Clinical Frailty Scale

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 ... Home About ClinicalFrailtyScale CFSTraining CFSAPP Resources Contact ClinicalFrailtyScale  Frailty&COVID-19:why,what,how,where&when?Pleasenote:**TheCFShasnotbeenwidelyvalidatedinyoungerpopulations(below65yearsofage),orinthosewithlearningdisability.Itmaynotperformaswellinpeoplewithstablelongtermdisabilitysuchascerebralpalsy,whoseoutcomesmightbeverydifferentcomparedtoolderpeoplewithprogressivedisability.Wewouldadvisethatthescaleisnotusedinthesegroups.However,theguidanceonholisticassessmenttodeterminethelikelyrisksandbenefitsofcriticalcaresupport,andseekingcriticalcareadvicewherethereisuncertainty,isstillrelevant.**Why?RapidNICEguidanceproducedinresponsetotheCOVIDoutbreakclearlyoutlinestheimportanceofidentifyingandgradingfrailtyusingtheClinicalFrailtyScale.Thepurposeistoidentifypatientswhoareatincreasedriskofpooroutcomesandwhomaynotbenefitfromcriticalcareinterventions.What?Frailtyisastateofincreasedvulnerabilitytopoorresolutionofhomoeostasisafterastressorevent,whichincreasestheriskofadverseoutcomes(1).ItcanbeassessedquicklyandsimplyusingtheClinicalFrailtyScale(Appendix1).Frailtyidentificationshouldtakenomoretheoneminute(2);themoreyouusethescale,thequickeritwillbecome.TheCFSisareliablepredictorofoutcomesintheurgentcarecontext(Appendix2)(3-9);criticalcarespecificoutcomesaresummarisedinAppendix3.Likeanydecisionsupporttool,isnotperfectandshouldnotbeusedinisolationtodirectclinicaldecisionmaking.Itwillsensitiseyoutothelikelyoutcomesingroupsofpatients,butclinicaldecisionmakingwithindividualpatientsshouldbeundertakenthroughamoreholisticassessment,usingtheprinciplesofshareddecisionmaking.How?TheCFScanbeundertakenbyanyappropriatelytrainedhealthcareprofessional(doctor,nurse,healthcareassistant,therapistetc.)withtrainingandsupport.Askthepatientortheircarer/nextofkin/paramedics/carehomestaffwhattheircapabilitywasTWOweeksago.DONOTbaseyourassessmentonhowthepatientappearsbeforeyoutoday.DecisionmakersusingtheCFStoinformclinicalmanagementMUSTcheckthescoretoensurethatitisaccurate.DObecarefulaboutdifferentiatingbetweenCFS6and7:CFS6(needhelpwithoutdooractivitiesandsomehelpwithbasicactivities)–allcausemortalityduringadmissiontoacutehospital=6%CFS7(completelydependentforpersonalcare)–allcausemortalityduringadmissiontoacutehospital=11%When?TheCFSshouldbeassessedatEDtriage,oranyfirstpointofcontactwithacutecare(includingbyparamedics),alongsideEarlyWarningScores.Itshouldbereassessedaftertwoweeksifclinicallyrelevant.UsingCFSinpracticeDOrememberthattheCFShasonlybeenvalidatedinolderpeople;ithasnotbeenwidelyvalidatedinyoungerpopulations(below65yearofage),orinthosewithlearningdisability.Itmaynotperformaswellinpeoplewithstablelongtermdisabilitysuchascerebralpalsy,whoseoutcomesmightbeverydifferentcomparedtoolderpeoplewithprogressivedisability.WewouldadvisethattheCFSisnotusedinthesegroups.However,theguidanceonholisticassessmenttodeterminethelikelyrisksandbenefitsofcriticalcaresupport,andseekingcriticalcareadvicewherethereisuncertainty,isstillrelevant.Askthepatient,theircarer/nextofkin/paramedics/carehomestaffwhatthepatient’scapabilitywasTWOweeksago.TheassessmentshouldNOTbebasedonhowthepatientappearsbeforeyoutoday.DecisionmakersusingtheCFStoinformclinicalmanagementMUSTcheckthescoretoensurethatitisaccurate.TOPTIPSTOHELPYOUUSETHECFS ProfessorKenRockwoodandcolleagueshavewrittenapaperonCOVID-19,frailtyandlong-termcare,andthepotentialimplicationsforpolicyandpractice,whichcanbefoundhere.AliceWarren,StaffNurseED,LeicesterRoyalInfirmaryAnujaChalishazar,JuniorDoctorED,LeicesterRoyalInfirmaryJayBanerjee,ConsultantinEmergencyMedicineED,LeicesterRoyalInfirmaryProfessorKenRockwoodProfessorofMedicine,DalhousieUniversityAppendix1:clinicalfrailtyscaleTheClinicalFrailtyScalewasdevelopedatDalhousieUniversityinHalifax,NovaScotiaCanada.Thelicenseisfreeforresearch,educational,andnot-for-profithealthcare.Usersareaskedtosignaformagreeingnottochangeorcommercializeit.request/correspondencecanbesenttotheGeriatricMedicineResearchUnitgmru@dal.ca Appendix2:Outcomesinacutecare(NOTCOVIDspecific)associatedwithfrailty Beloware(unpublished)datadisplayingthetimetodeathfromEDattendancefordifferentfrailtyscores,overtwoyears.Figure1Kaplan-MeiersurvivalplotfortimefromEDarrivaltodeath,byCFScategory,nr=notrecorded: Viewfullsize Appendix3:CriticalcareoutcomesassociatedwithfrailtyFrailtymeasuredusingtheCFSorFrailtyIndexisassociatedwithhigherin-hospital(relativerisk(RR)1.7)andlong-termmortality(RR1.5)(10).Frailpatientswerelesslikelytobedischargedhomethanfitpatients(RR0.6)(11).Additionalstudiesundertakensincethesereviewssupporttheimportanceoffrailtyasaprognosticmarker(Table1).Table1OutcomesfromICUusingfrailtyasapredictor Viewfullsize 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