What is the best method to assess and chart frailty in patients?

How to Chart Frailty

Use the Clinical Frailty Scale (CFS) for rapid bedside assessment in most clinical settings, or employ a Frailty Index with at least 30 deficits for comprehensive evaluation when time permits. 1

Primary Assessment Tools

Clinical Frailty Scale (CFS)

• The CFS is a 9-point judgment-based tool (1=very fit to 9=terminally ill) that can be completed in approximately 24 seconds, making it the fastest validated option for clinical charting. 2, 3
• Uses descriptors and pictographs to evaluate comorbidity, function, and cognition simultaneously 2
• Demonstrates 87% predictive accuracy for mortality and predicts complications 100% of the time 2
• Shows 94% agreement with other frailty scores, indicating robust construct validity 2
• In trauma settings, CFS scores of 6-7 independently predict adverse discharge disposition (OR 5.1) and increased 30-day mortality even with lower injury severity. 1

Frailty Index (Deficit Accumulation Model)

• Calculate as the fraction of deficits present divided by total deficits assessed; requires minimum 30 age-related items for validity. 1
• Can incorporate any combination of symptoms, signs, laboratory values, or functional measures 1
• Express the degree of frailty as a continuous score (e.g., 0.35 indicates 35% of assessed deficits are present) 1
• The specific deficits counted matter less than the total number assessed, provided ≥30 items are included 1

Frailty Phenotype (Fried Criteria)

• Score patients on 5 physical criteria: low grip strength, slow walking speed, unintentional weight loss, exhaustion, and reduced physical activity. 1, 4
• Chart as: robust (0 criteria), prefrail (1-2 criteria), or frail (≥3 criteria) 4
• Creates a 6-point scale based on number of attributes present 1
• Focuses specifically on physical frailty rather than broader health deficits 1

Setting-Specific Recommendations

Acute Care/Emergency Department

• Use CFS for immediate risk stratification—takes <30 seconds and predicts length of stay with severely frail patients averaging 12.6 days vs 4.1 days for non-frail. 5, 3
• Document CFS score prominently in admission notes 5

Surgical/Perioperative Settings

• Apply the Trauma-Specific Frailty Index (TSFI) for geriatric trauma patients—this 15-component modified scale predicts in-hospital complications (OR 2.5) and adverse discharge (OR 1.6). 1
• The modified Frailty Index (mFI-5 or mFI-11) can be extracted from NSQIP database variables for surgical risk assessment 1
• Chart preoperatively to guide prehabilitation decisions 1

Outpatient/Ambulatory Settings

• Implement routine frailty screening using standardized tools in all ambulatory patients with chronic conditions like cirrhosis. 1
• The FRAIL scale (self-report version with comorbidity item) achieves 99.4% feasibility and 90-second administration time 1, 3
• Repeat assessments at follow-up intervals to track trajectory, as frailty states are dynamic and bidirectional 4

Nursing Homes/Long-Term Care

• Use comprehensive Frailty Index based on CGA (FI-CGA) for detailed assessment 6
• Stratify as mild (FI-CGA 0-7), moderate (7-13), or severe (>13) 6

Documentation Format

Chart the following elements:

• Tool used (specify CFS, Frailty Index, Fried Phenotype, TSFI, etc.)
• Numeric score (e.g., "CFS 6" or "Frailty Index 0.42" or "3/5 Fried criteria")
• Frailty category (robust/non-frail, prefrail/mild-moderate, frail/severe)
• Date of assessment (critical since frailty is dynamic) 4
• Specific deficits identified (for Frailty Index approach) 1

Common Pitfalls to Avoid

• Do not use modified frailty indices with <30 items when attempting deficit accumulation approach—these have been criticized as too brief and may underestimate frailty. 1
• Avoid assuming frailty assessment is only for patients above arbitrary age cutoffs; frailty represents accumulated deficits, not chronological age 4
• Do not rely solely on comorbidity counts—true frailty assessment requires functional and physiologic measures 1
• In hospitalized patients unable to perform physical tests, prioritize muscle mass assessment or CFS over performance-based tools. 1

Key Clinical Implications

• Both CFS and Frailty Index consistently classify patients at increased risk of death and reduce the explanatory power of age alone. 1
• Frailty is potentially reversible through interventions targeting physical activity, nutrition, and deficit accumulation 4
• Women experience higher rates of severe frailty than men at equivalent ages 4
• After age 65, frailty develops at approximately twice the rate of younger individuals, with 12-24% of older adults demonstrating severe frailty. 4