A Clinical Focus on Frailty
Although frailty is not inevitable, its prevalence increases as we age, rising dramatically among the “old-old” population. Frailty has a profound impact on health and well-being; it increases risks of falls, injuries, disability, institutionalization, mood disorders, and other adverse health outcomes. It both makes the management of medical conditions and chronic problems much more difficult and contributes to caregiving needs and resource utilization. To consider what research to date has taught us about frailty, and to identify what future research should explore, the American Geriatrics Society (AGS) sponsored a working conference funded by the National Institute on Aging (NIA), entitled “Research Agenda for Frailty in Older Adults: Towards Better Understanding of Physiology and Etiology.” The January 2004 conference brought together researchers from a wide range of fields. The first of two papers on the conference recently appeared in Science of Aging Knowledge Environment (SAGE KE), one of Science’s online publications (sageke.sciencemag.org/). The paper is the work of the conference organizers Drs. Linda P. Fried, Evan Hadley, Jeremy Walston, Anne Newman, Jack Guralnik, Stephanie Studenski, Tamara Harris, William Ershler, and Luigi Ferrucci.1
The same authors collaborated on a second paper on the conference that will appear in an upcoming special article section of the Journal of the American Geriatrics Society. Much of the SAGE KE report is concerned with different conceptual approaches to frailty. These include the concept of “frailty as a clinical state,” which many of us employ when evaluating patients. In keeping with this concept, frailty is a state of vulnerability to stressors and may be manifested by unintentional weight loss, weakness, sense of exhaustion, slow walking speed, and low physical activity. A working definition of frailty—predicated on the hypothesis that a “critical mass” of these manifestations results in such vulnerability—stipulates the presence of three or more of these features. Although there are other conceptual approaches to frailty, and this approach has its limitations, studies have found that the presence of three or more of these features does predict adverse outcomes, such as falls, hospitalization, disability, and death. One such study appeared in the August issue of JAGS.2
Just as important, research has found that the presence of one or two of these features can identify a pre-frail stage, characterized by an intermediate risk of the same adverse health outcomes, the SAGE KE report notes. As the paper concludes, there are many questions about the causes, diagnosis, treatment, and prevention of frailty that remain to be answered, and much research remains to be done. In the interim, however, as clinicians we can continue to do our best to identify pre-frail and frail patients. The working definitions of frailty and pre-frailty, as indicated above, can guide us. We also need to do our best to help prevent pre-frailty and frailty among our patients. Efforts to prevent declines in strength and performance are warranted.
Clinicians are aware of the positive impact of regular exercise and appropriate attention to nutrition, weight, and other modifiable health habits. We continue to learn that genetic factors are not as important as modifiable factors (such as exercise) in promoting “healthy” or “successful” aging. The message for us is: We need to better recognize when patients are at risk for or are demonstrating decreased functional performance, especially regarding mobility. We should search for reversible factors rather than attribute these changes to “usual aging.” Finally, we should all be encouraging our patients to exercise regularly, and adopt and maintain healthy lifestyles as they age. The AGS Foundation for Health in Aging has published several extremely helpful reports on healthy lifestyles, written for patients and their caregivers, on its “Aging in the Know” website. Consider sharing these reports with your patients.