At what level of frailty, as measured by the Clinical Frailty Scale (CFS), is a SALT (Swallowing Assessment and Lifestyle Transition) assessment typically recommended?

SALT Assessment Recommendations Based on Clinical Frailty Scale (CFS) Level

SALT (Swallowing Assessment and Lifestyle Transition) assessment should be routinely performed in patients with a Clinical Frailty Scale (CFS) score of 6 or higher, as these patients are at significantly increased risk for dysphagia and related complications. 1

Understanding the Clinical Frailty Scale and SALT Assessment Relationship

The Clinical Frailty Scale (CFS) is a validated tool that evaluates frailty based on clinical examination, comorbidities, functional status, and activity levels in older patients 2. The scale ranges from 1 (very fit) to 9 (terminally ill) and has been shown to effectively predict adverse outcomes in older adults 3, 4.

When to Perform SALT Assessment Based on CFS:

• CFS 6-7 (Moderately Frail to Severely Frail): Patients at this level show clear evidence of frailty with dependence in activities of daily living (ADLs) and are at high risk for dysphagia, making SALT assessment strongly recommended 1

• CFS 7-9 (Severely Frail to Terminally Ill): These patients have complete functional dependence and are at very high risk for swallowing difficulties, making SALT assessment essential for safe care 1

• CFS 4-5 (Vulnerable to Mildly Frail): Consider SALT assessment if additional risk factors are present, such as neurological conditions, recent weight loss, or reported swallowing difficulties 5

Evidence Supporting This Recommendation

• Observational studies indicate that frail elderly nursing home residents (CFS 6-7) have significantly higher rates of dysphagia and swallowing difficulties, with studies showing up to 100% of severely frail patients experiencing some form of swallowing impairment 1

• Pre-admission frailty as measured by CFS 6 or 7 is independently associated with adverse discharge destinations (odds ratio 5.1; 95% CI 2.0 to 13.2) 1

• All patients who died in a prospective cohort study of geriatric trauma patients were classified as frail according to validated frailty indices, highlighting the importance of early intervention for these high-risk patients 1

• Greater frailty severity is associated with an increased likelihood of geriatric syndromes, including dysphagia, which can be detected through appropriate assessments 5

Clinical Algorithm for SALT Assessment Based on CFS

1. Perform routine SALT assessment for:

   • All patients with CFS ≥6 1
   • Any patient with neurological dysphagia regardless of CFS score 1

2. Consider SALT assessment for:

   • Patients with CFS 4-5 who have:
     • Recent unintentional weight loss (>5% in 3 months or >10% in 6 months) 1
     • Reported difficulty swallowing 1
     • Recurrent respiratory infections 1
     • Decreased oral intake 1

3. Timing of SALT assessment:

   • For patients with severe neurological dysphagia, initiate SALT assessment as soon as possible 1
   • For frail elderly (CFS 6-7), implement SALT assessment early in the care process 1

Common Pitfalls and Caveats

• Delayed assessment: Waiting until advanced undernutrition has developed significantly impedes the success of nutritional therapy. Early detection through routine screening is essential 1

• Overlooking mild dysphagia: Even patients with mild dysphagia (CFS 4-5) may benefit from SALT assessment if they have additional risk factors 5

• Failure to coordinate care: SALT assessment should be coordinated with other interventions, including rehabilitative exercise when possible, to help maintain muscle mass 1

• Not considering medication effects: Geriatric patients should have appropriate assessment of their polypharmacy profile as medications can affect swallowing function 1

• Terminal frailty exception: SALT assessment and tube feeding are not recommended in frail elderly who have progressed to an irreversible final stage (extreme frailty with complete dependence, immobility, inability to communicate) 1