Assessing Frailty in Older Adults

The term frailty refers to physiological decline associated with older age (RACGP 2019). People who are frail are among the most vulnerable demographic, with their risk of adverse health outcomes being considerably increased (Walston 2023).

Frailty is a multidimensional state of health that occurs when a person’s physical and cognitive reserves decrease with age, leading to increased vulnerability and reduced resilience to acute illness, trauma and other stressors in comparison to younger and non-frail adults (Health.vic 2021; RACGP 2019).

However, while frailty is associated with the ageing process, frailty is not the same as older age, and it is not an inevitable part of ageing (RACGP 2019).

Assessing Frailty Under the Strengthened Aged Care Quality Standards

Standard 5: Clinical Care - Outcome 5.4: Comprehensive care (Action 5.4.2) of the strengthened Aged Care Quality Standards requires aged care providers to determine an older person’s level of clinical frailty upon initiation of care, when the person’s needs change and at frequent intervals by performing a comprehensive clinical assessment (ACQSC 2024).

What Are the Impacts of Frailty?

Frailty is associated with a variety of adverse effects, including:

Difficulty coping with stressors such as illness
Increased risk of falls
Increased risk of poor health outcomes
Increased risk of complications during medical procedures
Increased susceptibility to medication side effects
Increased risk of requiring residential care
Increased risk of disability and death
Longer stays in hospitalc
Increased recovery time from illness and surgery.

(RACGP 2019; Health.vic 2015a, 2021; QAS 2021)

What Causes Frailty?

Frailty is believed to be associated with dysregulation of the immune, endocrine, stress and energy response systems, which may be caused by age-related molecular changes, genetics and disease (RACGP 2019).

Another contributing factor is age-related changes to hormones and inflammatory pathways, which are associated with sarcopenia (age-related loss of skeletal muscle) (RACGP 2019).

Undernutrition is another key factor involved in frailty, as it results in:

Decreased muscle strength
Impaired immune function and wound healing
Prolonged recovery from illness and surgery
Decreased psychosocial functioning
Poor clinical outcomes.

(RACGP 2019)

Risk Factors for Frailty

Older age (over 65)
Smoking
Low level of education
Post-menopausal therapy
Being unmarried
Depression
Intellectual disability
Being an Aboriginal and/or Torres Strait Islander person
Inactive lifestyle
Undernutrition
Chronic illness or multimorbidity.

(RACGP 2019; QAS 2021)

What are the Signs of Frailty?

assessing frailty signs woman lying in bed

Frailty may or may not have obvious signs. People who are frail might:

Be excessively fatigued
Experience unplanned weight loss
Experience frequent infections
Fall frequently, have a fear of falling or restrict their activity
Display cognitive changes
Have a fluctuating ability to care for themselves that varies from day to day.

(Health.vic 2015a)

Assessing Frailty

While there is no internationally recognised definition of frailty (Mendiratta et al. 2023), below are five of the most referenced frailty screening and assessment tools:

Cardiovascular Health Study (Fried’s Frailty Phenotype Approach)

Fried’s Frailty Phenotype is the most commonly used assessment tool to screen and measure frailty (Health.vic 2015b).

It involves assessing five physiological dimensions of frailty:

Unplanned weight loss (4 kg or more in the past year)
Exhaustion
Low moderate-intensity physical activity
Muscle weakness (reduced grip strength measured using a dynamometer)
Slow gait speed.

(Health.vic 2015b; RACGP 2019)

The amount of these problems being experienced by the person determines their score:

No problems	Robust
One or two problems	Pre-frail
Three to five problems	Frail

(ACI 2020)

Clinical Frailty Scale (CFS)

The Clinical Frailty Scale (CFS), developed by Professor Kenneth Rockwood, is a validated screening tool that effectively predicts poor outcomes for older adults in hospital environments (ACI 2020).

The CFS is a nine-point scale ranging from 1 (very fit) to 9 (terminally ill). It’s assessed based on a clinical judgement of the patient’s health two weeks ago (to avoid the influence of acute reversible illness). It includes both a written description and a pictorial representation of each score (ACI 2020; QAS 2021).

1. Very fit	Robust, active, energetic and motivated Exercises regularly Among the fittest for their age group
2. Well	No active disease symptoms Less fit than category 1 Exercises or is very active occasionally
3. Managing well	Medical issues are well-controlled Not regularly active, apart from routine walking
4. Vulnerable	Not dependent on others for daily help Activities may be limited by disease symptoms May be slow or tired during the day
5. Mildly frail	More evident slowing May require assistance with finances, transport, heavy housework and/or medications Has difficulty shopping, walking outdoors alone or preparing meals
6. Moderately frail	Requires help with all outside activities and housekeeping Has difficulty with stairs Requires help with bathing May require minimal help with dressing
7. Severely frail	Completely dependent on others for personal care due to physical or cognitive factors Appears stable; unlikely to die within six months
8. Very severely frail	Completely dependent on others Approaching the end of their life Unlikely to recover from even a minor illness
9. Terminally ill	Those with a life expectancy of under six months, who are otherwise not noticeably frail

(Adapted from Rockwood, cited in QAS 2021)

FRAIL Scale

The FRAIL Scale is a validated questionnaire that uses yes and no answers to assess five dimensions of frailty:

F - Fatigue	How much of the time during the past four weeks did the person feel tired?	All or most of the time = 1 point Some, a little or none of the time = 0 points
R - Resistance	In the last four weeks, independently and without mobility aids, has the person had any difficulty walking up 10 steps without resting?	Yes = 1 point No = 0 points
A - Ambulation	In the last four weeks, independently and without mobility aids, has the person had any difficulty walking for either 300 metres or one block?	Yes = 1 point No = 0 points
I - Illness	Does the person have any of the following conditions? Hypertension Diabetes Cancer (other than minor skin cancer) Chronic lung disease Heart attack Congestive heart failure Angina Asthma Arthritis Kidney disease	Person has 5 to 11 of these conditions = 1 point Person has 0 to 4 of these conditions = 0 points
L - Loss of weight	Has the person lost more than 5 kg or 5% of their body weight in the past year?	Yes = 1 point No = 0 points

(Sydney North Health Network 2018)

The person’s total score should then be added together:

0 points	Robust
1 to 2 points	Pre-frail
> 3 points	Frail

(Sydney North Health Network 2018)

assessing frailty older man being cared for in bed

Rockwood Mitnitski Frailty Index

The Frailty Index involves assessing the person against a predetermined list of deficits and counting how many of those deficits the person is experiencing (ACI 2020).

The total score is calculated by dividing the number of deficits experienced by the person by the total number of deficits on the list. For example, a person who has 10 deficits out of a list of 40 would have an index of 0.25 (ACI 2020).

0 to < 0.1	Robust
0.1 to < 0.2	Pre-frail
0.2 to < 0.25	Approaching frailty
> 0.25	Frail

(ACI 2020)

Reported Edmonton Frail Scale (REFS)

The Reported Edmonton Frail Scale (REFS) measures the person’s frailty across nine dimensions using both questions and activities:

1. Cognition	The person is provided with a pre-drawn circle and asked to pretend it is a clock. They then need to place the numbers in the correct positions, and move the clock hands to show the time ‘ten past eleven’.	No errors = 0 points Minor spacing errors = 1 point Other errors = 2 points
2. General health	How many times has the person been admitted to the hospital in the past year?	No times = 0 points One to two times = 1 point Two or more times = 2 points
2. General health	How would the person generally describe their health?	'Excellent', 'very good' or 'good' = 0 points 'Fair' = 1 point 'Poor' = 2 points
3. Functional independence	How many of the following activities does the person require help with? Meal preparation Shopping Transport Telephone calls Housekeeping Laundry Managing money Taking medications	Zero to one = 0 points Two to four = 1 point Five to eight = 2 points
4. Social support	When the person needs help, can they count on someone who is willing and able to help them meet their needs?	Always = 0 points Sometimes = 1 point Never = 2 points
5. Medication use	Does the person regularly take five or more different prescription medicines?	No = 0 points Yes = 1 point
5. Medication use	Does the person ever forget to take their prescription medicines?	No = 0 points Yes = 1 point
6. Nutrition	Has the person recently lost enough weight to cause their clothing to become looser?	No = 0 points Yes = 1 point
7. Mood	Does the person often feel sad or depressed?	No = 0 points Yes = 1 point
8. Continence	Does the person lose control of urine when they don’t want to?	No = 0 points Yes = 1 point
9. Functional performance	The person should be instructed to sit in a chair with their back and arms resting. When the assessor says 'GO', the person should stand up and walk at a safe and comfortable pace to a mark on the floor about three metres away, then return to the chair and sit down. Note: If this cannot be assessed, consider a self-report of the person’s functional performance over the past two weeks.	0 to 10 seconds = 0 points 11 to 20 seconds = 1 point More than 20 seconds, the person is unwilling to perform the task or the person requires assistance = 2 points

(BGS 2018; Alberta Health Services and Covenant Health 2015)

The person’s total score should then be added together:

0 to 5 points	Not frail
6 to 7 points	Vulnerable
8 to 9 points	Mild frailty
10 to 11 points	Moderate frailty
12 to 18 points	Severe frailty

(ACI 2020)

Which Frailty Assessment Tool is Best?

Each frailty assessment tool has pros and cons:

Tool	Pros	Cons
Cardiovascular Health Study (Fried’s Frailty Phenotype Approach)	Widely-used Has been extensively validated to predict health outcomes Four out of five items are objective and can be measured Correlates with physiological markers of poor health outcomes, including haemoglobin and pro-inflammatory markers	Only focuses on physical dimensions of frailty Requires special equipment to take measurements Requires knowledge of normative data
Clinical Frailty Scale	Easy to use Quick Assesses physical, psychological and social dimensions of frailty Precise grading	Involves subjective assessment Only validated for specialists Doesn’t give an indication of what referrals the person requires to help manage their frailty
FRAIL Scale	Easy to use Quick Can be self-reported by the person Requires no special equipment or measurements Identifies factors contributing to frailty Results indicate interventions that may be required	Only focuses on physical dimensions of frailty Does not assess polypharmacy Poor assessment of unplanned weight loss
Rockwood Mitnitski Frailty Index	Easy to use Assesses physical and psychological dimensions of frailty Can predict short and long-term mortality in acutely hospitalised older adults (if performed by a trained assessor) Allows for a high degree of agreement between independent assessors No need for extra equipment	Involves subjective assessment Only validated for specialists Doesn’t give an indication of what referrals the person requires to help manage their frailty Takes longer than the other tools
Reported Edmonton Frail Scale	Can be performed by non-specialist assessors Assesses physical, psychological and social dimensions of frailty Requires no special equipment or measurements Can be self-reported by the person	Can be time-consuming if performed in acute settings Difficult for people who do not speak English, or have a vision or hearing impairment

(ACI 2020; Health.vic 2015b; RACGP 2019)

Responding to Frailty

assessing frailty carer assisting older woman with mobilisation

Once frailty has been identified, the person typically requires various interventions to address underlying factors such as physical capacity, nutritional status, mental health and cognition. These might include:

Regular mobilisation
Improving and maintaining nutrition and hydration
Supporting and encouraging activities of daily living
Educating patients, family and carers
Referring the person to relevant specialists such as physiotherapists, dietitians, speech pathologists, occupational therapists, pharmacists etc.

(Health.vic 2015c)

These interventions will depend on the person and their specific needs.

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Question 1 of 3

A person scores 5 deficits out of 40 on the Rockwood Mitnitski Frailty Index. What is their frailty level?

Robust

Pre-frail

Approaching frailty

Frail

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Assessing Frailty in Older Adults

Assessing Frailty Under the Strengthened Aged Care Quality Standards

What Are the Impacts of Frailty?

What Causes Frailty?

Risk Factors for Frailty

What are the Signs of Frailty?

Assessing Frailty

Cardiovascular Health Study (Fried’s Frailty Phenotype Approach)

Clinical Frailty Scale (CFS)

FRAIL Scale

Rockwood Mitnitski Frailty Index

Reported Edmonton Frail Scale (REFS)

Which Frailty Assessment Tool is Best?

Responding to Frailty

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References

Additional Resources

Test Your Knowledge

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