top of page
Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Proactive Care

Case finding and populating/maintaining a Frail/elderly register

Suggested methods for case finding and populating/maintaining a Frail/elderly register include the use of :

(Lyndon L, 2014).


1. Rockwood Clinical Frailty Scale  and Gait Speed Test


Use the Rockwood Clinical Frailty Scale at every consultation with patients aged 75 years and over (very quick to complete).

Consider doing this routinely where a nurse sees the patient in association with a GP consultation to obtain basic data or perform routine investigations.

Consider doing this routinely at appropriate clinics, e.g. flu/shingles vaccine clinics, chronic disease clinics.

Rockwood scores can also be completed in the community by community nurses/community matrons, etc. and fed back to the practice.

Add those who are Rockwood >5 to the frailty/elderly register register.

The Gait Speed Test can be used as an additional tool if there is difficulty establishing frailty.

Clinical Frailty Scale - Rockwood

Rockwood Clinical Frailty Scale

Frailty evaluation tool

5 min.


Gait Speed Test (4 metre)

Simple assessment of functional mobility

5 min.

2. Prinary Care Record


Use the primary care record to identify patients who may be considered for completion of the Rockwood Scale and the gait speed test using the following criteria:

  • Those >85yrs.

  • Those in care homes (all will have Rockwood >5).

  • Those >75yrs of age admitted or who attended ED in last 3-6 months, and are not currently acutely ill (Rockwood may not be accurate in an acute illness).

  • Those with an obvious frailty syndrome. These include:

    Falls (e.g. collapse, legs gave way, ‘found lying on floor’).

    Immobility (e.g. sudden change in mobility, ‘gone off legs’, ‘stuck in toilet’).

    Delirium (e.g. acute confusion, sudden worsening of confusion in someone with previous dementia or known memory loss).

    Incontinence (e.g. change in continence – new onset or worsening of urine or faecal incontinence). Susceptibility to side effects of medication.

  • Those housebound or known to community nurse

  • Those on dementia register.

  • Those on EOL register or cancer care lists.

  • Those on >7 medications.

  • Those with neurological conditions, e.g. stroke, MS, Parkinson’s Disease.

  • Those with rheumatological conditions.

  • Those known to Adult Social Care and Support Services.


    To confirm frailty on these cases identified via Rockwood, if the score is borderline 4 or 5, a PRISMA7 score could be sent to the patient to confirm.

    Gait speed can be used if there seems to be a mismatch between Rockwood and PRISMA.



Use PRISMA7 to develop a birthday card system.

The practice sends out the PRISMA7 questionnaire to all patients from 75 years and over every year.

The frailty screening questionnaire is completed by the patient/carer and then scored by the practice.

Those who score 3 or more should be brought into the practice for Rockwood and brief CGA if appropriate.


Program of Research to Integrate Services for the Maintenance of Autonomy - 7

Assessment of presence of frailty

5 min.

Proactive Care Team, CGA based Proactive Primary Care of the Elderly

This is one of four Read More sectors of the

Proactive Care chapter of this toolkit

Back To : Proactive Care

bottom of page