12-phase flow (12)

1. 1FRAME
   Confirm geriatric scope: age >=65 with multimorbidity and/or polypharmacy and/or frailty concern; this is integrated person-centred geriatric care, not isolated single-disease management (ICFSR/Dent 2019)
   inputs: age
   advance: Patient meets criteria for integrated frailty/polypharmacy assessment; single-disease-only management excluded (BGS CGA)
2. 2ENTRY
   Capture and document the trigger and run a rapid frailty screen — FRAIL scale (Fatigue/Resistance/Ambulation/Illnesses/Loss-of-weight), gait speed (<0.8 m/s) or grip strength — to decide who needs full CGA confirmation (Morley 2012)
   inputs: age, gait_speed
   actions: calc.frail_scale
   advance: Entry trigger documented and rapid screen completed (FRAIL/gait speed); screen-positive or polypharmacy/multimorbidity present (ICFSR/Dent 2019)
3. 3CONTEXT
   Full reconciled medication history (incl. OTC/herbal), comorbidity list, functional/social/caregiver baseline, falls history, weight trajectory, and an explicit goals-of-care/values conversation that will calibrate care intensity (BGS CGA)
   inputs: current_meds, comorbidity_list, falls_history, goals_of_care, weight
   actions: workup.cga
   advance: Medication list reconciled, multimorbidity burden characterised, and patient goals/values documented (BGS CGA)
4. 4RED_FLAGS
   Acute functional decline / failure-to-thrive screen for occult acute illness, delirium superimposed on baseline, depression, malignancy, or elder abuse/neglect; severe undernutrition; a recent fall with injury; medication-induced emergency (hypoglycaemia, bleeding, syncope, AKI from a nephrotoxic combination); and end-stage frailty appropriate for a palliative pivot (ICFSR/Dent 2019)
   inputs: cognitive_status, nutrition_status, falls_history
   advance: No acute functional collapse / medication emergency / abuse, or each is addressed and worked up appropriately (BGS CGA)
5. 5INITIAL_WORKUP
   Comprehensive geriatric assessment (CGA) across all domains — cognition (MoCA/MMSE), mood (GDS-15), function (ADL/IADL), nutrition (MNA-SF), gait/grip, orthostatic BP — plus baseline labs (CMP/CBC) and renal function (CKD-EPI 2021) for drug dosing; screen reversible contributors with TSH and vitamin D (Rockwood CMAJ 2005; ESPEN 2019)
   inputs: functional_status, cognitive_status, mood_status, nutrition_status, egfr, orthostatic_bp
   actions: workup.cga, calc.moca, calc.gds_15, calc.ckd_epi_2021, panel.cmp, panel.cbc, panel.tsh, panel.vitamin_d
   advance: All CGA domains assessed; renal function and reversible-contributor labs reviewed (BGS CGA)
6. 6BRANCHING_WORKUP
   Systematic medication optimisation: STOPP/START v3 screen (potentially inappropriate prescribing AND potentially beneficial omissions), AGS Beers 2023 potentially-inappropriate-medication screen, and cumulative anticholinergic cognitive burden (ACB) — each branching to a deprescribe / start / dose-adjust / continue decision (O'Mahony Age Ageing 2023)
   inputs: current_meds, comorbidity_list, egfr, cognitive_status
   actions: workup.stopp_start_v3, workup.beers_screen, calc.acb_scale
   advance: STOPP violations, START omissions, Beers PIMs, and anticholinergic burden catalogued with clinical relevance and patient-goal alignment assessed (O'Mahony Age Ageing 2023)
7. 7DIFFERENTIAL
   Characterise the frailty construct (Fried phenotype vs deficit-accumulation Frailty Index vs Clinical Frailty Scale) and separate reversible/contributing drivers (depression, hypothyroidism, vitamin D deficiency, anaemia, sarcopenia/malnutrition, deconditioning, polypharmacy ADRs, occult malignancy) from irreversible end-stage frailty / terminal trajectory (ICFSR/Dent 2019)
   inputs: functional_status, nutrition_status, mood_status, cognitive_status
   advance: Frailty construct characterised; reversible contributors identified for targeting; overall trajectory (reversible/attenuable vs end-stage) assigned (ICFSR/Dent 2019)
8. 8RISK_STRATIFICATION
   Assign Clinical Frailty Scale (1 very fit → 3 managing well → 4 vulnerable/pre-frail → 5 mildly → 6 moderately → 7-8 severely/very-severely frail → 9 terminally ill); layer the anticholinergic cognitive burden score and medication/pill burden — CFS severity sets prognosis and the proportionate intensity of every downstream decision (Rockwood CMAJ 2005)
   inputs: functional_status, gait_speed, goals_of_care
   actions: calc.clinical_frailty_scale, calc.acb_scale
   advance: Frailty severity (CFS band) and anticholinergic burden assigned; deprescribing/intervention priority list ranked by harm and goal-alignment (Rockwood CMAJ 2005)
9. 9TREATMENT
   Frailty-attenuation + medication-optimisation: resistance + multicomponent exercise and protein/nutrition optimisation are the strongest evidence to reverse/attenuate frailty (treat malnutrition/sarcopenia, vitamin D if deficient); STOPP/START v3 + Beers + ACB-driven deprescribing (taper, never abrupt for benzodiazepine/PPI/beta-blocker/opioid) with proactive START of indicated omissions; manage comorbidity / cognition / mood / continence / falls / bone (osteoporosis) proportionate to frailty severity; advance care planning and goals-aligned, proportionate care intensity (relax treatment targets in the frail); caregiver support and respite (ICFSR/Dent 2019)
   inputs: current_meds, comorbidity_list, nutrition_status, goals_of_care
   actions: protocol.deprescribing_ppi, protocol.deprescribing_benzodiazepine, protocol.deprescribing_anticholinergic
   advance: Exercise + nutrition cornerstone prescribed; deprescribing/START plan agreed with patient/caregiver; comorbidity and goals-aligned plan set (ICFSR/Dent 2019)
10. 10DISPOSITION
    Predominantly outpatient with multidisciplinary CGA / geriatric day-hospital; inpatient only for acute functional collapse, deconditioning prevention, or a medication-related emergency; route to falls prevention programme and palliative care for end-stage (CFS 8-9) frailty (BGS CGA)
    inputs: goals_of_care
    advance: Care setting confirmed and multidisciplinary / falls / palliative referrals placed per frailty severity and goals (BGS CGA)
11. 11MONITORING
    Post-deprescribing surveillance for withdrawal/rebound (PPI acid rebound, benzodiazepine withdrawal, beta-blocker rebound HTN/angina, opioid withdrawal); CFS, function (ADL/IADL), gait speed, nutrition/weight, falls rate, and reconciled medication count/pill burden re-checked q3-6 months and at every care transition (STOPP/START v3 2023)
    inputs: current_meds, functional_status, nutrition_status
    actions: calc.clinical_frailty_scale, calc.acb_scale
    advance: Monitoring cadence set; no untreated withdrawal/rebound syndrome; frailty trajectory stable or improving on exercise/nutrition (STOPP/START v3 2023)
12. 12FOLLOWUP
    Advance care planning revisited at each transition and care escalation; medication review at every visit and transition (medication reconciliation is the single highest-yield transition intervention); periodic CGA interval set by frailty severity; caregiver support/respite referral; bidirectional falls-engine and deprescribing-engine follow-up (BGS CGA)
    inputs: goals_of_care
    advance: ACP documented; next medication review and CGA interval scheduled; caregiver support arranged; sibling-engine follow-up linked (BGS CGA)