FRAILTY IN THE ELDERLY: MANAGEMENT

Search date
27/04/2021

Author
Lucylynn Lizarondo PhD, MPhysio, MPsych

Question
What is the best available evidence regarding management of frailty in the elderly?

Clinical Bottom Line

Frailty is a geriatric syndrome with a significant impact on the older individual, their family, and society as a
whole.1 People are defined as frail if they meet pre-determined values for three or more of five criteria: slow
gait speed, weak grip strength, exhaustion, low energy expenditure and weight loss.1 It is reported that
older people with frailty are at a significant risk of sudden and dramatic changes in their physical and
mental wellbeing that may result in sudden changes such as falls, delirium and immobility.1 Literature
suggests that there is an increasing recognition of the importance of providing integrated services for older
people with frailty that are person-centered and coordinated.1
In a consensus-based best practice guideline for the management of frailty in the elderly (by the British
Geriatrics Society (BGS), Age UK and Royal College of General Practitioners), the following findings
were reported:1 (Level 5)
The standard for the care of people with frailty is Comprehensive Geriatric Assessment (CGA), which
includes multidimensional assessment, treatment plan and regular review delivered by a
multidisciplinary team (MDT) of doctors, nurses, physiotherapists, occupational therapists and social
workers.
It is recognized that much of the evidence about CGA comes from hospital settings; however, there is
evidence that provision of complex interventions (including CGA) to older frail people in community
settings could reduce hospital admissions, admissions to nursing homes and increase the chance of
continuing to live at home.
The BGS recommends a holistic medical review for all older people identified as living with frailty due
to the resource implications of MDT-led CGA and associated opportunity costs.
An individual with appropriate knowledge and adequate time is able to conduct a holistic medical
review. It does not always need to be conducted by a geriatrician. In community settings, the general
practitioner (GP) or a specialist nurse may conduct the review. They can then refer to a geriatrician (or
other community-based specialist such as old age psychiatrists, therapists and community nurses) for
help.
The holistic medical review should include:
diagnosis of medical illness and formulation of a care plan
applying evidence-based medication review checklists
discussion with older people with frailty and their carers to define the impact of illness and symptoms
on a day-to-day life
creating an individualized comprehensive care and support plan (CSP) in consultation with the older
 person.
The Asia-Pacific clinical practice guidelines for the management of frailty strongly recommend the
following: that frailty be identified using a validated measurement tool, that frail older adults be referred to
a progressive, individualized physical activity program that contains a resistance training component, that
polypharmacy be addressed by reducing or deprescribing any inappropriate medications. Conditional
recommendations were made for the following: that frail persons are screened for causes of fatigue, that
frail older adults who show unintentional weight loss be screened for reversible causes and considered
for food fortification/protein and caloric supplementation and, that vitamin D be prescribed to those who
have vitamin D deficiency.2 (Levels 1-5)
 The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed
clinical practice guidelines for the identification and management of frailty in older adults. The task force
strongly recommends that older adults aged 65 and over be screened for frailty using a simple, validated
frailty instrument that is suitable to the specific setting or context; those who screened positive for frailty
or pre-frailty should then undergo clinical assessment. Following assessment, a comprehensive
management plan should be implemented in older adults with frailty. The care plan should include
treatment of sarcopenia, polypharmacy, treatable causes of weight loss, and the causes of exhaustion
(depression, anemia, hypotension, hypothyroidism and vitamin B12 deficiency). The task force suggests
that, where appropriate, older persons with severe frailty be referred to a geriatrician. There is also a
strong recommendation for the implementation of a physical activity program that has a progressive
resistance training component. For frail adults who demonstrate weight loss or are diagnosed with
undernutrition, protein/caloric supplementation should be considered. Vitamin D supplementation should
only be considered in individuals who are vitamin D deficient. The guideline also suggests that older
adults with frailty be advised about the importance of oral health. The guidelines recommend against the
use of pharmacological treatment, cognitive or problem solving therapy and hormone therapy. Finally, the
guidelines recommend that adults with frailty should be offered as needed social support to assist with
unmet care needs and encourage compliance to the comprehensive management plan.3 (Levels 1-5)
The European clinical guidelines on the management of frailty recommend the use of CGA to develop an
individualized care plan and implement multidimensional interventions. The guidelines also recommend
the implementation of a structured multicomponent exercise program (endurance, flexibility, balance and
resistance training) using low to moderate intensity exercises for 30-40 minutes per session, three times
per week. Assessment of nutrition using a validated tool is also recommended. For individuals with
metabolic conditions or weight loss is of benefit, a weight loss of 8-10% of body weight over six months is
recommended, combined with exercise. Vitamin D supplementation can be considered if there is
deficiency. The guideline group also suggests that inappropriate prescriptions or polypharmacy should be
addressed.4(Levels 1-5)

Characteristics Of The Evidence

This summary is based on a structured search of the literature and selected evidence-based health care
databases. Evidence in this summary is from:
Clinical practice guidelines.1,2,3,4

Best Practice Recommendations

The multicomponent exercise program should be performed 30-40 minutes per session, three times per
week. (Grade B)
Polypharmacy should be addressed by reducing or deprescribing any inappropriate medications. (Grade
A)
 Older adults aged 65 and over should be screened for frailty using a validated instrument suitable to the
context or setting. (Grade A)
Older adults who screened positive for frailty should undergo a comprehensive assessment to inform the
development of a comprehensive care plan. (Grade A)
Older adults with frailty should receive a comprehensive care plan that includes targeted
multidimensional interventions. (Grade A)
Older adults with frailty should receive individualized and structured multicomponent exercise program
that has a resistance training component. (Grade A)
Older, frail adults who demonstrate weight loss or are diagnosed with undernutrition should be
considered for food fortification or protein/caloric supplementation. (Grade A)
Older adults who are deficient in Vitamin D should be prescribed with Vitamin D supplementation. (Grade
A)
A multidisciplinary team of doctors, nurses, physiotherapists, occupational therapists and social workers
should be involved in the management of frailty. (Grade B)
Older persons with severe frailty should be referred to a geriatrician. (Grade B)

References
1. Turner G, Clegg A. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of
General Practitioners report. Age Ageing. 2014; 43 (6): 744-747.
2. Dent E, Lien C, Lim WS, Wong WC, Wong CH, Ng TP, et al. The Asia-Pacific clinical practice guidelines for the management of
frailty. J Am Med Dir Assoc. 2017; 18(7):564-575.
3. Dent E, Morley JE, Cruz-Jentoft AJ, Woodhouse L, Roriguez-Manas L, Fried LP, et al. Physical frailty: ICSR international clinical
practice guidelines for identification and management. J Nutr health Aging. 2019; 23(9):771-787.
4. Gabrovec B, Antoniadou E. European guide for management of frailty at individual level including recommendations and roadmap.
Toledo, Spain. 2019.

Archived Publications
1. JBI-ES-3567-1 (Published at 30 April 2021)

The author declares no conflicts of interest in accordance with International Committee of Medical Journal Editors (ICMJE)standards.
How to cite: Lizarondo, L. Evidence Summary. Frailty in the Elderly: Management. The JBI EBP Database. 2021; JBI-ES-3567-2.
For details on the method for development see Munn Z, Lockwood C, Moola S. The development and use of evidence summaries for point of care information systems: A
streamlined rapid review approach. Worldviews Evid Based Nurs. 2015;12(3):131-8.
Note: The information contained in this Evidence Summary must only be used by people who have the appropriate expertise in the field to which the
information relates. The applicability of any information must be established before relying on it. While care has been taken to ensure that this Evidence
Summary summarizes available research and expert consensus, any loss, damage, cost or expense or liability suffered or incurred as a result of reliance on
this information (whether arising in contract, negligence, or otherwise) is, to the extent permitted by law, excluded.

Copyright © 2021 JBI Global licensed for use by the corporate member during the term of membership.