Gerontology, Palliative Care & Prevention · Topic 1 of 13

Comprehensive Geriatric Assessment & Frailty

Geriatrics · assessment and frailty

Comprehensive Geriatric Assessment & Frailty

Frailty is lost physiologic reserve: measure it (Fried phenotype, Clinical Frailty Scale) and assess function, health, cognition and social situation together.

Key numbers

Fried phenotype: 3 of 5 = frail≥ 3 of 5 criteria

Clinical Frailty Scale ≥ 5 = frailCFS ≥ 5 = frail

Failure to thrive: weight loss over 5%weight loss > 5%

01 · Defined byFried phenotype: 3 of 5 = frail

Fried frailty phenotype: unintentional weight loss (≥ 10 lb or ≥ 5% in a year), weak grip, slow gait, exhaustion and low physical activity — 3 or more = frail, 1–2 = prefrail.

02 · Defined byClinical Frailty Scale ≥ 5 = frail

The Clinical Frailty Scale grades baseline function (before the acute illness) from 1, very fit, to 9, terminally ill; ≥ 5 = frail: 5 mild (IADL dependence), 7 severe (personal-ADL dependence).

03 · DoCGA: function, health, cognition, social

A comprehensive geriatric assessment evaluates functional ability, physical health, cognition and mental health, and the socioenvironmental situation, usually by an interdisciplinary team, and pairs findings with tailored interventions.

What it is

Core idea

Frailty: lost reserve, vulnerable to minor stressors must knowFrailty is loss of physiologic reserve that leaves the patient vulnerable to disability and adverse outcomes after minor stressors; features include weakness, slowness, weight loss, sarcopenia, exhaustion, falls and immobility.

ADLs are self-care; IADLs are independent livingADLs: eating, dressing, bathing, transferring, toileting and continence. IADLs: preparing meals, housework, taking medications, shopping and errands, managing finances and using the telephone.

Aging blunts baroreflex, body water and thirstNormal aging lowers maximal heart rate, blunts the baroreflex (syncope risk), reduces total body water and thirst (dehydration risk), and impairs free-water excretion (hyponatremia risk).

Failure to thrive: weight loss over 5%Geriatric failure to thrive (Institute of Medicine) = weight loss over 5% of baseline, decreased appetite, poor nutrition and inactivity, often with dehydration, depressive symptoms, impaired immunity and low cholesterol.

Causes & risk factors

Why it happens

Frailty predicts falls, disability, hospitalization, deathFrail older adults are at increased risk of falls, disability, hospitalization and death; management is individualized to goals of care — exercise for the less frail, palliative symptom focus for the most frail.

Diagnosis & monitoring

Work-up

Normal creatinine can hide reduced GFRGFR falls about 8 mL/min/1.73 m² per decade after 40, yet serum creatinine often stays normal because older adults make less creatinine (less muscle) — estimate clearance before dosing renally cleared drugs.

Management

Orders

Failure to thrive: look for four syndromesEvaluate failure to thrive for impaired physical function, malnutrition, depression and cognitive impairment; review all medications and start with limited tests (CBC, chemistry panel, TSH, urinalysis), then treat reversible causes.

Failure to thrive should prompt goals-of-care talkA diagnosis of failure to thrive is a key decision point: discuss goals of care and end-of-life options to avoid interventions that only prolong suffering.

Treat frailty with exercise and nutritionOffer prefrail and frail patients a multicomponent physical-activity program (resistance and balance training) plus protein or nutritional supplementation when weight loss or undernutrition is present; vitamin D only for deficiency, no hormone therapy.

Quick screens: Mini-Cog, GDS, Timed Up and GoCommon CGA screens: Mini-Cog (3-item recall plus clock drawing) for cognition, Geriatric Depression Scale short form (> 5 suggests depression), and a timed chair rise–walk 10 feet–return test for gait and balance.

The rules

Know these

CGA improves function and survivalComprehensive geriatric assessment identifies more conditions, improves functional and mental status, reduces mortality and nursing-home and acute-hospital use; it is targeted at frail or chronically ill older adults.

New functional decline means disease, not agingMost organ functions decline gradually after about age 30 with little effect on daily activities, so disorders — not normal aging — are the main cause of functional loss; new decline warrants evaluation.

Fried phenotype or Clinical Frailty Scale?

Commonly confused

What it is	5 measured criteria
Items	Weight loss, weak grip, slow gait, exhaustion, low activity
Frail	3 or more criteria (1–2 = prefrail)
Needs	Dynamometer and timed walk

More detail

Reference

Show 5 reference facts

Frailty affects about 5–17% of older adults; transitions between not-frail, prefrail and frail occur in both directions.

The Rockwood frailty index counts health deficits present divided by deficits assessed; the Clinical Frailty Scale is a clinical judgment (not a questionnaire) that is not validated in younger patients or stable single-system disability.

Some experts recommend protein intake of 1.0–1.2 g/kg/day for healthy older adults without chronic kidney disease, combined with exercise.

There is no recommendation to screen all older adults for frailty; identify patients at risk or already frail when it will guide care and communication with families.

Failure to thrive affects 5–35% of community-dwelling older adults and 25–40% of nursing-home residents and is associated with infection, hip fracture, pressure injury and higher surgical mortality.

Pearl

Score frailty at the patient's baseline, not on the worst day in the ED — fit two weeks ago is still fit.

Sources · Merck Manual Professional — Comprehensive Geriatric Assessment (Apr 2026) · Allison R et al. Frailty: evaluation and management. Am Fam Physician 2021;103(4):219–226 · Montero-Odasso M et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing 2022;51:afac205 (frailty phenotype and CFS in risk stratification) · Rockwood K, Theou O. Using the Clinical Frailty Scale in allocating scarce health care resources. Can Geriatr J 2020;23:210–215 (CFS version 2.0) · Merck Manual Professional — Physical Changes With Aging · Merck Manual Professional — Pharmacokinetics in Older Adults · Merck Manual Professional — Hospital Care and Older Adults · Robertson RG, Montagnini M. Geriatric failure to thrive. Am Fam Physician 2004;70(2):343–350 · Merck Manual Professional — Prevention of Frailty · Usefulness of the Clinical Frailty Scale in patients with end-stage kidney disease. Clin Kidney J 2024 (CFS ≥ 4 vulnerable, ≥ 5 frail cut-offs) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).