Patient handout

Frailty assessment and polypharmacy management

PRODUCTION

1. Your condition

This handout is for frailty assessment and polypharmacy management. Your care team identified this based on: age >=65 — universal frailty/polypharmacy case-finding at routine, transition, or preoperative visit (icfsr/dent 2019).

Other reasons your team may use this plan: >=2 chronic conditions — multimorbidity burden prompting integrated geriatric review (bgs cga); >=5 chronic medications — polypharmacy trigger for stopp/start v3 + beers screening (o'mahony age ageing 2023); recurrent falls (>=2 in 12 months) or a fall with injury — frailty as the upstream driver (ags/bgs falls).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
rapid_frailty_screen	—	—	—	ICFSR/Dent 2019 — FRAIL scale + gait speed (<0.8 m/s) / grip case-find frailty; screen-positive triggers full CGA
comprehensive_geriatric_assessment	—	—	—	BGS CGA — multidimensional CGA (medical/functional/cognitive/mood/nutrition/social/polypharmacy) is the evidence-based confirmatory and care-planning instrument

Plan: Frailty attenuation + medication optimisation — screen → CGA → exercise+nutrition → STOPP/START+Beers+ACB deprescribing → comorbidity/falls/bone/mood → goals-aligned proportionate care + ACP

3. When to call your provider

Contact your care team if any of the following happen:

Acute functional decline / failure-to-thrive → urgent occult-illness/delirium/abuse workup (ICFSR/Dent 2019)
Fall with injury (fracture/head injury) → inpatient + fall-risk-med review (AGS/BGS falls)
Severe undernutrition / rapid weight loss → nutrition team ± inpatient (ESPEN 2019)
Medication-related emergency (severe hypoglycaemia, bleeding, syncope, AKI) → urgent care (AGS Beers 2023)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

New rapid functional decline / failure-to-thrive — sudden loss of ADL independence, anorexia/weight loss, withdrawal — until occult acute illness, delirium, depression, malignancy, or elder abuse is excluded (ICFSR/Dent 2019)
Fall resulting in fracture, head injury, or hospitalisation in a frail patient on fall-risk medications (AGS/BGS falls)
Severe undernutrition / unintentional weight loss >5% in 3 months (or >10% in 6 months) or MNA-SF in the malnourished range in a frail patient (ESPEN 2019)
Clinical Frailty Scale 8-9 (very severely frail / terminally ill) — limited life expectancy, complete functional dependence (Rockwood CMAJ 2005)(life-threatening)
Acute fluctuating inattention / altered cognition superimposed on baseline frailty, frequently medication-precipitated (AGS Beers 2023)(life-threatening)

5. Follow-up

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)

6. Sources

Guideline: Asia-Pacific / ICFSR Frailty Clinical Practice Guidelines (Dent 2017/2019) + STOPP/START v3 (O'Mahony Age Ageing 2023) + AGS Beers 2023 + BGS Comprehensive Geriatric Assessment