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geriatrics.frailty-polypharmacy.core.v1PRODUCTION
geriatrics.frailty-polypharmacy.core.v1

Frailty assessment and polypharmacy management

general_internal_medicinechronicgeriatricadult
Hard-required inputs
0 / 10
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
1
Actions
0
Advance rule
Set
Advance when

Patient meets criteria for integrated frailty/polypharmacy assessment; single-disease-only management excluded (BGS CGA)

Patient inputs (13)

Full reconciled medication list (incl. OTC/herbal) is the substrate for STOPP/START v3, Beers, and anticholinergic-burden screening (O'Mahony Age Ageing 2023)

Multimorbidity burden defines CGA domains, drug-disease interactions, and deprescribing priorities (BGS CGA)

Falls count and injury inform deprescribing prioritisation and falls-engine routing (AGS/BGS falls)

Patient goals/values and frailty severity set proportionate care intensity, treatment-target relaxation, and ACP timing (BGS CGA)

Frailty case-finding threshold >=65; Beers criteria are age-stratified (AGS Beers 2023)

eGFR (CKD-EPI 2021) drives renally-cleared drug dose-adjustment and deprescribing of renally-risky agents (STOPP/START v3 2023)

MoCA/MMSE cognitive domain — affects medication self-management capacity, consent, and anticholinergic-burden urgency (BGS CGA)

Depression (GDS-15) is a reversible mimic of frailty/failure-to-thrive and a CGA mood domain (ICFSR/Dent 2019)

ADL/IADL (Barthel/Lawton) defines the functional CGA domain and anchors the Clinical Frailty Scale (Rockwood CMAJ 2005)

Malnutrition/sarcopenia (MNA-SF, unintentional weight loss >5%/6mo) is a core frailty driver and a treatable target (ESPEN 2019)

Unintentional weight loss is a Fried phenotype criterion and undernutrition red flag (Fried 2001)

Gait speed <0.8 m/s is a robust frailty marker and a FRAIL/phenotype component used for rapid screening (Morley 2012)

Orthostatic hypotension is an antihypertensive/alpha-blocker deprescribing trigger and falls contributor (STOPP/START v3 2023)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningend_stage_frailty_palliative
    Clinical Frailty Scale 8-9 (very severely frail / terminally ill) — limited life expectancy, complete functional dependence (Rockwood CMAJ 2005)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdelirium_superimposed_on_frailty
    Acute fluctuating inattention / altered cognition superimposed on baseline frailty, frequently medication-precipitated (AGS Beers 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_functional_decline_failure_to_thrive
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefall_with_injury
    Fall resulting in fracture, head injury, or hospitalisation in a frail patient on fall-risk medications (AGS/BGS falls)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_undernutrition
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Frailty attenuation + medication optimisation — screen → CGA → exercise+nutrition → STOPP/START+Beers+ACB deprescribing → comorbidity/falls/bone/mood → goals-aligned proportionate care + ACP
axis: frailty_attenuation_and_medication_optimisationstep 1 - Step 1 — Rapid screen + CGA confirmation
Selected step "Step 1 — Rapid screen + CGA confirmation" — Any patient >=65 with multimorbidity, polypharmacy, or frailty concern (entry, before any intervention)
  • rapid_frailty_screen
    first line
    screening_action
    triggers: age_>=65, multimorbidity_or_polypharmacy
    ICFSR/Dent 2019 — FRAIL scale + gait speed (<0.8 m/s) / grip case-find frailty; screen-positive triggers full CGA
  • comprehensive_geriatric_assessment
    first line
    assessment_action
    triggers: screen_positive, polypharmacy, multimorbidity
    BGS CGA — multidimensional CGA (medical/functional/cognitive/mood/nutrition/social/polypharmacy) is the evidence-based confirmatory and care-planning instrument

outpatient playbook — drug actions (5)

  1. 1. rapid frailty screen + CGA
    n/a • n/a • at assessment
    trigger: >=65 with multimorbidity/polypharmacy/frailty concern
    ICFSR/Dent 2019 — FRAIL/gait-speed screen then multidimensional CGA
  2. 2. resistance + multicomponent exercise + protein/nutrition optimisation
    n/a (vitamin D 800-1000 IU PO daily ONLY if deficient) • n/a (PO for vitamin D) • ongoing
    trigger: Pre-frail/frail (CFS 4-7)
    ICFSR/Dent 2019 / ESPEN 2019 — strongest frailty-reversing intervention
  3. 3. STOPP/START v3 + Beers + ACB-driven deprescribing/START
    taper per protocol • n/a • at review + each transition
    trigger: Polypharmacy or any flagged/high-ACB agent
    O'Mahony 2023 / Beers 2023 — goal-aligned medication optimisation
  4. 4. comorbidity / falls / bone / mood / continence management
    n/a • n/a • per CGA findings
    trigger: CGA-identified domain needs
    BGS CGA — proportionate to frailty severity and goals
  5. 5. advance care planning + goals-aligned proportionate care
    n/a • n/a • early + each transition
    trigger: CFS band assigned
    BGS CGA — care intensity scaled to CFS and patient values

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Age >=65 — universal frailty/polypharmacy case-finding at routine, transition, or preoperative visit (ICFSR/Dent 2019); >=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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Frailty assessment and polypharmacy management** (geriatrics.frailty-polypharmacy.core.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Frailty attenuation + medication optimisation — screen → CGA → exercise+nutrition → STOPP/START+Beers+ACB deprescribing → comorbidity/falls/bone/mood → goals-aligned proportionate care + ACP** — step "Step 1 — Rapid screen + CGA confirmation".
1. rapid_frailty_screen (screening_action, first line) — ICFSR/Dent 2019 — FRAIL scale + gait speed (<0.8 m/s) / grip case-find frailty; screen-positive triggers full CGA
2. comprehensive_geriatric_assessment (assessment_action, first line) — BGS CGA — multidimensional CGA (medical/functional/cognitive/mood/nutrition/social/polypharmacy) is the evidence-based confirmatory and care-planning instrument

Setting playbook (outpatient) — Case-find and confirm frailty (screen → CGA), optimise medications (STOPP/START + Beers + ACB), establish the exercise + nutrition cornerstone, and set goals-aligned, proportionate care with ACP
3. rapid frailty screen + CGA n/a n/a at assessment — >=65 with multimorbidity/polypharmacy/frailty concern (ICFSR/Dent 2019 — FRAIL/gait-speed screen then multidimensional CGA)
4. resistance + multicomponent exercise + protein/nutrition optimisation n/a (vitamin D 800-1000 IU PO daily ONLY if deficient) n/a (PO for vitamin D) ongoing — Pre-frail/frail (CFS 4-7) (ICFSR/Dent 2019 / ESPEN 2019 — strongest frailty-reversing intervention)
5. STOPP/START v3 + Beers + ACB-driven deprescribing/START taper per protocol n/a at review + each transition — Polypharmacy or any flagged/high-ACB agent (O'Mahony 2023 / Beers 2023 — goal-aligned medication optimisation)
6. comorbidity / falls / bone / mood / continence management n/a n/a per CGA findings — CGA-identified domain needs (BGS CGA — proportionate to frailty severity and goals)
7. advance care planning + goals-aligned proportionate care n/a n/a early + each transition — CFS band assigned (BGS CGA — care intensity scaled to CFS and patient values)

Non-pharmacologic actions:
- Progressive resistance + multicomponent (balance/aerobic/functional) exercise programme
- Protein/nutrition optimisation (1.0-1.2 g/kg/day, ONS if intake inadequate); vitamin D ONLY if deficient
- Gradual deprescribing (never abrupt for benzodiazepine/PPI/beta-blocker/opioid); proactive START omissions
- Multifactorial falls prevention referral; home-safety and vision review
- Caregiver education/support/respite; relax disease targets in moderate-severe frailty
- ACP, surrogate, treatment-escalation/ceiling and resuscitation preferences early

AVOID / contraindication checks:
- Abrupt_benzodiazepine_withdrawal_seizure_risk_taper_gradually (AGS Beers 2023)
- Abrupt_ppi_withdrawal_rebound_hyperacidity_step_down (STOPP/START v3 2023)
- Abrupt_beta_blocker_withdrawal_rebound_HTN_angina (STOPP/START v3 2023)
- Abrupt_opioid_withdrawal_syndrome_taper_gradually (AGS Beers 2023)
- Vitamin_D_only_if_deficient_avoid_hypercalcaemia_and_granulomatous_disease (ICFSR/Dent 2019)
- Relax_BP_and_glycaemic_targets_in_frail_avoid_overtreatment_hypoglycaemia_orthostasis (STOPP/START v3 2023)

Monitoring

Regimen monitoring:
- CFS reassessment q6-12mo and each transition (Rockwood CMAJ 2005)
- function ADL IADL and gait speed q3-6mo (BGS CGA)
- falls rate q3mo (AGS/BGS falls)
- nutrition weight MNA SF q3-6mo (ESPEN 2019)
- reconciled medication count and pill burden q3-6mo (STOPP/START v3 2023)
- symptom rebound check 2-4wk post deprescribe (STOPP/START v3 2023)
- vitamin D and calcium level if supplementing q6-12mo (ICFSR/Dent 2019)

Setting (outpatient) monitoring:
- CFS + function (ADL/IADL) + gait speed q3-6mo (BGS CGA)
- Reconciled medication count + ACB + falls rate q3mo (STOPP/START v3 2023)
- Nutrition/weight (MNA-SF) q3-6mo; vitamin D q6-12mo if supplementing (ESPEN 2019)
- Symptom rebound 2-4 weeks post-deprescribe (STOPP/START v3 2023)

Follow-up plan: 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)
- Close-out criterion: ACP documented; next medication review and CGA interval scheduled; caregiver support arranged; sibling-engine follow-up linked (BGS CGA)

Monitoring phase: 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)

Disposition

Current setting: outpatient — Case-find and confirm frailty (screen → CGA), optimise medications (STOPP/START + Beers + ACB), establish the exercise + nutrition cornerstone, and set goals-aligned, proportionate care with ACP

Disposition criteria:
- Continue outpatient multidisciplinary CGA / geriatric day-hospital when stable (BGS CGA)
- Refer palliative care and de-intensify preventive therapy for end-stage frailty (CFS 8-9) (ICFSR/Dent 2019)

Escalation triggers (move to higher acuity):
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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)
- [SEVERE] 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)

Citations

- 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 [PMID:27817839](https://pubmed.ncbi.nlm.nih.gov/27817839/)
- Cited evidence (PMID 31375085) [PMID:31375085](https://pubmed.ncbi.nlm.nih.gov/31375085/)
- Cited evidence (PMID 36370996) [PMID:36370996](https://pubmed.ncbi.nlm.nih.gov/36370996/)
- Cited evidence (PMID 37139824) [PMID:37139824](https://pubmed.ncbi.nlm.nih.gov/37139824/)
- Cited evidence (PMID 16129869) [PMID:16129869](https://pubmed.ncbi.nlm.nih.gov/16129869/)

Last reconciled with current guidelines: 2026-05-16.
References
  • 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 — PMID:27817839
  • Cited evidence (PMID 31375085) — PMID:31375085
  • Cited evidence (PMID 36370996) — PMID:36370996
  • Cited evidence (PMID 37139824) — PMID:37139824
  • Cited evidence (PMID 16129869) — PMID:16129869