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Frailty

Last updated 1 Jun 2026 · Geriatric medicine

📋 Key Information Summary

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  • Frailty is a state of reduced physiological reserve leading to increased vulnerability to stressors; it is distinct from multimorbidity and disability but frequently coexists with both.
  • Prevalence in community-dwelling Australians aged ≥65 years is approximately 15%, rising to over 50% in residential aged care facilities (RACFs).
  • Two dominant models exist: the phenotype model (unintentional weight loss, exhaustion, weakness, slowness, low activity) and the deficit accumulation model (Frailty Index counting accumulated health deficits).
  • The Clinical Frailty Scale (CFS) is a validated 1–9 ordinal tool recommended by the Australasian Society for Sarcopenia and Frailty Research (ASSFR) for rapid bedside assessment.
  • Sarcopenia (low muscle mass + low strength/physical performance) is a key biological substrate of frailty; the SARC-F questionnaire is a validated screening tool.
  • Nutritional assessment (MNA-SF or MST) is mandatory; protein intake of 1.0–1.2 g/kg/day is recommended for frail older adults.
  • Multicomponent exercise (resistance + aerobic + balance) is the single most evidence-based intervention to reverse or attenuate frailty.
  • Medication review using STOPP/START criteria or a Home Medicines Review (HMR, MBS Item 900) reduces polypharmacy-related adverse events.
  • Frailty assessment should guide shared decision-making regarding surgical risk, intensive care escalation, and cancer treatment tolerability.
  • Aboriginal and Torres Strait Islander Australians experience frailty at younger ages; culturally safe, community-led models are essential.
  • Frailty is potentially reversible in its early (pre-frail) stages; early identification enables timely intervention.
  • The RACGP and Australian Commission on Safety and Quality in Health Care (ACSQHC) recommend routine frailty screening in patients aged ≥70 years or at any age with chronic disease burden.

Introduction & Australian Epidemiology

Frailty is a multidimensional syndrome characterised by decreased physiological reserve across multiple organ systems, resulting in increased vulnerability to acute stressors such as infection, surgery, or psychosocial disruption. It is not an inevitable consequence of ageing but rather a clinical state amenable to identification and intervention.

In Australia, frailty is a growing public health priority. The Australian Institute of Health and Welfare (AIHW) estimates that approximately 15% of community-dwelling adults aged ≥65 years meet criteria for frailty, with an additional 45% classified as pre-frail. Prevalence escalates sharply with age: among those aged ≥85 years, prevalence exceeds 40% in the community and 50–70% in residential aged care facilities (RACFs). Aboriginal and Torres Strait Islander Australians experience frailty at rates 1.5–2 times higher than non-Indigenous Australians and at significantly younger ages (often by 50–55 years).

Frailty is independently associated with falls, fractures, hospitalisation, prolonged length of stay, institutionalisation, and all-cause mortality. In Australian hospital data, frail patients have 2–3 times higher in-hospital mortality and significantly greater rates of post-operative complications. Recognising frailty helps clinicians identify older adults at higher risk and target interventions — including structured exercise programmes, nutritional optimisation, and comprehensive medication review — to improve outcomes and reduce healthcare utilisation.

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Clinical distinction: Frailty ≠ multimorbidity ≠ disability. A patient with well-controlled diabetes and hypertension may have multimorbidity without frailty. A patient with a hip fracture may have disability without baseline frailty. Each concept requires separate assessment and management.

Frailty Phenotype and Frailty Index

Two predominant conceptual models dominate frailty research and clinical practice. Understanding both is essential as they capture overlapping but non-identical populations.

Phenotype Model (Fried Criteria)

Developed by Fried et al. (2001) from the Cardiovascular Health Study, the phenotype model defines frailty as a clinical syndrome meeting ≥3 of five criteria:

Criterion Operationalisation Australian Measurement Notes
Unintentional weight loss ≥4.5 kg (≥5% body weight) in past 12 months Document at each GP visit; MBS-rebated chronic disease management items support longitudinal monitoring
Self-reported exhaustion CES-D scale items: "everything was an effort" or "could not get going" ≥3 days/week Screen for concurrent depression (PHQ-9) — overlap is common
Low physical activity Males: <383 kcal/week; Females: <270 kcal/week (PASE or IPAQ equivalent) PASE (Physical Activity Scale for the Elderly) freely available
Slow gait speed ≤0.8 m/s over 4 m walk (or lowest 20% by height/sex) Timed Up-and-Go (TUG) >12 s also acceptable; requires stopwatch and 3 m corridor
Weakness Low grip strength (lowest 20% by BMI/sex) measured by hand dynamometer Jamar dynamometer; Australian normative data available (AssFR reference ranges)

Classification: 0 criteria = robust; 1–2 = pre-frail; ≥3 = frail. The phenotype model is most useful in research and for targeted physical function interventions.

Frailty Index (Deficit Accumulation Model)

Developed by Rockwood and Mitnitski, the Frailty Index (FI) counts the proportion of accumulated health deficits from a comprehensive assessment. Typically 30–70 variables are assessed (symptoms, signs, diseases, disabilities, laboratory abnormalities) and the FI is calculated as:

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FI = number of deficits present ÷ total number of deficits assessed. An FI >0.25 generally indicates frailty; FI >0.4 indicates severe frailty.

The FI is a continuous, highly sensitive measure that correlates strongly with mortality, institutionalisation, and adverse health outcomes. It is more inclusive than the phenotype model, capturing cognitive, psychological, and social deficits. In Australian primary care, a 40-item FI can be feasibly calculated from a comprehensive geriatric assessment (CGA) or electronic health record data.

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Which model to use? In primary care, the CFS (see next section) or a simple gait speed test (≤0.8 m/s) is recommended for screening. For research or comprehensive geriatric assessment, the Frailty Index offers greater granularity. The phenotype model is best suited to exercise-intervention studies.

Clinical Frailty Scale (CFS)

The Clinical Frailty Scale (CFS) is a globally validated ordinal tool developed by Rockwood et al. (2005) and widely adopted in Australian emergency departments, hospitals, and aged care settings. It is endorsed by the Australasian Society for Sarcopenia and Frailty Research (ASSFR) and incorporated into the ACSQHC's National Safety and Quality Health Service Standards for perioperative care.

CFS Score Category Description Clinical Implication
1 Very Fit Robust, active, energetic, motivated; regularly exercises Standard surgical and medical pathways
2 Well No active disease but less fit; occasional vigorous activity Standard pathways
3 Managing Well Medical problems well controlled; not regularly active beyond walking Prehabilitation may benefit
4 Vulnerable Not dependent for daily help but symptoms limit activities; "slowed up" Targeted intervention; assess for pre-frailty
5 Mildly Frail Need help with higher-order instrumental ADLs (finances, transport, heavy housework) CGA referral; HMR; allied health referral
6 Moderately Frail Need help with all outside activities and housekeeping; may need assistance with dressing/bathing Community Aged Care Package (CHSP/ACP); consider My Aged Care referral
7 Severely Frail Completely dependent for personal care; stable, not otherwise terminally ill Residential care consideration; advance care planning essential
8 Very Severely Frail Completely dependent; approaching end of life Palliative care approach; comfort measures
9 Terminally Ill Approaching end of life; life expectancy <6 months not otherwise captured by CFS 8 Palliative care; advance care directive
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Important: The CFS should not be applied to younger individuals with stable disability (e.g., cerebral palsy, intellectual disability) who are otherwise functioning at their baseline. It requires clinical judgment and is validated for adults aged ≥65 years (or ≥50 years in ATSI populations).

A CFS of ≥5 is commonly used as a threshold for frailty in Australian hospital settings, guiding decisions regarding surgical candidacy, intensive care admission, and discharge planning. The CFS takes less than 2 minutes to complete, requires no special equipment, and can be administered by any trained clinician.

Sarcopenia and Nutrition Overlap

Sarcopenia: The Biological Substrate of Physical Frailty

Sarcopenia — defined by the European Working Group on Sarcopenia in Older People (EWGSOP2, 2019) as low muscle strength plus low muscle quantity/quality — is a principal biological driver of the physical frailty phenotype. The two conditions overlap substantially: approximately 40–60% of frail older adults meet criteria for sarcopenia. However, sarcopenia can exist without frailty (early sarcopenia without functional consequences) and frailty can exist without sarcopenia (driven by other systems such as cognition or immunity).

EWGSOP2 Stage Criteria Assessment Tool Cut-off
Probable sarcopenia Low muscle strength Handgrip dynamometry or Chair stand test Grip: <27 kg (M), <16 kg (F); Chair stand: >15 s for 5 rises
Confirmed sarcopenia Low strength + low muscle quantity/quality DXA (appendicular lean mass) or BIA or CT/MRI ALM/height²: <7.0 kg/m² (M), <5.5 kg/m² (F)
Severe sarcopenia Low strength + low quantity + low performance Gait speed, SPPB, TUG Gait speed ≤0.8 m/s; SPPB ≤8; TUG ≥20 s

SARC-F Screening

The SARC-F is a rapid 5-item screening questionnaire (Strength, Assistance walking, Rise from a chair, Climb stairs, Falls). Each item is scored 0–2; a total score ≥4 indicates likely sarcopenia requiring confirmatory testing.

Nutritional Assessment and Intervention

Malnutrition is both a cause and consequence of frailty and sarcopenia. The Mini Nutritional Assessment Short-Form (MNA-SF) or Malnutrition Screening Tool (MST) should be performed on all frail or at-risk older adults.

Screening Tool Administration Cut-off MBS Availability
MNA-SF 6 items; ≤5 min; nurse or GP ≤7 = malnourished; 8–11 = at risk No specific MBS item; use under CDM items (721, 723)
MST 2 items; <2 min; any clinician ≥2 = at risk Hospital: included in AROC benchmarking
Subjective Global Assessment (SGA) Detailed clinical assessment; dietitian-led B = mild–moderate malnutrition; C = severe Dietitian services under CHSP or hospital Allied Health
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Protein targets for frail older adults: 1.0–1.2 g/kg/day (up to 1.2–1.5 g/kg/day in acute illness or severe sarcopenia). Evenly distribute protein across meals (≥25–30 g per meal). Consider oral nutritional supplements (ONS) such as Ensure Plus® or Fortisip® when dietary intake is inadequate. Exercise enhances the anabolic response to protein intake — combine nutrition with resistance training for maximal benefit.
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Oral Nutritional Supplements (ONS)
Ensure Plus® · Fortisip® · Sustagen® Hospital Formula
Adult dose 1–3 cartons/day (each ~300 kcal, 12–18 g protein) between or with meals
Paediatric dose Paediatric-specific formulations (e.g., Ensure Kids®) — dose by dietitian assessment
Route Oral
Renal adjustment Use renal-specific formulations (e.g., Novasource® Renal) if eGFR <30 mL/min/1.73 m²
PBS status ✘ Not PBS-listed — funded through CHSP or hospital dietitian services

Vitamin D and Bone Health

Vitamin D deficiency is highly prevalent in frail older Australians (estimated 50–80% in RACF residents). Vitamin D supplementation (1,000–2,000 IU cholecalciferol daily) is recommended for all frail older adults with serum 25(OH)D <50 nmol/L, in conjunction with adequate calcium intake (1,300 mg/day from diet ± supplements).

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Cholecalciferol (Vitamin D₃)
Ostelin® · Various generics · Vitamin D supplement
Adult dose 1,000–2,000 IU (25–50 mcg) PO daily; loading dose 4,000–7,000 IU/day for 6–8 weeks if severely deficient (<25 nmol/L)
Frequency Daily (preferred) or weekly equivalent (e.g., 7,000 IU once weekly)
Duration Ongoing in high-risk individuals; recheck 25(OH)D at 3 months then annually
Renal adjustment Use calcitriol (active vitamin D) if eGFR <15 mL/min — nephrologist co-management
PBS status ✔ PBS General Benefit (Authority Required for calcitriol)

Prevention and Management

Frailty management requires a multidisciplinary, patient-centred approach. Evidence supports that pre-frail and mildly frail states are potentially reversible with targeted interventions. The following pillars form the basis of management.

1. Multicomponent Exercise

Exercise is the single most evidence-based intervention for frailty. A Cochrane review and multiple RCTs demonstrate that multicomponent programmes (resistance training + aerobic exercise + balance training) performed ≥2–3 times per week for ≥12 weeks improve physical function, reduce falls, and may reverse frailty status.

1
Resistance Training
2–3 sessions/week; 2–3 sets of 8–12 reps at 60–80% of 1RM; major muscle groups (legs, back, chest, arms). Start with body weight or resistance bands if severely deconditioned.
2
Aerobic Exercise
150 min/week moderate intensity (e.g., brisk walking, cycling). Even 10-min bouts are beneficial. Use RPE scale (target 3–5/10) for frail individuals unable to use heart rate.
3
Balance Training
3 sessions/week; tandem stance, single-leg stand, tai chi, Otago Exercise Programme. Critical for falls prevention (NHMRC Level I evidence).
4
Functional Practice
Task-specific training: sit-to-stand, stair climbing, reaching, carrying. Occupational therapy input for ADL-related goals. Linked to CHSP or NDIS funding where applicable.

2. Nutritional Optimisation

As detailed in the Sarcopenia section above, key interventions include:

  • Protein supplementation to 1.0–1.5 g/kg/day (combined dietary + supplement sources)
  • Oral nutritional supplements for those unable to meet targets from food alone
  • Vitamin D repletion (1,000–2,000 IU daily) with target serum 25(OH)D ≥50 nmol/L
  • Dietitian referral (MBS Item 10952 for specialist dietitian; CDM items 721/723 for GP Management Plan)
  • Texture-modified diet assessment if dysphagia present (Speech Pathology Australia guidelines)

3. Comprehensive Medication Review

Polypharmacy (≥5 regular medications) is highly prevalent in frail older adults and independently worsens frailty through adverse drug reactions, drug interactions, and cascading prescriptions. Medication review is a critical component of frailty management.

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STOPP/START Criteria v2: The Screening Tool of Older Persons' Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) should be applied during every medication review. Common deprescribing targets in frailty include benzodiazepines, proton pump inhibitors beyond 8 weeks, antipsychotics without clear indication, and anticholinergic medications (calculate Anticholinergic Cognitive Burden [ACB] score).

Australian medication review pathways:

  • Home Medicines Review (HMR): MBS Item 900 — GP-initiated, pharmacist-conducted in the patient's home. Available to all PBS-eligible patients, particularly those on ≥5 medications or experiencing adverse events.
  • Residential Medication Management Review (RMMR): MBS Item 903 — for permanent RACF residents; conducted at least annually or following a significant change in condition.
  • GP-led deprescribing: Use deprescribing.org.au algorithms for benzodiazepines, antipsychotics, opioids, PPIs, and antihyperglycaemics.

4. Comprehensive Geriatric Assessment (CGA)

CGA is a multidimensional, interdisciplinary diagnostic process that evaluates an older person's medical, functional, psychological, and social capacity. It is the gold standard assessment framework for frailty management and is associated with reduced mortality, reduced institutionalisation, and improved functional status.

CGA domains include: medical comorbidities, polypharmacy, mobility/balance, continence, nutrition, cognition, mood, social supports, and advance care preferences. In Australia, CGA is typically delivered by Aged Care Assessment Teams (ACATs/now called My Aged Care assessment services), geriatricians, or multidisciplinary community teams.

5. Multidisciplinary Team Approach

Discipline Key Role in Frailty Australian Access Pathway
Geriatrician CGA lead, complex comorbidity management, deprescribing oversight Medicare specialist referral; Geriatric Evaluation and Management (GEM) units
Physiotherapist Exercise prescription, falls prevention, mobility aids CHSP; NDIS (<65); hospital outpatient; private health insurance
Dietitian Nutritional assessment, ONS prescription, texture modification CDM items 721/723; hospital Allied Health; CHSP
Occupational Therapist ADL assessment, home modification, equipment prescription CHSP; NDIS; state-funded Community Rehabilitation programmes
Pharmacist HMR/RMMR, deprescribing, medication reconciliation MBS Item 900 (HMR), MBS Item 903 (RMMR)
Social Worker Social isolation assessment, carer support, advance care planning Hospital social work; My Aged Care; Carer Gateway (1800 422 737)
Exercise Physiologist Accredited exercise prescription for chronic conditions MBS items for chronic disease management; private health extras cover

6. Falls Prevention

Falls are both a consequence and accelerant of frailty. The NHMRC Clinical Practice Guidelines for Falls in Older Australians recommend a multifactorial falls risk assessment followed by targeted interventions. Key strategies include exercise programmes (Otago, tai chi), home hazard modification, medication review (particularly psychotropics, antihypertensives), vision assessment, footwear review, and vitamin D supplementation. State-based programmes such as NSW Health's "Stepping On" and Victoria's "Safe and Active Ageing" provide structured group-based falls prevention.

7. Advance Care Planning

For frail older adults, particularly those with CFS ≥6, advance care planning (ACP) should be proactively initiated. This includes discussion of goals of care, resuscitation preferences, and appointing a substitute decision-maker. In Australia, each state and territory has specific legislation for advance care directives (e.g., the Medical Treatment Planning and Decisions Act 2016 in Victoria, the Advance Care Directive Act 2013 in SA). The Advance Care Planning Australia programme (www.advancecareplanning.org.au) provides resources and training.

Special Populations

🧓 Elderly (≥85 years)
Frailty prevalence >40% in this age group; default to CFS assessment at every hospital admission and annual GP health assessment (MBS Item 707).
Medication review is paramount — reduced hepatic and renal clearance increases adverse drug event risk.
Exercise programmes must be supervised initially and tailored to capacity; seated resistance exercises are appropriate for the very frail.
Consider My Aged Care referral for CHSP or residential care assessment if CFS ≥6.
🫘 Renal Impairment
CKD (eGFR <60) and frailty frequently coexist; frailty is present in up to 70% of patients on dialysis.
Protein restriction in CKD conflicts with sarcopenia management — dietitian co-management essential to balance these competing needs.
If eGFR <30: use renal-specific nutritional supplements; adjust exercise intensity to anaemia and fluid status.
Frailty should inform dialysis decision-making; conservative kidney management may be appropriate for CFS ≥7.
🫁 Hepatic Impairment
Liver cirrhosis and frailty are strongly associated; sarcopenia affects 40–70% of cirrhotic patients.
Avoid hepatotoxic supplements; prioritise branched-chain amino acid (BCAA) supplementation.
Night-time snacking (late-evening nutritional supplement) reduces protein catabolism in cirrhosis.
Frailty assessment is critical in liver transplant candidacy evaluation.
🛡️ Immunocompromised
Frailty increases infection susceptibility independently of immunosuppressive medications.
Ensure pneumococcal and annual influenza vaccination (NIP-funded); COVID-19 booster doses as per ATAGI schedule.
Exercise improves immune function in frail older adults; avoid prolonged bed rest.
Frailty assessment should be incorporated into cancer treatment tolerance evaluation (e.g., comprehensive geriatric oncology assessment).
👶 Paediatric Relevance
Frailty as conceptualised in geriatrics is not applicable to paediatric populations.
However, children with complex chronic conditions or severe neurological impairment may exhibit analogous states of reduced physiological reserve.
Paediatric-specific tools are under development; management focuses on optimising growth, nutrition, and developmental milestones.
🤰 Pregnancy
Frailty in pregnancy is uncommon but has been described in very young adolescent mothers and those with severe chronic illness.
The concept is not routinely applied in obstetric practice; focus should be on optimising maternal nutrition and comorbidity management.
Postpartum women may be at risk of functional decline — early mobilisation and nutritional support are important.

Risk Stratification and Clinical Applications

Frailty assessment should not be performed in isolation but integrated into clinical decision-making across multiple healthcare settings.

Pre-Frail (CFS 3–4)
Early Intervention
Reversible state. Exercise prescription, nutritional counselling, medication review. Annual screening recommended.
Setting: Primary care / GP-led chronic disease management
Mild-Moderate Frailty (CFS 5–6)
Active Management
Multidisciplinary CGA, structured exercise programme, ONS, HMR, allied health, community support services.
Setting: Geriatric outpatient / CHSP / Transition Care Programme
Severe Frailty (CFS 7–9)
Comfort-Focused Care
Maintain function and quality of life. Advance care planning. Consider palliative care. Residential aged care or comprehensive home-based package.
Setting: RACF / Hospital-in-the-Home / Palliative care

Perioperative Frailty Assessment

Frailty is an independent predictor of postoperative complications, prolonged length of stay, and 30-day mortality. The ACSQHC recommends frailty screening for all patients aged ≥65 years undergoing elective surgery. Patients with CFS ≥5 should be discussed at multidisciplinary perioperative meetings and offered prehabilitation where time permits (ideally 4–6 weeks pre-operatively).

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Safety critical: Frailty should not be used as a sole basis for denying treatment. Rather, it should inform shared decision-making, set realistic expectations for recovery trajectories, and trigger proactive support planning (e.g., enhanced post-operative rehabilitation, early allied health input).

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Frailty among Aboriginal and Torres Strait Islander Australians occurs at significantly younger ages — often 10–15 years earlier than in non-Indigenous Australians. The Australian Institute of Health and Welfare (AIHW) reports that frailty-related hospitalisation rates for Indigenous Australians are approximately 2–3 times higher than for non-Indigenous Australians. This reflects the broader context of intergenerational trauma, social determinants of health, higher chronic disease burden, and systemic barriers to healthcare access.

Earlier onset
Frailty assessment should commence from age 50 years (rather than 65) for Aboriginal and Torres Strait Islander peoples. The CFS and SARC-F are validated for use at this younger threshold in this population.
Chronic disease burden
Higher prevalence of type 2 diabetes, cardiovascular disease, chronic kidney disease, and rheumatic heart disease accelerates frailty progression. Integrated chronic disease management through Aboriginal Community Controlled Health Organisations (ACCHOs) is essential.
Remote and rural access
Specialist geriatric services are limited in remote communities. Telehealth (MBS Items 99200–99215) enables geriatrician consultation. Royal Flying Doctor Service and state outreach programmes provide periodic clinics. Exercise programmes may need adaptation for community and cultural context.
Cultural safety
Assessment tools must be applied with cultural sensitivity. Yarning-based approaches to health assessment, preference for same-sex clinicians, and incorporation of Aboriginal health workers and practitioners into the care team improve engagement and outcomes.
Nutrition and food security
Food insecurity is prevalent in remote communities, with limited access to affordable fresh food. High-sugar, high-fat processed foods predominate. Community-controlled nutrition programmes, food box schemes, and traditional food education are important strategies.
Carer and family support
Aboriginal and Torres Strait Islander communities often have strong family-based caring structures. Respecting kinship obligations and supporting family carers through the Carer Gateway and Aboriginal-specific respite services is important. Elders hold significant community roles; maintaining their function is a priority.
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Key resource: The Aboriginal and Torres Strait Islander Aged Care Strategy (Department of Health and Aged Care) and NACCHO's guidelines on healthy ageing provide culturally specific frameworks for frailty management. All assessment and management should be delivered through or in partnership with ACCHOs wherever possible.

Investigations

There is no single laboratory test to diagnose frailty. Investigations serve to identify contributing and reversible causes, assess severity of sarcopenia, and guide nutritional management.

Essential Full blood count (FBC) Screen for anaemia (contributing to fatigue and weakness), infection, haematological malignancy. Available in all Australian pathology laboratories.
Essential Renal function (eGFR, electrolytes, creatinine) CKD screening; guides protein intake and medication dosing. MBS-rebated standard pathology.
Essential Liver function tests (LFTs) Hepatic impairment affects drug metabolism and nutritional status. Screen for underlying liver disease.
Essential Serum 25-hydroxyvitamin D High prevalence of deficiency in frail older adults; guides supplementation. MBS Item 66815.
Essential Thyroid function tests (TFTs) Both hypo- and hyperthyroidism contribute to frailty features (weight change, fatigue, weakness).
Available Serum albumin and pre-albumin Low albumin is a marker of malnutrition and inflammation (not specific). Pre-albumin (transthyretin) reflects acute nutritional change. Albumin is MBS-rebated; pre-albumin may require private billing in some settings.
Available Vitamin B₁₂, folate, iron studies Contribute to fatigue and cognitive impairment; particularly important if anaemia present.
Available HbA1c Diabetes screening and glycaemic control assessment. Over-treatment of diabetes in frailty increases hypoglycaemia risk — consider relaxing HbA1c targets to <53–64 mmol/mol.
Available DEXA / DXA (body composition) Appendicular lean mass index for sarcopenia confirmation. Also provides bone mineral density (T-score). MBS Item 12306 (bone density); body composition analysis not currently MBS-listed — available through hospital or research settings.
Specialist Bioelectrical impedance analysis (BIA) Bedside estimation of lean mass; validated for sarcopenia assessment. Not MBS-listed; available in some hospital and allied health settings.
Specialist CT/MRI body composition analysis Psoas muscle cross-sectional area or mid-thigh muscle mass. Used in research and specialist assessment (oncogeriatrics). MBS-rebated if clinically indicated (e.g., staging CT with incidental body composition analysis).

Monitoring

Frailty is a dynamic state that can improve, stabilise, or deteriorate over time. Regular monitoring is essential to track response to interventions and detect clinical deterioration early.

Every GP visit Weight measurement, functional enquiry (falls, ADL changes), medication review, mood screening. Brief gait speed or TUG if concern.
Every 3–6 months CFS re-assessment, grip strength (if available), SARC-F if sarcopenia suspected, MNA-SF for nutritional status. Review exercise adherence and allied health engagement.
Annually (MBS Item 707) Annual health assessment for patients ≥75 years (≥55 years for ATSI). Includes comprehensive functional assessment, medication review, immunisation status, advance care planning discussion.
At hospital admission CFS at triage or within 24 hours. Frailty status documented in discharge summary. Transition Care Programme referral if CFS ≥5.
Following acute illness Re-assess 4–6 weeks post-event. Acute illness can shift frailty category by ≥1 CFS level. Consider rehabilitation, increased community support, or residential care review.
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Trajectory awareness: Frailty typically follows one of three trajectories — gradual decline (most common), stepwise decline after acute events (e.g., hip fracture, pneumonia), or stable moderate frailty with good community support. Recognising the trajectory guides realistic goal-setting and resource allocation.

Quick Reference

Screening tool (primary care) CFS or gait speed ≤0.8 m/s 2 min All adults ≥70 years; ≥50 years if ATSI
Sarcopenia screening SARC-F questionnaire 1 min Score ≥4 → confirmatory grip strength / DXA
Nutritional screening MNA-SF or MST 2–5 min MNA-SF ≤7 = malnourished; MST ≥2 = at risk
Exercise prescription Resistance + aerobic + balance ≥150 min/week Supervised initially; home-based maintenance
Protein target 1.0–1.5 g/kg/day Daily ≥25–30 g protein per meal; ONS if insufficient
Vitamin D Cholecalciferol 1,000–2,000 IU/day Ongoing Target 25(OH)D ≥50 nmol/L; recheck at 3 months
Medication review HMR (MBS 900) / RMMR (MBS 903) As indicated STOPP/START criteria; deprescribing benzodiazepines, anticholinergics, PPIs

📚 References

  1. 1. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–M156.
  2. 2. Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–495.
  3. 3. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal. 2001;1:323–336.
  4. 4. Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis (EWGSOP2). Age Ageing. 2019;48(1):16–31.
  5. 5. Malmstrom TK, Morley JE. SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. J Am Med Dir Assoc. 2013;14(8):531–532.
  6. 6. Australian Institute of Health and Welfare. Older Australians at a glance. AIHW Cat. No. AGE 87. Canberra: AIHW; 2024.
  7. 7. Dent E, Morley JE, Cruz-Jentoft AJ, et al. International Clinical Practice Guidelines for Sarcopenia (ICFSR): screening, diagnosis and management. J Nutr Health Aging. 2018;22(10):1148–1161.
  8. 8. O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–218.
  9. 9. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021.
  10. 10. National Health and Medical Research Council (NHMRC). Preventing falls and harm from falls in older people: best practice guidelines for Australian community care. Canberra: NHMRC; 2009.
  11. 11. Dent E, Lien C, Lim WS, et al. The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. J Am Med Dir Assoc. 2017;18(7):564–575.
  12. 12. Apóstolo J, Cooke R, Bobrowicz-Campos E, et al. Predicting risk and outcomes for frail older adults: an umbrella review of frailty screening tools. JBI Database System Rev Implement Rep. 2017;15(4):1154–1208.
  13. 13. Hubbard RE, Peel NM, Samanta M, et al. Frailty status at admission to hospital predicts discharge destination in older patients. Age Ageing. 2017;46(4):644–648.
  14. 14. Dent E, Hoogendijk EO, Cardona-Morrell M, et al. Frailty in emergency departments. Lancet. 2016;387(10017):434–443.
  15. 15. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th ed. Melbourne: RACGP; 2018.
  16. 16. Government of Australia, Department of Health and Aged Care. Aboriginal and Torres Strait Islander Aged Care Strategy. Canberra: Commonwealth of Australia; 2023.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).