Frailty: A New Predictor of Outcome as We Age
It is instinctively known that someone frail probably is at risk for some health related problem. In fact we all have seen this all our lives, those who can’t function so well – can’t function so well. And in one of those rare cases, medical science has caught up with public perception – it usually is the other way.
During the past 15 years there has emerged in the geriatric medical community a “frailty syndrome” with a good bit of research around the diagnosis and the implications of the syndrome. Frailty syndrome is defined as age-related deficits in normal function and involving several body systems. This rather vague definition really means loss of muscle, stamina, endurance, sometimes weight, and general fitness. Often the definition involves the presence of two or more chronic diseases like cancer, arthritis, heart disease, etc. Criteria for diagnosis are weakness, slowness, low level of physical activity, easy exhaustion, poor endurance, and loss of weight. Most of these can be measured with tests like grip strength for weakness or time to walk 15 feet for slowness. One must have 3 or more of the criteria to qualify for frailty.
Among people over 65 in the U.S. the incidence of frailty ranges from 7 to 12 percent. Within this over 65 group, as we age the incidence goes up. For example frailty is found in only 3.9 percent of ages 65-74 years old, but 25 percent in those 85 and older. In other words, the longer one lives the greater chance that frailty can ensue. Women have a higher incidence than men – possibly because they tend to live longer and therefore the age affect makes women more likely to become frail.
What Are the Causes of Frailty?
Emerging theory about the cause of frailty in the elderly is that there is chronic inflammation going on and/or immune system activation. Certain laboratory tests such as the elevation of interleukin (IL)-6 and cortisol among many other inflammation markers have been found. It has been postulated that the chronic inflammation reduces muscle function, causes anemia, and reduces heart function. The loss of muscle mass and strength is called sarcopenia and this is a hallmark of the syndrome. Hormonal changes with age have been suspected of causing some of the problems seen in frailty. Both estrogen in women and testosterone in men when lessened with age can lead to a decline in muscle mass. Also elevated cortisol and reduced vitamin D levels are thought to contribute to frailty.
Why Is Frailty Important?
One of the important things to recognize is that frailty is a result of aging, but not all elderly are or will be frail. However, it has been shown that patients who meet the criteria for frailty have poorer outcomes when faced with any stress, like surgery or a new major disease (see figure 1). To be blunt: the medically frail have increased morbidity and mortality when stressed. Frailty predicts increased falls, hospitalization, and mortality. The frail are at increased risk when having many types of surgical procedures with a higher incidence of complications and poorer overall result. When exposed to influenza or pneumonia, the frail have more severe illness. Many types of cancer are more devastating in the frail than those robust. So all in all, the syndrome of frailty is a very good predictor of health outcome.
Figure 1 (above)
Prevention & Treatment of Frailty
There are four things to do in prevention and or treatment of frailty. The first and most important preventive strategy is to exercise regularly and to be sure to address major muscle groups – so if one walks or runs, balance that exercise with some weight lifting, push-ups, and sit-ups for the arms and abdominal muscles, respectively. People who exercise regularly are less likely to become frail and those who are frail and can improve with exercise. A second strategy is diet. It is important to eat a balanced diet for prevention and treatment of frailty. A third strategy for treatment and prevention is prevention of socioeconomic and environment stress by prudent financial planning and engagement socially with others. Finally, when diagnosed with frailty it has been reported that a team approach is best for keeping one as healthy as possible. The team is a geriatric physician, geriatric nurse, social worker, pharmacist, and occupational and physical therapists. These teams now exist in most geriatric centers and have proven to be invaluable when working together to improve a frail patient’s status.
The Bottom Line
There is a relatively new, but real syndrome in the elderly called frailty. It is not too common, but predicts poor outcome when faced with the many stresses encountered when aging. Frailty can be prevented or treated with exercise, diet, and good medical care. It is up to each of us to do our best to not join the medically frail as we age.