Frailty recognition and scoring

Frailty describes vulnerability, not an inevitable consequence of age. A relatively minor infection, medicine change or environmental disruption can produce disproportionate delirium, immobility or dependency because several physiological systems have little reserve. Some components improve with treatment and rehabilitation. Explain the concept without using labels such as weak or failing that can erase goals and agency.

Recognise frailty opportunistically when an older person has falls, slow gait, reduced activity, weight loss, exhaustion, recurrent admission, delirium or increasing help with daily tasks. Consider sarcopenia, malnutrition, depression, heart or lung disease, anaemia, neurological disease, pain and adverse medicines as contributors and mimics. A phenotype screen and a deficit-accumulation index describe related but not identical constructs.

NICE multimorbidity guidance suggests informal assessment of gait speed, self-reported health and formal tools such as the electronic frailty index in primary care. A gait speed below 0.8 metres per second, Timed Up and Go around twelve seconds or longer, or poor self-rated health can flag concern. These are case-finding signals affected by pain, environment and acute illness, not universal treatment thresholds.

The electronic frailty index uses coded health deficits to stratify population risk and support proactive case finding. Coding quality and lag matter, and the eFI cannot observe current physiology or goals. Confirm any category clinically before communicating it or using it in an individual plan. A person can be misclassified by missing codes or a temporary cluster of diagnoses.

The Clinical Frailty Scale integrates cognition, mobility, exercise and function. Determine what the person usually did around two weeks before the acute event, using concrete examples and collateral. Distinguish CFS 4 vulnerability from CFS 5, where help is needed with higher-order IADLs; CFS 6 usually includes help with outside activities and housework plus bathing; CFS 7 includes complete personal-care dependence but stable survival beyond six months.

Do not score the ward snapshot. Sepsis, fracture, sedation and delirium can make a previously independent person appear severely frail. Record baseline CFS and current acute dependency separately, with the evidence source and uncertainty. If no reliable history exists, say unscorable rather than manufacture precision. Revisit after delirium and acute organ dysfunction improve.

CFS should generally be used in older adults for whom acquired frailty is the construct. Lifelong cerebral palsy, spinal injury, learning disability and other stable disability may create dependence without the same biological vulnerability. In younger adults or atypical populations, describe function, comorbidity, cognition and physiological reserve directly and seek relevant specialist assessment.

Management begins with CGA rather than a frailty medicine. Treat acute and chronic disease, reconcile and optimise medicines, correct hearing and vision barriers, investigate weight loss, assess oral health and swallowing and address loneliness, housing and care. Physiotherapy and occupational therapy select achievable mobility and activity goals; community services support continuity after discharge.

Progressive resistance, balance and aerobic activity is first-line non-drug management when safe, adapted to symptoms and starting ability. Couple exercise with adequate energy and protein and investigate malnutrition rather than prescribing supplements automatically. Address vitamin D only according to bone-health guidance and deficiency risk, not as a cure for frailty.

Use frailty in proportional decisions as one prognostic variable alongside acute severity, organ-specific evidence, reversibility, previous function, treatment burden and the person's goals. Discuss uncertainty. A person with severe frailty may benefit greatly from fluids, antibiotics, pain control or a time-limited rehabilitation trial, while an invasive intervention with little chance of the desired outcome may reasonably be declined after shared decision.

Document the tool, version, date, baseline period, rater and evidence. Avoid copying a CFS indefinitely across admissions. Monitoring includes falls, mobility, ADLs and IADLs, weight, cognition, medicines, social participation and carer capacity. Improvement or deterioration should update the care plan rather than be treated as score performance.

At transitions, communicate both vulnerability and strengths: what the person can do, what support works, their goals, likely triggers of decompensation and early response plan. Linking frailty identification to a named CGA pathway, urgent community response and anticipatory care is more valuable than maximizing screening coverage.