14.3 Frailty, the Clinical Frailty Scale & Frailty Intervention Teams

Frailty, the Clinical Frailty Scale & Frailty Intervention Teams

RCSI lists Frailty as a topic heading, citing frailty identification and assessment, the Clinical Frailty Scale, and examples of Frailty Intervention Teams - including the FITT service at Beaumont Hospital, which is where the test itself is held. Frailty also appears as a current example for the older person care OSCE station.

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What Frailty Is

Frailty is a distinct clinical state of reduced physiological reserve across multiple organ systems, in which a relatively minor stressor - a urinary tract infection, a new drug, a change of environment, a small operation - produces a disproportionate and often abrupt deterioration in function from which recovery is slow or incomplete.

The essential picture: a fit 80-year-old with a UTI feels unwell for a few days and returns to normal. A frail 80-year-old with the same UTI becomes delirious, falls, stops eating, becomes incontinent and may never return to their previous level of independence.

Frailty is not the same as age, disability or multimorbidity, though they overlap. A 90-year-old can be fit; a 65-year-old can be severely frail. A person with a stable single disability may have full reserve. Frailty is about reserve and the ability to bounce back.

Two Models

• The phenotype model identifies frailty by five physical features: unintentional weight loss, self-reported exhaustion, weakness (low grip strength), slow walking speed and low physical activity. Three or more indicates frailty; one or two indicates a pre-frail state.
• The cumulative deficit model counts accumulated health deficits - symptoms, signs, diseases, disabilities, abnormal results - and expresses frailty as an index. The Clinical Frailty Scale derives from this tradition.

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The Clinical Frailty Scale

The Clinical Frailty Scale (CFS) is a nine-point, judgement-based scale developed from the Canadian Study of Health and Aging. It summarises a person's overall fitness or frailty from a clinical assessment of mobility, function, cognition and comorbidity. Version 2.0, issued in 2020, revised the terminology - level 2 changed from "Well" to "Fit", level 4 from "Vulnerable" to "Living with Very Mild Frailty", and levels 5 to 8 were restated as "Living with..." mild, moderate, severe and very severe frailty.

Scoring It Correctly

Three rules decide whether a CFS score is meaningful:

1. Score the baseline, not the acute episode. The CFS describes the person's usual state roughly two weeks before the acute illness. A previously independent person admitted acutely unwell and currently bed-bound is not a CFS 7. Getting this wrong - scoring the illness rather than the person - is the commonest error and can wrongly influence decisions about escalation of treatment.
2. It requires collateral history. Ask the person, the family, the carer, the nursing home or the public health nurse about function before admission: could they shop, cook, manage money and medicines, climb stairs, wash and dress unaided?
3. In people with dementia, the degree of frailty generally corresponds to the degree of dementia; the scale's own guidance links mild dementia with the mild frailty range and so on.

What the CFS is not. It is not a triage rule, not a tool for rationing care, and not a substitute for individual clinical judgment and the person's own wishes. It is a common language for describing reserve and for triggering the right assessment.

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Why Frailty Changes the Clinical Picture

Frail older adults present atypically. The classic textbook features of the underlying disease are often absent, and instead one of the frailty syndromes appears:

Practical consequences at the bedside:

• A frail patient may have sepsis without fever and without tachycardia; they may be hypothermic with a normal-looking observation set. Clinical concern is an escalation trigger on the INEWS chart in its own right.
• A fall is a symptom, not a diagnosis. Look for the cause.
• Polypharmacy is itself a risk factor. Every admission is an opportunity for medication review, particularly of anticholinergics, sedatives, antihypertensives and hypoglycaemics.
• Deconditioning accelerates fast. Days of bed rest in a frail person cause muscle loss that may never be recovered.

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Comprehensive Geriatric Assessment and Frailty Intervention Teams

Comprehensive geriatric assessment (CGA) is the multidimensional, multidisciplinary process that underpins frailty care. It assesses across four domains and produces a coordinated plan:

Frailty Intervention Teams bring CGA to the hospital front door. A typical team includes a consultant geriatrician, an advanced nurse practitioner or clinical nurse specialist, a physiotherapist, an occupational therapist, a medical social worker, and access to pharmacy, dietetics and speech and language therapy. Operating in the emergency department or acute medical assessment unit, the team identifies frailty early, performs CGA, and either supports safe same-day discharge with community wraparound or ensures the admission is directed to the right specialist pathway.

The evidence is that CGA increases the likelihood of a person being alive and in their own home, and that the trigger for all of it is early identification - which is a nursing action.

Nursing Priorities for the Frail Inpatient

• Screen for frailty at the front door and record a CFS based on the pre-illness baseline.
• Prevent deconditioning: up, dressed in their own clothes, moving, and eating at a table rather than in bed.
• Prevent delirium: the 4AT on admission, glasses and hearing aids, orientation, sleep protection, minimal ward moves.
• Prevent falls and pressure injury: falls risk assessment and the SSKIN bundle.
• Protect nutrition and hydration: MUST, food and fluid charts, assistance at meals.
• Support continence: toileting regimes rather than reflex catheterisation.
• Plan discharge from day one, with the carer, the public health nurse, home supports, equipment and follow-up. NMBI's Working with Older People: Professional Guidance frames the professional expectations here.