What are the recommended methods to assess frailty in elderly patients?

Methods to Measure Frailty in Elderly Patients

Use the Clinical Frailty Scale (CFS) or FRAIL scale as your primary frailty assessment tools in clinical practice, as these brief, validated instruments provide rapid severity grading and are accessible across all clinical settings. 1, 2, 3

Primary Recommended Assessment Tools

Clinical Frailty Scale (CFS)

• The CFS is a 9-point judgment-based scale ranging from 1 (very fit) to 9 (terminally ill) that provides practical frailty detection and severity grading to guide clinical decision-making. 1, 2, 3
• This tool has been validated in 29 studies encompassing approximately 44,000 older adults from 25 countries, demonstrating that it independently predicts adverse health outcomes. 3
• The CFS can be completed rapidly at the bedside and is recommended by the American Geriatrics Society for most clinical settings. 3
• It demonstrates strong predictive validity for length of hospital stay, with severely frail patients (CFS 7-8) having significantly longer stays compared to non-frail patients (CFS 1-4). 4

FRAIL Scale

• The FRAIL scale assesses five self-reported components: Fatigue, Resistance (difficulty climbing stairs), Ambulation (difficulty walking), Illnesses (≥5 comorbidities), and weight Loss (>5% in past year). 1, 2
• This tool is particularly useful for rapid screening and is straightforward enough for use by family medicine practitioners, psychiatrists, nutritionists, and therapists. 1
• Each component receives one point, with scores ≥3 indicating frailty. 2

Alternative Validated Assessment Methods

Fried Frailty Phenotype (Physical Frailty Model)

• Diagnose frailty when ≥3 of five physical criteria are present: unintentional weight loss (≥10 lbs in past year), self-reported exhaustion, weakness (low grip strength), slow walking speed, and low physical activity level. 2, 5
• This phenotype approach conceptualizes frailty as a specific physical syndrome rather than accumulated deficits. 5
• The tool requires objective measurements (grip strength, gait speed) which may limit feasibility in some settings. 2

Frailty Index (Cumulative Deficit Model)

• 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. 2, 3, 5
• Express frailty as a continuous score (e.g., 0.35 indicates 35% of assessed deficits are present). 3
• Each 0.1 increment represents a 10% increase in accumulated deficits and corresponds to measurably increased mortality risk. 3
• The Frailty Index can incorporate any combination of symptoms, signs, laboratory values, functional measures, cognitive deficits, psychological factors, and social health deficits. 2, 3
• Modified frailty indices using fewer than 30 items have been criticized as too brief and may underestimate frailty. 3, 5

PRISMA-7 Screening Tool

• The PRISMA-7 is a 7-item self-report questionnaire that demonstrated the highest accuracy (AUC 0.88) for separating frail from non-frail patients in emergency department settings. 6
• Use a cut-off score of ≥3 for initial screening, though a cut-off of ≥4 may reduce overestimation and enhance concordance with clinical assessments. 7
• This tool showed statistically significantly better accuracy than the ISAR tool (p = 0.008) but not significantly different from CFS (p = 0.15). 6
• PRISMA-7 score ≥3 predicts higher mortality (OR 2.46,95% CI 1.53-3.97) and increased healthcare utilization. 8

Algorithmic Approach to Frailty Assessment

Step 1: Initial Screening

• Screen all patients ≥65 years (or ≥75 years in primary care) using either the FRAIL scale or CFS for rapid assessment. 2, 7
• In emergency department settings, consider PRISMA-7 as an alternative screening tool given its superior accuracy. 6

Step 2: Severity Grading

• Categorize patients based on assessment results:
  • Non-frail: CFS 1-4, FRAIL score 0-2, PRISMA-7 <3 2, 4
  • Pre-frail: CFS 5, FRAIL score 1-2, Fried criteria 1-2 components 2
  • Mildly-to-moderately frail: CFS 5-6, FRAIL score ≥3, Fried criteria ≥3 components 3, 4
  • Severely frail: CFS 7-8, high Frailty Index scores 4

Step 3: Comprehensive Assessment (if frail or pre-frail)

• Conduct detailed evaluation including: nutritional status (Mini Nutritional Assessment-Short Form), physical function, cognitive function, mood assessment, social factors, polypharmacy review, and falls risk. 1, 2
• For nutritional screening, use the Mini Nutritional Assessment-Short Form initially, followed by Global Leadership Initiative on Malnutrition criteria if positive. 1

Setting-Specific Considerations

For Patients with Dementia

• The diagnostic tool must be brief, straightforward, and accessible to various clinicians including family practitioners, psychiatrists, nutritionists, and therapists. 1
• Both CFS and FRAIL scale are specifically recommended for this population. 1
• The Fried frailty phenotype and frailty index remain valuable for detecting frailty in individuals with cognitive impairments. 1

For Trauma Settings

• Apply the Trauma-Specific Frailty Index (TSFI), a 15-component modified scale that predicts in-hospital complications and adverse discharge. 3
• CFS scores of 6-7 independently predict adverse discharge disposition and increased 30-day mortality even with lower injury severity. 3

For Surgical Risk Assessment

• The modified Frailty Index (mFI-5 or mFI-11) can be extracted from NSQIP database variables. 3

Critical Implementation Points

Common Pitfalls to Avoid

• Do not use modified frailty indices with <30 items when attempting the deficit accumulation approach—these underestimate frailty. 3, 5
• Do not employ CFS as the sole triage instrument during resource scarcity (e.g., pandemic surges) without additional validation, as its acceptability and accuracy for short-term outcomes in that context remain uncertain. 3
• Avoid relying solely on biomarkers (inflammatory markers, skin autofluorescence, salivary α-amylase) as these cannot independently detect frailty. 2

Documentation Requirements

• Chart the following elements: tool used, numeric score, frailty category, date of assessment, and specific deficits identified. 3
• Repeat assessments at follow-up intervals to track trajectory, as frailty states are dynamic and bidirectional. 3

Clinical Implications

• Early identification enables timely interventions that can slow progression, preserve functional abilities, and enhance quality of life. 1, 2
• Both CFS and Frailty Index consistently classify patients at increased risk of death and reduce the explanatory power of age alone. 3, 5
• Frailty is potentially reversible through interventions targeting physical activity, nutrition, and deficit accumulation. 3