In 2005, Canadian researchers introduced a frailty index they developed using the comprehensive geriatric assessment (FI-CGA). The tool quantifies the CGA into a single measure, as described in Aging Clinical and Experimental Research, and was subsequently shown to predict a range of clinical outcomes.
In the Journal of the American Geriatrics Society, Lisa Cooper, MD, an advanced fellow physician in the Division of Aging at Brigham and Women’s Hospital, Houman Javedan, MD, clinical director of the division, and colleagues describe how they adapted the FI-CGA to be feasible for use by geriatricians to communicate complex geriatric concepts with multiple other clinics at the Brigham that care for older adults.
Adapting the FI-CGA
In 2015, geriatricians from the Division of Aging met with Dr. Kenneth Rockwood, one of the co-developers of the FI-CGA, and his colleagues at Dalhousie University in Nova Scotia to understand the foundations and applications of the FI-CGA. The Canadian group later helped the Brigham group decide which health deficits should be included in the adapted tool and how to score each one.
The final FI-CGA contained 60 variables (down from 70 in the original), with a minimum of 30 required for any given assessment. All variables are discernible from routinely collected bedside information such as cognitive evaluation, chart review, physical exam, collateral history and patient self-report.
Disseminating the FI-CGA
By a fortunate coincidence, the Brigham was transitioning to a new electronic health records system around the time the adapted FI-CGA was being completed. The FI-CGA was incorporated into the “Flowsheets” function of the EPIC system on January 1, 2018. Geriatricians can enter an FI-CGA in the current patient encounter, pull the FI-CGA into the clinical note, and track serial FI-CGAs.
After a year of having geriatricians standardize their frailty assessments, the use of the FI-CGA was expanded to embedded geriatricians in Primary Care; Orthopedic, Thoracic and Trauma Surgery; and Oncology. Later it was introduced in the Perioperative Clinic and Hospital Medicine. The tool is also an important element of two new initiatives, the Geriatric Surgery Verification Program, and Age-Friendly Health Systems certification.
Uptake of the FI-CGA
Documentation of the FI-CGA in the EPIC system increased rapidly over time, from 623 instances in 2018 to 1,434 in 2020. It’s been possible to sustain documentation during the COVID-19 pandemic because the FI-CGA was easily adapted to a telehealth format.
12 of 14 geriatricians in the Division of Aging responded to a recent survey:
- 100% reported always using the FI-CGA when assessing a new patient
- 82% said the FI-CGA “helps my management plan”
- None reported impediments to workflow, and 58% said the FI-CGA aids their workflow
Continuous Improvement
The process of refining the FI-CGA has continued as additional co-management services are established. In addition, non-physicians are being trained to interpret the CGA, which is expanding the application of the FI-CGA to multiple other clinical services.
Dissemination of the FI-CGA outside the Division of Aging presents inherent challenges. For instance, proper interpretation of the adapted FI-CGA relies on having the CGA performed in a uniform way.
Another difficulty is to define cutoff values for different degrees of frailty. Which FI-CGA cutoff values are valid for particular specialties and clinical environments has not yet been determined.
A major hazard is that non-geriatricians will reduce an individual patient’s health status to the single numeric score the FI-CGA generates. For example, two different patients may have the same frailty index, but one patient’s health deficits may be largely modifiable while the other’s are not.
Moreover, having a single cutoff without nuanced interpretation may advance “frailism”—biased treatment of patients considered frail by the FI-CGA. Frailty assessment and management are related but distinct concepts, and geriatricians must guide appropriate use of the FI-CGA.