Recognising frailty in clinical practice

People living with frailty may not present with a neat disease-specific symptom. Falls, sudden immobility, delirium, incontinence, reduced oral intake, medication problems or an unexplained loss of confidence can be the first visible sign of an acute illness superimposed on limited reserve. These syndromes should prompt a search for triggers as well as an assessment of baseline function.

A single observation can mislead. A person who needs two staff to transfer during pneumonia may normally walk independently. Another person who appears comfortable in bed may already have severe baseline dependence. Recognition therefore depends on change over time: what could the person do two weeks ago, three months ago, and a year ago; what has changed; and is the current change potentially reversible?

Pain, constipation, urinary retention, dehydration, infection, hypoxia, medication adverse effects, sleep disruption, sensory impairment and environmental change can all worsen mobility or cognition. Frailty increases vulnerability to these factors; it does not make them untreatable or inevitable. 'Frail' must never become a diagnostic stop sign.

When cognition, delirium, fatigue or communication difficulty limit self-report, collateral information becomes part of good clinical assessment. Family, carers, community teams, previous therapy notes, primary-care records and medication histories can clarify usual mobility, personal care, instrumental activities, cognition and recent trajectory.

Falls, delirium, immobility, incontinence and susceptibility to medication adverse effects are often described as frailty syndromes. The educational value is not the label itself but the recognition that apparently separate problems may share underlying vulnerability and require multidomain assessment.

Frailty recognition should lower the threshold for comprehensive assessment when there is multimorbidity, recurrent crisis, functional decline, complex medicines, cognitive change, carer strain, uncertain goals or difficulty coordinating services. CGA is explored in the companion course; here the learner should understand that frailty identification is the beginning of a care process, not its endpoint.

What will you do differently when you next assess an older person whose current function differs from their usual baseline? Record one specific change in history-taking, documentation, tool use or multidisciplinary communication.