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Frailty
In a study of 5317 community-dwelling adults older than 65 years in the Cardiovascular Health Study, the overall prevalence of frailty was 6.9% and 4-year incidence was 7.2%. Frailty was more common in women than in men and increased with age. Frailty is distinct from disability in that it represents a multisystem decrease in physiological reserve and resilience against stressors.
Guiding Questions
What is the frailty phenotype?
What are the consequences of frailty in terms of morbidity and mortality?
How does one assess for frailty?
How can we work to prevent frailty?
Frailty Phenotype
The frailty phenotype, distinct from disability, is defined by the presence of three of the following symptoms:
unintentional weight loss
self-reported exhaustion
low physical activity
slow walking speed
weakness
The “FRAIL” mnemonic can be used as a screening test to identify frail patients. In one longitudinal study, this questionnaire was predictive of frailty and disability in black patients aged 49-65 years.
The Frail Scale
| Fatigue ("Are you fatigued?") |
| Resistance ("Can you climb one flight of stairs?") |
| Ambulation ("Can you walk one block?") |
| Illnesses (≥5) |
| Loss of weight (>5% in the past 12 months) |
In the Cardiovascular Health Study, the frailty phenotype independently predicted both 3-year morbidity (falls, activities of daily living [ADL] disability, loss of mobility, hospitalization) and mortality. The frailty phenotype has also been shown to be a better predictor of poor post-surgical outcomes than age or traditional comorbidity indices (e.g., the American Society of Anesthesiologists (ASA) Physical Status Classification System).
Objective Assessment of Frailty
| Criterion | Method of Measurement |
|---|---|
| Weight loss | At least 10 pounds or 5% body weight lost in past year |
| Self-reported exhaustion | Self-report: feeling tired all the time |
| Low physical activity | Unable to walk/requires help to walk |
| Slow walking speed | Timed Up-and-Go test >19 seconds |
| Weakness | Grip strength in the lowest 20% (using handheld dynamometer) |
The Lifestyle Interventions and Independence for Elders (LIFE) trial evaluated the effects of structured, moderate-intensity physical activity to reduce major mobility disability in adults aged 70–89 with physical limitations. After 2.6 years, older adults randomized to the physical activity arm demonstrated an improvement in walking speed
Management of frailty requires a holistic approach to care, incorporating the assistance of doctors, nurses, physiotherapists, occupational therapists, and social workers. Close contact with caretakers and review of medication is important to assess the impact of illness and symptoms.
A summary of best practices for the management of frailty can be found here.