FAST and FRAIL – how to know when less is more

These two measures help to determine whether you are healthy enough to benefit from surgery, or other risky interventions. Because of perverse incentives in our healthcare system, it is not uncommon for vulnerable people to be approved for and/or encouraged to have procedures that may be more harmful than helpful based on their functional status. Dementia and frailty predict adverse events, poor outcomes, and death. While many measures have been developed in these areas, these two are fairly simple and work well to quantify vulnerability.

The FAST scale rates a continuum of functional impairment due to dementia.

1 = no difficulties subjectively or objectively

2 = some forgetfulness or word-finding problems

3 = decreased job functioning, difficulty organizing complex tasks

4 = difficulty managing finances, planning common events

5 = requires assistance choosing appropriate clothing

6 = cannot get dressed without assistance, trouble with toileting, bathing

7 = speech limited, loses ability to walk and sit independently

People in stage 5 or higher (moderate to severe dementia) have a significant risk for adverse events and negative health outcomes.


The FRAIL scale assesses overall physiological reserve and resilience.

Fatigue (Are you fatigued?)

Resistance (Can you climb one flight of stairs?)

Ambulation (can you walk one block?)

Illnesses (greater than 5)

Loss of weight (greater than 5 %)

Three or more “yes” answers indicate frailty, and two or more “yes” answers suggest pre-frailty.


If you or your loved one meets criteria for frailty and/or moderate-severe dementia, it is crucial to work with your care team to identify goals of care and optimize quality of life. “Less is more” should be applied to any potential test, procedure or new medication. Heeding these indicators can mean the difference in dying in the hospital of a complication or injury vs. supportive symptom management with an objective to live well and die in your preferred setting.