietitian; >5 illnesses can be used as a proxy for polypharmacy.
  • con Focus on physical components of frailty
  • con Misses polypharmacy
  • con Poor questioning to determine unintentional weight loss.

Additional comments

Domains: physical

Determines pre-frailty and outcome mortality.

Preferred questioning for unintentional weight loss is ‘have you lost weight recently without trying? If so, how much?’

Self-report with communication and/or cognitive issues relies on family and carer.

Specificity

Validated tool. The FRAIL Scale has been used and validated with diverse older populations and is predictive of disability and mortality.

Reference

Woo J, Leung J, Morley JE. Comparison of frailty indicators based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation. Journal of the American Geriatrics Society. 2012 Aug;60(8):1478-1486.

Clinical Frailty Scale (CFS)

Estimated time: < 10 min
Initially developed as a seven-point scale. Currently a nine-point global scale ranging from very fit to severely frail to terminally ill.

Classification or scoring

Levels of frailty

  1. Very fit
  2. Well
  3. Well, with treated comorbid disease
  4. Apparently vulnerable
  5. Mildly frail
  6. Moderately frail
  7. Severely frail
  8. Very severely frail
  9. Terminally ill.

Clinical settings

  • Hospital acute care
  • Outpatient clinical setting

Assessment process

Clinical judgement

Based on what the person was like two weeks ago (so takes out the effect of acute reversible illness on functional state)

Pictorial representation of frailty based on clinical judgement, intended to be used after a comprehensive clinical assessment

  • Special equipment is not required
  • Assessor training is required
  • Valid and reliable
  • Outcome prediction is good

Pros and cons

  • pro Robust indicator of frailty
  • pro Precise grading
  • pro Validated against adverse outcomes in large community cohorts
  • pro Precise measurement
  • pro Reproducible across populations and disease states.
  • con Length of time to complete may mean less compliance uptake outside of a research setting
  • con Cumbersome in clinical setting 
  • con Once completed, does not give an indication of referrals to make to help manage their frailty.

Additional comments

Domains: physical, psychological, social

It includes deficits such as osteoporosis, chronic illness, depression, anaemia and cognitive impairment.

Determines outcome mortality.

Specificity

Validated tool. A good predictor of poor outcomes in older people in hospital.

Reference

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.

Rockwood Mitnitski Frailty Index

Estimated time: about 30 min

Frailty index of cumulative deficits where a person is measured in terms of their deficits compared to a pre-determined list. Frailty Index = (number of health deficits present) ÷ (number of health deficits measured)

Classification or scoring

Uses a deficit count and proportion of potential deficits that a person has accumulated.

Range

  • Robust 0-<0.1
  • Pre-frail 0.1-<0.2
  • Approaching frailty 0.2-<0.25
  • Frail >0.25

The Frailty Index is calculated by counting the number of deficits out of a total list of potential deficits for that person. For example, if an individual has 10 deficits from a total of 40, the index is 0.25.

Clinical settings

  • Hospital acute care
  • Outpatient clinical setting
  • Community / general practice

Assessment process

Comprehensive geriatric assessment

  • Special equipment is not required
  • Assessor training is required
  • Valid and reliable
  • Outcome prediction is good

Pros and cons

  • pro Easy to use and implement
  • pro Demonstrated very good inter-rater reliability
  • pro Clinically feasible
  • pro When used by trained assessors, it predicts short- and long-term mortality in acutely hospitalised older adults
  • pro Can be completed based on routine clinical admission and there is no need for extra equipment
  • con Subjective assessment
  • con Has only been validated for use by specialists
  • con Frequently only the visual diagrams considered, without noting the descriptors beneath each picture
  • con Less valid if performed by non-trained staff without clinical assessment
  • con Does not identify contributing factors to frailty
  • con Once completed, gives a number, but not an indication of which referrals to make to help manage their frailty.

Additional comments

Domains: physical, psychological

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.

Determines pre-frailty and outcome mortality

Specificity

Validated in >65-year-olds. Used as a triage tool to help decide on the ideal treatment and care to address the older person’s goals and avoid further harm through iatrogenic (outcomes inadvertently induced by medical treatment or diagnotic procedures) means.

Reference

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

Reported Edmonton Frail Scale (REFS)

Estimated time: < 10 min
Hybrid of the Frailty Index and the Cardiovascular Health Study Frailty Phenotype Approach. Descriptor of a person’s level of frailty based on nine components: cognition, general health, functional independence, social support, medication use, nutrition, mood, continence, functional performance.

Classification or scoring

Five categories ranging from not frail to severe frailty. Scoring out of 17.

  • 0-5 not frail
  • 6-7 vulnerable
  • 8-9 mild frailty
  • 10-11 moderate frailly
  • 12-18 severe frailty

Clinical settings

  • Hospital acute care
  • Outpatient clinical setting
  • Community / general practice

Assessment process

Self-reported, observation of function

  • Special equipment is not required
  • Assessor training is required
  • Valid and reliable
  • Outcome prediction is good

Pros and cons

  • pro Can be administered by non-specialists (people with no training in geriatric assessment)
  • pro Physical and non-physical domains assessed.
  • con Time consuming in acute settings
  • con Has features which limit its use in patients who do not speak English, or who are hearing or vision impaired.

Additional comments

Domains: physical, psychological, social

Determines pre-frailty and outcome mortality.

Reference

1. Hilmer SN, Perera V, Mitchell S et al. The assessment of frailty in older people in acute care. 2009. Australasian Journal on Ageing, 28(4):182-8.

2. 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.

Cardiovascular Health Study (Fried’s Frailty Phenotype Approach)

Estimated time: < 10 min
Measures physiological deficits across five domains: weight loss, exhaustion, physical activity, muscle strength and walking speed.

Classification or scoring

Allows the identification of physical frailty.

  • Robust: no problems
  • Pre-frail: one or two deficits
  • Frail: three or more of five physiological deficits.

Clinical settings

  • Outpatient clinical setting
  • Community / general practice

Assessment process

Clinical judgement

Based on what the person was like two weeks ago (so takes out the effect of acute reversible illness on functional state)

Pictorial representation of frailty based on clinical judgement, intended to be used after a comprehensive clinical assessment

  • Special equipment is required
  • Assessor training is required
  • Valid and reliable
  • Outcome prediction is good

Pros and cons

  • pro Widely used
  • pro Extensively validated to predict health outcomes
  • pro Validated against adverse outcomes in large community cohorts
  • pro Four of the five items are objective (performance can be measured)
  • pro Correlation with physiologic markers of poor health outcomes including haemoglobin and pro-inflammatory markers.
  • con Some floor effects (occurs when test items are difficult and participants are unable to perform well on the least challenging items)
  • con Requires measurement of gait speed and hand grip strength
  • con Requires knowledge of normative data, particularly bottom 20% for grip strength and gait speed

Additional comments

Domains: physical

Determines pre-frailty and outcome mortality.

Specificity

Validated tool.

Reference

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.

Acknowledgement

Maxwell CA, Wang J. Understanding Frailty: A Nurse's Guide. Nurs Clin North Am. 2017;52(3):349-361. doi:10.1016/j.cnur.2017.04.003

References

1. Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G and Fried LP. 2019. Frailty: implications for clinical practice and public health. Lancet, 394:1365-1375.

2. Fried LP, Tangen CM, Walston J, et al. 2001. Frailty in older adults: evidence for a phenotype. Journal of Gerontology Series A, Biological sciences and medical sciences, 56:M146–56.

3. Song X, Mitnitski A, and Rockwood K. 2010. Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. Journal of the American Geriatrics Society, 58:681–87.

4. Clegg A, Young J, Iliffe S, Rikkert MO, and Rockwood K. 2013. Frailty in elderly people. Lancet, 381:752-762.