Medicine of the older adult. Ageing, frailty and comprehensive geriatric assessment

• Ageing: Why Older People Are Different | How the Body Changes with Age | Atypical Presentation of Illness
• Frailty: What Is Frailty? | Identifying and Measuring Frailty | The Frailty Syndromes | Sarcopenia
• Assessment: History-taking with Older People | Comprehensive Geriatric Assessment | Assessing Function | The Multidisciplinary Team
• Acute care: The Acutely Unwell Older Person | Hospital-associated Harm | Treatment Decisions and Ceilings of Care | Frailty in the Community
• Revision: Frailty and Assessment at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 Ageing, frailty and comprehensive geriatric assessment — page 1 of the Medicine of the Older Person chapter. Older people are the main users of hospitals, and most medicine is now geriatric medicine. The key ideas are that age itself is not a diagnosis, that frailty (not birthday) predicts how a person will cope with illness, and that comprehensive geriatric assessment — a structured, multidisciplinary approach — keeps older people alive and at home. Specific diseases are covered in their own chapters; this page is about the approach.
Your four questions for every older patient: What was this person like two weeks ago — and how are they different now? How frail are they (Clinical Frailty Scale)? What matters most to them — and what do they want from treatment? What will they need to get home safely — and who is going to help?

Why Older People Are Different

• Older people are very varied — two 85-year-olds can differ more than a 40-year-old and a 70-year-old. Biological age and frailty matter more than chronological age.
• Multimorbidity — most people over 75 have two or more long-term conditions; guidelines written for single diseases may conflict and add up to many medicines (NICE NG56).
• Reduced reserve ("homeostenosis") — organs work well at rest but cope poorly with stress; a small insult (UTI, new drug, constipation) can cause a large functional decline.
• Atypical presentation — illness often presents as confusion, falls, immobility or incontinence rather than classic symptoms.
• Several causes at once — one problem rarely explains everything; look for all contributing factors.
• Function matters most — success is measured in independence, quality of life and what matters to the person, not only disease markers.
• Social circumstances — living alone, carers, housing and finances shape what is possible.
• Ageism — avoid both under-treatment ("too old") and over-treatment (burdensome interventions that won't help). Decisions should be based on the individual.

How the Body Changes with Age

Atypical Presentation of Illness

• Older people often present with "non-specific" problems — "off legs", "acopia", "social admission", "generally unwell". These are not diagnoses — there is almost always a medical cause.
• Common atypical presentations:
  • Infection — confusion, falls, loss of appetite, no fever (or low temperature), normal white cell count.
  • Myocardial infarction — breathlessness, collapse, confusion, no chest pain (especially with diabetes).
  • Acute abdomen — little pain or tenderness (perforated ulcer, ischaemic bowel, diverticulitis).
  • Pulmonary embolism — collapse, unexplained tachycardia or breathlessness.
  • Thyroid disease — "apathetic" hyperthyroidism (weight loss, AF, low mood); hypothyroidism mistaken for ageing.
  • Depression — physical symptoms, memory complaints, withdrawal.
  • Hypercalcaemia, hyponatraemia, uraemia — confusion, falls, constipation.
  • Medication adverse effects — any new symptom (falls, confusion, constipation, retention).
• Normal tests can mislead — normal creatinine with low muscle mass, normal WCC with sepsis, no rise in temperature.
• Ask "what has changed?" — sudden decline from baseline means acute illness until proven otherwise.

⚠️ Safety Pearl — never label an older person a "social admission" until an acute medical cause has been actively excluded. Delirium, sepsis, fractures, MI and drug toxicity commonly present this way.

What Is Frailty?

• Frailty — a state of reduced physiological reserve across many body systems, making a person vulnerable to sudden, disproportionate deterioration after a minor stress (BGS).
• Example — a fit 80-year-old gets a UTI and feels unwell for a few days; a frail 80-year-old with the same UTI becomes delirious, falls, can't walk, and loses independence.
• How common — about 10% of people over 65, rising to 25–50% of those over 85; but frailty is not inevitable with age, and it can improve.
• Two main models:
  • Phenotype model (Fried) — frail if 3 or more of: unintentional weight loss, exhaustion, weak grip, slow walking speed, low physical activity (1–2 = "pre-frail").
  • Cumulative deficit model (Rockwood) — the more health deficits (diseases, symptoms, disabilities) a person has, the frailer they are — the basis of the electronic Frailty Index (eFI) used in UK primary care.
• Frailty predicts — falls, delirium, hospital admission, longer stays, complications after surgery and chemotherapy, care home admission and death.
• Frailty, multimorbidity and disability overlap but are different — a person can have many conditions without being frail, or be frail with few diagnoses.
• Frailty can be modified — exercise (especially resistance training), nutrition (protein), medication review and treating reversible conditions.

Identifying and Measuring Frailty

• Clinical Frailty Scale (CFS) — the commonest tool in UK hospitals; based on function 2 weeks before the current illness:

  Score	Category	Description
  1	Very fit	Robust, active, energetic, exercises regularly
  2	Fit	No active disease symptoms, occasionally active
  3	Managing well	Medical problems well controlled; not regularly active beyond walking
  4	Living with very mild frailty	Not dependent, but symptoms limit activities; "slowed up" or tired
  5	Living with mild frailty	Needs help with higher-level activities (finances, transport, heavy housework, shopping)
  6	Living with moderate frailty	Needs help with all outside activities and housekeeping; help with stairs and bathing; may need minimal help dressing
  7	Living with severe frailty	Completely dependent for personal care, but stable and not at high risk of dying within 6 months
  8	Living with very severe frailty	Completely dependent, approaching end of life; often could not recover even from a minor illness
  9	Terminally ill	Life expectancy under 6 months, otherwise not evidently frail

• Using the CFS well — score baseline function (not the acute illness); designed for people 65 and over — not validated in younger people, or those with stable single disabilities (e.g. learning disability, cerebral palsy); it should inform, never replace, individual decisions.
• Other tools:
  • Gait speed — slower than 0.8 m/s suggests frailty (e.g. 4-metre walk).
  • Timed Up and Go — stand from a chair, walk 3 m, turn, return and sit; over 12–14 seconds suggests falls risk.
  • PRISMA-7 questionnaire, Edmonton Frail Scale.
  • Electronic Frailty Index (GP records) — fit, mild, moderate, severe — used to identify people for proactive care.
• NHS GP contract — practices identify people 65 and over living with moderate and severe frailty and offer a review (medicines, falls, care planning).

The Frailty Syndromes

• Frailty often shows itself through five classic presentations (BGS "Fit for Frailty"):
  • Falls — collapse, "found on floor", "legs gave way".
  • Immobility — "off legs", sudden loss of mobility.
  • Delirium — acute confusion, "worsening dementia".
  • Incontinence — new or worsening.
  • Susceptibility to medication side effects — e.g. confusion with codeine, falls with antihypertensives.
• Each is a "red flag" for an underlying illness — look for infection, dehydration, drugs, metabolic disturbance, constipation, pain, new neurological or cardiac events.
• Each also needs specific management — falls (page 2), delirium (page 3), incontinence (page 5), medicines (page 4).
• The old "geriatric giants" — immobility, instability, incontinence and intellectual impairment (Bernard Isaacs) — the same idea.
• Other frailty-linked problems — weight loss, poor appetite, fatigue, pressure ulcers, social isolation, carer strain.

Sarcopenia

• Sarcopenia — progressive loss of muscle strength, mass and performance with age; a key driver of frailty, falls and disability.
• Causes and risk factors — ageing, inactivity and bed rest, low protein and calorie intake, chronic disease (heart failure, COPD, CKD, cancer), inflammation, low vitamin D, low sex hormones, steroids.
• EWGSOP2 approach:
  • Find — SARC-F questionnaire or clinical suspicion (falls, weakness, slow walking, weight loss).
  • Assess strength — grip strength (dynamometer — low under 27 kg in men, under 16 kg in women) or chair stand test (5 rises over 15 seconds).
  • Confirm — low muscle quantity (DEXA, bioimpedance, CT).
  • Severity — poor physical performance (gait speed 0.8 m/s or less, SPPB, TUG).
• Treatment — progressive resistance exercise (most effective), adequate protein (about 1.0–1.2 g/kg/day; more if ill), vitamin D if deficient, treat underlying disease, review drugs; no medicine is licensed for sarcopenia.
• Sarcopenic obesity — low muscle with high fat; easily missed because weight looks normal or high.

History-taking with Older People

• Prepare — quiet room, good light, face the patient, hearing aids in and switched on, glasses on, dentures in; check for a pocket talker or amplifier; allow time.
• Collateral history is essential — family, carers, care home staff, GP records, ambulance crew — especially with cognitive impairment or delirium.
• Key areas:
  • Baseline function (2 weeks ago) — mobility (aids, falls), personal care, continence, cognition, who helps.
  • What has changed and how quickly.
  • Full drug history — including over-the-counter, herbal, eye drops, inhalers, patches and recent changes; how medicines are taken (blister packs, who gives them); adherence.
  • Falls in the past year.
  • Cognition and mood.
  • Continence, bowels, nutrition and weight, swallowing, teeth.
  • Vision and hearing.
  • Social history — housing (stairs, toilet location), lives alone or with whom, carers and package of care (times per day), driving, alcohol, smoking, finances, pets.
  • What matters to the patient — goals, worries, previous wishes, advance care plans, LPA, ReSPECT form.
• Examination — full examination, including lying and standing BP, cognition screen, gait (if safe), feet, skin (pressure areas), rectal examination if constipation or retention suspected, weight and nutrition.

Comprehensive Geriatric Assessment

• Comprehensive geriatric assessment (CGA) — a multidimensional, multidisciplinary process to identify an older person's medical, psychological and functional problems and develop a coordinated plan to maximise health.
• Evidence — CGA in hospital increases the chance of being alive and living at home at 6–12 months, and reduces care home admission (Cochrane review).
• The domains of CGA:

  Domain	What is assessed
  Medical	Problem list, comorbidities, medication review, nutrition, continence, pain, sensory impairment, dentition
  Mental health	Cognition (delirium, dementia), mood (depression, anxiety), alcohol
  Functional	Basic activities of daily living (ADLs), instrumental ADLs, gait and balance, mobility, falls
  Social	Support network, carers and carer strain, care package, finances, isolation
  Environmental	Home layout and safety, access, equipment, telecare, transport

• Steps — assess → agree goals with the patient → make an individual plan → put it into action → review.
• Output — a written problem list and plan (including future care and escalation plans) shared with the patient, carers and GP.
• Where — hospital (geriatric wards, frailty units in ED, orthogeriatrics, surgical liaison — POPS), outpatients, day hospitals, intermediate care, primary care and care homes.
• Perioperative CGA — older people having surgery have fewer complications and shorter stays with CGA-based care (CPOC/BGS guidance on frailty and surgery).

Assessing Function

• Activities of daily living (ADLs) — basic self-care: feeding, bathing, dressing, grooming, toileting, continence, transfers, walking, stairs — measured by the Barthel Index (0–20 or 0–100).
• Instrumental ADLs (IADLs) — more complex tasks needed to live independently: shopping, cooking, cleaning, managing money, medications, telephone, transport (Lawton scale) — often lost first in cognitive decline.
• Mobility and balance:
  • Observe the patient standing up (without arms?), walking (aid, speed, steadiness), turning and sitting.
  • Timed Up and Go, gait speed, Berg Balance Scale (physiotherapy), Tinetti.
• Cognition — 4AT (delirium), AMTS, 6CIT, Mini-Cog, MoCA, ACE-III (see page 3).
• Mood — Geriatric Depression Scale, PHQ-9, Cornell Scale (dementia).
• Nutrition — MUST (Malnutrition Universal Screening Tool), weight trend, MNA.
• Occupational therapy — kitchen assessment, washing and dressing, home visit; equipment (perching stool, raised toilet seat, rails, commode, hospital bed).
• Why it matters — function predicts outcomes better than diagnoses, sets rehabilitation goals and determines what support is needed at discharge.

The Multidisciplinary Team

• Board rounds and MDT meetings — share goals, set an expected date of discharge, and identify barriers early.
• Patients and families are part of the team — shared decisions, realistic goals.

The Acutely Unwell Older Person

• Same ABCDE approach, with some differences:
  • NEWS2 may underestimate illness (beta-blockers mask tachycardia; blunted fever; "normal" BP may be low for a hypertensive person).
  • Lactate, capillary glucose and a blood gas are especially useful.
  • Look for multiple causes — sepsis plus dehydration plus drug effects plus constipation.
• Basic screen for the "generally unwell" older person — FBC, U&E, CRP, LFTs, bone profile, glucose, TFTs (if not recent), CK (after a long lie), troponin if indicated, blood cultures if febrile, ECG, chest X-ray, bladder scan, medication review, rectal examination (impaction), cognitive screen (4AT). Don't send urine dipsticks in people over 65 — bacteriuria is common and doesn't prove UTI (NICE/UKHSA).
• Same-day emergency care and frailty units — rapid CGA in ED or acute frailty units can avoid unnecessary admission (with community follow-up).
• Hospital at home and virtual wards — acute care at home for selected patients (e.g. frailty virtual wards) — similar outcomes, less delirium.
• Set treatment escalation plans early — discuss with patient and family what treatments would and wouldn't help (ICU, CPR, NIV, IV antibiotics).

Hospital-associated Harm

• Hospital can harm older people — the longer the stay, the greater the risk.
• Deconditioning — older people lose muscle strength rapidly in bed (a few per cent a day); many leave hospital less mobile than when they came in. Campaigns — "#EndPJparalysis" (get up, get dressed, get moving), "Last 1000 days".
• Other harms:
  • Delirium (up to a third of older inpatients).
  • Falls in hospital.
  • Pressure ulcers.
  • Hospital-acquired infections (C. difficile, pneumonia, catheter-associated UTI).
  • Malnutrition and dehydration (nil-by-mouth, missed meals).
  • Incontinence from inappropriate pads and catheters.
  • VTE.
  • Adverse drug events; loss of confidence and independence.
• Prevention — early mobilisation, own clothes, glasses and hearing aids, daytime activity, good sleep, hydration and nutrition (help with meals — "red trays"), avoid unnecessary catheters and cannulas, regular toileting, medicines review, involve families (John's Campaign — carers can stay).
• Discharge as soon as medically ready — "Home First" and Discharge to Assess: further assessment is better done at home (see page 6).

Treatment Decisions and Ceilings of Care

• Shared decision-making — explain options, benefits, harms and the option of doing nothing; find out what matters to the person (their goals and values).
• Benefit depends on the individual — frailty, prognosis, function and wishes matter more than age.
• Treatment escalation plans — agree in advance whether treatments such as ICU admission, intubation, NIV, CPR, surgery would be appropriate; record them clearly (e.g. a ReSPECT form).
• Frailty and critical care — higher CFS scores are linked with worse ICU outcomes, but CFS should be one factor in an individual assessment, never the sole criterion.
• Capacity — assume capacity; assess decision-specifically; if lacking capacity — best interests, involving LPAs and family (see page 6).
• "Not for escalation" never means "not for treatment" — continue active treatment within the agreed ceiling, plus good symptom control and comfort.
• Uncertain recovery — "hope for the best, prepare for the worst"; review regularly; involve palliative care early where appropriate.
• Prognostic tools — the "surprise question" (would you be surprised if this person died in the next 12 months?), SPICT (Supportive and Palliative Care Indicators Tool), Gold Standards Framework indicators.

Frailty in the Community

• Proactive care — identify people with frailty early (eFI, CFS) and offer CGA-based reviews, personalised care and support plans, and anticipatory care.
• Key interventions:
  • Strength and balance exercise (e.g. FaME, Otago programmes).
  • Medication reviews (structured medication reviews by GPs and pharmacists).
  • Falls prevention and bone health.
  • Nutrition and hydration.
  • Vaccinations — influenza, pneumococcal, COVID-19, shingles, RSV (UK programme for older adults).
  • Social prescribing — tackling loneliness and isolation.
  • Carer support and advance care planning.
• Community services — integrated neighbourhood teams, community geriatricians, district nurses, urgent community response (2-hour response to avoid admission), intermediate care, reablement, day hospitals, care home support (Enhanced Health in Care Homes).
• Older drivers — in the UK, drivers must renew their licence at 70 and every 3 years, declaring medical conditions; doctors should advise patients about fitness to drive (dementia, visual loss, syncope, stroke).

Frailty and Assessment at a Glance

Spot the Diagnosis

Exam-style Scenarios

1. An 87-year-old woman is brought in by her daughter because she is "not coping" at home and has been "off her legs" for 2 days. Her observations are normal except HR 98. She is muddled. The admitting team calls it a "social admission".
Answer: Acute illness presenting atypically — a frailty syndrome, not a social admission.

• Collateral history (baseline function 2 weeks ago, recent changes, medicines); 4AT for delirium.
• Screen — FBC, U&E, CRP, calcium, glucose, LFTs, CK, ECG, chest X-ray, blood cultures if indicated, bladder scan, rectal examination, medication review; look for pain and fractures.
• Treat causes, start CGA with the MDT (physio and OT early), prevent hospital harms, involve family in planning.

2. A 79-year-old man with heart failure, COPD, diabetes and CKD takes 14 medicines. He has had two falls and feels tired all the time. He says he wants to "stay in my own home and keep gardening".
Answer: Multimorbidity and frailty — needs CGA focused on his goals.

• Assess frailty (CFS), function, falls, cognition, mood, nutrition and home situation.
• Structured medication review — STOPP/START, stop drugs with no current benefit (e.g. tight glucose control, sedatives), check postural BP (see page 4).
• Strength and balance programme, OT home assessment, agree a personalised care plan with his goals, and discuss future care preferences.

3. An 81-year-old woman was admitted with pneumonia. She was independent before. On day 8 the infection has settled, but she needs two people to help her stand and is incontinent.
Answer: Hospital-associated deconditioning and functional decline.

• Look for reversible causes — delirium, pain, constipation, urinary retention, drugs, low mood, malnutrition, hypoactive delirium.
• Daily physiotherapy and active mobilisation, own clothes and routine, regular toileting (remove pads where possible), nutrition support.
• Plan rehabilitation — consider Discharge to Assess with community rehabilitation (intermediate care) rather than prolonged hospital stay.

4. An 89-year-old man (CFS 7, dementia, care home resident) is admitted with sepsis from a chest infection. His family ask whether he will "be put on a ventilator".
Answer: Treatment escalation planning in severe frailty.

• Assess his capacity for the decision (likely lacking); find any LPA (health and welfare), advance decisions or known wishes.
• Explain honestly that ICU and invasive ventilation are unlikely to help and may cause harm; agree a plan for ward-based active treatment (antibiotics, fluids, oxygen) with good symptom control.
• Complete a ReSPECT form and DNACPR decision with the family; review daily; involve palliative care if he deteriorates.

5. A 76-year-old woman with osteoarthritis has had two falls this year. Grip strength is low, she walks slowly, and has lost 4 kg over 6 months.
Answer: Frailty with sarcopenia.

• Check for causes of weight loss (bloods, TFTs, coeliac, cancer screening as indicated), mood, dentition and swallowing; MUST score.
• Progressive resistance and balance exercise; dietitian input — adequate protein and calories, oral nutritional supplements if needed; vitamin D if deficient.
• Multifactorial falls assessment (page 2), medication review, bone health assessment (FRAX).

Key Points

• Biological age and frailty matter more than chronological age.
• Older people present atypically — confusion, falls, immobility, incontinence; "social admission" and "acopia" are not diagnoses.
• Fever may be absent in infection; chest pain may be absent in MI.
• Frailty — reduced reserve, disproportionate decline after minor stress; it can improve.
• Clinical Frailty Scale — score baseline function 2 weeks before illness; use to inform, not decide.
• Frailty syndromes — falls, immobility, delirium, incontinence, drug side effects.
• Sarcopenia — low grip strength and slow gait; treat with resistance exercise and protein.
• Always get a collateral history and a full drug history.
• CGA — medical, mental health, functional, social and environmental domains, by an MDT — improves being alive and at home.
• Barthel for basic ADLs; Lawton for instrumental ADLs.
• Creatinine overestimates kidney function in low muscle mass.
• Don't dipstick urine in people over 65 to diagnose UTI.
• Hospital harms — deconditioning, delirium, falls, pressure ulcers, infection; mobilise early and discharge promptly.
• Agree treatment escalation plans early — "not for escalation" is not "not for treatment".