About Frailty
According to the Canadian Frailty Network, frailty is defined as a state of increased vulnerability, with reduced physical reserve and loss of function across multiple body systems. It predicts death, heightened vulnerability, institutionalization, and a reduced quality of life.
Older adults living with frailty:
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are more susceptible to large declines in health from minor illnesses such as the flu or adverse events like falls
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are more likely to be hospitalized, need long term care or die.
Click here to learn more about frailty and steps to AVOID it.
The Ontario Collaborative for Aging Well recommends that concepts such as complexity and frailty must include the physical, cognitive, mental, and social health of older adults and their care partners and the interaction and integration of these domains.
Considered this way, an older adult may simultaneously demonstrate some or all of the following:
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a change or reduction in function, or a decline following a relatively minor illness (physical);
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changes in thinking or memory that may also impact function (cognition);
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changes in mood (e.g., depression) or psychological well-being (mental health); and/or
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a limited or inconsistent support network, loneliness and social isolation, housing precarity, or food insecurity among other concerns, as well as the impacts of structural ageism, institutional racism and other forms of discrimination (social health).
Read more: Consensus Statement
Physical
Cognitive
Mental
Social
Considering that frailty is a dynamic condition, an individual’s frailty status may range from ‘No Frailty’ to ‘Terminal Illness’. Frailty status should be considered when developing care plans, as advanced frailty may impact the achievement of desired goals and outcomes.
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*Informed by evidence from various sources including Kojima et al Aging Research Reviews 2019, Geriatric Medicine Research Dalhousie University, and the NHS England National Frailty Approach.
To facilitate planning for health services for older adults living with complex and chronic health concerns, Provincial Geriatrics Leadership Ontario (PGLO) has updated the estimates of prevalence of frailty by census division, and projected these estimates to 2040. These estimates will provide a better understanding of the need for services that can respond to the specific requirements of older persons, and may be used in connection with data from PGLO’s Specialized Geriatric Services Asset Inventory.
Link to Excel workbook:
An Impact Summary of Frailty Pathways
Seniors Care Network’s Frailty Pathways are driving meaningful change in how care for older adults living with frailty is delivered. What began as a regional innovation has grown into a model that has been adopted across Ontario in Ontario Health Teams, specialized geriatric services, community support services, and emergency departments.
Our pathways are helping organizations strengthen coordination and create a more consistent approach to frailty care. Growing adoption and recognition at regional, provincial, and international forums reflects the momentum behind this innovative model. Explore the reach and impact of our Frailty Pathways through our Impact Summary.
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Frailty Management Resources
Frailty Screening and Management in the Emergency Department
The Guidance Document is intended to support the implementation of proactive frailty screening and management in hospital Emergency Departments (EDs), a strategy to prevent repeat/prolonged hospitalizations and ALC rates. It outlines how an older adult’s (65 plus) Frailty Status can be used as a criterion to inform decisions regarding care, flow, and transitions (i.e., from the ED to back in the community and/or acute care). The 4-step approach described in the document builds on recommendations made in the ALC Leading Practices and Ontario Health Operational Direction: Home First documents. This resource was developed through extensive consultations with colleagues across the Province, and includes key implementation considerations (with relevant metrics) to track changes.
An accompanying document titled Customizable Templates for Frailty Screening and Management in the Emergency Department has been developed to help providers tailor the recommended practices in accordance with their preferences and service & program availability in their local area/region.
Holistic Approaches to Frailty Screening and Management in Primary Care
Primary care providers can play a significant role in the early identification and management of frailty. In collaboration with Ontario Collaborative for Aging Well, Seniors Care Network has developed the following guidance document to support primary care providers with implementing standardized approaches to frailty screening and prevention (also referred to as frailty pathways) at their practices.
An accompanying document titled ‘Customizable Templates for Frailty Screening and Management in Primary Care’ has been developed to help providers tailor the recommended practices in accordance to their preferences and service & program availability in their local area/region.
Holistic Approaches to Frailty Screening and Management in Community
In collaboration with Ontario Collaborative for Aging Well, Seniors Care Network has developed the following guidance document to support community providers with implementing standardized approaches to frailty screening and prevention (also referred to as frailty pathways). This work also supports the design of regional approaches to frailty care for Ontario Health Teams, while allowing for local variation to reflect available resources and services.
An accompanying document titled Customizable Templates for Frailty Screening and Management in the Community has been developed to help providers tailor the recommended practices in accordance to their preferences and service & program availability in their local area/region.
Integrating Frailty into Chronic Disease Management: Enhancing Care for Older Adults living with Complexity
Unrecognized or unmanaged frailty can impact the achievement of desired outcomes for individuals living with chronic conditions such as Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Diabetes Mellitus (DM), etc.
The Guidance Document details a practical, 4-step approach for integrating frailty-informed care into Chronic Disease Management for older adults. Frailty is a dynamic condition that influences clinical outcomes, self-management capacity, and risk of harm. Identifying and addressing frailty early allows primary care providers and specialty care teams to tailor care plans, mobilize appropriate supports, and improve quality of life.
Holistic Approaches to Frailty Screening and Management in Community Paramedicine
Community paramedics are uniquely positioned to support coordinated care through early frailty identification, risk stratification, targeted interventions, and proactive service connections. The decision-tree outlines an innovative Community Paramedicine Frailty Pathway that uses a standardized, stepwise approach to integrate frailty into chronic disease management and ongoing patient monitoring. By facilitating timely referrals to Specialized Geriatric Services, rehabilitation programs, community supports, and other healthcare resources, the pathway promotes proactive frailty management. This approach can improve patient outcomes, reduce avoidable emergency department utilization, and help delay or prevent permanent institutionalization, supporting older adults to remain safely and independently in their communities for longer.
