Frailty Assessment and Management in Older Adults
Primary Assessment Tool Selection
Use the Clinical Frailty Scale (CFS) as your first-line assessment tool in routine clinical practice, as it can be completed in approximately 24 seconds and provides validated risk stratification across all acute and ambulatory settings. 1, 2
The CFS is a 9-point judgment-based scale ranging from very fit (1) to terminally ill (9), using descriptors and pictographs to grade pre-hospital mobility, energy, physical activity, and functional status. 3, 4 This tool independently predicts all-cause mortality, hospital readmission, length of stay, adverse discharge disposition, and functional decline in older adults. 3
When to Use Alternative Assessment Tools
For comprehensive evaluation when time permits: Use a Frailty Index incorporating at least 30 age-related deficits across multiple domains (symptoms, signs, laboratory values, functional measures). 1, 2 Calculate as the fraction of deficits present divided by total deficits assessed—for example, 0.35 indicates 35% of assessed deficits are present. 1
In surgical settings: Extract the modified Frailty Index (mFI-5 or mFI-11) from NSQIP database variables for perioperative risk assessment. 1
In trauma settings: Apply the Trauma-Specific Frailty Index (TSFI), a 15-component modified scale that predicts in-hospital complications and adverse discharge in geriatric trauma patients. 1
For rapid screening: Use the FRAIL scale, which covers five self-reported questions (Fatigue, Resistance, Ambulation, Illnesses, Loss of weight). 2
Risk Stratification and Clinical Implications
Each increment in frailty severity dramatically increases adverse outcomes, with CFS scores of 6-7 independently predicting adverse discharge and increased 30-day mortality even with lower injury severity. 1
For the Frailty Index, each 0.1 increment (10% increase in accumulated deficits) corresponds to measurably increased hazard ratios for both cardiovascular and non-cardiovascular mortality, stroke, spontaneous embolism, and major bleeding. 1
Severity Categories and Expected Outcomes
Non-frail (CFS 1-4): Mean hospital length of stay 4.1 days, 11% hospitalization rate in previous year, 19% readmission rate. 4, 5
Mild-to-moderately frail (CFS 5-6): Mean hospital length of stay 11.2 days, 22% hospitalization rate, 34.2% readmission rate. 4, 5
Severely frail (CFS 7-8): Mean hospital length of stay 12.6 days, 42% hospitalization rate, 31.2% readmission rate, with over 50% experiencing falls in the previous year. 4, 5
Management Algorithm
Step 1: Initiate Resistance Training Immediately
Prescribe strength-based resistance training as the single most effective first-line intervention for managing frailty—this is the only intervention with proven benefits in reducing mortality, improving function, and enhancing quality of life. 6
Specific exercise modalities with evidence include muscle power training, resistance exercises, computerized-based training/exergames, dance programs, inspiratory muscle training, and whole-body vibration training. 6 Home-based exercises combined with health education and telephone support are effective alternatives. 6
Step 2: Address Nutrition ONLY With Concurrent Exercise
Never prescribe protein supplementation alone—it provides zero benefit without concurrent resistance training and wastes resources. 6
Protein supplementation only works when combined with regular strength-based training. 6 Consider HMB (β-hydroxy-β-methylbutyrate) supplementation as an adjunct. 6 Screen all frail older adults for oral disease and refer for dental care, as poor oral health directly impacts nutritional status and frailty progression. 6
Step 3: Deprescribe Inappropriate Medications
Systematically review and deprescribe inappropriate medications using validated tools specifically developed for frail populations, as inappropriate medications are frequently prescribed and frailty increases medication harm risk. 6
Focus on prescription sedatives, analgesics, and medications with high anticholinergic burden. 6 Note that pharmacokinetics of common medications like paracetamol are altered in individuals with frailty, with high inter-individual variability. 6
Step 4: Implement Multidimensional Interventions for Those ≥80 Years
For adults 80 years and older, add multidimensional interventions including physical exercise programs, health education, and telephone support for adherence to prevent progression from pre-frailty to frailty. 6
Comprehensive Assessment Components
Beyond the initial frailty score, evaluate: 2, 7
- Nutritional status and oral health
- Physical function and mobility
- Cognitive function
- Mood and psychological health
- Social factors and isolation
- Polypharmacy burden
- Falls risk assessment
Monitoring and Documentation
Track frailty trajectory over time rather than relying on baseline status alone, as frailty fluctuates substantially and changes in frailty are more predictive of mortality than current status. 6
Document: tool used, numeric score, frailty category, date of assessment, and specific deficits identified. 1 Repeat assessments at follow-up intervals as frailty states are dynamic and bidirectional. 1
Special Populations
Frailty with Dementia
Individuals with both frailty and dementia have substantially increased vulnerability compared to dementia alone, requiring early frailty diagnosis and individually tailored interventions based on comprehensive geriatric assessment. 6
Oncology Patients
For patients ≥65 years receiving chemotherapy, geriatric assessment-guided interventions demonstrate fewer falls, more medications discontinued (reducing polypharmacy), higher chemotherapy completion rates (45% vs 28%), improved quality of life, and increased caregiver satisfaction. 6
Critical Pitfalls to Avoid
Do not use modified frailty indices with <30 items when attempting the deficit accumulation approach—these are too brief and underestimate frailty. 1
Do not prescribe protein supplements without concurrent resistance training—this provides no benefit. 6
Do not neglect oral health screening—this is consistently overlooked despite clear evidence of importance. 6
Do not implement integrated care programs where usual care is already excellent—you will see no additional benefit. 6
Lifestyle Modifications
Promote Mediterranean dietary patterns and reduce sedentary time through structured activity programs. 6 Mediterranean diet and residing in areas with green space delay frailty progression, while sedentary behavior and diets high in processed foods accelerate frailty. 6
Emerging Technologies
Artificial intelligence-based screening from electronic medical records can identify undiagnosed frailty. 6 Robotic navigation assistance, service robots for activities of daily living, and IoT-based monitoring systems show promise but require adequate digital support for frail older adults. 6