FFinalistSouthampton · 2027
Musculoskeletal
AKT · Musculoskeletal/Metabolic bone & tumours

Frailty & sarcopenia

Cumulative decline in physiological reserve across multiple systems

Overview

Frailty is a state of reduced reserve in which a minor stressor — a urinary tract infection, a new drug, an unfamiliar ward — produces a disproportionate and often sustained decline in function. Sarcopenia is the loss of skeletal muscle mass, strength and function that underpins much of it. Frailty is a diagnosis to be made explicitly, not a synonym for being old.

Recognise

  • The five frailty syndromes: falls, immobility (including "off legs"), delirium, incontinence, and susceptibility to medication side effects
  • Presentation is non-specific — the classic error is treating "social admission" as if it were not a medical problem
  • Clinical Frailty Scale 1–9, scored on function two weeks BEFORE the acute illness (1 very fit, 5 mildly frail, 7 severely frail, 9 terminally ill)
  • Sarcopenia: reduced grip strength, slow gait speed (<0.8 m/s), reduced muscle mass; SARC-F is a quick screen
  • Polypharmacy is both a cause and a consequence — anticholinergic burden in particular

Red flags

  • A sudden functional decline is an ACUTE illness until proven otherwise — new delirium, sepsis, fracture, retention or a drug effect. "Just frailty" is never a first-line explanation for a sudden change.

Differentials & how to tell them apart

DeliriumACUTE onset with fluctuating attention — always look for the trigger; frailty is the substrate, delirium is the event
DementiaProgressive cognitive decline over months to years with preserved alertness
DepressionLow mood and anhedonia with a subacute functional decline — highly treatable and frequently missed
Hypothyroidism / B12 deficiencyReversible on bloods — check them before attributing decline to age
Parkinson diseaseBradykinesia with rest tremor and rigidity; the gait is festinant rather than simply cautious
Adverse drug effectsTemporal link to a new or increased drug — sedatives, anticholinergics and antihypertensives are the usual culprits

Investigations

Comprehensive geriatric assessment is the intervention with the best evidence — a multidisciplinary review of medical, functional, psychological, social and environmental domains. Alongside it: Clinical Frailty Scale, structured medication review (STOPP/START), cognitive assessment (4AT for delirium, and a formal cognitive test when settled), bone health and falls assessment including a lying/standing blood pressure, plus bloods for reversible contributors — FBC, U&E, calcium, TFT, B12, folate, vitamin D, glucose.

Management

Comprehensive geriatric assessment, a structured medication review, and resistance exercise with adequate protein intake

  1. 1Identify and treat the acute precipitant first. Score the Clinical Frailty Scale on the pre-illness baseline, and document it — it guides escalation decisions and communicates more than any single observation.
  2. 2Comprehensive geriatric assessment: multidisciplinary review, structured medication review, falls and bone health assessment, continence, nutrition, mood and cognition, plus the home environment.Gate: Repeated admissions, or a decline that does not reverse → community frailty service or specialist geriatric follow-up
  3. 3Anticipatory care: an advance care plan, a treatment escalation plan and a ReSPECT form, discussed early and while the patient can participate. Progressive resistance exercise with adequate protein remains the only intervention shown to reverse sarcopenia.
Deprescribing (STOPP/START) — The most valuable "prescription" in frailty — reducing anticholinergic and sedative burden measurably improves function
Vitamin D ± calcium — Where deficient, alongside bone protection in those at fracture risk

Key points

Score the Clinical Frailty Scale on function two weeks BEFORE the illness — scoring it on the acutely unwell patient in front of you systematically overestimates frailty and can wrongly limit treatment. And "social admission" is a phrase to distrust: it usually conceals a treatable medical cause.

Monitor & prognosis

Repeat functional assessment after the acute illness has settled; review medications at every contact.

Frailty is dynamic, not one-way — mild frailty improves with exercise, nutrition and deprescribing. Severe frailty predicts high mortality and poor outcomes from aggressive intervention, which is why identifying it changes decisions.

Source: British Geriatrics Society — Fit for Frailty · NICE NG56 (multimorbidity) · Rockwood Clinical Frailty Scale