Thread by @Krockdoc

1/9 A second #ClinicalFrailtyScale tweetorial (tweetegesis?) prompted by three questions from last time: 1. Why include disability when discussing ways in which people can be frail - weren’t the two disentangled long ago? 2. Isn’t frailty a syndrome? 3. Can it be diagnosed? ->2

2/9 Hereabouts, we see deficit accumulation as primary. It’s what happens with age, and how frailty/risk arises. The risk isn’t just of death. Think, say, an injurious fall. It can occur in a fit person. If so, a single-system cause, and/or a big perturbation is most likely.->3

3/9 For such, the relevant ‘ologist (neurologist, cardiologist, traumatologist) is best. If the person was frail at baseline (or very old) this is where comprehensive geriatric assessment shines in its embrace of the patient’s (likely many) interacting medical & social issues ->4

4/9 With frailty, an injurious fall is less often single system: it’s whole-person-as-system failure, ie failure of the high-order, integrative, information-rich function of upright bipedal ambulation. (In standard geriatric parlance, that’s called “the predisposing factors”) ->5

5/9 Disability can be single-system/injury. The more deficits present though, the more likely that disability reflects failure of another evolutionary high-order function:“opposable thumbs”. To me, the disentangling needed in disability is whether it has one cause, or many. ->6

6/9 Q2. Is frailty a syndrome? There are many ways to be frail. “Physical frailty” is one, but so too would be the frailty syndromes of falls, disability, etc. The clinical utility is in the common approach needed, and the sensibility of embracing complexity, and acting on it.->7

7/n Q3: Can frailty be diagnosed? Let’s answer first with another question: if not a disease and not a syndrome, what is it? We see frailty as a state. Intelligent people of good likely will disagree on its diagnosability. Do we diagnose critical illness? Both are high-risk ->8

8/9 states with many causes. Knowing that either is present has non-trivial clinical consequences. Esp when first seen, they require up-front identification: a MAP of 50 is not “by the way”, it’s either “here are the five things we’re doing” or “come a-runnin’ “. In sum, I’m ->9

9/9happy to diagnose frailty, all the more by comprehensive geriatric assessment. And quantify it in a frailty index. And stage it. Our goal is the care plan. That obliges speaking plainly about disability, multimorbidity, mobility, and cognition. And knowing how they’re related.