Frailty & COVID-19: why, what, how, where & when?
Rapid NICE guidance produced in response to the COVID outbreak clearly outlines the importance of identifying and grading frailty using the Clinical Frailty Scale. The purpose is to identify patients who are at increased risk of poor outcomes and who may not benefit from critical care interventions.
Frailty is a state of increased vulnerability to poor resolution of homoeostasis after a stressor event, which increases the risk of adverse outcomes(1). It can be assessed quickly and simply using the Clinical Frailty Scale (Appendix 1). Frailty identification should take no more the one minute(2); the more you use the scale, the quicker it will become.
The CFS is a reliable predictor of outcomes in the urgent care context (Appendix 2)(3-9); critical care specific outcomes are summarised in Appendix 3. Like any decision support tool, is not perfect and should not be used in isolation to direct clinical decision making. It will sensitise you to the likely outcomes in groups of patients, but clinical decision making with individual patients should be undertaken through a more holistic assessment, using the principles of shared decision making.
The CFS can be undertaken by any appropriately trained healthcare professional (doctor, nurse, health care assistant, therapist etc.) with training and support.
Ask the patient, their carer/next of kin/paramedics/care home staff what their capability was TWO weeks ago.
DO NOT base your assessment on how the patients appears before you today.
Decision makers using the CFS to inform clinical management MUST check the score to ensure that it is accurate.
DO be careful about differentiating between CFS 6 and 7:
CFS 6 (need help with outdoor activities and some help with basic activities) – all cause mortality during admission to acute hospital = 6%
CFS 7 (completely dependent for personal care) – all cause mortality during admission to acute hospital = 11%
The CFS should be assessed at ED triage, or any first point of contact with acute care (including by paramedics), alongside Early Warning Scores. It should be reassessed after two weeks if clinically relevant.
Online training resources
Overview of frailty with tips on using the CFS.
Access overview >>
Appendix 1: Clinical Frailty Scale
The Clinical Frailty Scale was developed at Dalhousie University in Halifax, Nova Scotia Canada. The license is free for research, educational, and not-for-profit health care. Users are asked to sign a form agreeing not to change or commercialize it. Request / correspondence can be sent to the Geriatric Medicine Research Unit email@example.com
Appendix 2: Outcomes in acute care (NOT COVID specific) associated with frailty
Below are (unpublished) data displaying the time to death from ED attendance for different frailty scores, over two years.
Figure 1 Kaplan-Meier survival plot for time from ED arrival to death, by CFS category, nr = not recorded:
Frailty measured using the CFS or Frailty Index is associated with higher in-hospital (relative risk (RR) 1.7) and long-term mortality (RR 1.5)(10). Frail patients were less likely to be discharged home than fit patients (RR 0.6)(11). Additional studies undertaken since these reviews support the importance of frailty as a prognostic marker (Table 1).
Table 1 Outcomes from ICU using frailty as a predictor
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