Clinical Frailty Scale

Original Editor - Vidya Acharya

Top Contributors - Vidya Acharya, Lucinda hampton and Aminat Abolade  

Introduction

Frail lady with carer

The Clinical Frailty Scale (CFS) is a straightforward and accessible tool that can be used to quickly and simply assess frailty. It has been validated in adults aged over 65 years. This tool can help optimize quality of life outcomes for geriatric patients.

Key Points

• A score from 1 (very fit) to 9 (terminally ill) is given based on the descriptions and pictographs of activity and functional status.
• Intended Population: Frail elderly population, all individuals > 65 years should be screened for frailty.
• Particular attention should be paid to those who score 5 or more as this is the marker for requiring a comprehensive geriatric assessment and often referral to geriatric or frailty specialists.
• The Clinical Frailty Scale focuses on items that can be readily observed without specialist training, including mobility, balance, use of walking aids, and the abilities to eat, dress, shop, cook, and bank. Scoring should match the description, and should not be based solely on the pictures that accompany each level.

Method of Use

The CFS is easy and quick to administer in a clinical setting. It requires data collection by observing the patient mobilise and inquiring about their habitual physical activity and ability.

The clinicians assess whether the patient can independently perform tasks such as bathing, dressing, housework, going upstairs, going out alone, going shopping, taking care of finances, taking medications, and preparing meals. A person with a score ≥of 5 is considered frail.

Technique

The scale can be introduced by saying something like: “I’d like to know how you are doing overall.” and then enquiring about:

• How the person moved, functioned, thought, and felt about their health over the last two weeks?
• How active the person is?
• Which medications the patient is taking. Experienced clinicians can quickly estimate which illnesses are likely to be present from what medications are being prescribed and/or used.

Elaboration Of CFS Levels

Level 1– Very Fit: People who are robust, active, energetic, and motivated. These people commonly exercise regularly. They are among the fittest for their age.

Level 2 – Fit: Previously known as well: People who have no intense disease symptoms but are less fit than level 1. Often, they exercise or are very active occasionally, e.g., seasonally.

Level 3 – Managing Well: People whose medical problems are well controlled, but are not regularly active beyond routine walking.

Level 4 – Living with Very Mild Frailty-While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed-up” and being tired during the day.

Level 5 – Living with Mild Frailty: These people usually have more evident slowing and need help in higher-order instrumental activities of daily living (IADLs) such as finance, transportation, heavy housework, medications. Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation, and housekeeping.

Level 6 – Living with Moderate Frailty: They need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing, and might need minimal assistance (standby) with dressing.

Level 7 – Living with Severe Frailty: is characterized by progressive dependence in personal ADLs. Completely dependent on personal care from whatever cause (physical or cognitive). Even though they seem stable and not at high risk of dying (within six months). People living with severe frailty can be mobile. Progressively taking to bed—but not being largely bedfast—is the hallmark of the progression of severe frailty.

Using the CFS in People Towards the End of Life

Level 8 – Living with Very Severe Frailty: These patients are completely dependent, approaching the end of life. Typically, they could not recover even from minor illnesses. A frail person often takes to bed for weeks, prior to dying. This is either heralded by an identifiable episode, such as an infection, or the person just slips away, commonly after some days of reduced oral intake. Very severely frail people who die without a single apparent cause typically follow such a trajectory, commonly with little pain or even distress, often, except impaired bowel function. 

Level 9 – Terminally Ill: Approaching the end of life. This category applies to people with a life expectancy of under 6 months, which are not otherwise evidently frail. This level is notable for being the only level in which the current state surpasses the baseline state. The terminally ill person might have been operating at any frailty level at baseline. On the CFS card, a person in this category is pictured seated in a chair, reflecting the fact that many older adults who die with a single system illness (like cancer), have a reasonable level of function until about the very end. In case a terminally ill person is completely dependent for personal care at baseline, they will be scored as Level 8.

Pointers About Scoring and Next Steps

Individual characteristics will vary within each level of the CFS. About 80% or more of people fit the description offered for a given level. If they fit two categories equally well, in routine care it is best to score the scale at the higher or more dependent level. Clinicians also need to recognize the possibility of some variability in judgement in specific circumstances.

Scoring the CFS in People with Cognitive Impairment: The degree of dementia is correlated to the level of frailty.

• Mild dementia would go with mild frailty. In both cases, the person is independent in their personal or basic ADLs, but dependent on one or more instrumental ADLs (such as finance, transportation, heavy housework, medications).
• Recent memory is very impaired in people with moderate dementia, even though they seemingly can remember their past life events well. As with moderate frailty, they can do their personal care with prompting or set-up.
• In severe dementia, as in severe frailty, people have progressive difficulty in performing personal ADLs and require increasing amounts of hands-on assistance.

Evidence

Reliability: The CFS is a reliable instrument to identify frailty in the emergency department. It might provide useful information for decision-making with triage, disposition, and treatment. Applying the CFS to patients requires a clinical judgment of the examining clinician and thus may lead to inter-observer variation. The inter-rater reliability of the CFS is very good, however, several biases may play a role in scoring, especially with clinicians who are inexperienced using the scale.

Validity: CFS score is a valid diagnostic instrument to measure frailty in older hospitalized patients and patients in the emergency department. CFS-Korean version is a valid scale for measuring frailty in older Korean patients. This scale has largely not been validated in younger people as a disability in younger people (including both acquired, as in spinal cord injury, and life-long, as in intellectual disability) does not have the same meaning for prognosis that it does with age-related disability.

Miscellaneous

• CFS is seen as one of the most promising and practical ways of screening frailty in routine assessment and especially in acute care as it combines clinical judgment with objective measurement. It provides valuable information to guide patient care and health policy development.
• Studies have shown that the CFS is mostly used within geriatric medicine, cardiology, intensive care, general medicine, emergency medicine, surgery, and dialysis.
• Research has suggested that CFS can be used as a tool that can guide the rationing of critical care resources if they become overwhelmed in the COVID-19 pandemic.

Links

CFS GUIDANCE & TRAINING