Frailty

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

Your Role as a Health Care Provider

We cannot change what we do not measure. Understanding and screening for frailty will help you:

  • Understand the overall health of your patients and tailor care to individual needs
  • Achieve patient-identified outcomes
  • Align, or reframe, patient, family, and/or caregiver expectations to better support outcomes
  • Inform patients about what may be expected in the future
  • Empower patient decision-making and help patients focus on remaining capabilities
  • Understand and connect with caregiver capacity and needs. Frail persons typically depend on at least one other person
  • Prompt improvements in the care for all patients

Identifying Frailty

A local frailty identification tool, the Frailty Screen form, was developed for use by non-geriatric focused clinicians. It is intended for use by all clinical team members, such as physicians, nurses, and interdisciplinary staff. The Frailty Screen form provides:

  • An opportunity to investigate specific domains of frailty (mobility, function, and cognition)
  • Direction to ask for collateral source information regarding a patient's social circumstances
  • Consistency with documenting patient's baseline cognitive status and baseline frailty level
  • Frailty levels that are compatible with the Clinical Frailty Scale

It will be up to each clinical area in which care is provided to determine when the form will be used, and by whom, and where it will be placed within patient charting. It is best to complete a frailty screening during the initial contact or assessment time with patients/clients as knowing baseline frailty level earlier may impact the patient’s care path.

Using the Frailty Screening Form

Before using the Frailty Screening form, it is important to keep key concepts about frailty and the domains of frailty in mind.

All members of the health care team should feel comfortable with the concept of frailty - what it is and what it generally means for patient care. In order to provide appropriate patient care, all members of the health care team should be able to contribute to the assignment of a patient’s frailty level.

Frailty is determined using baseline characteristics. Acute changes don’t count.

Examples:

  • We wouldn’t say a patient is visually impaired if the patient's eyes are dilated for an exam.
  • We wouldn’t say a patient has lung disease if the patient is suffering from pneumonia.

Within your care setting, baseline typically refers to:

Care Sector Determining Baseline
Inpatient/Emergency Department How was the patient before getting sick? (Approximately 2 weeks prior to experiencing the acute issue that brought the patient to the hospital)
Outpatient (Ambulatory Care/Primary Care) As a caregiver/family member of the patient/client, is what you are seeing in terms of mobility and cognition a good reflection of the patient/client’s usual self?
  • If yes, use your observations of mobility, cognition and functional history to stage frailty.
  • If no, determine when patient/client was at baseline and what mobility, cognition and function were like at that time.

Cognitive Screen

Cognition means memory and thinking (i.e., language, orientation, ability to plan and carry out activities, ability to remember and recognize people). When it comes to frailty, we are interested in changes in cognition. Changes in cognition in frailty are often due to delirium or dementia. It’s important to consider that mood disorders, such as depression, can also impact a person’s memory and cognitive testing.

Characteristics of Dementia vs. Delirium

Feature Dementia Delirium
Onset Usually gradual over months or years Sudden change within days
Course Progressive (gets worse over time) Symptoms of delirium fluctuate during the delirium
Duration Permanent Days to weeks
20% of patients never return to prior baseline

Cognition is the most under-recognized driver of frailty. Once recognized, cognitive impairment should cue providers to take special care in how information is gathered and delivered and with how decisions are made. Often, this requires involvement of a caregiver, family member or substitute decision maker.

Although the diagnosis of dementia or delirium is often provided by a physician, all members of the health care team should be able to ask the patient questions according to a standard scheme. This informs the assignment of the patient’s baseline frailty level. A brief cognitive screen tool is available as part of the Frailty Screen form.

Cognitive impairment is only one component of frailty. For example, if a person has moderate dementia, that person may be severely frail on the frailty scale if physical problems impair basic activities of daily living (e.g. personal care).

Consider using the optional cognitive screening tool if:

  • It is your preferred tool
  • No geriatric consultation information is available regarding cognitive status
  • No other cognitive screening tool is available to you

The cognitive tool takes approximately 5-10 minutes to administer. Other cognitive tools can also be utilized (e.g. Mini Mental Status Exam) and resources can be accessed (e.g. geriatric consultation).

 The Frailty Assessment Care Planning Tool

Nova Scotia Health Authority, 2017.

Mobility & Function

In addition to understanding baseline cognitive status, understanding baseline frailty in terms of mobility and function is equally important. For example, when assigning a frailty level, a person could be mildly frail due to their cognitive level but may also need minor assistance with bathing, due to physical limitations. This functional impairment would move them into the moderately frail level.

Frailty Level Descriptors table can be used for:

  • Reference purposes within your clinical area
  • A helpful point of reference for teams to use
    • in case conferences
    • within clinician offices 
    • when discussing frailty levels with colleagues

Collateral Sources

It is important to connect with others in the patient/client’s support system who can offer or validate information about the patient’s baseline status. Collateral sources include people such as:

  • Family members
  • Friends
  • Paid caregivers
  • A neighbour
  • A landlord/superintendent

Some key questions to ask of the collateral source(s) include:

  • Is this person their usual self today in terms of their memory and thinking?
  • Do you have any concerns about this person’s memory or thinking?
  • Tell me how this person was doing with their walking when they were well.
  • Tell me how things were going with their ability to accomplish day-to-day activities when they were well.

Rules for Screening

It is important to consider the following points when establishing a patient’s frailty level:

  • The cognitive screen is only valid for staging frailty if the collateral says the patient is at their cognitive baseline. If the patient is not at their baseline, consider delirium.
  • Regardless of cognitive status, information used to inform function and mobility should be from the collateral historian or the health care provider’s observation of the patient.
  • The level refers to baseline cognition, mobility and function. Function, mobility or cognition during an acute illness is unlikely to represent baseline frailty.
  • The ‘worst’ level wins. Remember: A patient only needs to experience one of the descriptors within a level to place there.
  • If the patient reaches a new plateau in their health status (further gains are not expected), they may be at a new baseline. Therefore, the new frailty level is to be re-assessed.

Reassessment

In some settings (e.g. acute care), a patient may reach a plateau in recovery related to cognition, mobility, or function. When this occurs, a new baseline frailty level should be assigned.

To determine the frailty level, ask yourself :

Is this the best we can expect this person to be in the future—is this their new baseline?

If yes, assign a new frailty score using the same process.

In other care setting (e.g. primary care), it is important to ask yourself if you have seen any changes in the patient since you last saw them. Alternatively, if an event has occurred that could impact frailty (a fall, a recent visit to the emergency department, changes observed in memory or thinking), re-visiting the frailty level using a similar process is suggested.