Grades are shown as the source states them. GRADE strength (strong or conditional) with certainty of evidence (high to very low); consensus-based recommendations were made where evidence was limited.
Key recommendations
Offer everyone aged 65 or over opportunistic screening for frailty with a simple, validated instrument suited to the setting.
Strong; low certaintyRecommendation 1
Follow a positive screen for frailty or pre-frailty with a clinical assessment of frailty.
Strong; low certaintyRecommendation 2
Build a comprehensive care plan that systematically addresses polypharmacy, sarcopenia, treatable causes of weight loss and causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, vitamin B12 deficiency).
Strong; very low certaintyRecommendation 3
Make a multicomponent physical activity programme with a progressive resistance-training component the first-line intervention.
Strong; moderate certaintyRecommendations 5–6
Currently available drug treatments are not recommended for treating frailty itself.
Consensus; very low certaintyRecommendation 10
Diagnosis
The ICFSR's recommended standard for clinical assessment is the physical frailty phenotype: frail with three or more of weakness, slowness, unintentional weight loss, self-reported exhaustion and low physical activity; pre-frail with one or two.
Recommendation 2 (discussion)
Rapid screening instruments discussed include the Clinical Frailty Scale, the FRAIL scale and the Edmonton Frail Scale. On the Clinical Frailty Scale, scores above 6 suggest disability in activities of daily living rather than frailty.
Recommendation 1 (discussion)
Distinguish frailty from multimorbidity and disability, which are managed differently; a person can be frail without either.
What is physical frailty?; Recommendation 2 (discussion)
Investigations
Look for the causes of exhaustion the guideline names — depression, anaemia, hypotension, hypothyroidism and vitamin B12 deficiency — and evaluate other causes of fatigue such as heart failure.
Recommendation 3 (discussion)
Confirm a formal diagnosis of undernutrition before recommending nutritional supplementation.
Recommendation 7 (discussion)
Treatment
Offer a multicomponent physical activity programme to people with frailty, and to people with pre-frailty as prevention.
Strong; moderate certaintyRecommendation 5
Refer people with frailty to physical activity programmes that include progressive resistance training.
Strong; moderate certaintyRecommendation 6
Consider protein or calorie supplementation when weight loss or undernutrition has been diagnosed.
Conditional; very low certaintyRecommendation 7
Nutritional or protein supplementation may be offered together with a physical activity prescription.
Conditional; low certaintyRecommendation 8
Offer social support as needed to meet unmet care needs and help people follow the care plan.
Strong; very low certaintyRecommendation 14
Home-based training can be considered.
ConditionalRecommendation 15
Vitamin D is not recommended for treating frailty unless deficiency is present; hormone therapy is not recommended; cognitive or problem-solving therapy is not systematically recommended.
Consensus; very low certaintyRecommendations 11–13
Important geriatric considerations
Frailty is dynamic: people move between states. A hospital admission can tip a robust person into frailty, and physical activity may partly reverse it.
What is physical frailty?
Unintentional weight loss is usually the last phenotype component to appear, and once it has occurred frailty is much harder to reverse.
What is physical frailty?
Fit the care plan to the person's preferences, goals and level of frailty.
Recommendation 3 (discussion)
Advise people with frailty about the importance of oral health.
Consensus; no dataRecommendation 9
Social isolation is a major risk factor for frailty progression; people with cognitive impairment are especially likely to need support.
Recommendation 14 (discussion)
Drug doses
Not covered in this summary — see the original guideline.
When to refer
Where appropriate, refer people with advanced (severe) frailty to a geriatrician. Where no geriatrician is available locally, frailty is managed in primary care.
Consensus; no dataRecommendation 4
Red flags
Not covered in this summary — see the original guideline.
Recent updates
Not covered in this summary — see the original guideline.