What is the best approach to assess and manage an older adult's frailty score?

Frailty Assessment in Older Adults

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 recommended by the American Geriatrics Society for rapid bedside assessment in most clinical settings. 1
• This tool provides fast, validated risk stratification and consistently classifies patients at increased risk of death while reducing the explanatory power of age alone. 1, 2
• In trauma settings, CFS scores of 6-7 independently predict adverse discharge disposition and increased 30-day mortality even with lower injury severity. 1

Frailty Index (Deficit Accumulation Approach)

• Calculate the Frailty Index as the fraction of deficits present divided by total deficits assessed, requiring a minimum of 30 age-related items for validity. 1, 2
• The specific deficits counted matter less than the total number assessed, provided ≥30 items are included. 1
• Express the degree of frailty as a continuous score (e.g., 0.35 indicates 35% of assessed deficits are present). 1
• Each 0.1 increment in the frailty index represents a 10% increase in accumulated deficits and corresponds to measurably increased hazard ratios for both cardiovascular and non-cardiovascular mortality. 1
• The Frailty Index can incorporate any combination of symptoms, signs, laboratory values, or functional measures. 1

Fried Frailty Phenotype

• Score patients on 5 physical criteria: low grip strength, slow walking speed, unintentional weight loss, exhaustion, and reduced physical activity. 1, 2
• Frailty is diagnosed when three or more of these five features are present. 2

Setting-Specific Assessment Approaches

Surgical and Trauma Settings

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

Oncology Settings

• The American Society of Clinical Oncology recommends geriatric assessment for patients ≥65 years receiving chemotherapy to identify vulnerabilities. 3, 4
• A geriatric assessment must include sufficient domains: physical and cognitive function, emotional health, comorbid conditions, polypharmacy, nutrition, and social support. 3
• Use the Practical Geriatric Assessment (PGA) as the most concise, evidence-based version that aligns with available data and can be integrated into variably resourced clinical settings. 3

Ambulatory and Community Settings

• Implement routine frailty screening using standardized tools in all ambulatory patients with chronic conditions like cirrhosis. 1
• Use simple, validated frailty screening instruments rather than complex assessments. 4
• Artificial intelligence-based screening from electronic medical records is an emerging technology that can identify undiagnosed frailty. 3, 4

Cognitive Impairment and Dementia

• For older adults with cognitive impairment due to dementia, expert consensus recommends using brief, straightforward tools accessible to various clinicians. 2

Documentation Requirements

Chart the following elements for every frailty assessment: 1

• Tool used (CFS, Frailty Index, Fried Phenotype, etc.)
• Numeric score
• Frailty category (not-frail, pre-frail, or frail)
• Date of assessment
• Specific deficits identified

Monitoring and Reassessment

• Repeat assessments at follow-up intervals to track trajectory, as frailty states are dynamic and bidirectional. 1
• Frailty status fluctuates substantially, and changes in frailty are more predictive of mortality than current frailty status alone. 4
• After age 65, frailty develops at approximately twice the rate of younger individuals, with 12-24% of older adults demonstrating severe frailty. 1

Critical Pitfalls to Avoid

• Do not use modified frailty indices with <30 items when attempting the deficit accumulation approach—these have been criticized as too brief and may underestimate frailty. 1, 2
• Do not rely on clinical judgment alone to assess frailty, as it has not proven reliable in assessing frailty. 3
• Recognize that frailty is potentially reversible through interventions targeting physical activity, nutrition, and deficit accumulation. 1

Emerging Assessment Technologies

• Automated frailty indices developed using artificial intelligence and machine learning can case-find older adults with undiagnosed frailty from electronic medical records. 3, 4
• Biomarkers including skin autofluorescence and salivary α-amylase are newly identified markers, though more rigorous research is needed for omic-based biomarkers. 3
• Telephone-based frailty assessment has emerged as a practical option, particularly relevant during periods requiring remote consultation. 3

Clinical Implications of Assessment

• Both CFS and Frailty Index consistently classify patients at increased risk of death and reduce the explanatory power of age alone. 1, 2
• The degree of frailty fundamentally alters treatment decision-making by identifying patients who respond differently to standard therapies. 1
• Frailty assessment improves prognostication of toxicity outcomes, prediction of life-expectancy, communication about aging-related concerns, patient and family satisfaction with care, and outcomes when used to guide care. 3
• Use frailty assessment results to guide shared decision-making about goals of care, choice of interventions to prevent aging-related outcomes (such as falls and polypharmacy), and likelihood of receiving goal-concordant care. 3