Healthy Ageing & Frailty

Healthy Ageing & Frailty

What is Frailty?

Frailty is a common syndrome that occurs from a combination of de-conditioning and acute illness on a background of existing functional decline that is often under recognised.

Frailty can affect up to 25% people aged 70 and over this equated to approximately 26,000 people residing in Northern Sydney.

People with frailty have 2 to 3 times the health care utilisation of their non-frail counterparts and experience higher morbidity, mortality as well as lower quality of life.

Frailty can increase functional  decline, increase the risk of falls, contribute to longer length of hospital stay and increased chance of institutionalisation.

Many of the causes of frailty can be managed and, in some cases reversed to create better health outcomes and quality of life. It is  therefore important to identify older people who are living with frailty.

How to Identify Frailty

Not all older people are frail and not all people living with frailty are old. However, it is important to identify frailty early in order to combat the condition and it effects. Current health guidelines suggest that people over the age of 70 should be screened routinely.

The use of a validated screening tool will ensure accuracy, reliably and consistency of identification of frailty. In Northern Sydney we recommend the use of the  “The FRAIL Scale” to identify a level of frailty.

The Frail Scale

A score of 1 to 2 indicates pre-frailty and a score of 3 or more indicates frailty.

Frailty is more common in females and the risk of frailty increases with age.

How to Manage Frailty

Early intervention can allow people to stay active and healthy longer, keeping them in their homes and out of hospital.

Correctly managing frailty can significantly improve a persons function and quality of life. It can also provide a better chance of recovery from acute illness as it reduces susceptibility to  negative health outcomes.

Once you have assessed a persons level of frailty a (pre-frail or frail,) it is important to develop a management plan that addresses the corresponding sections of the frail scale.

This targeted approach can include:

  • Referral to appropriate allied health professional such as a physiotherapist or dietitian
  • Exercise classes
  • Reviewing medications
  • Managing weight loss

The decision support tool below provides more detail and some guidance for best course of action.

Frailty Management and Decision Support

Things to consider when implementing the Frail scale

Clinical Resources

The Best Practice and Medical Director templates

The Best Practice and Medical Director templates (.rtf files) can be imported to your software. These templates should not be opened and viewed before importing them. You will need to right click, copy and save or drag the .rtf file onto your desktop. Refer to the instructions below.

Frail Scale Templates for Medical Director

  • Directions on how to upload templates Read Instructions.
  • Frail Scale for Medical Director (MD). To download, please Right Click and save link (clicking directly on this link will load the BP file into your web browser instead).
  • 75+ assessment that includes Frail scale (MD). To download, please Right Click and save link (clicking directly on this link will load the BP file into your web browser instead).

Frail Scale Templates for Best Practice

  • Directions on how to upload templates Read Instructions.
  • Frail Scale for Best Practice (BP). To download, please Right Click and save link (clicking directly on this link will load the BP file into your web browser instead).
  • 75+ assessment that includes Frail scale (BP). To download, please Right Click and save link (clicking directly on this link will load the BP file into your web browser instead).

Other Resources

  • Online PARC frailty screen Click Here
  • Suggested Management tool to accompany Frail Scale Click Here
  • HealthPathways – Frailty Pathway Click Here
  • Northern Sydney Frailty Initiative – Healthy Ageing and Frailty clinician brochure Open Brochure
  • When Seniors Say No brochure Open Brochure
  • Basic Steps (falls prevention program) resources order form Open form
  • Steeping On referral form Open Form

Evidence to Support Frail Scale: 

  • Asia Pacific Clinical Practice Guidelines for the Management of frailty Read Guidelines
  • Nutritional Interventions in Sarcopenia Read Article
  • Effects of physical exercise interventions in frail older adults Read Article
  • The Effectiveness of Exercise Interventions for the Management of Frailty: A Systematic Review Read Article
  • Interventions for Treating Sarcopenia: A Systematic Review and Meta-Analysis of Randomized Controlled Studies Read Article
  • Inappropriateness of Medication Prescriptions to Elderly Patients in the Primary Care Setting Read Article
  • Beliefs and attitudes of older adults and carers about deprescribing of medications Read Article


Please find the following links and searches to help you find the most appropriate service for your patients.

For detailed clinical referral , assessment and management information related to the Northern Sydney region please visit Sydney North HealthPathways site. Click on the logo below – note: log in details are required and if you do not already have these please email healthpathways@snhn.org.au and they will be sent directly to you.

HealthPathways logo

Log onto HealthPathways


To refer to a Geriatrician for a comprehensive geriatric assessment please use the following:

  • You can search for a Geriatrician via postcode on Healthshare Open Search
  • NSLHD Geriatrician referral
    • Hornsby Ku-Ring-Gai Hospital – Ph: (02) 9477 9514  / Fax:  (02) 9477 5684
    • Royal North Shore Hospital Campus – Ph: (02) 9462 9333 / Fax: (02) 9906 4301
    • Brookvale Community Centre – Ph: (02) 9998 6120 / Fax: (02) 9979 7876
    • Mona Vale Community Centre – Ph (02) 9998 6120 / Fax: (02) 9979 7876


Search for Allied Health Professionals in Sydney North

Please use this search tool for Allied Health providers in Northern Sydney listed with an interest in frailty as registered in the Primary Health Network, this includes pharmacists that can assist with polypharmacy review.


Frailty prevention exercise program options in NSW can be searched using the Active and Healthy website: Click Here

For patients requiring individual exercise prescription, a physiotherapist or exercise physiologist can assess gait and balance, design an individually-tailored program, provide one-on-one progressive exercises and recommend correct use of assistive devices.

  • Australian Physiotherapy Association: Find a physiotherapist (treatment: gerontology or musculoskeletal) Open Search
  • Exercise & Sports Science Australia: Find an exercise physiologist (specialty: older adult) Open Search
  • NSLHD outpatient Physiotherapy referral information can been seen here Click Here

For patients requiring dietary advice

  • Search via Dietitian Association Australia Open search
  • NSLHD outpatient Dietitian referrals (accepts GP referral) Open Form

For referral to home safety assessment and occupation therapy:

  • Search via Occupational Health Australia Open Search
  • NSLHD outpatients
    • Hornsby Ku-ring-gai Hospital Outpatients – Ph: (02) 9477 9493 
    • Northern Beaches Health Service –  Ph: (02) 9998 6100 
    • Royal North Shore Hospital – Ph: (02) 9462 9666
    • Ryde Hospital – Ph: (02) 9858 7888

Sydney Home Nursing Safe and Steady Program

Care coordination links to assist in conducting 75+ health assessments with patients, Regal Home Health – Ph: (02) 9264 4555 Click Here

My Aged Care portal Click Here

Patient Resources

Eating well booklet Open Booklet

Living Well brochure Open Brochure

Staying active booklet Open Booklet

Staying active website Click Here

Health coaching website (self referred NSW free health coach) Click Here

Stepping On brochure (falls prevention program) Open Brochure

My Aged Care brochure Open Brochure

Meals on wheels contact numbers:

  • Crows Nest –  Ph: (02) 9437 7517
  • Hornsby Ku-Ring Gai – Ph: (02) 9144 2044
  • Hunters Hill Ryde – Ph: (02) 9817 0101
  • Lane Cove –  Ph: (02) 9427 6425
  • Mosman –  Ph: (02) 9978 4130
  • Willoughby  – Ph: (02) 9777 7830
  • Manly –  Ph: (02) 9976 1469
  • Northern Beaches –  Ph: (02) 9970 8399

NSLHD Health Contact Centre  – Ph: 1300 732 503 (Mon-Fri: 7.30 am to 6.30pm)

NSLHD Carer support information website Click Here

  • Here are simple exercise videos to improve strength and balance that patients can do at home.

Sit to Stand

Side Leg Raises

  • Patients should include at least 10gm of protein with every meal – here are some examples

Stepping up a step

Knee Raises

News and Education

Education events – 10th & 11th December 2018

The Northern Sydney Frailty Initiative held two education event in December 2018.

The education event aimed to assist health professionals further understand the impact of frailty on patients and how early identification and targeted intervention can reduce frailty, avoid inappropriate hospital admissions, keep people well and at home for longer and reduce need for RACF and hospital admissions. It also demonstrated the use of the frail scale scaler and supporting management plans to address the reversible contributing factors of frailty in your day to day practice.

Presenters for the sessions included:

  • Professor Susan Kurrle

Professor of Health Care of Older People, Director, NHMRC Partnerships Centre on Cognitive Decline, Geriatrician Hornsby Ku-ring-gai Hospital

  • Dr Christopher Bollen – MBBS MBA FRACGP FACHSM MAICD

Dr Bollen has been practicing as a GP since 1990. He has a special interest in older people, and is a RACGP representative on Centre for Research Excellence in Frailty (Adelaide)

  • Jane Bollen RN

Jane works at Allenby Gardens Family Practice in Adelaide running a nurse led (team based care) “Healthy Ageing Clinic

You can read a copy of the presentation here Read Presentation

Frailty Articles 2018

An article has been written by Dr Chris Bollen for the Norther Sydney Frailty Initiative. It is article 1 of a 3 part series based on the concepts of frailty and better care for older people from a GP perspective.

You can read “Healthy Ageing in General Practice” Part 1 written by Dr Chris Bollen MBBS MBA FRACGP FACHSM MAICD here: Read Article