Frailty
Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor event, identified using validated tools and managed through comprehensive geriatric assessment.
Key Facts
Frailty affects approximately 10% of people >65 and 25-50% of people >85 in the UK Fried's frailty phenotype: ≥3 of — unintentional weight loss, exhaustion, low physical activity, slow walking speed, weak grip strength Clinical Frailty Scale (CFS): 9-point scale widely used in UK clinical practice; CFS ≥5 indicates mild frailty Electronic Frailty Index (eFI): uses primary care data to automatically screen for frailty (GP contract requirement) Comprehensive Geriatric Assessment (CGA) is the gold standard management approach; reduces mortality and institutionalisation (meta-analysis evidence) Frailty is potentially reversible in early stages with exercise, nutrition, and medication optimisation Frailty and acute illness: frail patients are at higher risk of delirium, falls, prolonged hospital stay, and death NICE NG56: all people ≥65 should be assessed for frailty using a validated tool at GP encounters
Overview
Key Facts
Frailty is a distinct clinical syndrome, not an inevitable consequence of ageing. Early identification allows intervention to prevent or slow decline.
Epidemiology
- Prevalence: ~10% of people >65; ~25-50% >85
- Pre-frailty (intermediate state): ~40% of people >65
- More common in women, lower socioeconomic groups, and those with multimorbidity
- Frail individuals have 2-3× higher risk of falls, hospitalisation, disability, and death
Aetiology
- Biological ageing: sarcopenia, immune dysregulation, neuroendocrine decline
- Multimorbidity: cumulative effect of multiple chronic conditions
- Polypharmacy: drug side effects and interactions
- Social factors: isolation, poverty, malnutrition
- Psychological: depression, cognitive decline
Pathophysiology
- Sarcopenia: age-related loss of muscle mass and function (central to frailty)
- Chronic inflammation: elevated IL-6, TNF-α, CRP ("inflammageing")
- Neuroendocrine dysregulation: reduced IGF-1, DHEA-S, testosterone
- Immune senescence: impaired response to infection and vaccination
- Dysregulated stress response: reduced physiological reserve → disproportionate decline after minor stressor (e.g. UTI → delirium → falls → hip fracture → death)
Clinical Presentation
Frailty Syndromes
- Falls
- Delirium
- Immobility
- Incontinence
- Susceptibility to medication side effects
Fried's Frailty Phenotype (≥3 of 5)
- Unintentional weight loss (>4.5 kg in past year)
- Self-reported exhaustion
- Low physical activity
- Slow walking speed (<0.8 m/s)
- Weak grip strength (below age/sex norms)
Clinical Frailty Scale
- 1-3: Well/managing well
- 4: Vulnerable (not dependent but slowing)
- 5: Mildly frail (needs help with IADLs)
- 6: Moderately frail (needs help with ADLs and IADLs)
- 7: Severely frail (completely dependent, approaching end of life)
- 8: Very severely frail (completely dependent, bed-bound)
- 9: Terminally ill
Red Flags
- Rapid functional decline
- Unintentional weight loss >5% in 6 months
- Recurrent hospital admissions ("revolving door")
- New delirium or confusion
- Polypharmacy (≥10 medications)
- Social crisis (carer breakdown, self-neglect)
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Depression | Low mood, anhedonia, fatigue | PHQ-9, GAD-7 |
| Hypothyroidism | Fatigue, weight gain, cold intolerance | TFTs |
| Heart failure | Dyspnoea, oedema, fatigue | BNP, echocardiography |
| Malignancy | Weight loss, fatigue, pain | Bloods, imaging |
| Anaemia | Fatigue, pallor, dyspnoea | FBC, haematinics |
| Dementia | Cognitive decline, functional impairment | Cognitive assessment, MRI |
Diagnosis / Investigation
Bedside
- Clinical Frailty Scale: quick bedside assessment
- Functional assessment (ADLs, IADLs)
- Nutritional screening (MUST score)
- Cognitive screening (4AT, AMT, MoCA)
- Mood assessment (GDS-15)
- Gait speed and grip strength
Bloods
- FBC, U&Es, LFTs, TFTs
- Vitamin D, B12, folate, ferritin
- HbA1c, albumin (nutritional marker)
- CRP (chronic inflammation)
Imaging
- As directed by CGA findings (not routine for frailty itself)
- CXR if respiratory symptoms
- DEXA if osteoporosis risk
Special Tests
- Electronic Frailty Index (eFI): automated from GP electronic health records
- Comprehensive Geriatric Assessment (CGA): holistic multidomain assessment
- FRAX/QFracture: fracture risk
- Medication review using STOPP/START criteria
Management
Non-pharmacological
- Comprehensive Geriatric Assessment (CGA): multidimensional assessment by MDT (geriatrician, physiotherapist, OT, dietitian, social worker, pharmacist)
- Exercise: resistance training + balance exercises (most effective single intervention)
- ≥150 minutes/week moderate activity; strength exercises ≥2 days/week
- Nutrition: adequate protein intake (1.0-1.2 g/kg/day); high-calorie supplements if malnourished (Fortisip, Ensure)
- Social support: address isolation, befriending, day centres
- Advance care planning: discuss preferences for future care
- Falls prevention: as per NICE CG161
Pharmacological
- Medication optimisation: deprescribing using STOPP/START criteria
- Stop: unnecessary PPIs, long-term benzodiazepines, anticholinergics, duplicate drugs
- Consider stopping statins if life expectancy <1 year
- Vitamin D supplementation: 800-1,000 IU daily
- Treat underlying conditions: anaemia, hypothyroidism, depression, heart failure
- Vaccination: annual influenza, pneumococcal, COVID-19, shingles
Surgical/Interventional
- Frailty assessment should inform surgical decision-making (CFS used in perioperative risk assessment)
- Prehabilitation before elective surgery in frail patients
- Rockwood CFS ≥5 associated with increased surgical complications and mortality
Referral Criteria
- Moderate-severe frailty (CFS ≥6): geriatric medicine assessment
- Complex multimorbidity: MDT CGA
- Recurrent admissions: community geriatrics/integrated care team
- Carer strain: social services, carer support
- Approaching end of life: palliative care referral
Prognosis
- Pre-frailty is reversible in approximately 40% with exercise and nutrition
- Mild frailty may stabilise or improve with intervention
- Moderate-severe frailty: progressive in most; focus shifts to maintaining quality of life
- CGA in hospital reduces mortality (OR 0.76) and increases likelihood of being alive and at home at 12 months
- Frail older adults have 2-3× mortality compared to non-frail age-matched individuals
- Frailty index predicts mortality better than age or individual comorbidities
- Quality of life and patient-centred goals should guide management in advanced frailty
Other Relevant Information
Clinical Frailty Scale (Rockwood)
| Score | Category | Description |
|---|---|---|
| 1 | Very fit | Robust, active, energetic |
| 2 | Well | No active disease, less fit than category 1 |
| 3 | Managing well | Medical problems well controlled |
| 4 | Vulnerable | Not dependent but symptoms limit activities |
| 5 | Mildly frail | Needs help with IADLs (finances, transport, housework) |
| 6 | Moderately frail | Needs help with ADLs and IADLs |
| 7 | Severely frail | Completely dependent; approaching end of life |
| 8 | Very severely frail | Completely dependent; cannot recover from minor illness |
| 9 | Terminally ill | Life expectancy <6 months |
Comprehensive Geriatric Assessment Domains
| Domain | Assessment |
|---|---|
| Medical | Problem list, medication review, comorbidities |
| Functional | ADLs, IADLs, mobility, falls |
| Cognitive | MMSE, MoCA, 4AT (delirium) |
| Psychological | Depression (GDS), anxiety |
| Nutritional | MUST, weight, dietary intake |
| Social | Living situation, carers, isolation, finances |
| Environmental | Home safety, aids and adaptations |