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ABSTRACT
The key idea behind the Clinical Frailty Scale (CFS) is that,
as people age, they are more likely to have things wrong with
them. Those things they have wrong (health decits) can,
as they accumulate, erode their ability to do the high order
functions which dene their overall health. These high order
functions include being able to: think and do as they please;
look after themselves; interact with other people; and move
about without falling. The Clinical Frailty Scale brings that
information together in one place. This paper is a guide for
people new to the Clinical Frailty Scale. It also introduces an
updated version (CFS version 2.0), with revised level names
(e.g., “vulnerable” becomes “living with very mild frailty”)
and minor edits to level descriptions. The key points discussed
are that the Clinical Frailty Scale assays the baseline state, it
is not widely validated in younger people or those with stable
single-system disabilities, and it requires clinical judgement.
The Clinical Frailty Scale is now commonly used as a triage
tool to make important clinical decisions such as allocating
scarce health care resources for COVID-19 management;
therefore, it is important that the scale is used appropriately.
Key words: frailty, Clinical Frailty Scale, ageing
Why This Paper?
This short paper is meant to be a guide for people new to
the Clinical Frailty Scale. It should be seen as supplement-
ing, not competing with, the many useful guides that have
become available, especially in the setting of the COVID-19
pandemic. This work builds on existing resources about how
to use the scale. Here we will discuss what frailty is, how the
Clinical Frailty Scale arose, how it works now, and what can
be done to check on its reliability and usefulness (both sit
within the traditional notion of validity). We will introduce an
updated version (CFS version 2.0) with revised level names
and minor edits to level descriptions (Figure 1). We will also
suggest some steps that may be helpful to those who wish to
use frailty for assessment rather than for screening. These are
meant to complement, not replace, their individual disciplin-
ary approach. Finally, we will reect on what we have learned
about using the Clinical Frailty Scale over the years, and on
the frailty discourse that began long before the Scale was de-
veloped. Most is grounded in evidence; that which is specula-
tive we hope will be useful, if only for hypothesis generation.
The Clinical Frailty Scale is being used in many settings
to help guide decisions that are based on the degree of frailty.
That is neither rare nor, on its own, undesirable. Care plans
should vary by the degree of frailty—for example, by the
ability to climb stairs before being discharged, or to under-
take (versus be assisted with) personal care. The COVID-19
pandemic brings with it an uncomfortable difference. With
these assessments now come decisions about offering—or not
offering—resources that are, or may become scarce, such as
intubation or agents that increase blood pressure in someone
in shock. Although rationing is not part of ordinary care, it is
inevitable; if done properly, it can be made acceptable at the
system level in the setting of a public health emergency.(1)
That being the case, many people less than familiar with
the notion of frailty are now being called upon to conduct frailty
assessments. This is challenging because the evaluation of
people who are frail requires not only cognitive skills, but also
the affective and attitudinal ones needed to work with people
who have multiple, interacting medical and social problems.(2)
What Is Frailty?
Frailty is a state of increased risk.(3) Inasmuch as most health
risks increase with age, a handy way to think about frailty is
that it is a risk compared with others of the same age.* Like
the risk of dying, on average frailty increases with age. People
are frail when they have more things wrong with them than do
Using the Clinical Frailty Scale in Allocating
Scarce Health Care Resources
Kenneth Rockwood, MD1, Olga Theou, PhD1,2
1Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Dalhousie University;
2School of Physiotherapy, Faculty of Health, Dalhousie University, Halifax, NS
https://doi.org/10.5770/cgj.23.463
COMMENTARIES
© 2020 Author (s). Published by the Ca nadia n Ger iat rics So ciety. This i s an Op en Acces s ar ticle dis trib uted u nder th e ter ms of the C reat ive Commons At tr ibution No n-Com mer cial
No-De rivative lic ense (http://creativecommons.org/licenses/by-nc-nd/2.5/ca/), which perm its unrest ricted non -commerc ial use and di stribution, provid ed the origi nal work is prop erly cited.
*This conforms to the statistical notion of frailty as variability in
risk compared with others with the same degree of exposure. The
scale is built on the idea of age-related decit accumulation. People
of the same age are at greater risk in virtue of having more health
decits than do others of the same age. The Clinical Frailty Scale
maps the consequences of this that precede death: decrements in
high order functions.
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others of the same age. Although that might not seem like a
big deal, it is a real challenge for how we deliver health care.
Medicine’s tremendous success in treating people one illness
at a time leads to the belief that is how people should get sick.
As our population ages though, because frailty and age travel
together, many of our patients have many things wrong at
the same time. That is the challenge we face: their chance of
having more things wrong with them increases as they age.
As these health decits accumulate, they have clinical
consequences, including in how diseases present, how often
more than one illness is active at a time, how people are able
to tell us about their symptoms or cooperate with our exams,
how drugs work, and how likely it is that we can succeed
similar to when treating people who have just a single pre-
dominant illness. By understanding frailty and changing what
we offer to meet the needs of people who live with it, we can
face that challenge. The Clinical Frailty Scale, developed in
Halifax, Nova Scotia in the 1990s, considers the things that
most often go wrong as age-related health decits accumulate.
(4) It robustly predicts adverse health outcomes in a variety of
settings, including acute care.(5)
What is the Clinical Frailty Scale?
The Clinical Frailty Scale is an inclusive 9-point scale that was
originally developed to summarize the overall level of tness
or frailty of an older adult after they had been evaluated by
a health care professional. The scale is scored so that higher
scores mean greater risk. It is not a questionnaire. Grading
the degree of frailty requires clinical judgement that is based
in part on screening criteria, and which then considers what
broadly straties degrees of tness and frailty. The scale fo-
cuses on items that can be readily observed without specialist
training, including mobility, balance, use of walking aids,
and the abilities to eat, dress, shop, cook, and bank. For this
reason, scoring should match the description, and should not
be based solely on the pictures that accompany each level.
The key to scoring the Clinical Frailty Scale is to de-
termine the person’s baseline health state. This is especially
needed in clinical settings where health can change quickly.
For example, many older patients in the Emergency Depart-
ment who were t two weeks ago (their baseline state), may
appear to be frail while ill; a prospect that becomes more
likely the longer they wait there. Still, as discussed below,
FIGURE 1. The Clinical Frailty Scale (CFS) version 2.0
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their prognosis requires information about both their baseline
degree of frailty, and the severity of their acute illness.
In ordinary time (i.e., with no pandemic), the Clinical
Frailty Scale is used both in prognosis and to set care goals. In
geriatric medicine, goals of care extend much beyond the often
desultory exercise of “getting the code status”. Usually much
more relevant is understanding the baseline state and current
decrements from it, which raise questions such as: “Does the
patient have the manual dexterity to handle the mechanics of
toileting? Do they need to climb stairs to get home?” If not,
and depending on the capacity of whomever (if anyone) might
be able to help them at discharge, goals of care need to be set
in these domains. This information also facilitates prognosis:
the greater the decline from the baseline state, the more energy
it will take to recover. Given that intensity of effort may be
limited by illness, this energy is often expressed as a function
of time to recovery. Recovery time can be monitored from
the start. It appears that the rst 48 hours of hospitalization
(preliminary data from Dr. Samuel D. Searle at our centre
suggest up to 4 days in ICU patients) is information rich.(6)
Those who improve in how they move in bed do well; those
who show decline fare especially poorly. In consequence,
even recognizing the interplay between baseline frailty and
severity of illness, many patients are well served by a trial
of therapies. This provides a way to avoid the common, but
false, dichotomy between “letting your father die” and “doing
everything we can”.
In a pandemic, these nuances may be less relevant when
an older person has become ill enough that admission to the
intensive care unit is being considered. Critical illness car-
ries a clear age-related burden; in Italy, of the initial 18,366
COVID-19 deaths, 83% were aged 70 years and older.(7) As in
ordinary time, the stratication of risk must also consider the
severity of illness.(8,9) In critically ill people with COVID-19,
this appears to be substantial for adults aged 65+ years—the
risk of death is more than 50% after 28 days.(10)
It is important to understand which older adults who are
critically ill with COVID-19 disease might withstand both
the illness and its treatment in an Intensive Care Unit. Inter-
national responses vary, but seem to settle around a Clinical
Frailty Scale score of 5(11) to 6(12) or higher being excluded
from ICU admission.
Before reviewing how the scale is used, it is crucial
to make a key additional point. The Clinical Frailty Scale,
developed to study frailty in older adults, has largely not
been validated in younger people. That is important because
disability in younger people (including both acquired, as in
spinal cord injury, and life-long, as in intellectual disability)
does not have the same meaning for prognosis that it does
with age-related disability. Understanding both this point and
that the Clinical Frailty Scale is a judgement-based measure†
of the baseline state, we can proceed.
The scale can be introduced by saying something like:
“I’d like to know how you are [your parent is] doing overall.”
We then ask about four features: how the person moved,
functioned, thought, and felt about their health over the last
two weeks. We can ask about which medications the person
uses; experienced clinicians can quickly assay which illnesses
are likely present from what medications are being prescribed
and/or used. We also ask about how active the person is.
Using the Clinical Frailty Scale to Grade Degrees
of Fitness Prior to the Level of Risk Associated
with Frailty
How a person moves, functions, and think helps to delineate
the rst three levels of the scale. For example, consider a
patient who is not impaired in any instrumental or personal
activity of daily living (ADL), who is able to move read-
ily, and who is taking an angio-converting enzyme (ACE)
inhibitor. If that person is taking the ACE inhibitor for treat-
ment of hypertension and exercises or engages in vigorous
activity daily, their score would be Level 1– Very Fit. The
same prole, with regular but less frequent or less vigorous
physical activity would be scored as Level 2 – Fit (previously
“Well”). Another person who ts the broad description and
who is using the ACE inhibitor as part of post myocardial
infarction management, but whose ischemic heart disease has
been otherwise asymptomatic, would also be scored based
on their degree of physical activity. If their symptoms were
mostly controlled, but not entirely so, they would be scored
as Level 3 – Managing Well. Likewise, a person on an ACE
inhibitor as part of symptomatic management of congestive
heart failure would be scored as Level 3 – Managing Well,
as long as their symptoms did not limit activities, in which
case they would be scored as Level 4 – Living with Very Mild
Frailty (previously “Vulnerable”).
Using the Clinical Frailty Scale to Grade Clinically
Meaningfully Increased Risk
For Levels 4 to 7, mobility, function, and cognition are key
factors. Each reects high-order aspects of health: they inte-
grate a lot of information. This means that there are many ways
to have mobility problems, for example: a sprained ankle,
diabetic nerve damage, dehydration, heart failure, kidney
damage or pneumonia. In consequence, these key domains
are sensitive signs of health, but are not very specic. It is
the combination of impaired function and impaired mobility,
which are commonly accompanied by several illnesses, that
make it likely someone is frail.
Level 4 – previously “Vulnerable” is now Living with
Very Mild Frailty, reecting recent research with the Can-
adian Longitudinal Study of Aging that captures the increased
risk with the corresponding degree of decit accumulation.(13)
People with many chronic conditions often report incomplete
symptom control, and of feeling “slowed up” or tired. A similar
complaint is that their health stands in the way of doing as they
wish, or that what they had done easily is now accomplished
only with great effort. Otherwise, Level 4 is characterized by
†Like many skills in clinical medicine, judgement should increase
with time. Particularly at the start, if how to classify the person is
not clear, ask a colleague whose judgement you trust.
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the person who, although not completely dependent in perform-
ing daily activities, seems at risk of at least mild dependence.
Identiable characteristics of this risk include incomplete
symptom control and a reduction in demanding activities.
Problems with heavy housework, lifting (e.g., difculty taking
out the trash) or climbing more than a ight of stairs are useful
signs. Although these activities might still be attempted, often
they are not done as well or as often. When asked, “compared
to others of your own age, how would you rate your health?”,
many at this stage will no longer rate their health as “excellent”
or even “good”, but rather as “fair” or “poor”.
Levels 5 to 7 relate to changes in function. Varying
degrees of dependence in instrumental ADLs dene Level
5 – Living with Mild Frailty (previously “Mildly Frail”). At
this level, typically, there is no more pretense of doing heavy
housework or the like—items that began to be impaired in
Level 4. A person does not need to be dependent in all de-
manding activities to qualify as Level 4, nor in all aspects of
instrumental ADLs to qualify as Level 5. We are interested in
change; someone who never did the banking would not now
be scored as dependent in that.
With Level 6 – Living with Moderate Frailty (previ-
ously “Moderately Frail”), dependence now extends past
instrumental ADLs to intermediate ones, notably including
dependence in bathing. Often at this level minimal assistance
with personal care might be needed. Moderate dementia is the
case when people who are dependent in their performance of
instrumental ADLs can still do their basic or personal ADLs
with prompting. This can also be the case in people who are
cognitively intact, but whose disability obliges them to have
someone nearby (so-called “standby assistance” or “set-up”).
Again considering bathing, an example of moderate frailty
might be requiring someone to draw the bath when the dis-
abled person has difculty managing the taps, or assisting
with transferring in and out of the tub, or washing their hair.
Notably, a systematic review found that bathing disability is
a risk factor for greater disability in personal ADLs.(14)
Level 7 – Living with Severe Frailty (previously “Se-
verely Frail”) is characterized by progressive dependence in
personal ADLs. People need not be dependent in every aspect
of personal care to be scored as Level 7. When assessing
functional dependence in intermediate (Level 6) and personal
(Level 7) ADLs, lifelong habit is a less relevant consideration;
most everyone needs to bathe, groom, and use the toilet. Still,
people living with severe frailty can be mobile. Progressively
taking to bed—but not being largely bedfast—is the hallmark
of the progression of severe frailty.
Using the Clinical Frailty Scale in People Towards
the End of Life
The understanding of what happens at the end of life has
evolved in relation to its association with ageing. Older people
who are terminally ill are much more likely to receive formal
palliative care if they have a diagnosis of cancer than if they
have a disease with a recognized terminal phase, such as
dementia or heart failure.(15)
Level 8 – Living with Very Severe Frailty (previously
“Very Severely Frail”) is the not uncommon state in which
a frail person takes to bed, often for weeks, prior to dying.
This is either heralded by an identiable episode, such as an
infection, or the person just slips away, commonly after some
days of reduced oral intake. Very severely frail people who
die without a single apparent cause typically follow such a
trajectory, commonly without much pain or even distress,
often, with the exception of impaired bowel function.
Level 9 – Terminally Ill is notable for being the only
level in which the current state trumps the baseline state, in
that the terminally ill person might have been operating at
any frailty level at baseline. On the Clinical Frailty Scale
card, this person is pictured seated in a chair. This reects
the fact that many older adults who are dying with a single
system illness—notably cancer—have a reasonable level of
function until about the very end. That is why we portray the
situation in that way. Even so, if a terminally ill person was
completely dependent for personal care at baseline, they would
be scored as Level 8.
Final Hints About Scoring and Next Steps
Within each level of the Clinical Frailty Scale, individual
characteristics will vary. About 80% or more of people will
t the description offered for a given level. If they t two
categories equally well, in routine care it is best to score the
scale at the higher or more dependent level. Sometimes we
see people who are dependent in a single instrumental ADL
that arises in a specic circumstance (e.g., relying on someone
whom they trust to do banking duties due to the closure of a
nearby bank branch or difculty with the automated banking).
In that case, the determination will often rest on the extent
to which the person is aware of income and outow; being
aware of it and knowing that it remains a matter of import-
ance can sufce. We recognize that there is likely to be some
variability in judgement in these circumstances, especially in
the extent to which the rater or the person (or the informant)
feel comfortable discussing such matters. This is inherent in
a judgement-based measure and, in our view, a price worth
paying compared with attempting to automate scoring that can
specify all the variants its designers can imagine.
Scoring the Clinical Frailty Scale in People with
Cognitive Impairment
The degree of dementia generally corresponds to the degree
of frailty. That is, mild dementia would go with mild frailty.
In both cases, the person is independent in their personal or
basic ADLs, but dependent in one or more instrumental ADLs.
These accompany common symptoms of mild dementia:
being able to recall a recent event but forgetting its details,
repeating questions throughout the day, and no longer being
able to use routines or cues to aid in either not losing items
or nding them once lost.
In moderate dementia, recent memory is very im-
paired, even though they seemingly can remember their past
life events well. As with moderate frailty, they can do their
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personal care with prompting or set-up. In severe dementia,
as in severe frailty, people have progressive difculty in
performing personal ADLs and require increasing amounts
of hands-on assistance.
Using a Classication Tree to Improve the
Reliability of Scoring
As of Spring 2020, we are beginning a multi-centre, multi-
country study using a classication tree to assist with grading
the degree of frailty; clinical judgement is still required to score
the Clinical Frailty Scale. Our goal is to improve the reliability
of scoring the CFS using the classication tree. Inasmuch as
the reliability will be measured in relation to the score given
by an experienced rater, this is also a form of validity. We will
further test validity by the ability to predict several outcomes
in relation to COVID-19, including progression from mild to
severe frailty, critical illness, mortality, and health care use.
Summary
This is a brief account of key points in using the Clinical
Frailty Scale. It can be read in conjunction with two con-
temporary papers in the Canadian Geriatrics Society CME
Journal(16,17) and with a paper on the Pictorial Fit-Frail Scale.
(18) The latter can help to bridge between screening and assess-
ment measures, and can itself be summarized by the Clinical
Frailty Scale. Additional resources include “Top Tips to help
you use the Clinical Frailty Scale” developed by our group,(19)
a Clinical Frailty Scale App developed by the Acute Frailty
Network in the UK(20) (this may be a useful alternative to
the classication tree we are testing), a Clinical Frailty Scale
Training Module developed by the AIMS Research Group at
the Ottawa Hospital,(21) and a Clinical Frailty Scale Education
Tool developed by the Non-Consultant Hospital Doctors of
the Cork University Hospital.(22)
Our target audience is people who are new to the Clinical
Frailty Scale and those who may be teaching about its use.
We put this work in the context that it must be used carefully
and combined with clinical judgement.(23) It should not be
used in younger people in whom lifelong or single system
disability does not have the same prognostic value as does that
seen as a manifestation of wide-spread decit accumulation.
Even so, applied properly, the Clinical Frailty Scale seems
likely to be much preferable to age when decisions must be
made about allocating scarce resources.(17,24) An additional
point to underscore is this: grading the degree of frailty in the
context of COVID-19 is not the same as using it in ordinary
care in geriatric medicine. In geriatric medicine, the goal of
grading the degree of frailty is both to ease communication
through a shared language, and also as the foundation for a
care plan. The care plan needs to address the gap between
the current level of function, cognition, mobility, and social
relationships (especially with the primary carer) and how
those have changed with the acute illness (when present).
There the focus is on trying to restore the baseline state, or as
close to that as might be achieved. This is a crucial distinction,
and one that requires considerable skill to dene, negotiate,
evaluate, and adjust over the course of an inpatient stay. It
should not be confused with the more instrumental purpose
to which the Clinical Frailty Scale is now being put, which
is no substitute for a patient-centred care plan. Even so, we
hope that widespread use of the Clinical Frailty Scale can at
least introduce new users to the manifold benets that are
possible with such an approach.
We have emphasized key general points: assay the base-
line state, do not use it with younger people or those with
stable single-system disabilities, use judgement, and be pre-
pared to examine your judgement as experience grows. Sev-
eral specic points relating to each level of the scale are noted.
Finally, we draw to attention that this is an inclusive scale.
There is room on it for everyone—a reminder of the frailty
that we all face, if we are lucky enough to live a long life.
CONFLICT OF INTEREST DISCLOSURES
Kenneth Rockwood has asserted copyright of the Clinical
Frailty Scale through Dalhousie University. Use is free for
research, education, or not-for-prot care. (Users are asked
not to change it or charge for its use.) In addition to academic
and hospital appointments, he is President and Chief Sci-
ence Ofcer of DGI Clinical, which in the last ve years has
contracts with pharma and device manufacturers (Baxter,
Baxalta, Biogen, Shire, Hollister, Nutricia, Roche, Otsuka)
on individualized outcome measurement. In 2017 he attended
an advisory board meeting with Lundbeck. He is Associate
Director of the Canadian Consortium on Neurodegeneration
in Aging, which is funded by the Canadian Institutes of Health
Research (CAN-137794), with additional funding from the
Alzheimer Society of Canada and several other charities. He
receives research support through grants from the Canadian
Institutes of Health Research, the Canadian Frailty Network,
the Nova Scotia Health Research Foundation, the Nova Sco-
tia Health Authority Research Fund, the Dalhousie Medical
Research Fund as the Kathryn Allen Weldon Professor of
Alzheimer Research, and the Fountain Family Innovation
Fund of the QEII Health Science Centre Foundation.
Olga Theou declares that no conicts of interest exist.
REFERENCES
1. World Health Organization. Ethical considerations in developing
a public health response to pandemic inuenza. Geneva, Switzer-
land: WHO; 2007. https://www.who.int/csr/resources/publications/
WHO_CDS_EPR_GIP_2007_2c.pdf Accessed May 3 2020.
2. Rockwood K. Medical management of frailty: confessions of
a gnostic. CMAJ. 1997;157(8):1081–84.
3. Rockwood K, Howlett SE. Age-related decit accumulation and
the diseases of ageing. Mech Ageing Dev. 2019;180:107–16.
4. Rockwood K, Song X, MacKnight C, et al. A global clini-
cal measure of tness and frailty in elderly people. CMAJ.
2005;173(5):489–95.
5. Theou O, Squires E, Mallery K, et al. What do we know about
frailty in the acute care setting? A scoping review. BMC Geriatr.
2018;18(1):139.
ROCKWOOD & THEOU: ALLOCATING SCARCE HC RESOURCES
215
CANADIAN GERIATRICS JOURNAL, VOLUME 23, ISSUE 3, SEPTEMBER 2020
6. Hatheway OL, Mitnitski A, Rockwood K. Frailty affects the
initial treatment response and time to recovery of mobility in
acutely ill older adults admitted to hospital. Age Ageing. 2017;
46(6):920–25.
7. Boccardi V, Ruggiero C, Mecocci P. COVID-19: a geriatric
emergency. Geriatrics. (Basel). 2020;5(2):E24.
8. Romero-Ortuno R, Wallis S, Biram R, et al. Clinical frailty
adds to acute illness severity in predicting mortality in hospi-
talized older adults: an observational study. Eur J Intern Med.
2016;35:24–34.
9. Pulok M, Theou O, van der valk A, et al. The role of illness
acuity on the association between frailty and mortality in Emer-
gency Department patients referred to internal medicine. Age
Ageing 2020 May 11:afaa089. Published online ahead of print.
Correction in Age Ageing 2020 Jul 24:afaa153. Published online
ahead of print.
10. Bhatraju PK, Ghassemieh BJ, Nichols M, et al. Covid-19 in
critically ill patients in the Seattle region—case series. N Engl
J Med. 2020;NEJMoa2004500. Published online ahead of print,
2020 Mar 30.
11. National Institute for Health and Care Excellence. COVID-19 rap-
id guidelines: critical acre in adults (update 27 March 2020). Lon-
don, UK: NICE; 2020. https://www.nice.org.uk/guidance/ng159/
resources/critical-care-admission-algorithm-pdf-8708948893
12. The Swiss Society of Emergency and Rescue Medicine.
COVID-19: Prehospital triage and care under resource scar-
city in the hospital sector. V2.0-EN / 06.04.2020. Geneva,
Switzerland: SSERM; 2020. https://www.sgnor.ch/leadmin/
user_upload/Dokumente/Algo_Covid_enV2c.pdf
13. Perez-Zepeda MU, Godin J, Armstrong JJ, et al. Frailty among
middle-aged and older Canadians: Population norms for the
Frailty Index using the Canadian Longitudinal Study on Aging.
and Ageing (in press).
14. Golding-Day M, Whitehead P, Radford K, et al. Interventions
to reduce dependency in bathing in community dwelling older
adults: a systematic review. Syst Rev. 2017;6(1):198.
15. Hill AD, Stukel TA, Fu L, et al. Trends in site of death and
health care utilization at the end of life: a population-based
cohort study. CMAJ Open. 2019;7(2):E306–E315.
16. Varshney N. COVID-19 and ethical critical care triage—util-
izing this period to further knowledge translation of frailty and
ICU evidence during a pandemic and beyond. Can Geriatr Soc
CME J. 2020;10(1). Available from: https://canadiangeriatrics.
ca/wp-content/uploads/2020/05/Varshney_Covid19-Formatted_
FINAL-1.pdf
17. Rockwood K, Dykes L. Communicating an ethical basis for
decision-making in relation to frailty and allocation of scarce
resources in the COVID-19 pandemic. Can Geriatr Soc CME J.
2020;10(1). https://canadiangeriatrics.ca/wp-content/uploads/
2020/05/Communicating-an-Ethical-Basis-for-Decision-Making
-COVID-19.pdf
18. Theou O, Andrew M, Ahip SS, et al. The Pictorial Fit-Frail
Scale: developing a visual scale to assess frailty. Can Geriatr
J. 2019;22;(2):64–74.
19. Rockwood K, Theou O, Fay S, et al. Top Tips to help you use
the Clinical Frailty Scale. Accessed on July 28, 2020. Available
from: www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale/
cfs-guidance.html
20. Acute Frailty Network. Clinical Frailty Scale App. Accessed
on July 28, 2020. Available from: www.acutefrailtynetwork.
org.uk/Clinical-Frailty-Scale/Clinical-Frailty-Scale-App
21. AIMS Research Group. Clinical Frailty Scale Training Module.
Accessed on July 28, 2020. Available from: https://rise.articulate.
com/share/deb4rT02lvONbq4AfcMNRUudcd6QMts3#/
22. Moloney E, Ahern E, O’Caoimh R. Clinical Frailty Scale
Education Tool. Accessed on July 28, 2020. Available
from: https://ucc.cloud.panopto.eu/Panopto/Pages/Viewer.
aspx?id=ce9a4d94-fc1c-44ca-8a39-ab9600f624f3
23. Hubbard RE, Maier AB, Hilmer SN, et al. Frailty in the face
of COVID-19. Age Ageing. 2020 Jul 1;49(4):499-500.
24. Montero-Odasso, Hogan DB, Lam R. et al. Age alone is not
adequate to determine health-care resource allocation during
the COVID-19 pandemic. Can Geriatr J. 2020;23:152–54.
Correspondence to: Kenneth Rockwood, MD, Suite 1421
Veterans Memorial Bldg., 5955 Veterans Memorial Lane,
Halifax, NS B3H 2E1
E-mail: kenneth.rockwood@dal.ca
