Over the course the next week I’ll be blogging on medical decision making in end-of-life care and in patients who have newly admitted to the hospital, assisted living unit, or nursing home.
These posts are inspired by Dr. Atul Gawande’s outstanding book on aging, Being Mortal: Medicine and What Matters in the End.
In the book, Dr. Gawande looks at medical decision making at the end-of-life. The book is poignant and instructive and includes reflections on his own father’s care.
This is post will define frailty and how the diagnosis of frailty might be integrated into your medical decision making for your care (or for the care of a loved one).
The CGA Toolkit Plus website is an incredibly valuable resource. I recommend starting here. Everything you need for a primary care Comprehensive Geriatric Assessment (including all the background information) is here.
The following links are to the various sections of The CGA Toolkit Plus website:
A multidimensional holistic assessment of an older person which considers health and well being and formulates a plan to address issues which are of concern to the older person (and their family and carers when relevant) , arranges interventions according to the plan and then reviews the impact.
Frailty is a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death’
The term “geriatric syndrome” is used to describe the unique features of common health conditions in older people that do not fit into discrete disease categories. Included here are : Falls, Delirium, Dementia, Urinary Incontinence, Pressure Ulcers, and Sleep Disorders.
Aimed at providing the best care and support for people with complex health and social care needs, Proactive Care is a process whereby an individual’s needs are assessed and evaluated, eligibility for service is determined, care plans are drafted and implemented, services are provided and needs are monitored and re-assessed
Personalised Care Planning is a collaborative process in which a conversation, or series of conversations, between a patient and a clinician lead them to jointly agree on goals and actions for managing the patient’s health problems, in a way that is consonant with the patient’s values and concerns.
Find here all Toolkit resources including all Tools on Paper, Computer, and Mobile Devices. Also collected here are all the “Keep it Short and Simple” documents and Patient Handouts on various topics, as well as the videos and documents featured in Practice Spotlight.
The following are excerpts are from Resource (1)
What is frailty?
• Frailty describes a condition in which multiple body
systems gradually lose their in-built reserves.
• Older people with frailty are at significant risk of sudden
and dramatic changes in their physical and mental wellbeing
after a seemingly small event that challenges their
health, such as a minor infection or new medication. Falls, delirium and immobility are the usual sudden, dramatic
changes observed in frailty.
• Older people with frailty are also at increased longer term
risk of disability, care home admission and mortality.
• There is an emerging evidence that appropriate exercise
and nutrition can stabilise frailty and thus reduce the resulting
Recognition of frailty
• Frailty might not be apparent unless actively sought in an
individual. Many people with multiple long-term conditions
will also have frailty which may be overlooked if the focus
is on disease-based, long-term conditions such as diabetes
or heart failure.
• The BGS recommends that all encounters between health
and social care staff and older people should include an
assessment for frailty as this will affect the way health care
is organised for that person.
• Frailty can be recognised in various ways.
- In a routine encounter, there are several ways to recognise frailty. A gait speed <0.8 m/s (taking >5 s to walk 4 m) or a timed-up-and-go-test (TUGT) >10 s are simple assessments. A score of ≥3 on the PRISMA 7 questionnaire can also indicate the possible presence of frailty. The accuracy (sensitivity and specificity) of these tools is variable compared with a gold standard .
- Different tools will be better for different circumstances
—for example, gait speed and TUGT will be useful for
clinical staff during routine assessment, and the
PRISMA 7 questionnaire could be used as a self assessment test. Although evidence on diagnostic accuracyis unavailable, the BGS consensus recommendation is that the Edmonton Frail Scale may be a useful tool to identify frailty when considering a surgical interventionas it might help with pre-operative optimisation [11, 12].
- The common clinical presentations of frailty (falls, delirium and sudden immobility) can themselves be used to alert health and social care professionals to the possible presence of frailty. They often mislead carers and emergency personnel, because an apparently straightforward symptom can mask a serious underlying illness.
(1) Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report [PubMed Abstract] [HTML] [Full Text PDF]. Age and Ageing, Volume 43, Issue 6, 1 November 2014, Pages 744–747.
(3) Fit for Frailty Part 2: Developing, commissioning and managing services
for people living with frailty in community settings – Guidance for GPs, Geriatricians, Health Service managers, social service managers and commissioners of services [Full Text PDF] 2015 by The British Geriatric Society and The Royal College of General Practioners in association with Age UK
Frailty in the elderly increases their vulnerability and leads to a greater risk of adverse events. According to various studies, the prevalence of the frailty syndrome in persons age 65 and over ranges between 3% and 37%, depending on age and sex. Walking speed in itself is considered a simple indicator of health status and of survival in older persons. . . . The objective of this work was to estimate frailty-syndrome prevalence and walking speed in an urban population aged 65 years and over, and to analyze the relationship between the two indicators from the perspective of early diagnosis of frailty in the primary care setting.
Frailty-syndrome prevalence is high in persons aged 75 and over. Detection of walking speed <0.8 m/s is a simple approach to the diagnosis of frailty in the primary care setting.
Frailty is theoretically defined as a clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic
systems such that the ability to cope with everyday or acute stressors is comprised. In theabsence of a gold standard, frailty has been operationally defined by Fried et al. [Citation Resource 10 below] as meeting three out of five phenotypic criteria indicating compromised energetics: low grip strength, low energy, slowed waking speed, low physical activity, and/or unintentional weight loss (2)(Table 1). A pre-frail stage, in which one or two criteria are present, indentifies a subset at high risk of progressing to frailty. Various adaptations of Fried’s clinical phenotype have
emerged in the literature, which were often motivated by available measures in specific studies rather than meaningful conceptual differences.
Based on frailty criteria developed in CHS, the overall prevalence of frailty in community dwelling older adults aged 65 or older in the United States ranges 7-12%. In the CHS, prevalence of frailty increased with age from 3.9% in the 65-74 age group to 25% in the 85+ group and was greater in women than men (8% vs. 5%) (2). African Americans were more
than twice as likely to be frail than Caucasians in CHS (13% vs. 6%) and WHAS (16% vs. 10%). The estimate for the 1996 Mexican Americans from the Hispanic Established Populations for Epidemiologic Studies of the Elderly was 7.8%, similar to those of Caucasians (4).
While specific treatments for frailty are yet to be developed and tested, the existing clinical measures of frailty provide useful means for identify high risk individuals, therefore could lead to improved treatment decision making and management of care by taking into account individual vulnerabilities and propensity for adverse health outcomes.
(6) Screening and early diagnosis of frailty [Full Text PDF]
(7) The PRISMA 7 Questionnaire to screen for possible frailty
(8) PRISMA-7: A case-finding tool to identify older adults with moderate to severe disabilities [PubMed Abstract].
(10) Frailty in older adults: evidence for a phenotype. [PubMed Abstract]. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56:
Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%.
This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.
(11) Edmonton Frail Scale [PDF]
(12) Performance of Edmonton Frail Scale on frailty assessment: its association with multi-dimensional geriatric conditions assessed with specific screening tools [PubMed Abstract] [Full Text HTML] [Full Text PDF]. BMC Geriatrics (2017) 17:2
Assessment of frailty
Edmonton Frail Scale (EFS): The EFS assesses nine
domains of frailty (cognition, general health status,
functional independence, social support, medication
usage, nutrition, mood, continence, functional performance)
Test results can be from 0 to 17. The participants were
classified conventionally into three categories, and a
higher score represents a higher degree of fragility.
Severe Frail and non-frail participants were defined according
of the EFS score from No frailty (≤5 points)
Apparently vulnerable (6 ≤ n ≥ 11 points) and Severe
frailty (12 ≤ n ≥ 17) respectively.
Of note, the EFS was validated in the hands of nonspecialists
who had no formal training in geriatric care
and the administration requires few minutes .