CONSIDER: identify people who may be living with frailty [mild, moderate and severe] opportunistically or systematically.

Groups with high frailty prevalence

  • People who are resident in care homes.
  • People living with dementia.
  • People aged over 65 who have experienced one of the major frailty syndromes: Immobility (e.g. sudden change in mobility) , Delirium (e.g. acute confusion, sudden worsening of confusion in someone with previous dementia or known memory loss), Incontinence (e.g. change in continence – new onset or worsening of urine and faecal incontinence) and susceptibility to side effects of medication.
  • People aged 65 or above with multimorbidity due to 4 or more long term conditions.
  • People on over 10 medications.
  • People known to community nurses or social care and support services with continuous support needs.
  • People on end of life (EOL) register or cancer care lists or with complex neurological problems (stroke, MS, Parkinson’s disease) or older people with severe mental illness.
  • All people aged over 85.
  • People who are housebound or living in sheltered schemes or extra care or in ‘ordinary’ housing with telecare aids (e.g. ‘life alarms’).

From: Toolkit for general practice in supporting older people living with frailty. NHS England ( with modification.

Frailty screening tools

  • The Electronic Frailty Index (eFI) can be used for population screening in general practice settings.
  • Tools for screening individuals include Clinical Frailty Scale, PRISMA-7, Gait Speed, Timed up and go Test and the Edmonton Frailty Scale.

For more information to aid local delivery see what works, resource links, benefits, evidence, local stories and case studies as well as impact/measures see Frailty Toolkit document page 26-38

Useful resources

Toolkit for general practice in supporting older people living with frailty 2017 –

Fit for Frailty (part 1), section 3

iHUB (Health improvement Scotland) – slide deck ‘frailty tools’  screening and assessment comparators –

NICE guidance: Multimorbidity: Clinical Assessment and Management.

Pathfields Tool: a frailty case-finding tool using primary care IT—implications for population health management –