PART 3 OF 4: FRAILTY & DUTY TO PROTECT. It is useful to identify your elderly client as robust or frail. This article features one popular assessment method to help massage therapists make this determination, which includes five frailty assessments. The article also includes information about mandates that serve to protect certain populations, including the frail elderly.

Massage therapists need to identify elderly clients as robust or frail. Not every elderly individual will become frail, but the risk of frailty increases with age and is more common in older women than older men.


One approach to determining geriatric frailty is to use Fried’s Frailty Criteria, which includes five domains and combines both self-reported and performance-based measures (1). While this assessment method is intended for elderly populations, it is useful for clients who have chronic conditions.

  1. Slow walking speed
  2. Muscle weakness evidenced by weak handgrip and sarcopenia
  3. Self-reported exhaustion
  4. Low level of physical activity
  5. Underweight or unintentional weight loss

Clients who meet three or more frailty criteria are defined as “frail.” Clients who do not meet any of the frailty criteria are defined as “robust.”

  1. Slow walking speed – Pay attention to how fast or slow your client is walking. Frail elderly clients walk more slowly and may appear unstable or fearful while walking. Robust clients have a faster-paced walking speed and a steady gait.
  2. Muscle weakness evidenced by weak handgrip and sarcopenia – Ask your client to shake and squeeze your hand. Weak handgrip strength can indicate frailty, poor health, and increased dependency on others for activities of daily living. Robust clients have a strong handshake and good grip strength. Look at and palpate muscles of the lower extremities. Are they of adequate size and firm or small and flattened. The latter is a sign of sarcopenia or reduced muscle mass and muscle tone with accompanying loss of strength from age-related inactivity. Robust clients have good muscle tone and resultant muscle strength.
  3. Self-reported exhaustion – Ask your client about his or her energy level. Frail clients may say they are often tired, have low energy, are fatigued, or have no pep or get-up-and-go. They may look fatigued. Energy levels also may be determined by how clients describe their lifestyle during the intake. Frail clients will report spending much of their time at their residence. Robust clients may report participation in activities such as fishing or gardening or share stories about vacations taken recently or planned.
  4. Low level of physical activity – Ask your client about the types and amounts of physical activity in which he or she participates. A strong indicator of a client’s health is their level of physical activity and the client’s reports of routine tasks, such as caring for neighbors or family members. Low levels of physical activity are an indicator of frailty. Robust clients are typically physically active, which may include regular exercise. A strong indicator of a client’s health is their level of physical activity and the client’s reports of routine tasks, such as caring for neighbors or family members.
  5. Underweight or unintentional weight loss – Ask your client if he or she has experienced recent weight loss and if it was intentional through means of diet and/or exercise. Robust clients experience normal age-related weight loss of approximately a quarter to half pound per year beginning about age 65 to 70 resulting from changes in hormones regulating appetite and satiety and decreases in basal metabolic rates.


Massage and the Elderly: Robust elderly adults require few, if any, age-related massage modifications. If your client is frail, use techniques that are rhythmic, slow, gentle, and lighter in pressure. Frail elderly adults may require fewer changes. Please refer back to Geriatric Massage: Setting and Preparation as well as Positioning and Techniques for more information.

All states have mandates to protect certain population segments, including the elderly. These mandates require individuals to report suspected abuse or neglect, including self-neglect. Approximately 10% elderly population are abused (2) and women are more likely to abused than men (2). If a massage therapist suspects physical abuse through observations of bruises (especially bilateral bruising that might suggest grabbing), black eyes, welts, broken eye glasses, or marks that indicate restraint, report your observations to the supervisor if working in a spa or medical facility.

If the massage therapist is a sole practitioner, make the report to an agency such as the adult protection services or call an eldercare hotline (800-677-1116). The person at these service agencies will file the report or direct you to another agency. If someone is in immediate danger, call 911.

Picture Credits:

Articles and Journals Referenced:

  1. Fried LP, et al: Frailty in older adults: evidence for a phenotype, J Gerontol A Biol Sci Med Sci 56(3):146–156, 2001.
  2. National Committee for the Prevention of Elder Abuse: Retreived at

View More:

Dr. Susan Salvo is a massage therapist, author, educator, researcher, explorer, and perpetual student. To learn more, check out the “About Susan” tab. You can contact Susan at