Compare Identification / risk thresholds (eFI, clinical tools) for Frailty across NICE, RCP, and BGS. Built for Older adults. Setting: Primary & Secondary. Urgency: Routine.
Clear thresholds help clinicians answer "when do I act?" for frailty, aligning expectations between NICE, RCP, and BGS. Use this side-by-side view to decide when to refer, escalate, monitor, or initiate treatment.
Frailty affects approximately 10% of the UK population aged 65+ and 25-50% of those aged 85+, representing a significant clinical challenge in ageing populations. The core difficulty lies in distinguishing normal ageing from pathological frailty and determining when routine monitoring should transition to active intervention.
Missed frailty identification can lead to delayed comprehensive geriatric assessment, inappropriate acute admissions, accelerated functional decline, and increased mortality. Conversely, over-identification may cause unnecessary anxiety and healthcare utilisation.
NICE adopts a population health approach with systematic screening, the Royal College of Physicians (RCP) emphasizes hospital-based identification with acute presentation triggers, while the British Geriatrics Society (BGS) provides specialist-level guidance focusing on comprehensive assessment thresholds. Understanding these philosophical differences helps clinicians select the most appropriate identification strategy for their practice setting.
| Guideline body | Primary focus | Typical setting | Publication/update |
|---|---|---|---|
| NICE | Population screening and primary prevention | Primary care, community services | 2023 (NG) |
| RCP | Acute care identification and rapid assessment | Secondary care, emergency departments | 2024 (clinical guidelines) |
| BGS | Specialist assessment and management | Geriatric medicine services, MDT settings | 2025 (position statement) |
Primary care teams should default to NICE guidance for routine screening, while hospital clinicians should prioritise RCP recommendations for acutely unwell older adults. BGS guidance becomes essential when considering referral to specialist geriatric services or managing complex multifactorial frailty. Cross-referencing between guidelines is recommended when patients transition between care settings.
| Guideline body | Position | Population & urgency |
|---|---|---|
| NICE | Position on Identification / risk thresholds (eFI, clinical tools) for Frailty | Older adults | Urgency: Routine | Setting: Primary & Secondary |
| RCP | Position on Identification / risk thresholds (eFI, clinical tools) for Frailty | Older adults | Urgency: Routine | Setting: Primary & Secondary |
| BGS | Position on Identification / risk thresholds (eFI, clinical tools) for Frailty | Older adults | Urgency: Routine | Setting: Primary & Secondary |
| Threshold measure | NICE | RCP | BGS | Notes |
|---|---|---|---|---|
| Electronic Frailty Index (eFI) | ≥0.12 (mild), ≥0.24 (moderate), ≥0.36 (severe) | ≥0.16 suggests frailty in acute setting | ≥0.25 indicates need for CGA | eFI calculated from 36 deficits in primary care records |
| Clinical Frailty Scale (CFS) | ≥5 indicates frailty | ≥5 in hospitalised patients | ≥6 warrants specialist referral | CFS ranges from 1 (very fit) to 9 (terminally ill) |
| PRISMA-7 score | ≥3 suggests frailty | Not routinely recommended | ≥3 in community screening | 7-item questionnaire for primary care |
| Gait speed | <0.8 m/s suggests frailty | <0.6 m/s in acute setting | <0.6 m/s indicates significant impairment | 4-metre walk test standard |
NICE recommends systematic frailty identification for all patients aged 65+ through:
RCP focuses on acute presentation triggers and rapid assessment:
BGS provides specialist-level monitoring intervals:
| Trigger scenario | NICE action | RCP action | BGS action |
|---|---|---|---|
| Rapid functional decline (≥2 points CFS in 3 months) | Urgent GP review within 1 week | Same-day acute geriatric opinion | Immediate CGA referral |
| Recurrent falls (≥2 in 6 months) | Falls service referral | Inpatient falls assessment | Specialist falls and frailty clinic |
| Carer breakdown/imminent | Social services assessment | Crisis response team activation | Urgent multidisciplinary meeting |
| Medication concerns (≥10 medications) | Medication review | Clinical pharmacist input | Geriatric pharmacotherapy assessment |
| Nutritional decline (unintentional weight loss >5%) | Dietitian referral | Nutritional support team | Comprehensive nutritional assessment |
| Cognitive concerns with frailty | Memory assessment service | Delirium screening and management | Joint cognitive-frailty assessment |
Presentation: 78-year-old woman with hypertension, osteoarthritis, and mild cognitive impairment. Lives alone, manages independently but reports "slowing down." eFI score 0.18, CFS 4.
Analysis: NICE would classify as mild frailty with 6-monthly review. RCP would not trigger acute assessment. BGS would recommend watchful waiting with community support. Most appropriate action: implement NICE mild frailty pathway with community occupational therapy referral and safety checks.
Presentation: 85-year-old man admitted with UTI, known moderate frailty (eFI 0.28, CFS 6). Daughter reports significant functional decline over 2 weeks.
Analysis: NICE recommends GP follow-up post-discharge. RCP mandates inpatient CGA within 72 hours. BGS suggests specialist geriatric input during admission. Action: Prioritise RCP pathway with immediate CGA, then arrange BGS-recommended specialist follow-up.
Presentation: 82-year-old with heart failure, COPD, diabetes, and osteoporosis. Recent fall with fracture, CFS 7, carer strain increasing.
Analysis: NICE recommends falls service and social care assessment. RCP focuses on acute medical management. BGS emphasises comprehensive geriatric assessment. Action: Implement BGS pathway with urgent multidisciplinary assessment addressing medical, functional, and social domains simultaneously.
Several validated tools support frailty identification threshold decisions:
Electronic Frailty Index (eFI): Automatically calculated from primary care records using 36 deficits. NICE recommends its use for population stratification, with scores ≥0.12 triggering frailty pathways. The tool provides reproducible, objective data but requires electronic record implementation.
Clinical Frailty Scale (CFS): Rapid bedside assessment using clinical judgement. All three bodies endorse CFS, particularly valuable in acute settings where electronic data may be unavailable. Training improves inter-rater reliability.
PRISMA-7: Seven-item questionnaire suitable for community screening. NICE and BGS recommend for patients without comprehensive electronic records. Quick to administer but relies on patient self-report.
Interpretation guidance: Use eFI for systematic screening, CFS for rapid clinical assessment, and PRISMA-7 when electronic data is limited. Always corroborate tool results with clinical judgement, particularly in borderline cases.
Refer to the full guidelines for exact wording and local adaptations. This summary is for rapid orientation and multidisciplinary alignment.
This comparison is intended for clinical decision support and education. Always refer to the full published guidelines for definitive recommendations and the most up-to-date evidence. Clinical decisions should be individualized based on patient context and preferences.