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Frailty: Management and Treatment

John E. Morley, M.D.
 
Frailty is a vitally important issue in the treatment of the elderly. It is something that most people who live to an advanced age will probably face. Frailty can strongly affect how an elderly person will respond to medical treatment, as well as how long and how well they will live. Surprisingly, though common, it remains poorly understood.

Part of the problem is that it defies exact definition. Frailty is not really a disease but rather a combination of the natural aging process and a variety of medical problems. It is a little like the classic definition of pornography — experts may disagree on exactly what it is but most people know frailty when they see it.

Recently, however, gerontologists (doctors who specialize in the elderly) have been putting a new focus on frailty, beginning with a more precise definition.1 Gerontologists suggest that if someone has three or more of five factors, then that person should be considered frail. These factors are:
  • Unintentional weight loss (10 pounds or more in a year)
  • General feeling of exhaustion
  • Weakness (as measured by grip strength)
  • Slow walking speed
  • Low levels of physical activity.

Using this definition, researchers studied a group of fairly healthy elderly people who were living in the community, that is, people who were not in a hospital or a nursing home. They found that 6.9% of these elderly were frail.(1) They also found that frailty was a reliable predictor of a general decline in health. The frail faced an immediate future of falls, deteriorating mobility, disability, hospitalization and death. Frailty was also highly associated with with cardiovascular disease, low education and poverty.

How a Person Becomes Frail
The definition above, which is known as the Fried framework after its author, Dr. Linda Fried, has made it easier to identify frailty and to understand the complex interaction between physiological factors, external factors and aging that causes it. By the Fried definition, frailty is not a disease but rather a sort of intermediate state — between being functional and nonfunctional, and between being healthy and being sick.

Frailty may not be a disease, but there is no question that certain diseases and medical problems play a large role in it, which other researchers(2)(3) believe also need to be considered. These include:
  • Anorexia, or loss of appetite
  • Sarcopenia, or loss of body mass
  • Immobility or decreased physical activity
  • Atherosclerosis
  • Balance impairment
  • Depression
  • Cognitive impairment

Anorexia
It is well recognized that older persons often develop anorexia, loss of appetite, as a natural part of the aging process. Add this to eating problems caused by certain diseases and the result is chronic undernutrition and, eventually, fatigue, weakness, cachexia (general wasting away) and micronutrient (vitamins and minerals) deficiencies.(4) Hormone problems such as testosterone deficiency can aggravate anorexia.

Sarcopenia
Sarcopenia is defined as an excessive loss of muscle associated with aging. While genetically predetermined to some extent, several factors can accelerate the process. They include, among others, decreased physical activity, and testosterone and growth hormone deficiencies.(5)

Immobility
Immobility can be caused by illnesses such as arthritis, which decreases the ability to move a joint, or by pain. Illness can also cause fatigue. Osteoporosis can set the stage for hip fracture which initiates a cycle of immobility whose endpoint is frailty.

Atherosclerosis
Atherosclerosis, or clogging of the arteries, produces frailty as less oxygen ("VO2") reaches the tissues and organs. Clogging of the arteries can also cause small strokes, which, in turn, can lead to cognitive impairment. In the legs, vascular disease caused by atherosclerosis can result in nutrient deprivation of the muscles, slowed walking speed and, ultimately, sarcopenia.

Balance impairment
Balance deteriorates naturally over a person's lifetime. Decreased balance can initiate a vicious cycle in which accidental falls lead to a fear of falling, which leads to decreased mobility, which makes frailty worse. The good news is that animal studies have shown that exercise, such as those associated with Tai Chi, the ancient Chinese exercise form, can reverse the cycle, restoring balance.(6)

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Readers Comments
(3) Comments have been made

Valerie James
My parents have both become frail. It frightens me to see this, and makes me wonder about my own future since I too have a painful muscle disease. I see myself able to do less each year. I'm hoping to make not becoming frail my main goal. Thank you for the information related to that.
Posted Sat, May. 15, 2010 at 9:09 pm EDT
 
Maria Tadd
Kudos to Dr. Morley. Too often doctors are complacent when they see frail patients and don't look at what can be done using a more holistic approach. Good nutrition and exercise are the mainstay for people of all ages in order for them to remain as healthy as possible. My book "Happiness Is Growing Old at Home" covers these topics as well. Maria Tadd, www.agingathome.info.
Posted Wed, Jan. 6, 2010 at 9:59 am EST
 
OPGUpta
it covers most of the aspect of fraility in brief good one
Posted Mon, Jan. 4, 2010 at 9:41 pm EST



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