Table 1 Interventions and guidelines to address the common patterns of frailty in the clinical setting

Unstable health conditions

Medical assessment

Medical management may include geriatrician review, medication review, intervention to increase compliance, referral for follow-up of medical conditions, for example memory clinic, continence clinic.

Specific information for common health conditions is provided in Additional file 2.

Under nutrition

Setting appropriate screening, e.g. Mini Nutritional Assessment [48]

Referral to a dietician for nutritional support, which may include: education about foods rich in energy and protein, nutrition advice about general healthy eating and benefits of regular exercise to improve health and overall wellbeing, and nutrition support.

The NICE clinical guideline 'Nutrition Support in Adults' provides high quality evidence for oral nutrition support in adults with malnutrition http://guidance.nice.org.uk/CG32 (Chapter 8 in particular).

Psychological factors

Geriatric Depression Scale (short form) [49]

The Victorian Government Health Information toolkit for depression

http://www.health.vic.gov.au/older/toolkit/06Cognition/03Depression/index.htm

Frail older depressed patients are particularly susceptible to side effects of antidepressant medication [27]. Antidepressant medication should therefore not be used as front line therapy. Antidepressant medication is effective in the treatment of older people [50], and a comparison of treatments is outlined in the Cochrane review by Mottram and colleagues [27].

The NICE clinical guideline 'Occupational therapy interventions and physical activity interventions to promote the mental wellbeing of older people in primary care and residential care', http://guidance.nice.org.uk/PH16

Impaired cognition

Mini Mental Status Examination (MMSE) [51] and/or informant questionnaire (IQ Code) [52]

The NICE clinical guideline, 'Dementia: Supporting people with dementia and their carers in health and social care', http://guidance.nice.org.uk/CG42

Impaired vision/hearing

Brief clinical assessment

Referral for specialist medical assessment

Facilitate liaison with local/national foundation for blindness and low vision, for aids and advice

Facilitate self-management of aids for vision/hearing

Decreased mobility

Timed 4 m walk

Timed Up and Go

Lower limb strength: Timed sit to stand

Balance: 4-point balance test

Falls risk: Physiological Profile Assessment [53]

Appropriately designed exercise interventions are effective in preventing falls in older people living in both the community [28] and nursing care settings [29]. Exercise should be ongoing, challenge balance and be undertaken at least two hours per week [43].

Home safety interventions reduce falls rate in this high-risk frail group, and multifactorial falls assessment and intervention are also effective [28]. The team should intervene or refer to appropriate disciplines.

Strategies to facilitate behavior change to enhance participation in intervention programs are outlined in the NICE Guidance 'The most appropriate means of generic and specific interventions to support attitude and behaviour change at population and community levels', http://www.nice.org.uk/PH6[33].

We also encourage the implementation of the Recommendations on physical activity for health for older Australians http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-physical-rec-older-guidelines[54].

Lack of participation in life roles

Clinical assessment

Barriers to participation should be assessed. Randomized controlled trials have demonstrated increased participation with intervention targeting risk factors, such as modification of the home environment [30] and specific training of community interactions [31].

Setting individualised goals and tailoring interventions to meet these goals may also be effective.

Enlist help of significant others/carers to encourage goal attainment.

Problems with services or support systems

Clinical assessment

There should be early and ongoing engagement with support and education of formal and informal carers [25]. Caregivers and family should be taught about frailty, interventions to optimize function, and be involved in planning and development of management plans.

Provision and co-ordination of services, with preference given to packages of care, followed by single services, followed by a residential aged care facility. The case co-ordinator must ensure the frail individual and their family/carers understand the services provided and how to promptly access greater assistance in times of increased need.

Advice for assisting carers is provided in the NICE clinical guideline 'Dementia: Supporting people with dementia and their carers in health and social care' http://guidance.nice.org.uk/CG42, Section 1.11.