How to use the Clinical Frailty Scale in Primary Care

Introduction

The Clinical Frailty Scale ranges from 1 being very fit to 9 being terminally ill. The description attached to each scale gives a good idea about how people would function, enabling you to assess them against this scale.

Asking if people use any support services can help you assess the middle range of frailty. If people are completely independent and managing well at home (i.e., scale 1-3), then go on to ask them about level of fitness or exercise which determines whether they are CFS 1, 2, or 3.

At the frailer end of the scale, these are people who are fully dependent on others. These are people who are severely frail and often in residential care, though many live at home with intensive family or carer support. (ANZHFR Training and Education, 2022)

In this article, we present our quality improvement project, a practical guide to assessing frailty using the Rookwood Clinical Frailty Scale and supporting clinical decision-making.

The Science Behind the Scale

The Clinical Frailty Scale (CFS) was developed by Rockwood et al. as part of the Canadian Study of Health and Aging. It provides a standardised way to summarise a patient’s overall level of fitness or frailty after clinical assessment.

Unlike other frailty measures that require specific tests or lengthy questionnaires, the CFS is designed to be completed quickly by clinicians based on their clinical judgement after evaluating a patient’s:

• Mobility and activity levels
• Independence in daily activities
• Level of support required from others

Research has consistently shown that the CFS is a strong predictor of adverse outcomes including mortality, hospitalisation, and institutionalisation. This makes it an invaluable tool for clinical decision-making, particularly in acute care settings and when planning treatment approaches.

The Nine Levels Explained

CFS 1-3: Fit to Managing Well

These individuals are independent and do not require help from others for daily activities.

CFS 4-5: Vulnerable to Mildly Frail

These individuals are slowing down and may need some help with activities.

• 4 – Vulnerable: Not dependent on others but symptoms limit activities. Often complain of being “slowed up” or tired.
• 5 – Mildly Frail: More evident slowing. Need help with high-order activities like shopping, walking outside alone, or managing finances.

CFS 6: Moderately Frail

These individuals need help with all outside activities and with keeping house.

• 6 – Moderately Frail: Need help with bathing, dressing, and stairs. May have problems with stairs and need minimal assistance with personal care.

CFS 7-9: Severely Frail to Terminally Ill

These individuals are completely dependent on others for personal care.

• 7 – Severely Frail: Completely dependent for personal care but stable and not at high risk of dying within 6 months.
• 8 – Very Severely Frail: Completely dependent, approaching the end of life. Could not recover from even a minor illness.
• 9 – Terminally Ill: Approaching end of life with a life expectancy of less than 6 months. Not otherwise evidently frail.

How Our Assessment Tool Works

Our digital tool and printable form follow a logical flowchart approach that mirrors clinical reasoning:

1. Terminal Illness Check

First, we identify patients who are terminally ill (CFS 9) regardless of their functional status.

2. Complete Dependency Assessment

Next, we identify those who are completely dependent on others for all personal care (CFS 7-8). This applies whether they live in care or at home with family.

3. Support Services

For those with some independence, we ask about help with daily activities (shopping, housework, medications). This helps identify the middle range (CFS 4-6).

4. Personal Care and Mobility

For those receiving help, we refine further by asking about personal care needs (bathing, dressing) and mobility limitations.

5. Fitness Assessment

For fully independent individuals, we assess their activity and fitness level to distinguish between CFS 1, 2, 3, and 4.

This branching logic ensures that clinicians can quickly navigate to the correct CFS level with just a few questions, making it practical for busy clinical settings.

The Printable Assessment Form

We’ve also created an A4 printable form that follows the same logic. This is designed for:

• Home visits where digital access may be limited
• Care home assessments
• Training purposes for staff
• Documentation in patient records

The form includes tick boxes for each decision point, clear routing instructions, and a reference table of all nine CFS descriptors.

Case Study: Using CFS to Guide Care Decisions

Patient Profile

Mrs. Margaret T., 84 years old, resident in a Care Home for 18 months. Referred by care home staff following a 2-day history of acute confusion (delirium) secondary to urinary tract infection.

Let’s walk through how the assessment tool guides the clinician to determine Mrs. T’s Clinical Frailty Scale level:

Step 1

Question: Is the patient terminally ill?

Life expectancy less than 6 months, not otherwise evidently frail

Answer: No – Mrs. T has no terminal diagnosis. Continue assessment.

Step 2

Question: Is the patient completely dependent for personal care?

Requires full assistance with all personal care from whatever cause – physical or cognitive

Answer: Yes – Care home staff assist with all washing, dressing, and toileting. Mrs. T has advanced dementia and cannot manage any personal care independently.

Step 3

Question: How stable is the patient?

Consider their overall health trajectory

Answer: Stable – Despite the current infection, Mrs. T’s baseline is stable. She has been in the care home for 18 months with a gradual decline but is not actively approaching end of life.

Result

Clinical Frailty Scale: 7 – Severely Frail

Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk (within 6 months) of dying.

Clinical Implications

With Mrs. T’s CFS level documented as 7 (Severely Frail), the clinical team can now make informed decisions about her care:

Decision: Community-Based Care

Given her CFS of 7, the team decides that hospital admission for the UTI would likely cause more harm than benefit. The unfamiliar environment would worsen her confusion, and she is at high risk of hospital-acquired complications. Instead, they arrange:

• Oral antibiotics administered by care home staff
• Increased fluids and monitoring
• Daily GP review for 3 days
• Clear escalation criteria for deterioration

Advance Care Planning

The CFS assessment also prompts a conversation with Mrs. T’s family about her overall prognosis and preferences for future care. A ReSPECT form is completed documenting that her preferred place of care is the care home, with a focus on comfort and quality of life rather than life-prolonging treatments.

This case illustrates how a quick CFS assessment can consolidate clinical decision-making, supporting a holistic approach that prioritises the patient’s wellbeing while providing a documented rationale for the care plan.

Conclusion

The Clinical Frailty Scale is a powerful tool for primary care. When used systematically, it helps clinicians:

• Identify frailty levels quickly and consistently
• Communicate effectively with colleagues about patient status
• Support evidence-based decisions about hospital admission
• Initiate appropriate advance care planning conversations

Our digital tool and printable form make this assessment accessible in any setting, ensuring that frailty can be assessed quickly and documented clearly – ultimately leading to better, more personalised care for our patients.

Try the Calculator

Use our Clinical Frailty Scale calculator for your next patient assessment. Go to Calculator.

Best wishes.

References

ANZHFR Training and Education (2022). Clinical Frailty Scale. [online] YouTube. Available at: https://www.youtube.com/watch?v=ao9M_A4sytQ [Accessed 2 Jan. 2026].