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 syndrome is more prevalent than expected in persons with HIV compared to lifestyle-similar persons without HIV and may occur at an earlier age. Early identification and management of frailty is a priority since it is potentially reversible.

Screening for Frailty

Screening for frailty in persons with HIV above 50 years of age should be considered. The age cut-off was chosen as the incidence of frailty in persons with HIV has been shown to increase 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.). The instruments available for screening frailty are gait speed measurement, Short Physical Performance Battery (SPPB), Clinical Frailty Scale (CFS) and FRAIL Scale (FS). In the absence of a gold standard, the choice of one tool over another will depend on the available resources.

Frailty Screening Tools 

Gait speed1

Description: Mark a 4-metre distance on the floor. Ask the patient to walk at usual pace from a standing start and stop the watch once they cross the 4-metre line without stopping (metres/second)

Measure Time Equipment Setting
Objective Quick (< 2 min) Stopwatch
4m space

Short Physical Performance Battery (SPPB)2

Description: Test for standing balance: side by side stands, semi-tandem, and tandem plus 4-metre gait speed test plus testing the ability to rise from a chair and sit down again five times (seconds)

Measure Time Equipment Setting
Ceiling effects
Takes 5 min Stopwatch
4m space
A chair

FRAIL Scale3

Description: Short 5-question assessment of fatigue, resistance, aerobic capacity, illnesses, and loss of weight

Measure Time Equipment Setting
Subjective Quick (< 2 min) None Clinic

Clinical Frailty Scale (CFS)4

Description: A judgement-based frailty tool that evaluates comorbidity, function, and cognition to generate a frailty score ranging from 1 (very fit) to 9 (terminally ill)

Measure Time Equipment Setting
Subjective Quick (< 2 min) None Hospitalisation

1) Studenski S. JAMA. 2011;305(1):50-58. 2) Guralnik JM. J Gerontol. 1994 Mar;49(2):M85-94. 3) Morley JE, JAMDA 2013;14:392–7. 4) Rockwood K. CMAJ. 2005 Aug 30;173(5):489–495.

Algorithm Recommended for Frailty Screening

Algorithm Recommended for Frailty Screening.png

Adapted from Brañas F, et al. European Geriatric Medicine. 2019;10(2):259-265

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


In persons with HIV who are frail:
    1. Promote Comprehensive Geriatric Assessment (CGA)
    2. Sustain and recover physical function impairment and sarcopenia by prescribing physical exercise with a resistance training component
    3. Address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications, see Prescribing in older persons with HIV
    4. Screen for, and address modifiable causes of fatigue
    5. For persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation
    6. 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-metre 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 with the mean value of three consecutive measurements of the dominant hand (adjusted by sex and BMI quartile based on the Cardiovascular Health Study (CHS) population) as follows:
– 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