Frailty in Older Adults - Early Identification and Management

Effective Date: October 1, 2008
Revised Date: January 18, 2012

Recommendations and Topics


This guideline addresses the early identification of patients who are at risk for frailty and the management of patients aged 65 years or older who are identified as frail. Over a series of planned office visits, this guideline will facilitate enhanced individualized planning for patients who are frail or at risk for frailty, and implementation of patient-centred strategies to prevent further functional decline, particularly during transitions in care.

Elements of Care

  • In people over 65, those at risk of frailty will be identified proactively (see Frailty Scale [PDF, 59KB])
  • Significant issues, including safety risks, will be noted through targeted assessment
  • Patient goals will be identified and recorded in a Care Plan that includes a medication review, advance care planning and scheduled follow-up
  • Appropriate community referrals will be made and monitored
  • The Care Plan will accompany the patient to consultations or admissions
  • Key management information will be available to other health care providers after regular business hours as required
  • Care contact names and phone numbers will be recorded and updated regularly

Care Summary

This guideline focuses on the development of a Care Plan. The Care Plan is individually developed and addresses modifiable biological and psychosocial factors while integrating individual disease factors that impede the health goals of patients. The recommended approach to care incorporates patient-centred preferences and tolerance for intervention and support. The approach is grounded in the philosophy that frailty may be prevented or delayed and that patients can improve their function and quality of life through rehabilitation.1


Identification of Frail Patients and Patients at Risk for Frailty

Each visit provides an opportunity to engage the patient in individualized care planning, and to identify any follow-up needs.2

Older adults may share a number of non-specific concerns that could lead the physician to think about their older patients as frail or at risk for frailty, such as:3-6

  • difficulty managing daily activities at home
  • unintentional weight loss
  • fatigue or loss of energy (often occurs over a period of time)
  • recent fall(s), fear of falling
  • memory loss
  • concerns about the patient, expressed by the family/caregiver(s)

Once a patient is identified as frail, or at risk for frailty, it is recommended that the Canadian Study on Health and Aging (CSHA) Clinical Frailty Scale7 be used to categorize the needs of the patient. The scale is based largely on a person’s function for Basic and Instrumental Activities of Daily Living (ADL and IADL).


Further Assessment

Patients with identified frailty (CSHA Scale, Level 4 and above) require additional assessment in order to support the development or refinement of a Care Plan (see Appendix A for a sample Seniors Assessment Tool).

Ideally, the physician and other health professionals will work collaboratively to complete assessments, in order to create one comprehensive Care Plan that is used by the patient and all health professionals involved in the patient’s care. For example, if community case managers have completed their comprehensive initial assessment using the Minimal Data Set-Home Care8, a list of identified problem areas generated by that assessment could help to further inform the physician assessment and Care Plan.

In addition to the collection of information on underlying chronic conditions, some practical areas to pursue in assessing older adult patients are noted below. 9-12Observed changes in these areas constitute early warning signs of frailty (CSHA Frailty Scale Level 4), while a combination of impairments may signal progression toward frailty (CSHA Frailty Scale Levels 5-7):

  • weight change
  • reduced physical activity levels and endurance
  • impaired balance and mobility
  • increased number and frequency of falls or first fall if not with cause
  • declining functional status
  • difficulties due to polypharmacy and psychoactive medications
  • impaired vision/hearing
  • increased alcohol consumption
  • driving competency
  • difficulty maintaining continence
  • irregular patterns of sleep
  • frequent/increased pain
  • inappropriate behaviour
  • social isolation
  • transition in living circumstances
  • change in family/caregiver support
  • advanced caregiver stress
  • irrational fears/concerns
  • altered mental health status, including presentation of delirium, depression and/or dementia

(see the Clinical Practice Guidelines page Cognitive Impairment: Recognition, Diagnosis and Management in Primary Care to access the Geriatric Depression Scale [GDS] and the Standardized Mini-Mental State Examination [SMMSE])

Collaborative Goal Setting

It is important to have a shared understanding of desired care with the patient and family/caregiver.1 One approach is to combine the physician’s problem list with the patient and family/caregiver concerns and preferences for care:

  • What are the patient’s or family/caregiver’s concerns?
  • What are the physician’s concerns?
  • What are the patient’s priorities for their care when considering both the physician’s concerns and their own concerns?
  • What does the patient or family/caregiver hope to achieve from medical treatment?
  • Incorporate and document discussion of advance care planning

Collaborative goal setting will inform the development and implementation of a functional Care Plan.


Development and Implementation of a Care Plan

The Care Plan (see sample, Appendix B) is generated from these collaborative goals. Develop a Care Plan by first noting the most bothersome complaint, as voiced by the patient, and proceed with consideration for:

  • Patient rehabilitation potential
  • Appropriate prevention activities for the patient13
  • Self-management support for the patient and family/caregiver(s)

In this complex population of older adults, it is recommended that the Care Plan also include:

  • A Medication Review 10,14-16 (see Appendix C)
  • Advance care planning17
  • Goals associated with significant health and safety risks (e.g. falls, living alone)18
  • Plans to manage significant co-morbidities in relation to patient goals19
  • Expected outcomes
  • Names and contact information of other providers involved in the care of the patient (i.e. for case conferencing as required)
  • Plans for follow-up

Sharing Care Plan Documents with Patients

Communication for coordination and continuity of care is particularly important with older adult patients.20 Key management information should be made available at transitions of care to other providers including medical specialists, as well as emergency room staff and acute care practitioners. The Care Plan, including advance care planning documentation, could be given to the patient (and/or family/caregivers) to carry as they become involved with other care providers and as they transition across care settings. The patient could also carry a copy of the Medication Review (includes medication list paired with medical problem list).

Monitoring, Follow-up and Re-evaluation

A scheduled Care Plan review should include input from the patient, family/caregiver(s), and other involved health care providers. The review should be undertaken as scheduled, at the request of the patient, or when there is a transition (planned or unplanned), such as:

  • significant change in a patient’s health status;
  • transition across care locations (e.g. into and out of the emergency room and/or hospital, into assisted living or a care facility, etc.); and
  • change in patient’s caregiver support.



While many older adults living in British Columbia are robust and active, some older adults who are frail, or at risk for frailty, have a limited capacity to respond to stresses and are at significant risk of morbidity or death. A prudent response is to identify older adults in our population who are frail, or at risk for frailty, and take steps to reduce or manage the risks associated with frailty.1,5,21-23

A common approach to assessment is needed that would enable physicians:

  • to evaluate older adults based upon level of risk and prioritize unmet needs in collaboration with the patient;
  • to efficiently determine whether older adult patients require additional care and support interventions in their current environment (particularly with respect to risk factors associated with the social determinants of health); and
  • to identify patients who are frail or at risk for frailty and refer those patients for further comprehensive assessment as needed.

Information collected during assessment visits will inform the development of a Care Plan – an essential tool for capturing key medication information, patient/provider goals and patient preferences for care. To help facilitate shared understanding within a multi-disciplinary approach, the Care Plan could be given to the patient (and/or family/caregivers) to carry as they become involved with other care providers and as they transition across care settings.



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  2. Hebert R, Durand PJ. Frail elderly patients: New model for integrated service delivery. Canadian Family Physician. 2003;49:992-997.
  3. Fried LP, Tangen JW, Walston J, et al. Frailty in older adults: Evidence for a phenotype. Journal of Gerentology. 2001;56(3):M146-M156.
  4. Bergman H, Beland F, Karunananthan S, et al. Developing a working framework for understanding frailty. Gérentologie et Societé. 2004;109:15-29.
  5. Fried LP, Ferrucci L, Darer J, et al. Untangling the concepts of disability, frailty, and comorbidity: Implications for improved targeting and care. Journal of Gerontology Medical Sciences. 2004;59A(3):255-263.
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  8. interRAI Minimum Data Set - Home Care (MDS-HC). Details of MDS-HC tool available online at:
  9. Pereles LR, Boyle NG. Comprehensive geriatric assessment in the office. Canadian Family Physician. 1991;37:2187-2194.
  10. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults. Archives of Internal Medicine. 2003;163:2715-2724.
  11. Ensberg M, Gerstenlauer C. Incremental geriatric assessment. Primary Care: Clinics in Office Practice. 2005;32:619-643.
  12. Examples of available tools for screening and evaluation (Appendices). Primary Care: Clinics in Office Practice. 2005;32:829-853.
  13. Gill TM, Baker DI, Gottschalk M, et al. A program to prevent functional decline in physically frail elderly persons who live at home. New England Journal of Medicine. 2002;347(14):1068-1074.
  14. Petrone K, Katz P. Approaches to appropriate drug prescribing for the older adult. Primary Care: Clinics in Office Practice. 2005;32:755-775.
  15. LeCouteur DG, Hilmer SN, Glasgow N, et al. Prescribing in older people. Australian Family Physician. 2004;33(10):777-781.
  16. Holmes HM, Hayley DC, Alexander GC, et al. Reconsidering medication appropriateness for patients late in life. Archives of Internal Medicine. 2006;166:605-609.
  17. Temkin-Greener H, Gross DL. Advance care planning in a frail older population. Research on Aging. 2005;27(6):659-691
  18. Sloan J. Keeping Frailty out of the hospital. BC Association of Geriatric Care Physicians. Spring News. 2004:4.
  19. Durso SC. Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. Journal of the American Medical Association. 2006;295(16):1935-1940.
  20. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. Journal of the American Medical Association. 2007;297(8):831-841.
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  22. Kramer BJ, Auer C. Challenges to providing end-of-life care to low-income elders with advanced chronic disease: Lessons learned from a model program. The Gerentologist. 2005;45(5):651-660.
  23. Stock RD, Reece D, Cesario L. Developing a comprehensive interdisciplinary senior healthcare practice. Journal of the American Geriatrics Society. 2004;52:2128-2133.



Aboriginal Resources


This guideline is based on scientific evidence current as of the Effective Date.

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.


Appendix A - Seniors Assessment Tool (PDF, 137KB)

Appendix B - Sample Care Plan Template (PDF, 135KB)

Appendix C - Medication Review (PDF, 127KB)

Associated Documents

The following documents accompany this guideline:

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate responses to common medical situations
  • recommend actions that are sufficient and efficient, neither excessive nor deficient
  • permit exceptions when justified by clinical circumstances.
Contact Information
Guidelines and Protocols Advisory Committee
Victoria BC V8W 9P1
Web site:


Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.