Family physicians need easy instruments for frailty

Abstract

SIR—This is with reference to the article ‘Development of an easy prognostic score for frailty outcomes in the aged’ written by G. Ravaglia, P. Forti, A. Lucicesare, N. Pisacane, E. Rietti, C. Patterson[1]. As general practitioners involved in research about primary care for older people we agree that frailty is an emerging concept with important clinical consequences. Ravaglia et al. describe ‘an easy prognostic score’[1], but for whom is it easy? For general practitioners using electronic health records, demographic data and co-morbidity are by default known, and other elements of the score, like living status and lifestyle, are easy to ask about. However, assessment of nutritional and functional status requires time and consultation planning. The use of the Mini-Mental State Examination and Geriatric Depression Scale can be difficult to integrate into routine encounters in primary care, especially in combination with all the other items proposed by the authors. The proposed score therefore is not an easy one, but extensive. General practitioners need to think of a two-step approach, with a simple heuristic tool (a ‘rule of thumb’) as the first step, and a more complex assessment (like the Ravaglia tool) as the second. In many European countries general practitioners could integrate the first step into their daily work, and delegate the second step. Short instruments exist and some of them have proven their clinical value in a stepwise diagnostic procedure[2–5]. Enhancement of current clinical skills by adding a more formal assessment of frailty, using either Fried's heuristic or a validated tool, could potentially strengthen case-finding strategies for dementia or other chronic diseases in primary care, or guide clinicians in policy choices, especially if burdensome treatment is involved, such as chemotherapy or radiation therapy in cancer. Research should now focus on how the transition to a more in-depth geriatric assessment in primary care can be most effectively facilitated, and on the added value of such an assessment for frail, community-dwelling older people.