Question 10

a)    Outline how frailty can be assessed in a patient admitted to the ICU.    (40% marks)

b)    Outline the limitations of assessing frailty of a patient at the time of ICU admission.
(30% marks)

c)    Outline how a frailty score might be used in the management of critically ill patients. 
(30% marks)

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College answer

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a) Assessment of frailty:

  • Multidimensional assessment, consisting of:
    • History, eg. self-reported exhaustion, fatigue, mood, social participation
    • Proxy functional assessment, eg. use of mobility equipment, reliance on services, hospital admissions, frequency of falls
    • Functional disability assessment, eg. hand grip, gait, balance, cognitive assessment
    • Biometric data, eg. weight loss, muscle mass
    • Physical examination findings, for example:
      • Sarcopenia
      • Clinical features of malnutrition
      • Evidence of decreased energy expenditure
      • Features of multiple health deficits or comorbidities
    • Objective biological findings eg. echo findings, chronic organ system dysfunction, low serum prealbumin, etc.
  • Use of a validated frailty scoring scale is recommended:

b) Limitations of this assessment at the time of ICU admission:

  • Assessment of frailty in general:
    • There may only be limited information regarding baseline function
    • Clinical features of frailty may be exaggerated by critical illness
    • Frailty may be absent on admission, but can then develop during the ICU stay
  • Assessment using a fraily scoring scale:
    • There may be no time to use a comprehensive scoring scale
    • The use of such scales requires training
    • They are validated only among stable community outpatients
    • Their reliability is poorly studied (De Vries et al, 2011)

c) Utility of a frailty score in the management of critically ill patients:

  • Prevention of non-beneficial therapies:
    • Frail patients have poorer ICU outcomes. 
    • High frailty scores are associated with discharge into residential care facilities,  medium to long term disability, and poor quality of life
    • Screening for frailty can be used as a prognostic indicator to inform decisionmaking around the goals of care and limitations of therapy
  • Triage of critical care services
    • Under scenarios of system stress (eg. a pandemic response), frailty scoring may be a valid mechanism of allocating access to scarce critical care resources
  • Redirection of clinical priorities: increased clinician attention to management strategies designed to maximise the preservation of function and the prevention of further enfeeblement, such as:
    • Nutrition (high caloric and high protein supplementation)
    • Micronutrient and vitamin replacement
    • Early extubation
    • Early mobility and physiotherapy
    • Delirium screening
    • Referral to services such as social work, psychology, occupational therapy and specialist geriatrician services


Falvey, J. R., and L. E. Ferrante. "Frailty assessment in the ICU: translation to ‘real‐world'clinical practice." (2019): 700-703.

McDermid, Robert C., Henry T. Stelfox, and Sean M. Bagshaw. "Frailty in the critically ill: a novel concept." Critical Care 15.1 (2011): 1-6.

De Biasio, Justin C., et al. "Frailty in critical care medicine: a review.Anesthesia and analgesia 130.6 (2020): 1462.

Panhwar, Yasmeen Naz, et al. "Assessment of frailty: a survey of quantitative and clinical methods." BMC Biomedical Engineering 1.1 (2019): 1-20.

Darvall, Jai N., et al. "Frailty in very old critically ill patients in Australia and New Zealand: a population‐based cohort study." Medical Journal of Australia 211.7 (2019): 318-323.

Darvall, Jai N., et al. "Routine frailty screening in critical illness-a population-based cohort study in Australia and New Zealand." Chest (2021).

Flaatten, Hans, et al. "The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (≥ 80 years)." Intensive care medicine 43.12 (2017): 1820-1828.

De Vries, N. M., et al. "Outcome instruments to measure frailty: a systematic review." Ageing research reviews 10.1 (2011): 104-114.