Experienced and busy clinicians are unlikely to change their current practice without adding value for the patient and their workflow. How can the Edmonton Frail Scale offer that added value?
When simple case finding isn't enough
Many frailty measures are designed to classify an individual as frail. However, frailty is complex, dynamic, and individualized. Comprehensive Geriatric Assessment (CGA) is one way to go beyond case-finding, but it can be time-consuming and resource-intensive. A multidimensional frailty measure that defines both severity and the areas of concern is a nice compromise. Primary care providers and the teams with whom they work should be empowered to define and address frailty before deciding whether more sophisticated CGA is required.
When there is little or no patient record
A frailty index is calculated from a pre-determined list of possible deficits, each which must be classified as present or absent. Judgment-based measures can be completed very quickly, but will depend on a prior clinical assessment including medical, functional and cognitive information. By comparison, the administration and scoring of performance-based measures, questionnaires and the EFS do not require this.
When time is limited
The administration time of a tool, and the division of labor for a care team will impact its feasibility in clinical care. The EFS requires 5-10 minutes to administer and score.
When frailty severity matters
Performance-based measures, frailty questionnaires and the Frailty Phenotype do not inform care providers about the severity of frailty. The CFS (1), eFI (2), and EFS do provide this information. Frailty severity may help estimate prognosis, and determine when to proceed to CGA.
When component definition matters
Frailty is only a starting point. Of the various categories, multidimensional measures such as the EFS are the only ones that define the problem areas that underlie the frailty status. This helps a front-line clinician decide how to spend their time to better understand the particular vulnerable components in their own patient. This information can be used to help decide which inter-professional team members are best suited to assess further. It may also be used as part of an order-set that provides personalized guidance, depending on the area(s) of interest.
When frailty informs the care plan
When we add the component definition step, we walk through a door that opens up options for a patient-centered care plan. If indeed frailty is multidimensional, then we should expect that the constellation of problems and vulnerabilities are uniquely defined in each individual, and the care plan must thereby be tailored to their particular circumstances. Short of referring all frailty cases for CGA, only multidimensional frailty tools will help primary care providers and teams move forward independently.
References
Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173(5):489-95.
Clegg A, Bates C, Young J, Ryan R, Nichols L, Ann Teale E, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age and ageing. 2016;45(3):353-60.
