Clinical review of frailty
A clinical review of frailty is a structured assessment conducted during any interaction between an older person and health or social care staff. Its purpose is to proactively identify the risk of frailty, determining the extent or level of frailty and inform targeting intervention strategies.
This review should be embedded in routine care settings, including:
- Outpatient appointments (e.g. orthopaedic, GI, vascular, ophthalmic)
- Mental health services (e.g. memory clinics)
- Social care assessments
- Community care team reviews
- Primary care long-term condition clinics
- Ambulance call-outs after falls or urgent events
The frequency of clinical reviews will depend on the risk factors, level of frailty and clinical context. Reviews may be prompted by a significant event such as a fall, significant bereavement, new diagnosis. They should be undertaken regularly every 3, 9, or 12 months, based on assessment, severity of frailty, clinical, psychological or social factor.
A clinical review for frailty is a holistic, person-centred assessment that typically includes:
- Frailty assessment tools – e.g Clinical Frailty Scale (CFS) Frailty Scoring Tools, Rockwood Score, Prisma 7
- Comprehensive Geriatric Assessment (CGA) – covering medical, functional, cognitive, social, and nutritional factors, as well as medication review and advance care planning
- Care plan formulation – aligning with patient goals, optimizing polypharmacy, prescribing exercise, balance and nutrition interventions, and involving multidisciplinary resources.
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