Guidelines for preventive activities in general practice

Miscellaneous

Frailty

      1. Frailty

Miscellaneous | Frailty

Screening and case-finding age bar

0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80

Frailty generally occurs later in life and results in physiological decline. It is estimated that more than 20% of Australians will become frail as they age,1 with declines in multiple domains, including physical function (eg weakness, slow walking speed, unintentional weight loss), cognition and nutritional status (eg appetite loss).2 Older people who are frail are vulnerable to adverse health outcomes, including procedural complications, falls, institutionalisation, disability and death.3,4 Frailty is on a spectrum, with older people with mild frailty (becoming ‘slow’ and losing muscle strength) at increased risk of becoming severely frail (resulting in loss of independence, and need for care in residential aged care home).

Frailty can also occur in younger adults, particularly vulnerable people with disability or onset of illness;5 however, more research is needed in this area.6

Screening

Recommendation Grade How often References
Consider screening for frailty as part of an assessment of elderly patients (aged ≥75 years) using a validated rapid frailty instrument suitable to the specific setting or context (refer to Further information). Practice point Every 12 months. 2
 

Case finding

Recommendation Grade How often References
Consider screening for frailty as part of an assessment of patients (aged 65–74 and who have factors associated with frailty) using a validated rapid frailty instrument suitable to the specific setting or context (refer to Further information). Practice point Every 1–3 years. 2
 

Preventive activities and advice

Recommendation Grade How often References
To slow or reverse the progression of frailty:
  • offer a multi-component progressive physical activity program, including resistance and aerobic exercise; consider early involvement of a physiotherapist or exercise physiologist if possible
  • encourage optimised nutrition
  • provide medication management
  • encourage enhanced social connectedness.
 
Practice point N/A 2
 

Risk factors for frailty

There are a number of factors associated with increased risk of frailty. These include:4

  • older age
  • current smoker
  • lower educational level
  • current use of postmenopausal therapy
  • not being married
  • depression
  • intellectual disability
  • being of Aboriginal and Torres Strait Islander descent
  • sedentary lifestyle
  • undernutrition
  • chronic disease
  • multimorbidity
  • polypharmacy
  • obesity.

Screening for frailty

A health assessment for people aged ≥75 years provides a good opportunity for GPs to case-find people who are frail or pre-frail.

Screening for frailty helps to identify functional decline. Commonly used frailty scoring tools include the following.4 

  • Frailty indicators – ask about and score:
    • unintentional weight loss (≥4 kg in the past year)
    • self-reported exhaustion
    • weakness (reduced grip strength)
    • slow gait speed
    • low physical activity.

Frailty = ≥3 of the above; pre-frailty = 1–2 of the above; not frail = none of the above.7

  • Frailty index – based on the accumulation of illnesses, functional deficits, cognitive decline and social circumstances, it involves answering >20 medical and functional questions.8
  • Clinical Frailty Scale – helpful scale that takes very little time.
  • Edmonton Frail Scale – scale that rates frailty from 0 to 17.9
  • Frail Scale Risk Assessment – scale that assesses fatigue, resistance, ambulation, illness, and loss of weight.
  • Other useful simple tests with variable specificity and sensitivity:10
    • slow walking speed (>5 seconds to walk 4 metres)
    • Timed Up & Go test (>10 seconds to stand from a chair, walk 3 metres, turn around, walk back to the chair and sit down again).

The screening tool may include a number of components, such as assessing:2,4

  • slow gait speed
  • unintentional weight loss
  • mood
  • accumulation of illnesses
  • social circumstances
  • cognitive difficulties
  • polypharmacy
  • weakness
  • exhaustion.

Pathophysiology of frailty

For information on the pathophysiology of frailty, including further detail about the immune, endocrine, stress and energy response systems changes that contribute to the development of frailty, please refer to the ‘Frailty’ chapter in the RACGP aged care clinical guide (Silver Book) – Part A.

There are no additional recommendations for Aboriginal and Torres Strait Islander people.

Further information about frailty in an aged care setting:
Frailty | RACGP aged care clinical guide (Silver book) – Part A | RACGP

  1. Thompson, M, Theou O, Karnon J, et al. Frailty prevalence in Australia: Findings from four pooled Australian cohort studies. Australas J Ageing 2018;37: 155–58. doi: 10.1111/ajag.12483.
  2. Dent E, Morley JE, Cruz-Jentoft AJ, et al. Physical frailty: ICFSR international clinical practice guidelines for identification and management. J Nutr Health Aging 2019;23(9):771–87. doi: 10.1007/s12603-019-1273-z.
  3. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in older people. Lancet 2013;381(9868):752–62. doi:
  4. The Royal Australian College of General Practitioners. RACGP aged care clinical guide (Silver Book). 5th edn. RACGP, 2019.
  5. Spiers GF, Kunonga TP, Hall A, et al. Measuring frailty in younger populations: A rapid review of evidence. BMJ Open 2021;11:e047051. doi: 10.1136/bmjopen-2020-047051.
  6. Loecker C, Schmaderer M, Zimmerman L. Frailty in young and middle-aged adults: An integrative review. J Frailty Aging 2021;10(4):327–33. doi: 10.14283/jfa.2021.14. PMID: 34549246.
  7. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56(3):M146–56. doi: 10.1093/Gerona/56.3.m146.
  8. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci 2007;62(7):722–27.
  9. Wryko Z. Frailty at the front door. Clin Med (Lond) 2015;15(4):377–81.
  10. Turner G, Clegg A; British Geriatrics Society; Age UK; Royal College of General Practitioners. Best practice guidelines for the management of frailty: A British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing 2014;43(6):744–47.
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