Frailty screening, screening algorithm, assessment, management

Frailty is defined as a clinical syndrome associated with decreased reserve, high vulnerability to stressors and associated with risk of negative health-related outcomes including mortality. Frailty should be regarded as a distinct entity to the disease or condition that may be contributing to it. This geriatric syndrome is more prevalent than expected in PLWH compared to HIV-negative matched controls and may occur at an earlier age. Early identification and management of frailty is a priority since it is potentially reversible. Older PLWH aged 50 years and over should be offered screening for frailty using a validated rapid frailty instrument. An algorithm to identify those PLWH who may benefit from a frailty assessment is detailed below.

Screening for Frailty

Screening for frailty in PLWH above 50 years of age should be considered. The age cut-off was chosen as the incidence of frailty in PLWH has been shown to increase in PLWH above this age. Evidence of benefit is still unknown. It is advocated by some experts.

Screening has to be performed using validated tools for this purpose and can be provided by any trained health staff (nurses, general practitioners, etc.). In the absence of a gold standard, the instrument to screen frailty we suggest is the FRAIL Scale (FS) because it is easy, cheap and quick to develop but other validated tools, such as walking speed measurement or Short Physical Performance Battery (SPPB) can also be used.

How much time during the previous 4 weeks did you feel tired? All the time, most of the time = 1 point
Do you have any difficulty walking up 10 steps alone without resting and without aids? Yes = 1 point
Do you have any difficulty walking several hundred meters alone with/without aids? Yes = 1 point
How many illnesses do you have from this list?:
hypertension, DM, cancer, chronic lung disease, heart attack, congestive heart failure, angina, asthma, arthritis, stroke and kidney disease.
> 5 = 1 point
Have you had weight loss of 5% or more? Yes = 1 point


Formal Frailty Assessment and Management

How to diagnose frailty

Feature Frailty Phenotype Frailty Index
Clinical Definition Clinical syndrome based on presence of specific signs and symptoms Based on accumulation of deficits
How to assess

Assessed by five specific features:
1. self-reported weight loss (a)
2. self-reported exhaustion (b)
3. low levels of physical activity as measured by Minnesota Leisure physical activity questionnaire (c)
4. measured 4 m walk speed time (d)
5. measured grip strength (e)

A frailty index is calculated based on the number of health deficits out of > 30 assessed health deficits

Health variables, including signs and symptoms of disease, laboratory measures, and self-reported data

Data routinely collected in medical records can be included if they characterise age-related, acquired health deficits which cover a range of physiologic systems

How to interpret Categorical variables
Total score of 5 items:
0 deficits = fit
1-2 deficits = pre-frail
3 + deficits = frail
Continuous variables
Index ranges from 0 to 1:
≤ 0.25 = fit
0.25 – 0.4 = frail
> 0.4 = most frail
How to address frailty Promote Comprehensive Geriatric Assessment (CGA), aimed at personalising interventions according to benefits/priorities for a given person through a multidisciplinary diagnostic and treatment process, that identifies medical, psychosocial, and functional limitations aimed at maximising overall health with ageing and the improvement of quality of life
Recommendations In PLWH who are frail:
1. Sustain and recover physical function impairment and sarcopenia prescribing physical activity with a resistance training component
2. Address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications, see Prescribing in Elderly PLWH
3. Screen for, and address modifiable causes of fatigue
4. For PLWH exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation
5. Prescribe vitamin D for individuals deficient in vitamin D. See Vitamin D Deficiency: Diagnosis and Management


(a) Self-reported unintentional weight loss was considered present if exceeding 4.5 kg or ≥ 5% of body weight in the last year

(b) Exhaustion is present if the participant answers ‘‘occasionally’’ or ‘‘most of the time’’ to both of the following statements (questions from the Center for Epidemiologic Studies Depression Scale): During the last week, how often have you felt that 1. everything you did was an effort, or 2. you could not ‘get going’

(c) Low physical activity as considered present if the participant’s physical activity is lower than 383 kcal/week in men and 270 kcal/week in women which is equivalent to < 2.5 hours/week in men and < 2 hours/week in women using the Minnesota Leisure Time Activity Questionnaire

(d) Walk speed time, is measured by a 4-meter walking test in usual pace (one trial). A deficit is assigned according to the following gender-specific criteria
– Men: height ≤ 173 cm and speed ≤ 0.6531 m/s; height > 173 cm and speed ≤ 0.762 m/s
– Women: height ≤ 159 cm and speed ≤ 0.6531 m/s; height > 159 cm and speed ≤ 0.762 m/s

(e) Maximum grip strength can be assessed using a handheld dynamometer the mean value of three consecutive measurements of the dominant hand (adjusted by sex and BMI quartile based on CHS population):
– Men: BMI ≤ 24 kg and strength < 29 kg; BMI 24.1–26 and strength < 30 kg; BMI 26.1–28 and strength < 30 kg; BMI > 28 and strength < 32 kg
– Women: BMI ≤ 23 and strength < 17 kg; BMI 23.1–26 and strength < 17.3 kg; BMI 26.1–29 and strength < 18 kg; BMI > 29 and strength < 21 kg