Frailty is a syndrome characterized by loss of physiologic reserve and dysregulation across multiple systems, ultimately resulting in greater risk of poor health outcomes. One well-recognized model defines frailty as a phenotype that includes weakness, slow gait speed, decreased physical activity, weight loss, and exhaustion or low energy. While there is not one universally agreed upon definition or assessment tool for frailty, an individual is defined as frail when three or more of the above features are present. Persons with frailty are at increased risk for falls, hospitalization, functional decline, and death. Frailty is also recognized as a risk of worse outcomes following surgery.
How is frailty diagnosed?
• Phenotype model:
• Walking speed reduced, grip strength low, immune deficits, reduced ability of withstand an “insult”
• Useful in clinical trials, difficult to implement on large scale,
• Walking speed
• timed up and go test (TUGT) used
Clinical Frailty Scale
- Very Fit – People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.
- Well – People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally
- Managing Well – People whose medical problems are well controlled, but are not regularly active beyond routine walking.
- Vulnerable – While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day.
- Mildly Frail – These people often have more evident slowing, and need help in high order IADLs(finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.
- Moderately Frail – People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.
- Severely Frail – Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months).
- Very Severely Frail – Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.
- Terminally Ill – Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail.
Scoring frailty in people with dementia
The degree of frailty corresponds to the degree of dementia. Common symptoms in mild dementia include forgetting the details of a recent event, though still remembering the event itself, repeating the same question/story and social withdrawal.
In moderate dementia, recent memory is very impaired, even though they seemingly can remember their past life events well. They can do personal care with prompting.
In severe dementia, they cannot do personal care without help.
Frailty and multimorbidity
Multimorbidity is defined as the coexistence of multiple diseases and medical conditions in the same individual. Multimorbidity and catabolic diseases represent a risk factor for frailty, potentially contributing to the decompensation of multiple physiological regulatory systems that underlie frailty. Frailty and multimorbidity are two distinct concepts, although they may contribute to each other.
A recent meta-analysis on frailty and multimorbidity examined more than 14000 community-dwelling older adults enrolled in nine different studies. The results showed that about three-quarters of people with frailty presented with multimorbidity (two or more diseases), and that frailty was present in 16% of people with multimorbidity.
Similarly, analyses from the UK Biobank of data from approximately half a million participants aged 37–73 years showed that frailty was associated with multimorbidity, reaching a frailty prevalence of 18% among participants with four or more diseases
(Ref: Frailty: implications for clinical practice and public health by; Emiel O Hoogendijk, Jonathan Afilalo, Kristine E Ensrud, Paul Kowal, Graziano Onder, Linda P Fried; available at www.thelancet.com Vol 394 October 12, 2019)
Prevention and management
• “healthy ageing” reduces the risk of developing frailty:
• Good nutrition
• Not too much alcohol
• Staying physically active
• Remaining engaged in local community/ avoiding loneliness