Special Article| Volume 14, ISSUE 6, P392-397, June 2013

Frailty Consensus: A Call to Action


      Frailty is a clinical state in which there is an increase in an individual’s vulnerability for developing increased dependency and/or mortality when exposed to a stressor. Frailty can occur as the result of a range of diseases and medical conditions. A consensus group consisting of delegates from 6 major international, European, and US societies created 4 major consensus points on a specific form of frailty: physical frailty.
      • 1.
        Physical frailty is an important medical syndrome. The group defined physical frailty as “a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual's vulnerability for developing increased dependency and/or death.”
      • 2.
        Physical frailty can potentially be prevented or treated with specific modalities, such as exercise, protein-calorie supplementation, vitamin D, and reduction of polypharmacy.
      • 3.
        Simple, rapid screening tests have been developed and validated, such as the simple FRAIL scale, to allow physicians to objectively recognize frail persons.
      • 4.
        For the purposes of optimally managing individuals with physical frailty, all persons older than 70 years and all individuals with significant weight loss (≥5%) due to chronic disease should be screened for frailty.


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        • Walston J.
        • Hadley E.C.
        • Ferrucci L.
        • et al.
        Research agenda for frailty in older adults: Toward a better understanding of physiology and etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults.
        J Am Geriatr Soc. 2006; 54: 991-1001
        • Cerreta F.
        • Eichler H.G.
        • Rasi G.
        Drug policy for an aging population—the European Medicines Agency's geriatric medicines strategy.
        N Engl J Med. 2012; 367: 1972-1974
      1. Available at: Accessed April 22, 2013.

        • Rockwood K.
        • Mitnitski A.
        Frailty defined by deficit accumulation and geriatric medicine defined by frailty.
        Clin Geriatr Med. 2011; 27: 17-26
        • Fried L.P.
        • Ferrucci L.
        • Darer J.
        • et al.
        Untangling the concepts of disability, frailty, and comorbidity: Implications for improved targeting and care.
        J Gerontol A Biol Sci Med Sci. 2004; 59: 255-263
        • Sourial N.
        • Bergman H.
        • Karunananthan S.
        • et al.
        Contribution of frailty markers in explaining differences among individuals in five samples of older persons.
        J Gerontol A Biol Sci Med Sci. 2012; 67: 1197-1204
        • Collard R.M.
        • Boter H.
        • Schoevers R.A.
        • Oude Voshaar R.C.
        Prevalence of frailty in community-dwelling older persons: A systematic review.
        J Am Geriatr Soc. 2012; 60: 1487-1492
        • Rodríguez-Mañas L.
        • Féart C.
        • Mann G.
        • et al.
        • on behalf of the FOD-CC group
        Searching for an operational definition of frailty: A Delphi method based consensus statement. The Frailty Operative Definition-Consensus Conference Project.
        J Gerontol A Biol Sci Med Sci. 2013; 68: 62-67
        • Rockwood K.
        What would make a definition of frailty successful?.
        Age Ageing. 2005; 34: 432-434
        • Fried L.P.
        • Tangen C.M.
        • Walston J.
        • et al.
        Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: Evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156
        • Bandeen-Roche K.
        • Xue Q.L.
        • Ferrucci L.
        • et al.
        Phenotype of frailty: Characterization in the women's health and aging studies.
        J Gerontol A Biol Sci Med Sci. 2006; 61: 262-266
        • Ensrud K.E.
        • Ewing S.K.
        • Taylor B.C.
        • et al.
        Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women.
        Arch Intern Med. 2008; 168: 382-389
        • Kiely D.K.
        • Cupples L.A.
        • Lipsitz L.A.
        Validation and comparison of two frailty indexes: The MOBILIZE Boston Study.
        J Am Geriatr Soc. 2009; 57: 1532-1539
        • Rockwood K.
        • Abeysundera M.J.
        • Mitnitski A.
        How should we grade frailty in nursing home patients?.
        J Am Med Dir Assoc. 2007; 8: 595-603
        • Rockwood K.
        • Mitnitski A.
        • Song X.
        • et al.
        Long-term risks of death and institutionalization of elderly people in relation to deficit accumulation at age 70.
        J Am Geriatr Soc. 2006; 54: 975-979
        • Abellan van Kan G.
        • Rolland Y.M.
        • Morley J.E.
        • Vellas B.
        Frailty: Toward a clinical definition.
        J Am Med Dir Assoc. 2008; 9: 71-72
        • Abellan van Kan G.
        • Rolland Y.
        • Bergman H.
        • et al.
        The I.A.N.A. Task Force on Frailty assessment of older people in clinical practice.
        J Nutr Health Aging. 2008; 12: 29-37
        • Romero-Ortuno R.
        The Frailty Instrument of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI) predicts mortality beyond age, comorbidities, disability, self-rated health, education and depression.
        Eur Geriatr Med. 2011; 2: 323-326
        • Romero-Ortuno R.
        • Walsh C.D.
        • Lawlor B.A.
        • Kenny R.A.
        A frailty instrument for primary care: Findings from the Survey of Health, Ageing and Retirement in Europe (SHARE).
        BMC Geriatr. 2010; 10: 57
        • Min L.C.
        • Elliott M.N.
        • Wenger N.S.
        • Saliba D.
        Higher vulnerable elders survey scores predict death and functional decline in vulnerable older people.
        J Am Geriatr Soc. 2006; 54: 507-511
        • Min L.
        • Yoon W.
        • Mariano J.
        • et al.
        The vulnerable elders-13 survey predicts 5-year functional decline and mortality outcomes in older ambulatory care patients.
        J Am Geriatr Soc. 2009; 57: 2070-2076
        • Biganzoli L.
        • Boni L.
        • Becheri D.
        • et al.
        Evaluation of the cardiovascular health study (CHS) instrument and the Vulnerable Elders Survey-13 (VES-13) in elderly cancer patients. Are we still missing the right screening tool?.
        Ann Oncol. 2013; 24: 494-500
        • Gobbens R.J.
        • van Assen M.A.
        • Luijkx K.G.
        • et al.
        The Tilberg Frailty Indicator: Psychometric properties.
        J Am Med Dir Assoc. 2010; 11: 344-355
        • Gobbens R.J.
        • van Assen M.A.
        • Luijkx K.G.
        • et al.
        Determinants of frailty.
        J Am Med Dir Assoc. 2010; 11: 356-364
        • Peters L.L.
        • Boter H.
        • Buskens E.
        • Slaets J.P.
        Measurement properties of the Groningen Frailty Indicator in home-dwelling and institutionalized elderly people.
        J Am Med Dir Assoc. 2012; 13: 546-551
        • Hoogendijk E.O.
        • van Hout H.P.
        Investigating measurement properties of the Groningen Frailty Indicator: A more systematic approach is needed.
        J Am Med Dir Assoc. 2012; 13: 757
        • Morley J.E.
        • Abbatecola A.M.
        • Argiles J.M.
        • et al.
        Sarcopenia with limited mobility: An international consensus.
        J Am Med Dir Assoc. 2011; 12: 403-409
        • Fielding R.A.
        • Vellas B.
        • Evans W.J.
        • et al.
        Sarcopenia: An undiagnosed condition in older adults. Current consensus definition: Prevalence, etiology, and consequences. International Working Group on Sarcopenia.
        J Am Med Dir Assoc. 2011; 12: 249-256
        • Muscaritoli M.
        • Anker S.D.
        • Argiles J.
        • et al.
        Consensus definition of sarcopenia, cachexia and pre-cachexia: Joint document elaborated by Special Interest Groups (SIG) “cachexia-anorexia in chronic wasting disease” and “nutrition in Geriatrics.”.
        Clin Nutr. 2010; 29: 154-159
        • Cruz-Jentoft A.J.
        • Baeyens J.P.
        • Bauer J.M.
        • et al.
        Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People.
        Age Ageing. 2010; 39: 412-423
        • Von Haehling S.
        • Morley J.E.
        • Anker S.D.
        From muscle wasting to sarcopenia and myopenia: Update 2012.
        J Cachexia Sarcopenia Muscle. 2012; 3: 213-217
        • Morley J.E.
        Developing novel therapeutic approaches to frailty.
        Curr Pharm Des. 2009; 15: 3384-3395
        • Lacas A.
        • Rockwood K.
        Frailty in primary care: A review of its conceptualization and implications for practice.
        BMC Med. 2012; 10: 4
        • Pialoux T.
        • Goyard J.
        • Lesourd B.
        Screening tools for frailty in primary health care: A systematic review.
        Geriatr Gerontol Int. 2012; 12: 189-197
        • Sternberg S.A.
        • Wershof Schwartz A.
        • Karunananthan S.
        • et al.
        The identification of frailty: A systematic literature review.
        J Am Geriatr Soc. 2011; 59: 2129-2138
        • Hubbard R.E.
        • Rockwood K.
        Frailty in older women.
        Maturitas. 2011; 69: 203-207
        • Pijpers E.
        • Ferreira I.
        • Stehouwer C.D.
        • et al.
        The frailty dilemma. Review of the predictive accuracy of major frailty scores.
        Eur J Intern Med. 2012; 23: 118-123
        • Morley J.E.
        Frailty: Diagnosis and management.
        J Nutr Health Aging. 2011; 15: 667-670
        • Shamliyan T.
        • Talley K.M.
        • Ramakrishnan R.
        • Kane R.L.
        Association of frailty with survival: A systematic literature review.
        Ageing Res Rev. 2012; (Mar 12 [Epub ahead of print])
        • Tinetti M.E.
        • Fried T.R.
        • Boyd C.M.
        Designing health care for the most common chronic condition—multimorbidity.
        JAMA. 2012; 307: 2493-2494
        • Rockwood K.
        • Song X.
        • MacKnight C.
        • et al.
        A global clinical measure of fitness and frailty in elderly people.
        CMAJ. 2005; 173: 489-495
      2. Royal College of Physicians. Acute Care Toolkit 3: Acute Medical Care for Frail Older people. March 2012. Available at: Accessed December 20, 2012.

        • Rolland Y.
        • Benetos A.
        • Gentric A.
        • et al.
        Frailty in older population: A brief position paper from the French society of geriatrics and gerontology.
        Geriatr Psychol Neuropsychiatr Vieil. 2011; 9: 387-390
        • Hyde Z.
        • Flicker L.
        • Almeida O.P.
        • et al.
        Low free testosterone predicts frailty in older men: The Health in Men study.
        J Clin Endocrinol Metab. 2010; 95: 3165-3172
        • Lopez D.
        • Flicker L.
        • Dobson A.
        Validation of the frail scale in a cohort of older Australian women.
        J Am Geriatr Soc. 2012; 60: 171-173
        • Morley J.E.
        • Malmstrom T.K.
        • Miller D.K.
        A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans.
        J Nutr Health Aging. 2012; 16: 601-608
        • Woo J.
        • Leung J.
        • Morley J.E.
        Comparison of frailty indicators based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation.
        J Am Geriatr Soc. 2012; 60: 1478-1486
        • Subra J.
        • Gillette-Guyonnet S.
        • Cesari M.
        • et al.
        The integration of frailty into clinical practice: Preliminary results from the Gérontopôle.
        J Nutr Health Aging. 2012; 16: 714-720
        • Singh N.A.
        • Quine S.
        • Clemson L.M.
        • et al.
        Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: A randomized controlled trial.
        J Am Med Dir Assoc. 2012; 13: 24-30
        • Yamada M.
        • Arai H.
        • Sonoda T.
        • Aoyama T.
        Community-based exercise program is cost-effective by preventing care and disability in Japanese frail older adults.
        J Am Med Dir Assoc. 2012; 13: 507-511
        • Theou O.
        • Stathokostas L.
        • Roland K.P.
        • et al.
        The effectiveness of exercise interventions for the management of frailty: A systematic review.
        J Aging Res. 2011; 2011: 569194
        • Gillespie L.D.
        • Robertson M.C.
        • Gillespie W.J.
        • et al.
        Interventions for preventing falls in older people living in the community.
        Cochrane Database Syst Rev. 2012; : CD007146
        • Landi F.
        • Laviano A.
        • Cruz-Jentoft A.J.
        The anorexia of aging: Is it a geriatric syndrome?.
        J Am Med Dir Assoc. 2010; 11: 153-156
        • Morley J.E.
        Undernutrition: A major problem in nursing homes.
        J Am Med Dir Assoc. 2011; 12: 243-246
        • Morley J.E.
        Weight loss in older persons: New therapeutic approaches.
        Curr Pharm Des. 2007; 13: 3637-3647
        • Milne A.C.
        • Potter J.
        • Vivanti A.
        • Avenell A.
        Protein and energy supplementation in elderly people at risk from malnutrition.
        Cochrane Database Syst Rev. 2009; : CD003288
        • van Wetering C.R.
        • Hoogendoorn M.
        • Broekhuizen R.
        • et al.
        Efficacy and costs of nutritional rehabilitation in muscle-wasted patients with chronic obstructive pulmonary disease in a community-based setting: A prespecified subgroup analysis of the INTERCOM trial.
        J Am Med Dir Assoc. 2010; 11: 179-187
        • Neelemat F.
        • Bosmans J.E.
        • Thijs A.
        • et al.
        Post-discharge nutritional support in malnourished elderly individuals improves functional limitations.
        J Am Med Dir Assoc. 2011; 12: 295-301
        • Morley M.E.
        • Argiles J.M.
        • Evans W.J.
        • et al.
        Nutritional recommendations for the management of sarcopenia.
        J Am Med Dir Assoc. 2010; 11: 391-396
        • Tieland M.
        • van de Rest O.
        • Dirks M.L.
        • et al.
        Protein supplementation improves physical performance in frail elderly people: A randomized, double-blind, placebo-controlled trial.
        J Am Med Dir Assoc. 2012; 13: 720-726
        • Volpi E.
        • Campbell W.W.
        • Dwyer J.T.
        • et al.
        Is the optimal level of protein intake for older adults greater than the recommended dietary allowance?.
        J Gerontol A Biol Sci Med Sci. 2012; (Nov 26 [Epub ahead of print])
        • Paddon-Jones D.
        Perspective: Exercise and protein supplementation in frail elders.
        J Am Med Dir Assoc. 2013; 14: 73-74
        • Malafarina V.
        • Uriz-Otano F.
        • Iniesta R.
        • Gil-Guerrero L.
        Effectiveness of nutritional supplementation on muscle mass in treatment of sarcopenia in old age: A systematic review.
        J Am Med Dir Assoc. 2013; 14: 10-17
        • Tieland M.
        • Dirks M.L.
        • van der Zwaluw N.
        • et al.
        Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: A randomized, double-blind, placebo-controlled trial.
        J Am Med Dir Assoc. 2012; 13: 713-719
        • Morley J.E.
        Do frail older persons need more protein?.
        J Am Med Dir Assoc. 2012; 13: 667-668
        • Cawood A.L.
        • Elia M.
        • Stratton R.J.
        Systematic review and meta-analysis of the effects of high protein oral nutritional supplements.
        Ageing Res Rev. 2012; 11: 278-296
        • Waters D.L.
        • Vawter R.
        • Qualls C.
        • et al.
        Long-term maintenance of weight loss after lifestyle intervention in frail, obese older adults.
        J Nutr Health Aging. 2013; 17: 3-7
        • Murad M.H.
        • Elamin K.B.
        • Abu Elnour N.O.
        • et al.
        Clinical review: The effect of vitamin D on falls: A systematic review and meta-analysis.
        J Clin Endocrinol Metab. 2011; 96: 2997-3006
        • Bischoff-Ferrari H.A.
        • Willett W.C.
        • Orav E.J.
        • et al.
        A pooled analysis of vitamin D dose requirements for fracture prevention.
        N Engl J Med. 2012; 567: 40-49
        • Rejnmark L.
        • Avenell A.
        • Masud T.
        • et al.
        Vitamin D with calcium reduces mortality: Patient level pooled analysis of 70,528 patients from eight major vitamin D trials.
        J Clin Endocrinol Metab. 2012; 97: 2670-2681
        • Muir S.W.
        • Montero-Odasso M.
        Effect of vitamin D supplementation on muscle strength, gait and balance in older adults: A systematic review and meta-analysis.
        J Am Geriatr Soc. 2011; 59: 2291-2300
        • Rolland Y.
        • Onder G.
        • Morley J.E.
        • et al.
        Current and future pharmacologic treatment of sarcopenia.
        Clin Geriatr Med. 2011; 27: 423-447
        • Sukuma K.
        • Yamaguchi A.
        Molecular mechanisms in aging and current strategies to counteract sarcopenia.
        Curr Aging Sci. 2010; 3: 90-101
        • Gnjidic D.
        • Hilmer S.N.
        • Blyth F.M.
        • et al.
        Polypharmacy cutoff and outcomes: Five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes.
        J Clin Epidemiol. 2012; 65: 989-995
        • Flaherty J.H.
        • Perry 3rd, H.M.
        • Lynchard G.S.
        • Morley J.E.
        Polypharmacy and hospitalization among older home care patients.
        J Gerontol A Biol Sci Med Sci. 2000; 55: M554-M559
        • Rockwood K.
        Medical management of frailty: Confessions of a gnostic.
        CMAJ. 1997; 157: 1081-1084
        • Bronskill S.E.
        • Gill S.S.
        • Paterson J.M.
        • et al.
        Exploring variation in rates of polypharmacy across long term care homes.
        J Am Med Dir Assoc. 2012; 13: 309.e15-309.e21
        • Gokce Kutsal Y.
        • Barak A.
        • Atalay A.
        • et al.
        Polypharmacy in the elderly: A multicenter study.
        J Am Med Dir Assoc. 2009; 10: 486-490
        • Kojima G.
        • Bell C.
        • Tamura B.
        • et al.
        Reducing cost by reducing polypharmacy: The polypharmacy outcomes project.
        J Am Med Dir Assoc. 2012; 13: 818.e11-818.e15
        • Fitzgerald S.P.
        • Bean N.G.
        An analysis of the interactions between individual comorbidities and their treatments—implications for guidelines and polypharmacy.
        J Am Med Dir Assoc. 2010; 11: 475-484
        • Tamura B.K.
        • Bell C.L.
        • Lubimir K.
        • et al.
        Physician intervention for medication reduction in a nursing home: The polypharmacy outcomes project.
        J Am Med Dir Assoc. 2011; 12: 326-330
        • Morley J.E.
        Polypharmacy in the nursing home.
        J Am Med Dir Assoc. 2009; 10: 289-291
        • Merle L.
        • Laroche M.L.
        • Dantoine T.
        • Charmes J.P.
        Predicting and preventing adverse drug reactions in the very old.
        Drugs Aging. 2006; 22: 375-392
        • Resnick B.
        • Pacala J.T.
        2012 Beers Criteria.
        J Am Geriatr Soc. 2012; 60: 612-613
        • Gallagher P.
        • Ryan C.
        • Byrne S.
        • et al.
        STOPP (Screening Tool of Older Person's Prescription) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation.
        Int J Clin Pharmacol Ther. 2008; 46: 72-83
        • Pyszka L.L.
        • Seys Ranola T.M.
        • Milhans S.M.
        Identification of inappropriate prescribing in geriatrics at a Veterans Affairs hospital using STOPP/START screening tools.
        Consult Pharm. 2010; 25: 365-373
        • Theou O.
        • Rockwood K.
        Should frailty status always be considered when treating the elderly patient?.
        Aging Health. 2012; 8: 261-271
        • Espinoza S.
        • Walston J.D.
        Frailty in older adults: Insights and interventions.
        Cleve Clin J Med. 2005; 72: 1105-1112
        • Vellas B.
        • Cestac P.
        • Morley J.E.
        Implementing frailty into clinical practice: We cannot wait.
        J Nutr Health Aging. 2012; 16: 599-600
        • Ogawa K.
        • Fujiwara Y.
        • Yoshida H.
        • et al.
        [The validity of the “Kihon Checklist” as an index of frailty and its biomarkers and inflammatory markers in elderly people.].
        Nihon Ronen Igakkai Zasshi. 2011; 48 (Japanese): 545-552
        • Tomata Y.
        • Hozawa A.
        • Ohmori-Matsuda K.
        • et al.
        [Validation of the Kihon Checklist for predicting the risk of 1-year incident long term care insurance certification: The Ohsaki Cohort 2006 Study.].
        Nihon Koshu Eisei Zasshi. 2011; 58 (Japanese): 3-13
        • Fukutomi E.
        • Okumiya K.
        • Wada T.
        • et al.
        Importance of cognitive assessment as part of the “Kihon Checklist” developed by the Japanese Ministry of Health, Labor and Welfare for prediction of frailty at a 2-year follow up.
        Geriatr Gerontol Int. 2012, Nov 22; ([Epub ahead of print])
        • Afilalo J.
        Frailty in patients with cardiovascular disease: Why, when and how to measure.
        Curr Cardiovasc Risk Rep. 2011; 5: 467-472
        • Ruiz M.
        • Reske T.
        • Cefalu C.
        • Estrada J.
        Management of elderly and frail elderly patients: The importance of comprehensive geriatrics assessment and the need for guidelines.
        Am J Med Sci. 2012; (Nov 17 [Epub ahead of print])
        • Shilpak M.G.
        • Stehman-Breen C.
        • Fried L.F.
        • et al.
        The presence of frailty in elderly persons with chronic renal insufficiency.
        Am J Kidney Dis. 2004; 43: 861-867
        • Desquilbet L.
        • Jacobson L.P.
        • Fried L.P.
        • et al.
        HIV-1 infection is associated with an earlier occurrence of a phenotype related to frailty.
        J Gerontol A Biol Sci Med Sci. 2007; 62: 1279-1286
        • Sinclair A.
        • Morley J.E.
        • Rodriguez-Mañas L.
        • et al.
        Diabetes mellitus in older people: Position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes.
        J Am Med Dir Assoc. 2012; 13: 497-502
        • Partridge J.S.
        • Harari D.
        • Dhesi J.K.
        Frailty in the older surgical patient: A review.
        Age Ageing. 2012; 41: 142-147