How do I use the Clinical Frailty Scale?

Frailty identification instruments improve patient outcomes, enhance care and help plan for future needs.

While it is well documented that frailty is not an inevitable part of ageing (Afilalo et al 2019, Young and Smithard 2020), healthcare professionals have a responsibility to identify people who are living with frailty and support them to optimise their health and well-being.

Establishing and developing the knowledge of how to assess and identify people living with frailty increases positive outcomes for them (Lewis et al 2020). An effective and relatively simple way to identify frailty in clinical practice is to use an instrument to support decision-making and enhance person-centred care (Pritchard et al 2017).

The Clinical Frailty Scale is an example of a frailty identification instrument (Rockwood et al 2005). Often informally known in practice as ‘The Rockwood’, it is a freely available, nine-point scale used as part of a holistic assessment. The assessing healthcare professional uses the information gathered to make a judgement on an individual’s level of frailty, ranging from 1 (very fit) to 9 (terminally ill).

It is imperative that the same instrument is used in any one service

The Clinical Frailty Scale is easy to use, making the most of a pictorial structure and numerical scoring system. It recognises an individual’s level of independence with activities of daily living, while acknowledging the implications of a progressive diagnosis and end of life trajectory (Church et al 2020).

The expanse of frailty identification instruments used in clinical practice means that there can be some discrepancies in the identification of differing levels of frailty. Therefore, it is imperative that the same instrument is used in any one service (Specialised Clinical Frailty Network (SCFN) 2018).

In the authors’ team, the Clinical Frailty Scale is used throughout the patient journey. We discuss how it is used in our team, though these principles can be applied to other community and hospital-based settings by any registrant who has been taught how to use the tool.

We are a multiprofessional community frailty support team working with people who are experiencing decompensation of a frailty syndrome. Some people referred to the team will already have a documented frailty score. This may be the electronic Frailty Index (eFI) (Clegg et al 2016) or, if they have previously been on our caseload, a baseline Clinical Frailty Scale score.

Continual assessment is completed at each face-to-face contact

In England, changes to the GP contract in 2017-18 mean that the eFI is used in general practice to identify patients living with frailty who are 65 and over (NHS England 2021), which makes it important to document the initial Clinical Frailty Scale score used (SCFN 2018).

As we move through our initial triage, completing a holistic assessment including medical history, psychosocial factors, polypharmacy and physical/cognitive functional status, we use this information to determine an initial Clinical Frailty Scale score regardless of setting, for example in a person’s home or in the emergency department.

It is important that the score is based on the person’s usual functional status approximately two weeks before the current illness/decompensation of frailty, and not on how they are presenting in real time.

Throughout the patient journey continual assessment is completed at each face-to-face contact, considering any interventions, treatment options or diagnoses that have been made that could affect an individual’s ability to live well with frailty. As supported by the British Geriatrics Society (2014), frailty is not a static condition and there are many factors that can influence an individual’s level of frailty.

Consistency across services is important to ensure a high standard of clinical care

By working with individuals to optimise their health and well-being throughout their journey, frailty scores fluctuate, making reassessments vital (Juma et al 2016).

We ensure the Clinical Frailty Scale score and the scale used are documented on the discharge letter to the GP, which allows for accurate and safe communication between services. This enables GPs to code each patient accurately on their system, which aids in recognising those on their caseload most at risk and allows GPs to plan and commission for the appropriate services.

Using a frailty identification instrument improves patient outcomes, enhances care and provides the opportunity to plan for future care needs. However, there continue to be discrepancies between services as to which instrument should be used. Consistency across services is important to ensure a high standard of clinical care.

Practice Question is written by members of the Nurses and AHPs Council of the British Geriatrics Society

References

• Afilalo J, Joshi A, Mancini R (2019) If you cannot measure frailty, you cannot improve it. JACC. Heart Failure. 7, 4, 303-305.
• British Geriatrics Society (2014) Fit for Frailty Part 1: Consensus Best Practice Guidance for the Care of Older People Living in the Community and Outpatient Settings.
• Church S, Rogers E, Rockwood K et al (2020) A scoping review of the Clinical Frailty Scale. BMC Geriatrics. 20, 1, 393.
• Clegg A, Bates C, Young J et al (2016) Development and validation of an electronic frailty index using routine primary care electronic health record data. Age and Ageing. 45, 3, 353-360.
• Juma S, Taabazuing M-M, Montero-Odasso M (2016) Clinical Frailty Scale in an acute medicine unit: a simple tool that predicts length of stay. Canadian Geriatrics Journal. 19, 2, 34-39.
• Lewis LA, Corbett T, Burrows K et al (2020) Wessex Acute Frailty Audit: applying quality improvement methodology to design and implement a regional frailty audit using a collaborative, multiprofessional approach. BMJ Open Quality. 9, 1, e000870.
• NHS England (2021) Identifying Frailty.
• Pritchard JM, Kennedy CC, Karampatos S et al (2017) Measuring frailty in clinical practice: a comparison of physical frailty assessment methods in a geriatric out-patient clinic. BMC Geriatrics. 17, 1, 264.
• Rockwood K, Song X, MacKnight C et al (2005) A global clinical measure of fitness and frailty in elderly people. CMAJ. 173, 5, 489-495.
• Specialised Clinical Frailty Network (2018) Clinical Frailty Scale.
• Young RL, Smithard DG (2020) The Clinical Frailty Scale: do staff agree? Geriatrics. 5, 2, 40.