Using Frailty Measures

This resource is intended to provide guidance to clinicians in providing care that is tailored to the needs of older adults who live with frailty. The primary focus is on frailty measures that have been adopted in the province of Alberta, Canada, but the principles can be applied to other measures and jurisdictions. Frailty measures add context to person-centered decisions about goals of care and care planning. The Clinical Frailty Scale (CFS) (1) and Edmonton Frail Scale (EFS) (2) are complimentary in achieving this, and are highly correlated in critical care settings (3).

Goals of Care

Frailty measures add context to advanced care planning. An unhurried dialogue that empowers the individual with information about their health and future goals is best done well before a crisis. Frailty measures can aid in making decisions on hospital and intensive care, but under normal circumstances should not exclude patients from these settings.

Defining Care Needs

Frailty measures are also used to define what aspects of frailty can be addressed. Multidimensional measures such as the Edmonton Frail Scale are well suited to this task. Frailty inclusive care defines how to best enhance care, especially in community settings. This helps avoid hospital admission and shortens length of stay.

When virtual administration is needed, we recommend using the EFS-AC. The EFS-AC retains the same categories and scoring characteristics of the original EFS, while enhancing usability in virtual and acute care. Please note that the EFS-AC replaces the Clock-Drawing Test and Timed Up and Go based on previously validated interview items (6,7). The EFS-AC as a whole has not yet been concurrently validated in comparison to the EFS and other frailty measures, nor has it been prospectively validated. However, the face validity in comparison to the EFS is very good.

Frailty Inclusive Care

Frailty Inclusive Care prioritizes the multidimensional needs of the person living with frailty. It is based on advanced care planning, but is not the same as Palliative Care or End-of-Life support. It Emphasizes principles of Comprehensive Geriatric Assessment.

Frailty Inclusive Care helps address two hazards with frailty measures: the problem of labeling and the use of frailty as an exclusion criteria.

Two Important Cautions

Labeling is when we assign an unwanted identity. Frailty should never define a person. Rather, it is a health related characteristic that should be of most interest to the individual. Try to use terms like “living with frailty”, “having less resilience”, and “having less room for error”. Reckless use of ‘frailty’ as a label can have negative consequences (8).

Frailty as an exclusion criteria. Only in the most extreme circumstances of overwhelmed surge capacity should a health care system consider rationing resources based on frailty. Frailty should be part of a person-centered discussion before, during, and after health care stress such as acute illness or highly invasive procedures. Frailty should inform affirmative approaches to care.

References

  1. Rockwood K, Song X, MacKnight C, et al., A global clinical measure of fitness and frailty in elderly people. CMAJ, 2005. 173(5): p. 489-495 DOI: 10.1503/cmaj.050051.

  2. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K Validity and Reliability of the Edmonton Frail Scale.  Age and Ageing 2006 Sep;35(5):526-9.

  3. Darvall JN, Greentree K, Braat MS, et al., Contributors to frailty in critical illness: Multi-dimensional analysis of the Clinical Frailty Scale. J Crit Care, 2019. 52: p. 193-199 DOI: 10.1016/j.jcrc.2019.04.032

  4. Wallis SJ, Wall J, Biram RW, and Romero-Ortuno R, Association of the clinical frailty scale with hospital outcomes. Qjm, 2015. 108(12): p. 943-949 DOI: 10.1093/qjmed/hcv066.

  5. McNeil, S, Andrew M and other co-investigators in the Serious Outcomes Surveillance Network. See http://cirnetwork.ca/network/serious-outcomes/

  6. Hilmer SN, Perera V, Mitchell S, Murnion BP, Dent J, Bjoreck B, Matthews S, Rolfson DB, The assessment of frailty in older people in acute care. Australas J Ageing. 2009 Dec;28(4):182-8.

  7. Rose M, Yang A, Welz M, Masik A, Staples, M. Novel modification of the Reported Edmonton Frail Scale. Australa J Ageing 2018Dec;37(4):305-308. doi: 10.1111/ajag.12533

  8. Warmoth K, Lang IA, Phoenix C, Abraham C, Andrew M, Hubbard R, Tarrant M. ‘Thinking you’re old and frail’: a qualitative study of frailty in older adults. Ageing & Society 36, 2016, 1483-1500. doi:10.1017/S0144686X1500046X