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Frailty and Elder Care Network

The Frailty and Elder Care Network enhances care for older adults in Nova Scotia, particularly those living with frailty - a condition that increases a person's vulnerability, which can lead to greater risk of adverse health outcomes.

What is Frailty?

Frailty is not a disease, but it profoundly influences disease expression.

Howlett, Rutenberg & Rockwood, 2021

Frailty is a "geriatric syndrome [that is] a state of increased vulnerability across multiple health domains that leads to adverse outcomes" (Allison, Assadzandi & Adelman, 2021).

  • Frailty increases with age.
  • People living with increased frailty have more complex needs than others of the same age.
  • Frailty increases an individual’s vulnerability to adverse health outcomes like the risk of dying.
  • Frailty challenges how we currently deliver health care.

Why Frailty Matters

Nova Scotia’s population is aging and people are living longer; however, increased longevity does not always mean more years of good health and quality of life. Older adults living with frailty face a higher risk of adverse health outcomes such as falls, hospitalizations, institutionalization, disability, and death. 

Current health care systems are not designed to handle the complex needs of patients with multiple chronic conditions.

Understanding frailty is critical for healthcare providers to improve care pathway planning and patient outcomes.

– Canadian Institute for Health Information. A profile of hospitalized seniors at risk of frailty in Canada — Infographic. Accessed February 29, 2024.

Link to A profile of hospitalized seniors at risk of frailty in Canada

Canadian Institute for Health Information. A profile of hospitalized seniors at risk of frailty in Canada — Infographic. Accessed February 29, 2024.

Prevention

Is frailty an unavoidable consequence of aging? 
The answer is NO. 

Frailty is often preventable and can even be modified. 

Link to text version of How to Prevent and Manage Frailty for You and Your Patients Infographic

How to Prevent and Manage Frailty for You and Your Patients

  • Exercise
  • Nutrition
  • Sleep
  • Smoking cessation
  • Social supports and engagement
  • Management of chronic disease
  • Reduced polypharmacy
  • Fall precautions
— Frailty and Elder Care Network, Nova Scotia Health

Frailty and Hospitalization

Functional decline is one of the leading complications of hospitalized older adults living with frailty. A higher frailty score at the time of hospital admission is a strong predictor of adverse outcomes, including loss of independence and functional abilities. 

Research shows, on discharge, approximately:

  • 83-100% of frail older adults’ time is spent in bed
  • 34% lose independence with one basic ADL (feed, dress, bath & groom, continence)
  • 20% are no longer able to walk without assistance

Unintentional hospital harm and functional decline occurs in as little as 48 to 72 hours of admission and is often driven by factors such as: 

  • Off load delays
  • New malnutrition
  • Decreased mobility
  • IVs and catheters that stay in too long
  • Sleep deprivation
  • Unrecognized delirium
  • Incontinence

To prevent unintentional hospital harm, including functional loss, it is essential for healthcare providers to know a patient's baseline functional status from two weeks before they became ill or hospitalized to assess frailty upon admission.

Clinical Frailty Scale (CFS)

The Clinical Frailty Scale (CFS) is a 9-point risk stratification tool that assists clinicians assess the overall level of frailty in older adults. Developed in Halifax, Nova Scotia in the 1990s by Dr. Ken Rockwood, the CFS scores range from 1 (Very fit) to 9 (Terminally ill), with higher scores indicating greater frailty and risk for adverse health outcomes.

The CFS is the most widely used frailty tool, extensively cross-validated, and applied internationally across a range of clinical settings and research. It serves as a practical frailty measurement tool, enabling healthcare professionals to identify older adults at increased risk and to guide care planning and resource allocation.

  Link to Clinical Frailty Scale Information and Resources

Establishing the Patient’s Baseline

The CFS score is based on a patient’s baseline functional status — what a patient was able to do two weeks prior to the onset of illness or hospitalization. The baseline does not reflect the patient’s current state or appearance; rather, it offers clinicians a clear picture of the patient’s functional abilities before illness, which is crucial for establishing appropriate recovery or management goals.

The patient’s baseline is determined by asking about the patient’s mobility, and ability to complete activities of daily living (ADLs), such as dressing and feeding, and instrumental activities of daily living (IADLs) such as meal preparation, banking, driving, managing medications, two weeks prior to illness. Understanding a patient’s functional baseline is essential for individualized care planning and for discussions about prognosis and goals of care with patients and their families.

Key Points

The Clinical Frailty Scale:

  • Is a risk stratification tool which informs care planning and predicts patient outcomes.
  • Has been validated on older adults 65 years +.
  • Is a 9-point scale ranging from 1 "Very Fit" to 9 "Terminally Ill", with increasing scores corresponding to living with a higher degree of frailty.
  • Incorporates the notion of degrees of frailty. Saying someone is frail or not frail does not provide a clear enough picture to avoid arbitrary clinician decisions.

CFS is not a questionnaire; rather, it uses judgement based on information gathered from a clinical encounter and verified by speaking with the patient’s essential care partners to determine a patient’s functional baseline what they were able to do two weeks prior to illness or hospitalization.
 

LMS

Nova Scotia Health Learning Management System Course:

  • Clinical Frailty Scale Course code: 1182

Frailty Management and Care Pathway Planning

Early identification allows for the development and implementation of individualized, proactive care plans that prioritize mobility, nutrition, cognitive support, and the minimization of unnecessary medical interventions. This approach can help maintain independence and quality of life for older adults during and after hospitalization.

Recognizing and managing frailty in older adults guides:

  • Estimated Date of Discharge (EDD)
  • Development of strength-based care plans
  • Appropriate consults: Who to include in the care of the patient
  • Discharge planning for home
  • Dignity of Risk: Respecting the patient’s wishes and values
  • Goals of care discussion 

More Resources and References