Why Frailty Is Examined
Frailty is a state of increased vulnerability to stressors due to reduced physiological reserve. As the UK population ages, frailty assessment is now a core NHS competency. OSCEs examine it in: clinical assessment stations, communication stations (discussing frailty with a patient/carer), and clinical reasoning (a frail 84-year-old with pneumonia — how do you approach this?).
💡 Tip
Frailty is not the same as age. A 90-year-old who runs 5k weekly is not frail; a 65-year-old with multiple comorbidities, sarcopaenia, and functional decline may be severely frail. Assess function, not age.
Fried Frailty Phenotype — Five Domains
The original validated frailty model identifies five phenotypic criteria:
| Domain | Definition | Measurement |
|---|---|---|
| 1. Unintentional weight loss | Over 4.5 kg (10 lbs) in past year | History, serial weights |
| 2. Exhaustion | Self-reported fatigue most days | "Did you feel that everything you did was an effort?" |
| 3. Low physical activity | Bottom 20% of population by kcal/week | Minnesota Leisure Activity questionnaire |
| 4. Slowness | Gait speed below 0.8 m/s | Timed 4-metre walk |
| 5. Weakness | Grip strength (bottom 20% by BMI/sex) | Jamar dynamometer |
| Score | Category |
|---|---|
| 0 | Robust |
| 1-2 | Pre-frail |
| 3-5 | Frail |
Clinical Frailty Scale (CFS) — Rockwood
The CFS is widely used in NHS clinical practice and is the most commonly examined frailty tool in UK OSCEs. It uses a 9-point scale based on clinical judgment about function and dependence.
🧠 Mnemonic
CFS 1-9 — a functional ladder:
- 1 Very fit: active, energetic, exercises regularly
- 2 Well: no active disease, less active than level 1
- 3 Managing well: medical problems well controlled, occasional activity only
- 4 Living with very mild frailty: early functional limitation, not dependent on others
- 5 Living with mild frailty: more slowing, needs prompting for some ADLs
- 6 Living with moderate frailty: help needed with all outside activities and housework; problems with stairs
- 7 Living with severe frailty: completely dependent for personal care; medically stable
- 8 Living with very severe frailty: completely dependent, approaching end of life
- 9 Terminally ill: expected life expectancy under 6 months, not overtly frail
Remember: CFS 5 or above = frail; CFS 7-8 = severe frailty; CFS 9 = terminal.
Comprehensive Geriatric Assessment (CGA)
CGA is the multidimensional assessment of an older person's medical, functional, cognitive, social, and environmental status. It drives care planning.
Domains of CGA
| Domain | What to assess | Tools |
|---|---|---|
| Medical | Active conditions, medications, falls risk | Standard history and examination, medication review |
| Functional | ADLs, iADLs | Barthel Index, Lawton iADL Scale |
| Cognitive | Baseline and current cognition | MMSE, MoCA, AMT |
| Mental health | Depression, anxiety | GDS-15, PHQ-9 |
| Nutritional | Weight loss, intake, swallowing | MUST score |
| Social | Home circumstances, carer support, social isolation | Social history |
| Environmental | Housing suitability, access, falls hazards | OT home assessment |
| Goals and values | What matters most to the patient | Advance care planning discussion |
💎 Clinical Pearl
"What matters to you?" is one of the most powerful questions in geriatric medicine — and increasingly in OSCEs. A patient may value remaining at home over aggressive hospital treatment. Their goals should shape every management decision.
Assessing Activities of Daily Living
Basic ADLs (Barthel Index domains):
🧠 Mnemonic
BATHED:
- B athing
- A mbulation (mobility/transfers)
- T oileting
- H aving meals (feeding)
- E veryday dressing
- D efecation (continence — bowel and bladder)
Instrumental ADLs (iADLs): shopping, cooking, managing finances, using the telephone, driving, housework, managing medications.
Ask: "Before this admission, what were you able to do independently at home?" Establish baseline function before the acute illness — this is the target for rehabilitation.
Goals of Care Discussion
Exploring goals of care with a frail older adult (or their family) is a key communication OSCE task.
Framework — ICE + Future focus:
- 1Understand their perspective: "What has the team told you about your situation?"
- 2Explore values: "What are the things that matter most to you in your day-to-day life?"
- 3Explore concerns: "Is there anything you worry about when you think about the future?"
- 4Explore hopes and fears: "What do you hope we can achieve? What would concern you most if your health were to deteriorate?"
- 5Discuss what they would and would not want: "If you became very unwell, is there anything you would want us to know about what treatments you would or would not want?"
⚠️ Red Flag
Goals of care discussions are not about withdrawing treatment — they are about ensuring care is aligned with what matters most to the individual. Never present them as "giving up." Frame as: "We want to make sure everything we do is aimed at what's important to you."
Frailty in Acute Settings — OSCE Approach
When assessing a frail patient in an acute deterioration scenario:
- 1Establish premorbid function (baseline CFS)
- 2Identify reversible causes of deterioration
- 3Consider goals of care early — aggressive intervention may not align with patient wishes
- 4Involve multidisciplinary team: OT, physiotherapy, social work, dietetics
- 5Plan for discharge early: home with package of care, rehabilitation unit, or long-term care
Frequently Asked Questions
"What is the difference between frailty and multimorbidity?"
Multimorbidity is the co-existence of two or more chronic conditions. Frailty is a state of physiological vulnerability — reduced reserve across multiple organ systems that increases susceptibility to adverse outcomes from stressors. A person can be multimorbid without being frail (well-controlled conditions, preserved function) or frail without many diagnoses (primary sarcopaenia and deconditioning). They frequently co-exist.
"How do you calculate the Clinical Frailty Scale?"
The CFS is a global clinical judgement — not a calculated score from individual items. You assess the patient's functional status (what they can do independently), exercise tolerance, and dependence on others for personal care. You then select the scale point that best describes their usual state. Use the patient's baseline (pre-illness) function, not their current acute presentation.
"What is sarcopaenia?"
Sarcopaenia is age-related progressive loss of skeletal muscle mass and function. It is a key component of frailty and independently associated with falls, functional decline, and mortality. Diagnosed by low muscle mass plus low grip strength or slow gait speed. Management: resistance exercise, adequate protein intake (1.0-1.2 g/kg/day), and treating reversible causes (vitamin D deficiency, hypothyroidism).
"When should DNACPR be discussed in a frail patient?"
DNACPR should be discussed when CPR is unlikely to be successful or when the patient's values suggest they would not want it. In a patient with CFS 7-8, the survival to discharge after in-hospital cardiac arrest is very low. These conversations should happen proactively — not at the point of acute deterioration. Always involve the patient (if they have capacity) and document discussions carefully.
"What is an advance care plan?"
An advance care plan (ACP) is a documented record of a patient's wishes, values, and preferences for future care — made while they have capacity. It can include preferred place of care, preferred place of death, and decisions about specific treatments. It is not legally binding but should be respected. A Lasting Power of Attorney (LPA) for health and welfare is a separate legal instrument that gives a named person authority to make decisions if the patient loses capacity.
Related Posts
- Delirium Assessment OSCE — frailty as the key predisposing factor for delirium
- Medication Review OSCE — deprescribing in frail older adults to reduce harm
- Nutrition Screening OSCE — malnutrition and weight loss as core frailty domains