Clinical review of frailty
The frequency of clinical reviews for frail patients depends on the level of frailty and clinical context. This can be every 3, 9, or 12 months, depending on the severity of frailty and clinical triggers
A clinical review for frailty is a holistic, person-centred assessment that typically includes:
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Frailty assessment tools – e.g Clinical Frailty Scale (CFS) Frailty Scoring Tools, Rockwood Score, Prisma 7
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Comprehensive Geriatric Assessment (CGA) – covering medical, functional, cognitive, social, and nutritional factors, as well as medication review and advance care planning
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Care plan formulation – aligning with patient goals, optimizing polypharmacy, prescribing exercise, balance and nutrition interventions, and involving multidisciplinary support
Who should review?
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General Practitioner or specialist nurse – at least 45–60 mins for a holistic review, often prompting for CGA if needed
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Multidisciplinary team for those with moderate/severe frailty or multiple needs
| Frailty Severity | Suggestion (subject to your clinical judgement) |
|---|---|
| Mild/Moderate Frailty | – Assessments during routine GP/nurse visits – Reassessment every 3–6 months or if clinical change occurs |
| Moderate/Severe Frailty | – Full CGA as soon as frailty is identified – Follow-up reviews every 3 months (especially if n home care) – Review whenever patient deteriorates |
| Stable but Frail | – At least annual full assessments – Medication and CGA review yearly |