Geriatric MedicineTier 2Approach to a presentation

Frailty

Red flags

Rapid, unexplained functional decline, recurrent falls, or a new inability to manage previously independent tasks
Weight loss/reduced appetite with muscle wasting (sarcopenia)
An acute presentation (e.g. minor illness or medication change) producing a disproportionately severe deterioration - a hallmark of reduced physiological reserve

By underlying driver

Sarcopenia-predominant - progressive muscle mass/strength loss, often nutrition and inactivity related
Multimorbidity-predominant - cumulative burden of several chronic conditions, each individually modest but combining to reduce reserve
Cognitive frailty - cognitive impairment compounding physical frailty, with a particularly high risk of rapid decompensation with acute illness
Social/psychological contributors - isolation, depression, and financial hardship can both mimic and accelerate physical frailty, and must be assessed alongside it

Baseline (pre-morbid) function and its trajectory over recent months, not just current snapshot function
Falls history, weight change, appetite, mobility aids used, and recent hospital presentations
Social supports, carer availability, and living situation

Gait speed (a simple, validated marker - slow gait speed correlates strongly with adverse outcomes) and grip strength as objective functional measures
General inspection for muscle wasting, nutritional status, and functional mobility (e.g. timed up-and-go test)

Clinical Frailty Scale (a simple 9-point clinician-judgement scale, widely used given its speed and reasonable predictive validity) or the Fried frailty phenotype (weight loss, exhaustion, weakness, slow walking speed, low physical activity - 3+ criteria = frail) for more formal characterisation
Comprehensive geriatric assessment to identify and quantify the specific contributing domains (medical, functional, cognitive, social) rather than treating "frailty" as a single undifferentiated diagnosis

Exercise (particularly resistance training) and adequate protein/nutritional intake have the best evidence for improving frailty markers, more than any pharmacological intervention
Medication review/deprescribing to reduce sedative/anticholinergic burden and polypharmacy-related risk
Address identified domains specifically (nutrition, mobility, mood, social support) via multidisciplinary input, rather than a single generic intervention
Frailty status should directly inform the intensity of investigation/treatment offered for other conditions (see judicious use of investigations) - not as a reason to withhold care, but to calibrate its likely benefit and burden

Assuming frailty is untreatable/fixed - frailty is often at least partially modifiable, particularly with exercise and nutrition intervention, and is not simply an inevitable, static endpoint of ageing
Treating "frailty" as a diagnosis in itself rather than identifying and addressing its specific underlying contributors
Using chronological age as a proxy for frailty - frailty and age correlate imperfectly, and a fit 90-year-old can have a lower frailty burden than a multimorbid 70-year-old

1. Frailty is a spectrum, not a label

"I assess frailty by domain (physical, cognitive, social) rather than applying a single category, since each domain often needs a different intervention."

2. Exercise is the best-evidenced treatment

"Resistance exercise and adequate protein intake improve frailty markers more reliably than any drug currently available."

3. Frailty calibrates, it doesn't dictate, treatment intensity

"A high frailty score changes how I weigh the benefit and burden of a treatment - it's not an automatic reason to withhold it."

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