Tools and resources to assist health care providers with routinely identifying, documenting and communicating frailty in patient care settings.


Clinical Practice Guidelines

Frailty-specific guidelines and recommendations for the treatment of common diseases have been published by Palliative and Therapeutic Harmonization (PATH) and include:

  • Type 2 Diabetes
  • Hypertension
  • Statin use
  • Depression

General Frailty Care Guidelines

General guidelines, for each level of frailty, have also been compiled and made specifically for each care sector. These guidelines are intended to:

  • Serve as a prompt for health care providers to ask themselves some key questions about patients/clients. Related action items are outlined intended for health care providers to consider incorporating into care planning
  • Guide care planning using a frailty lens
  • Assist providers across all care sectors to communicate to other providers about areas for follow-up as patients transition from one care area to another (e.g. from inpatient back home – about follow-up actions required by the family physician)

Ambulatory/Primary Care

Outpatient clinics are rarely set up for frailty. Patients who are frail may have more difficulty attending outpatient appointments or arranging for a family member or caregiver to attend with them. The complexity of the health history may make it harder to retain and apply information discussed.

Multidisciplinary teams can help address the multidimensional issues that arise in frailty. The following frailty level-specific guidelines may assist in formulating a care plan.

Continuing Care

The vast majority of continuing care clients receiving support in the community have some degree of frailty. An aging population means that caregivers are also more likely to be frail. While the goal of community support is to maintain client independence in the community, the inherent risks required to foster independence may be challenging for care providers and families to understand and accept. The following frailty level-specific guidelines may assist in formulating a care plan that fosters independence while acknowledging the dignity of risk.

Emergency Department & Inpatient

Emergency Department

The inherent physical, medical and social complexities of frailty present challenges in a busy emergency department. Patients who are frail often present with atypical signs and symptoms. Delirium is prevalent. The following frailty level-specific guidelines may assist in delivering care that takes frailty into account.


Hospital admission is a risky time in frailty. Often frail patients are in the throes of a health crisis and require attentive and proactive care to promote recovery. The following frailty level-specific guidelines may assist in formulating a care plan.