Clinical frailty scale for assessment of frailty and level of care in elderly patients

The Clinical Frailty Scale is used to summarize the overall level of fitness or frailty of an older adult. The original tool was introduced in the second clinical examination of the Canadian Study of Health and Aging (CSHA) and included seven-point scale. Since 2007, the instrument has been modified to contain nine-point scale ranging from the assessment very vital to terminally ill.

What systematic reviews and primary studies are there investigating the use of Clinical Frailty Scale (CFS) to assess frailty and level of care in elderly patients?

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Published: Revised: 10/2/2020 Report no: ut201922 Registration no: SBU 2019/269

Identified studies

Five systematic review (1–5) with high risk of bias and 41 primary studies (6–46) were found relevant for the question. The primary studies were not assessed for risk of bias.


  1. Bouillon K, Kivimaki M, Hamer M, Sabia S, Fransson EI, Singh-Manoux A, et al. Measures of frailty in population-based studies: an overview. BMC geriatrics 2013;13:64.
  2. de Vries NM, Staal JB, van Ravensberg CD, Hobbelen JS, Olde Rikkert MG, Nijhuis-van der Sanden MW. Outcome instruments to measure frailty: a systematic review. Ageing research reviews 2011;10:104-14.
  3. Faller JW, Pereira DDN, de Souza S, Nampo FK, Orlandi FS, Matumoto S. Instruments for the detection of frailty syndrome in older adults: A systematic review. PloS one 2019;14:e0216166.
  4. Goldstein JP, Andrew MK, Travers A. Frailty in older adults using pre-hospital care and the emergency department: A narrative review. Canadian Geriatrics Journal : CGJ 2012;15:16-22.
  5. Jorgensen R, Brabrand M. Screening of the frail patient in the emergency department: A systematic review. Eur J Intern Med 2017;45:71-3.
  6. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. Cmaj 2005;173:489-95.
  7. Rockwood K, Abeysundera MJ, Mitnitski A. How should we grade frailty in nursing home patients? J Am Med Dir Assoc 2007;8:595-603.
  8. Curtis E, Romanowski K, Sen S, Hill A, Cocanour C. Frailty score on admission predicts mortality and discharge disposition in elderly trauma patients over the age of 65 y. J Surg Res 2018;230:13-9.
  9. Alabaf Sabbaghi S, De Souza D, Sarikonda P, Keevil VL, Wallis SJ, Romero-Ortuno R. Allocating patients to geriatric medicine wards in a tertiary university hospital in England: A service evaluation of the Specialist Advice for the Frail Elderly (SAFE) team. Aging Medicine 2018;1:120-124.
  10. Basic D, Shanley C. Frailty in an older inpatient population: using the clinical frailty scale to predict patient outcomes. J Aging Health 2015;27:670-85.
  11. Cardona M, Lewis ET, Kristensen MR, Skjot-Arkil H, Ekmann AA, Nygaard HH, et al. Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study. Eur Geriatr Med 2018;9:891-901.
  12. Cheung A, Haas B, Ringer TJ, McFarlan A, Wong CL. Canadian Study of Health and Aging Clinical Frailty Scale: Does It Predict Adverse Outcomes among Geriatric Trauma Patients? J Am Coll Surg 2017;225:658-665 e3.
  13. Chong E, Ho E, Baldevarona-Llego J, Chan M, Wu L, Tay L. Frailty and Risk of Adverse Outcomes in Hospitalized Older Adults: A Comparison of Different Frailty Measures. J Am Med Dir Assoc 2017;18:638 e7-638 e11.
  14. Chua XY, Toh S, Wei K, Teo N, Tang T, Wee SL. Evaluation of clinical frailty screening in geriatric acute care. J Eval Clin Pract; 2019.
  15. Conroy S, Dowsing T. The ability of frailty to predict outcomes in older people attending an acute medical unit. Acute Med 2013;12:74-6.
  16. Davies J, Whitlock J, Gutmanis I, Kane SL. Inter-Rater Reliability of the Retrospectively Assigned Clinical Frailty Scale Score in a Geriatric Outreach Population. Can Geriatr J 2018;21:1-5.
  17. Flaatten H, De Lange DW, Morandi A, Andersen FH, Artigas A, Bertolini G, et al. The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (>/= 80 years). Intensive Care Med 2017;43:1820-8.
  18. Fronczek J, Polok K, Nowak-Kózka I, Wludarczyk A, Górka J, Czuczwar M, et al. Frailty increases mortality among patients = 80 years old treated in Polish ICUs. Anaesthesiology Intensive Therapy 2018;50:245-51.
  19. Gregorevic KJ, Hubbard RE, Lim WK, Katz B. The clinical frailty scale predicts functional decline and mortality when used by junior medical staff: a prospective cohort study. BMC Geriatr 2016;16:117.
  20. Hartley P, Adamson J, Cunningham C, Embleton G, Romero-Ortuno R. Clinical frailty and functional trajectories in hospitalized older adults: A retrospective observational study. Geriatr Gerontol Int 2017;17:1063-8.
  21. Hartley P, Keevil VL, Romero-Ortuno R. The association between clinical frailty and walking speed in older hospitalized medical patients: A retrospective observational study. European Geriatric Medicine 2017;8:130-3.
  22. Hawker M, Romero-Ortuno R. Social determinants of discharge outcomes in older people admitted to a geriatric medicine ward. J Frailty Aging 2016;5:118-20.
  23. Hernandez-Luis R, Martin-Ponce E, Monereo-Munoz M, Quintero-Platt G, Odeh-Santana S, Gonzalez-Reimers E, et al. Prognostic value of physical function tests and muscle mass in elderly hospitalized patients. A prospective observational study. Geriatr Gerontol Int 2018;18:57-64.
  24. Islam A, Muir-Hunter SW, Speechley M, Montero-Odasso M. Facilitating Frailty Identification: Comparison of two methods among community-dwelling order adults. J Frailty Aging 2014;3:216-21.
  25. Juma S, Taabazuing M-M, Montero-Odasso M. Clinical Frailty Scale in an acute medicine unit: a simple tool that predicts length of stay. Canadian Geriatrics Journal 2016;19:34-9.
  26. Langlais E, Nesseler N, Le Pabic E, Frasca D, Launey Y, Seguin P. Does the clinical frailty score improve the accuracy of the SOFA score in predicting hospital mortality in elderly critically ill patients? A prospective observational study. J Crit Care 2018;46:67-72.
  27. Leahy-Warren P, O'Caoimh R, FitzGerald C, Cochrane A, Svendrovski A, Cronin U, et al. Components of the Risk Instrument for Screening in the Community (RISC) that correlate with public health nurses' perception of risk. J Frailty Aging 2015;4:149-54.
  28. Lewis ET, Dent E, Alkhouri H, Kellett J, Williamson M, Asha S, et al. Which frailty scale for patients admitted via Emergency Department? A cohort study. Arch Gerontol Geriatr 2019;80:104-114.
  29. Martocchia A, Frugoni P, Indiano I, Tafaro L, Comite F, Amici A, et al. Screening of frailty in elderly patients with disability by the means of Marigliano-Cacciafesta polypathology scale (MCPS) and Canadian Study of Health and Aging (CSHA) scales. Arch Gerontol Geriatr 2013;56:339-42.
  30. Matusik P, Tomaszewski K, Chmielowska K, Nowak J, Nowak W, Parnicka A, et al. Severe frailty and cognitive impairment are related to higher mortality in 12-month follow-up of nursing home residents. Arch Gerontol Geriatr 2012;55:22-4.
  31. McGibbon CA, Slayter JT, Yetman L, McCollum A, McCloskey R, Gionet SG, et al. An Analysis of Falls and Those who Fall in a Chronic Care Facility. J Am Med Dir Assoc 2019;20:171-6.
  32. Muessig JM, Nia AM, Masyuk M, Lauten A, Sacher AL, Brenner T, et al. Clinical Frailty Scale (CFS) reliably stratifies octogenarians in German ICUs: a multicentre prospective cohort study. BMC Geriatr 2018;18:162.
  33. Nolan M, Power D, Long J, Horgan F. Frailty and its association with rehabilitation outcomes in a post-acute older setting. International Journal of Therapy & Rehabilitation 2016;23:33-40.
  34. O'Caoimh R, Gao Y, Svendrovski A, Healy E, O'Connell E, O'Keeffe G, et al. The Risk Instrument for Screening in the Community (RISC): a new instrument for predicting risk of adverse outcomes in community dwelling older adults. BMC Geriatr 2015;15:92.
  35. Ozsurekci C, Balci C, Kizilarslanoglu MC, Caliskan H, Tuna Dogrul R, Aycicek GS, et al. An important problem in an aging country: identifying the frailty via 9 Point Clinical Frailty Scale. Acta Clin Belg 2019:1-5.
  36. Provencher V, Sirois MJ, Ouellet MC, Camden S, Neveu X, Allain-Boule N, et al. Decline in activities of daily living after a visit to a Canadian emergency department for minor injuries in independent older adults: are frail older adults with cognitive impairment at greater risk? J Am Geriatr Soc 2015;63:860-8.
  37. Ritt M, Bollheimer LC, Sieber CC, Gassmann KG. Prediction of one-year mortality by five different frailty instruments: A comparative study in hospitalized geriatric patients. Arch Gerontol Geriatr 2016;66:66-72.
  38. Ritt M, Ritt JI, Sieber CC, Gassmann KG. Comparing the predictive accuracy of frailty, comorbidity, and disability for mortality: a 1-year follow-up in patients hospitalized in geriatric wards. Clin Interv Aging 2017;12:293-304.
  39. Ritt M, Schulein S, Lubrich H, Bollheimer LC, Sieber CC, Gassmann KG. High-technology based gait assessment in frail people: Associations between spatio-temporal and three-dimensional gait characteristics with frailty status across four different frailty measures. J Nutr Health Aging 2017;21:346-53.
  40. Romero-Ortuno R, Forsyth DR, Wilson KJ, Cameron E, Wallis S, Biram R, et al. The association of geriatric syndromes with hospital outcomes. J Hosp Med 2017;12:83-9.
  41. Romero-Ortuno R, Wallis S, Biram R, Keevil V. Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study. Eur J Intern Med 2016;35:24-34.
  42. Sirois MJ, Griffith L, Perry J, Daoust R, Veillette N, Lee J, et al. Measuring frailty can help emergency departments identify independent seniors at risk of functional decline after minor injuries. J Gerontol A Biol Sci Med Sci 2017;72:68-74.
  43. Theou O, Brothers TD, Mitnitski A, Rockwood K. Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality. J Am Geriatr Soc 2013;61:1537-51.
  44. Wallis SJ, Wall J, Biram RW, Romero-Ortuno R. Association of the clinical frailty scale with hospital outcomes. QJM 2015;108:943-9.
  45. Wong RY, Miller WC. Adverse outcomes following hospitalization in acutely ill older patients. BMC Geriatr 2008;8:10.
  46. Darvall JN, Greentree K, Braat MS, Story DA, Lim WK. Contributors to frailty in critical illness: Multi-dimensional analysis of the Clinical Frailty Scale. J Crit Care 2019;52:193-9.

Literature search

PubMed via NLM 190515
Title: Clinical frailty scale
The search result, usually found at the end of the documentation, forms the list of abstracts
  Search terms Items found
1. "clinical frailty scale"[Title/Abstract] 216
Final 1. 216


Embase via 190515
Title: Clinical frailty scale
/exp = Includes terms found below this term in the EMTREE hierarchy; ’ ’ = Citation Marks; searches for an exact phrase
  Search terms Items found
1. ('clinical frailty scale'/exp OR 'clinical frailty scale') AND [embase]/lim 436
Final 1 436


CINAHL with Full Text, SocINDEX with Full Text and psychinfo via 190521
Title: Clinical frailty scale
The search result, usually found at the end of the documentation, forms the list of abstracts

AB = Abstract; TI = Title; “ “ = Citation Marks; searches for an exact phrase
  Search terms Items found
1. TI "clinical frailty scale" OR AB "clinical frailty scale" 136
Final 1 136


Epistemoikos 190521
Title: Clinical frailty scale
  Search terms Items found
The search result, usually found at the end of the documentation, forms the list of abstracts
1. “clinical frailty scale” AND systematic review 53
Final 1 53

Project group

Christel Hellberg, Sara Fundell and Miriam Entesarian Matsson at SBU.

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