Comprehensive geriatric assessment (CGA), initially introduced by Marjory Warren, extends beyond traditional medical history and incorporates an interdisciplinary diagnostic process to identify medical, functional, and psychosocial issues in order to develop a personalized care plan to maximize the well-being of the older adult ( 4, 5 ). According to the Korean Health Insurance Review and Assessment Service, in 2012 a total of 36,052 people died in nursing homes, a 60 percent increase compared to that in 2009.66, There have been task force discussions to promote early screening of frailty in nursing homes.67 The FRAIL-NH scale has been developed to identify frail persons in nursing homes.68 It is comprised of 7 items; energy, transferring, mobility, continence, weight loss, feeding and dressing. The Edmonton Frail Scale (EFS), being a performance-based multidimensional frailty assessment tool, is designed to aid in the assessment and screening of frail elderly patients in the primary care . On the CFS card, a person in this category is pictured seated in a chair, reflecting the fact that many older adults who die with a single system illness (like cancer), have a reasonable level of function until about the very end. The scale can be introduced by saying something like: Id like to know how you are doing overall. and then enquiring about[4]: Level 1 Very Fit: People who are robust, active, energetic, and motivated. Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. It is known that physical frailty is a manageable condition that can be targeted for intervention. In both cases, the person is independent in their personal or basic ADLs, but dependent on one or more instrumental. In summary, frailty has no gold standard measure, however there are two commonly used frailty models. . Finally, various intervention models that target frailty in various settings need to be developed. The FRAIL Scale considers five attributes: the presence of fatigue, the ability to climb stairs, difficulty with ambulation, comorbidities (greater than 5), and unexpected weight loss (greater than 5% in a 12-mo period). Validation of the clinical frailty scale for prediction of thirty-day mortality in the emergency department. If they fit two categories equally well, in routine care it is best to score the scale at the higher or more dependent level. Typically, they could not recover even from minor illnesses. Federal government websites often end in .gov or .mil. In case a terminally ill person is completely dependent for personal care at baseline, they will be scored as Level 8. References: A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial. Cautions have been raised against rushing to implement frailty assessment and CGA in general clinical settings. Each of these instruments, and more,are detailed in the following sections. Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. Frailty assessment often rely on subjective frailty assessment, such as 'the end-of-the-bed' or 'eyeball' test. Eamer G, Taheri A, Chen SS, Daviduck Q, Chambers T, Shi X, et al. Feasibility and effectiveness of intervention programmes integrating functional exercise into daily life of older adults: a systematic review. 2018; 22 (1):20-5. doi: 10 . The inter-rater reliability of the Clinical Frailty Scale between the pre-assessment consultant and pre-assessment nurse was determined by comparing their frailty scores for each patient. Vitamin D with calcium reduces mortality: patient level pooled analysis of 70,528 patients from eight major vitamin D trials. 4) Apparently vulnerable (not dependent but 'slowed up' or with disease symptoms) Time to complete: varies depending on number and type of measures included. Use of the frailty index and FRAIL-NH scale for the assessment of the frailty status of elderly individuals admitted in a long-term care hospital in Korea. Harrison's Principles of Internal Medicine. Moving frailty toward clinical practice: NIA intramural frailty science symposium summary. Gleason LJ, Benton EA, Alvarez-Nebreda ML, Weaver MJ, Harris MB, Javedan H. FRAIL questionnaire screening tool and short-term outcomes in geriatric fracture patients. Objective: Validity: CFS score is a valid diagnostic instrument to measure frailty in older hospitalized patients and patients in the emergency department. Another assessmentof deficit accumulation-type frailty is the Edmonton Frail Scale: Category III. Kim DH, Afilalo J, Shi SM, Popma JJ, Khabbaz KR, Laham RJ, et al. Jones DM, Song X, Rockwood K. Operationalizing a frailty index from a standardized comprehensive geriatric assessment. sharing sensitive information, make sure youre on a federal Usual gait speed is associated with frailty status, institutionalization, and mortality in community-dwelling rural older adults: a longitudinal analysis of the Aging Study of Pyeongchang Rural Area. References: Abellan van Kan G, Rolland YM, Morley JE, Vellas B. Frailty: toward a clinical definition. The clinical tools deployed by geriatricians to assess frailty can be grouped into two categories; using a questionnaire-based method or analyzing the physical performance of the subject. Intended Population: Frail elderly population, all individuals, Particular attention should be paid to those who score 5 or more as this is the marker for requiring a. WTP2.2 Subjective Assessment of Frailty Compared to Validated Frailty The original 7th category, 'Severely frail,' has since been split into categories 7-9. Recognizing the Needs of High-Need High-Risk Veterans. A striking, large-scaled, randomized controlled trial published in the New England Journal of Medicine revealed that a one-time frailty assessment by a consultative team cannot improve mortality and functional status for hospitalized patients.36 They emphasized that hospitalized frail older patients only benefit from CGA when optimized management programs are accompanied continuously. Palliative Care Needs of Physically Frail Community-Dwelling Older Adults With Heart Failure. McAdams-DeMarco MA, Law A, King E, Orandi B, Salter M, Gupta N, et al. Forman DE, Rich MW, Alexander KP, Zieman S, Maurer MS, Najjar SS, et al. Prevalence and associated factors of frailty in patients with chronic kidney disease: a cross-sectional analysis of PEAKING study. CGA provides physicians with information on the reversible area of frailty and the leading cause of deterioration in frail older adults. The influence of outpatient comprehensive geriatric assessment on survival: a meta-analysis. A prospective population-based comparison of outcome in fractured neck of femur. Comprehensive geriatric assessment for older people admitted to a surgical service. A scoping review of the Clinical Frailty Scale. Chuang HW, Kao CW, Lee MD, Chang YC. Category II. 2023 Aug 9. doi: 10.1007/s11255-023-03720-z. A multicomponent frailty intervention for socioeconomically vulnerable older adults: a designed-delay study. On the other hand, deficit accumulation model which calculates FI is more time-consuming. Pre-Disability Assessment:This assessment model has emerged as a definition of frailty that posits frailty as a precursor to overt disability in older persons. Comprehensive geriatric assessment (CGA) is the process of identifying and quantifying frailty by examining various risky domains and body functions, which is the basis for geriatric medicine and research. Frailty instruments have been used for a number of different purposes in research studies; please see Matching the Assessment Method to the Goal for further detail. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. 22 There are 5 components: fatigue, resistance, ambulation, illnesses, and loss of weight. Nevertheless it provides a more quantitative value of frailty and can acquire information on the vulnerability domain and reversible cause which has substantial benefits.9 FI can be calculated using items from the standard CGA and does not require a separate CGA process.18,19 The FI-CGA was initiated by both using data from a standardized CGA and data derived from the clinical examination of a population study.18,19 The FI-CGA correlated highly with an empirical FI and was associated with higher risk of death and institutionalization. In the area of surgery, frailty is an independent risk factor for mortality, morbidity, length of stay, and postoperative complication.4,22 Frailty assessment has been most widely used in orthogeriatrics for hip fracture surgery. Boyd PJ, Nevard M, Ford JA, Khondoker M, Cross JL, Fox C. The electronic frailty index as an indicator of community healthcare service utilisation in the older population. The goal of this scoping review was to describe current use of the CFS in emergency medicine and to identify gaps in research. Prevention of functional decline by reframing the role of nursing homes? Frailty: Evaluation and Management | AAFP FRAIL Questionnaire Screening Tool and Short-Term Outcomes in - PubMed Theou O, Rockwood K. Should frailty status always be considered when treating the elderly patient? Pham HM, Nguyen AP, Nguyen HTT, Nguyen TN, Nguyen TX, Nguyen TTH, Nguyen HTT, Nguyen AT, Nguyen QN, Tran GS, Vu HTT. About 80% or more of people fit the description offered for a given level. Frailty assessment and CGA can be applied in risk stratifications such as mortality or morbidity, disease-specific treatment-related risk assessment, goal of care and advanced care planning, and frailty-targeted intervention.2 However, a full CGA is rather time-consuming and its effectiveness is far limited without inter-department collaborative care and frailty-targeted optimized intervention programs.3 In this review article, we summarize the clear benefits and limitations of frailty assessment and CGA in various clinical settings and decision making. Would you like email updates of new search results? Dent E, Kowal P, Hoogendijk EO. Background: We aimed to evaluate the potential utility of the Robinson Frailty Score (RFS), the Edmonton Frail Scale (EFS), and the G8 tool for predicting postoperative adverse events (AEs) in older adults with cancer. Phenotypic frailty proposed by Fried and colleagues, views frailty as a biologic syndrome of decreased physiologic reserve. Assessment of frailty in Saudi community-dwelling older adults: validation of measurements. Frailty is defined as a clinical syndrome driven by age-related biologic changes that drive physical characteristics of frailty and eventually, adverse outcomes. Frailty is defined as a reduced physiologic reserve vulnerable to external stressors. The frailty phenotype or physical frailty approach, views frailty as a syndrome whereas the FI approach views frailty as a spectrum of aging.8,9 Frailty phenotype itself can detect high risk patients, however it is difficult to work out the causal relationship between the risk domains. A common complaint is being slowed-up and being tired during the day. Higher proportion equates to a higher level of frailty. Age Ageing. sharing sensitive information, make sure youre on a federal An official website of the United States government. It has been validated in adults aged over 65 years. Operationalizing phenotypic frailty can be adapted and altered by measurements based on CGA.11 We need to try and evaluate all physical domains in CGA, however it can differ due to clinical settings and subspecialty.21. Kaeppeli T, Rueegg M, Dreher-Hummel T, Brabrand M, Kabell-Nissen S, Carpenter CR, Bingisser R, Nickel CH. In patients undergoing kidney transplantation, the frailty phenotype showed significant ability to distinguish patients at high-risk of death or early readmission.27 For older patients with end-stage liver disease waiting liver transplantation, researchers found that the frailty status determined the deterioration of quality of life rather than severity of liver disease.28 Guidelines from American College of Surgeons for Surgery and National Institute for Health and Care Excellence also emphasized frailty assessment in acute care settings or preoperative period as a new screening criterion for fitness.9,23, Oncology is one of the areas where frailty is most widely integrated into clinical practice. Reducing delirium after hip fracture: a randomized trial. Annual Health Insurance Statistics for 2012. Frailty assessment is a critical approach in assessing the health status of older people. . https://www.physiospot.com/research/frailty-scale-classification-tree/, Validation of the Clinical Frailty Scale for retrospective use in acute care. VA's 2020 study looked at data on more than 400,000 Veterans who had non-cardiac surgeries at a VA facility. [8] This scale has largely not been validated in younger people as a disability in younger people (including both acquired, as in spinal cord injury, and life-long, as in intellectual disability) does not have the same meaning for prognosis that it does with age-related disability[4]. RCT = randomized controlled trials, Adm = admission, Readm = readmission. Like physical frailty, deficit accumulation frailty predicts adverse outcomes. The accumulation of deficits definition of frailty, often termed as the frailty index (FI) is based on the cumulative effect of medical, functional and psychosocial age-related deficits. Further trials on CGA based geriatric interventions are ongoing.48, In older adults admitted to hospital as an emergency, they were significantly more likely to survive admission and return home, fewer will die or experience deterioration and more will have improved cognitive functioning if they undergo CGAs while they are inpatients.49, The prevalence of frailty is estimated to be 10% in community dwelling older adults and increases up to 60% in those with advanced cardiovascular disease.59 Several randomized controlled trials have tested the effect of interventions targeting mainly physical inactivity, nutritional status, depression or falls in community settings shown in Table 2.60,61,62,63,64 The Lifestyle Interventions and Independence for Elders pilot study reported that a 12-month physical activity intervention was associated with 9% lower frailty prevalence.61. care practice and is useful in the identification of patients who may require referral for comprehensive geriatric assessment. Jung HW, Yoo HJ, Park SY, Kim SW, Choi JY, Yoon SJ, et al. The FI developed by Rockwood and colleagues, is a count of 70 clinical deficits from the Canadian Study of Health and Aging. Frailty is defined as a condition of decreased physiologic reserve that leads to a vulnerable state and increase the risk of adverse health outcomes when exposed to a stressor in older adults.1 Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic process that evaluates medical, functional, psychological, and social capabilities, to eventually assess frailty status and various geriatric syndromes. When selecting a frailty assessmentinstrument for research or to inform clinical care, it is important to identify an instrument that best fits the purpose of the study or clinical need. Each item is scored, and then all scores are summed out of 17 points possible. Frailty in older adults: evidence for a phenotype. Table 3 shows previous interventions for frail older adults in nursing homes.70,71,72,73,74 Also nutritional interventions such as protein supplement to prevent functional decline in nursing home patients are in progress.75 However, intervention trials for nursing homes are still lacking and need more evidence and programs. Comprehensive geriatric assessment - UpToDate RCT = randomized controlled trials, ADL = activities of daily living. 2001;56(3):M146-M156. The most persuasive evidence of CGA comes from programs that rely on specialized inpatient units and long hospital stays. It is important to note that the sub-groups deemed frail by different methods often have minimal overlap (Cigolle et al., 2009; Xue et al., 2019). Frailty: emergence and consequences in women aged 65 and older in the women's health initiative observational study. The CFS is easy and quick to administer in a clinical setting. They may include different measures from different domains (e.g., physical function, cognition nutrition). Walston J, Bandeen-Roche K, Buta B, Bergman H, Gill TM, Morley JE, et al. Given a highly prevalence of frailty and disability in nursing homes, intervention trials to reverse frailty status or physical function are limited. Kaehr EW, Pape LC, Malmstrom TK, Morley JE. Reliability: The CFS is a reliable instrument to identify frailty in the emergency department. 8600 Rockville Pike Kim DH, Schneeweiss S, Glynn RJ, Lipsitz LA, Rockwood K, Avorn J. A Simple Frailty Questionnaire (Frail) Predicts Outcomes in Middle Aged There are 4 possible treatments that appeared to have some efficacy in the treatment of frailty; 1) exercise (resistance and aerobic), 2) caloric and protein support, 3) vitamin D, 4) reduction of polypharmacy.39,40 Exercise in frail individuals increase functional performance, decrease hospitalizations and falls.39 Protein-calorie supplementation is effective in the treatment of weight loss, increase in muscle mass and grip strength.41 Vitamin D supplementation is also known to reduce falls, hip fractures and mortality.42,43 Polypharmacy, a possible major contributor to the pathogenesis of frailty can be reduced to decrease costs and medication side effects in frail populations.44,45. Frailty and Comprehensive Geriatric Assessment - PMC CGA has been around for more than 3 decades and is one of the cornerstones of modern geriatric care and helps to develop a coordinated and integrated plan for treatment and long-term follow-up.15 The core domains of CGA are functional status, cognition, emotional status, nutritional status, comorbidities, polypharmacy, and geriatric syndromes (fall risk, delirium, urinary incontinence, dentition, visual, or hearing impairments. descriptive scales, disability assessments and comorbidity assessments. A clinician assigns one of the seven categories based on observation of the patient and review of medical records. As mentioned above, detailed frailty assessment is burdensome especially if applied to all older adults. An interdisciplinary protocol for frail trauma patients, including early ambulation, bowel/pain regimens, nonphar- macologic delirium prevention, nutrition/physical therapy consults, and geriatrics assessments, was implemented in 2016. Frailty: its scope and implications for geriatricians. High scores in these are associated with adverse outcomes in elderly patient populations and may aid clinical management. FI calculated during routine CGA of post-operative hip fracture patients, was significantly associated with adverse outcome including mortality and length of hospital stay.23 Also, frailty was associated with increased length of stay, complications after surgery and discharge to rehabilitation facilities in fracture patients.24, To establish treatment and discharge strategies for trauma elderly patients, the 15-item trauma-specific frailty index (TSFI) was validated from various centers. Various clinical specialties are beginning to adapt frailty assessment and CGA into their treatment plans. Evaluating the properties of a frailty index and its association with mortality risk among patients with systemic lupus erythematosus. Conclusion: Therefore frailty screening is more efficient in a large population as a first step of frailty assessment.20 However in high risk older patients or patients undergoing interventions that have a high likelihood of treatment-related adverse outcomes, detailed frailty assessment from the beginning may be more effective. 7) Severely frail (completely dependent, but stable) Objectives: To explore the feasibility of using the FRAIL scale in community screening of older Chinese people aged 65 years and older, followed by clinical validation by comprehensive geriatric assessment of those classified as pre-frail or frail. Therapeutic interventions for frail elderly patients: part I. Pilotto A, Cella A, Pilotto A, Daragjati J, Veronese N, Musacchio C, et al. . Table 2 Person completing Clinical Frailty Scale assessment. Thompson MQ, Theou O, Adams RJ, Tucker GR, Visvanathan R. Frailty state transitions and associated factors in South Australian older adults. Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation, and housekeeping. Morley JE, Malmstrom TK, Miller DK. Comprehensive geriatric assessment (CGA) is the process of identifying and quantifying frailty by examining various risky domains and body functions, which is the basis for geriatric medicine and research. Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. Online ahead of print. Preoperative Frailty Assessment - Palliative Care Network of Wisconsin Weber M, Belala N, Clemson L, Boulton E, Hawley-Hague H, Becker C, et al. Frail older adults often have multi-domain risk factors in terms of physical, psychological, and social health. Clegg A, Bates C, Young J, Ryan R, Nichols L, Ann Teale E, et al. Therefore before establishing a frailty assessment it is important to apprehend the systemic pros and cons of each frailty assessment tool. Frailty has been conceptualized as a pre-disability state, however it can also be described as co-existing with disability.4. This definition has been operationalized using the Short Physical Performance Battery (SPPB) as a SPPB score of 3-9 among persons with no mobility disability (Cesari et al., 2017). THE SOLUTION The online Johns Hopkins Frailty Assessment Calculator allows a clinician or researcher to enter five standardized measurements. Prevalence of frailty in community-dwelling older persons: a systematic review. The Phenotype of Frailty identifies older adults as frail if they have three or more of five criteria and being at risk for frailty is having one or two criteria: slow walking speed, weak grip strength, exhaustion, low physical activity level, and unintentional weight loss (Fried et al., 2001). Phenotypic frailty validated by the CHS criteria is less time-consuming and is closely related to sarcopenia, neuroendocrine decline, immune dysfunction and adverse health outcomes.7 However, because only limited items are evaluated, an accurate evaluation of the body function needs to be performed to reduce the bias of the test. Score range 0 to 5. Pahor M, Blair SN, Espeland M, Fielding R, Gill TM, Guralnik JM, et al. Full size table. Kojima G, Bell C, Tamura B, Inaba M, Lubimir K, Blanchette PL, et al. In depth understanding will help choose adequate frailty measures to track longitudinal changes of frailty in clinical settings and research. and transmitted securely. The 5-item FRAIL scale was used for screening for frailty. Clin Interv Aging. Australia; frailty; mortality; screening. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Results: Level 3 Managing Well: People whose medical problems are well controlled, but are not regularly active beyond routine walking. Please note: The followinglist of frailty instruments within each categoryis not meant to be exclusive or exhaustive;rather it is intended to provide an overview of commonly-usedinstruments, their potential utility, as well as access to specific assessments.Category I. Effects of a physical activity intervention on measures of physical performance: Results of the lifestyle interventions and independence for Elders Pilot (LIFE-P) study. Stille K, Temmel N, Hepp J, Herget-Rosenthal S. Ko RE, Moon SM, Kang D, Cho J, Chung CR, Lee Y, Hong YS, Lee SH, Lee JH, Suh GY. FRAIL-NH predicts outcomes in long term care. Screening for frailty has been recommended to identify older adults who would most benefit from a CGA.17 Frailty assessment using the frailty phenotype-5 items validated by the CHS criteria is less time-consuming in assessing frailty and its severity. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. A standard procedure for creating a frailty index. A pooled analysis of vitamin D dose requirements for fracture prevention. Intermediate / prefrail = 1-2 criteria present. Age Ageing. Individually tailored multifactorial interventions was found to improve frailty status and physical function.40 Therefore, it is essential to develop and utilize interventional managements that can aim to reverse or provide support in areas of impairment identified on CGA. Clinical Frail Scale (CFS): a single-item assessment involving a 7-point scale grounded by pictograms and descriptions of functional capacities (16). Ninety-seven patients were included in the analysis (median age 72 years, 84% male and 16% female). Other assessments with a similar pre-disability focusinclude the Gill Frailty Measure (Gill et al., 2002); gait speed as a single measure (Abellan van Kan et al., 2009); and the Vulnerable Elders Survey (VES-13; Saliba et al., 2001). Previous reports have consistently shown that frailty status increased the risk of all-cause mortality, postoperative complication, and chemotherapy-related adverse events. CGA = comprehensive geriatric assessment, FI = frailty index, CSHA = Canadian Study of Health and Aging, SHARE = Survey of Health, Aging and Retirement in Europe. Poor Endurance/exhaustion (Rand-36 Vitality Score) Legge A, Kirkland S, Rockwood K, Andreou P, Bae SC, Gordon C, et al. It provides valuable information to guide patient care and health policy development. Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review. 5) Mildly frail (limited dependence) 2023 May 30;16:1521-1529. doi: 10.2147/JMDH.S409535. Nursing home patients are shown to be very frail. [4], Level 9 Terminally Ill:Approaching the end of life. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al.
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