Frailty is defined as a syndrome of physiological decline in later life, characterised by marked vulnerability to adverse health outcomes and has been recognised for centuries and was described by Shakespeare in As You Like It,
“… the sixth age shifts into the lean and slipper’d pantaloon, with spectacles on nose and pouch on side, his youthful hose well sav’d, a world too wide, for his shrunk shank…”.
(Stage 1 Infancy, Stage 2 Schoolboy, Stage 3 Teenager, Stage 4, Young man, Stage 5, Middle aged, Stage 6, Old man, Stage 7, Dotage and death. To shrink is to grow smaller and ‘shank’ is meat cut from a leg of an animal and so the man’s legs have grown narrower with age.)
Frailty is associated weakness, slowing, decreased energy, lower activity and when severe, unintended weight loss and falls. |Old age itself does not define frailty and some patients remain vigorous, despite advanced age, while others have gradual yet unrelenting functional decline in the absence of apparent disease states or failure to rebound following illness or hospitalisation as they are less able to adapt to stressors such as acute illness, trauma, extremes of heat and cold, infection, injury, or even changes in medication than younger or non-frail older adults. As we age our bodies gradually lose their in-built reserves, leaving us vulnerable to dramatic, sudden changes in health triggered by seemingly small events such as a minor infection or a change in medication or environment. In medicine, frailty defines the group of older people who are at highest risk of adverse outcomes such as falls, disability, admission to hospital, or the need for long-term care and thus is syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults. As a population ages, a central focus of geriatricians and public health practitioners is to understand and then beneficially intervene on, the factors and processes that put elders at such risk, especially the increased vulnerability to stressors that characterises many older adults. This increased vulnerability contributes to increased risk for multiple adverse outcomes, including procedural complications, falls, institutionalisation, disability, and death. Increasingly, frailty in older patients is considered a forerunner to many other geriatric syndromes, including falls, fractures, delirium, and incontinence.
A frailty index (FI) is used to measure the health status of older individuals and serves as a proxy measure of ageing and vulnerability to poor outcomes. Although there is no gold standard for detecting frailty in older adults, multiple frailty screening tools have been developed and utilised for risk assessment and epidemiological study. A FI score is defined as the proportion of deficits present in an individual out of the total number of age-related health variables considered. There are a number of FIs of varying complexity and in elderly medicine there is a great deal of research into making and adapting these to make them a more accurate measure of risk of hospital admission and death so that individuals scoring highly can be identified and interventions offered to lower their risk. In the elderly a hospital admission even for a simple condition such as a urine infection can lead to a situation whereby the threshold of Independence Vs Dependence is crossed and it may be difficult or impossible to regain the previous state.
Frail patients often present to doctors with an increased burden of symptoms, medical complexity and reduced tolerance for medical interventions. Awareness of frailty and associated risks for adverse outcomes and an understanding of its biological basis, can improve care for this most vulnerable subset of patients.
The British Geriatric Society refers to five ‘frailty syndromes’:
- Falls (e.g. collapse, legs gave way, ‘found lying on floor’).
- Immobility (e.g. sudden change in mobility, ‘gone off legs’ ‘stuck in toilet’).
- Delirium (e.g. acute confusion, ’muddledness’, sudden worsening of confusion in someone with previous dementia or known memory loss).
- Incontinence (e.g. change in continence – new onset or worsening of urine or faecal incontinence).
- Susceptibility to side effects of medication (e.g. confusion with codeine, hypotension with antidepressants).
Motion is lotion, rest is rust. The saying “if you don’t use it, you lose it” is true when it comes to mobility so USE IT or don’t be surprised when it hurts to pick something up, reach overhead, twist, or any other basic function of the human body.
Walk for your life
Prof. Emmanuel Stamatakis and his team at the University of Sydney have explored the links between walking speed and mortality. They found an “average” walking pace was linked with a 20 percent lower risk of mortality from all causes, walking at a “fast” pace was tied to a 24 percent lower risk.
When it came to specific life-shortening causes such as cardiovascular disease, the team found that brisk walkers has a 21 percent lower risk of associated mortality. For individuals walking at an average pace, this risk was reduced by 24 percent.
Older people may reap stronger benefits as the researchers also noticed that older individuals, in particular, seemed to reap more benefits from walking at a brisker pace with participants aged 60 or over had a 46 percent lower risk of death related to cardiovascular diseases if they walked at an average pace, and a 53 percent lower risk if they walked fast. These findings, say Prof. Stamatakis and colleagues, should be ground enough for public health messages to mention the importance not just of walking, but also of walking pace.
Frailty makes us tired. Even small amounts of activity can be exhausting so it’s easy to retreat into the comfort of an armchair but this can accelerate the frailty process and result in more muscle loss, especially the leg, chest and heart muscles so for most people the simple advice is to keep active, use the stairs etc. It may not be an act of kindness to fetch and carry for an elderly relative if it results in them becoming less active, weaker and thus more prone to frailty and the risk inherent in that.
Weight loss is a characteristic feature of frailty as muscles become thinner and weaker, which in medicine is called the sarcopenia aspect of frailty.
Many older people with frailty report a diminished appetite it seems likely that if at least one substantial hot meal is available each day along with snacks and hot drinks this will afford some mitigation.
A slice of Christmas cake and a glass of milk, which can be supplemented with a spoonful of powdered milk, is roughly equivalent to the calorie content of a bottle of a meal replacement shake and tastes a lot better!
Too many medicines?
Older people with frailty are very sensitive to medicines because the body has trouble getting rid of them. This can mean a normal dose of medicine can build-up in the body can cause an adverse reaction. Adverse Drug Reactions (ADRs) account for 6.5 per cent of hospital admissions for older people and it is estimated that about 70 per cent of these might be avoidable. There are common culprit drugs for falls and Benzodiazepines (Sometimes used for anxiety and insomnia although should be used only infrequently or not at all) are particularly nasty drugs in older people with increased risk for falls and delirium, and they contribute the fatigue state of frailty. Poly-pharmacy, the use of multiple medications is common in the elderly and risk vs benefit assessments are important. “First, do no harm” is often attributed to the ancient Greek physician Hippocrates but it isn’t a part of the doctors Hippocratic Oath at all. (It is actually from another of his works called Of the Epidemics.)
“Do you feel lonely?”
Being housebound is a risk factor for loneliness and loneliness is itself a risk factor for depression, poor sleep, impaired thinking skills, higher use of health care, higher use of medication, and higher incidence of falls.
Q1. Are you FRAIL or heading that way? (Find your FI score here)
Q2. Are there some simple things you can do to mitigate the risk of frailty in future?
Q3. Can you see ‘Frailty’ in a loved one? What can you do to help?