Approach to Frailty in Older Adults

Claus Hamann

Kenneth L. Minaker

Care of older adults embraces a five-phase continuum: (a) successful aging with no overt diseases (occurs in a small minority of elders); (b) independent function despite established diseases (more common); (c) frailty, a syndrome of increased vulnerability to external and internal stressors with risk for developing disability; (d) disability, with established, dependent, and more vulnerable function due to accumulated deficits; and (e) preterminal condition, or end of life. In each phase, balanced individualized strategies for health promotion, disease and disability prevention, and restoration and palliation offer opportunities for improving quality of life. Identifying and treating risk factors for frailty to prevent its development and consequences are central challenges of the primary physician caring for older adults.

PATHOPHYSIOLOGY AND CLINICAL PRESENTATION (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13)

Frailty is a clinical syndrome with predominant musculoskeletal, nutritional, and neuropsychiatric manifestations due to subclinical or overt impairments in multiple, interrelated physiologic systems. Most frail older adults have chronic illnesses affecting multiple organ systems, diminishing physiologic reserve, and making them vulnerable to destabilization. They require the support of other persons to function optimally. Frail older adults are at greater risk of dying than are the nonfrail, often due to infection complicating coexistent illnesses. Frailty usually has a long prodrome that offers many opportunities for remediation; if left unattended, it leads to an accelerated pace of decline—“failure to thrive.”

Frailty comprises diminished muscle strength, decreased physical activity, easy fatigability, slow unsteady gait, increased risk and fear of falling, poor appetite with unintentional weight loss, and, often, impaired cognition and depression.

Endocrine and immune antecedents for the frailty cycle have been identified. Serum levels of growth hormone and insulinlike growth factor 1 decline progressively during aging, and an association with frailty has been proposed. Age-dependent changes in testosterone, erythropoietin, and other hormones also appear to herald frailty in the elderly, particularly via their effects on muscle mass, strength, and bone density. These changes may contribute to the activation of catabolic cytokines (e.g., interleukin-6), C–reactive protein, and markers of coagulopathy, such as fibrinogen and D-dimer. In addition, periodontal disease, pulmonary disease, bladder infections, renal insufficiency, and diverticula may stimulate chronic, low–level inflammation. Women appear to be twice as likely to develop frailty as men, perhaps due to lower protective levels of baseline lean body mass, testosterone and growth hormone, and greater dysregulation of cortisol.

Nutritional factors may contribute to frailty. These include early satiation, or the “anorexia of aging,” arising from signals in the stomach and from changes in the central feeding drive, in particular from a decrease in the opioid-rewarding properties for fatty foods. Diminished nutritional drive may also be caused by higher leptin levels associated with lower testosterone in aging men and by increased cytokines from common inflammatory conditions.

Physical frailty is associated with a reduction in the fasting rate of muscle protein synthesis, which contributes to muscle protein wasting in advancing age. Sarcopenia is also partly due to the apoptosis of myocytes. Bone loss ensues from inactivity, hormonal changes, deficient calcium and vitamin D, and decreases in calcium absorption (see Chapter 164). Many of these molecular events can be at least partially reversed through physical exercise.

ASSESSMENT (14, 15, 16, 17, 18, 19 and 20)

Many patients and their caregivers volunteer advancing age as the primary reason for frailty. Although age is a risk factor for frailty and illness in general, it should not be invoked reflexively because it can lead to the erroneous conclusion that “I can do nothing about your advancing age, so I can do nothing about your frailty.” Instead, a two-pronged approach is recommended: first, a traditional search for medical causes and, second, a specific geriatric assessment that identifies frailty indicators, refines disability assessment, and tests for physical performance and mental status. Direct review of medications and assessment for nonadherence and potential drug-drug and drug-disease interactions are especially important components of the evaluation (see Chapters 166, 169, 173, 226, and 227).

Standard Medical Evaluation

The assessment should be directed at preventing destabilization of preexisting conditions, such as congestive heart failure (see Chapter 32), renal insufficiency (see Chapter 142), and chronic lung disease (see Chapter 47). The differential diagnosis more commonly includes infection, anemia, hypo– or hyperthyroidism, malignancy, and depression—and less commonly, hypogonadism, hypoadrenalism, and hypopituitarism.

Geriatric Assessment

The geriatric assessment utilizes the history and physical examination to identify specific indicators of frailty, review core activities of daily living (ADLs), check for syndromes that contribute to or result from frailty, and evaluate the patient’s social situation.

Checking for Indicators of Frailty

Specific indicators of frailty should be sought, including

Exhaustion: “Everything was an effort,” or “I could not get going” for at least half of the previous week.
Unintentional weight loss: loss of 10% or more of body weight during the last year or (lower threshold) 10 lb (4 kg) over 5 years; body weight less than numerical age is pathognomonic.
Inactivity: less than 20 minutes of brisk walking per week
Immobility: taking 7 or more seconds to walk 15 feet
Weakness: diminished grip strength, measured using a handheld dynamometer

Having more frailty indicators predicts worsening mobility and limitation in ADLs, as well as increased risk for hospitalization and death.

Inquiring into Activities of Daily Living

Inquiry into difficulty with core ADLs provides an important functional assessment that helps not only with the overall evaluation but also in determining qualification for additional
services and financial support, which are often ADL based. There are six core ADLs:

Shopping for personal items like toiletries or medicines
Managing money (keeping track of expenses or paying bills)
Doing light housework (washing dishes, straightening up, or light cleaning)
Walking across the room
Transferring from bed or chair and back
Bathing or showering

Refined from traditionally longer lists of ADL items, these six items identify 93% of community-living older adults vulnerable to frailty, having difficulty functioning independently, and in need of help.

Reviewing for Geriatric Syndromes and Social Isolation

A history of other geriatric syndromes contributing to or resulting from frailty—delirium, falls, urinary incontinence, and constipation— should be sought. Social isolation, financial hardships, and caregiver strain also need to be noted since they are critical to management.

Focusing the Physical Examination

Focusing the physical examination on a few key areas is essential to the overall assessment. One is the “get–up–and–go test,” which asks the patient to stand up safely from a chair without using the arms and then walk across the room and back. Taking longer than 15 seconds to perform this means fall risk is increased, and strength and gait training are indicated. Nutritional insufficiency can be detected with the 4-minute, well-validated Mini Nutritional Assessment Screening Form, which quantifies loss of appetite and weight, recent acute psychological or physical disease, dementia and/or depression, impaired mobility, and low body mass index. Checking for dental disease—a risk factor for malnutrition—is also essential. During the visit, the patient’s cognitive function (recall, use of language, visual/spatial abilities, thinking) and mood provide clues for depression and cognitive impairment, which are major determinants of frailty. Use of brief instruments to screen for cognitive impairment can help detect early stages of dementia, but systematic review for the U.S. Preventive Services Task Force finds no evidence of improved clinical decision-making or outcomes with earlier detection (see also Chapters 169 and 173). As advances in treatment of dementia emerge, the value of screening for early cognitive impairment should increase markedly.

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