Frailty is most often defined as an aging-related syndrome of physiological decline, characterized by marked vulnerability to adverse health outcomes. Frail older patients often present with an increased burden of symptoms including weakness and fatigue, medical complexity, and reduced tolerance to medical and surgical interventions. Awareness of frailty and associated risks for adverse health outcomes can improve care for this most vulnerable subset of patients.

Dr Jeremy D. Walston, MD

Assessment

There is no universal set of criteria for defining frailty. However, most researchers use Linda Fried’s study “Frailty in older adults: evidence for a phenotype” as a basis for its definition. Fried et al suggested that frailty could be defined by the presence of three or more of the following criteria (1):

  • Unintentional weight loss (10lbs or more in the past year)
  • Self-reported exhaustion
  • Weakness (hand grip strength)
  • Slow walking speed
  • Low physical activity

Presence of one or two of the criteria qualifies an individual as “pre-frail”, which is a subset at high risk of progressing to frailty (2).

Problem

Frailty manifests as the inability to tolerate stressful events and is associated with adverse outcomes, such as falls, resulting in trauma including fractured neck of femur, delirium, institutionalization, incident disability, and increased mortality. This is also an independent risk factor for poor outcomes after surgery or femoral neck fracture (3), including prolonged hospitalizations, increased susceptibility to deconditioning, faster functional decline, increased mortality risk, and higher health care use and corresponding costs.

According to research conducted by Johns Hopkins University School of Medicine, risk rises with age, from one in 25 people between ages 65 and 74 to one in four of those older than age 84. The situation will only increase in the future. By 2050, approximately 21.3% of the global population will be 60 years or older, up from 9.2% in 1990.

Frailty older than 84
Frailty Sarcopenia Gripwise

Frailty in the US

A study by Bandeen-Roche et al., found that 15% of those aged 65 or older in the US are frail, whilst a further 45% are pre-frail (4). Frailty was found to be more prevalent amongst women, racial and ethnic minorities and persons of lower income. Thus, it is important to state that prevalence of frailty varies due to socio-economic and biological disparities. The study also found that chronic disease and disability prevalence increase steeply with frailty. Among the frail, 42% were hospitalized in the previous year, compared to 22% of the prefrail and 11% of people considered robust. Hip, back, and heart surgery in the last year were associated with frailty. Furthermore, over half of all frail people had a fall in the previous year (4).

In fact, this study highlights that 47.4% of people aged 80 and over were considered pre-frail and between 33.3% and 37.9% of the population was considered frail4. It should also be noted that the US population is aging, with the number of those aged 65 or older estimated to double to 90 million people by 2050. The relative frequency of frailty in the population is expected to grow proportionately.

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