Frailty: Evaluation and Management

 

Am Fam Physician. 2021 Feb 15;103(4):219-226.

Related Lown Right Care: Preoperative Evaluation and Frailty Assessment in Older Patients

Author disclosure: No relevant financial affiliations.

Frailty, which is a geriatric syndrome that affects 5% to 17% of older adults, is a state of increased vulnerability across multiple health domains that leads to adverse health outcomes. Frail older adults are at increased risk of falls, disability, hospitalizations, and death. Frailty may initially be overlooked or incorrectly identified as part of the normal aging process because of the variable nature of the presentation and diagnosis. Symptoms include generalized weakness, exhaustion, slow gait, poor balance, decreased physical activity, cognitive impairment, and weight loss. There is no current recommendation for routine screening. A comprehensive geriatric assessment can identify risk factors and symptoms that suggest frailty. Several validated frailty assessment tools can evaluate a patient for frailty. Patients are diagnosed as not-frail, prefrail, or frail. Patients with a larger number of frail attributes are at higher risk of poor outcomes. The management of frail patients must be individualized and tailored to each patient's goals of care and life expectancy. Physical activity and balance exercises may be suitable for patients who are less frail. Palliative care and symptom control may be appropriate for those who are more frail.

Frailty is a syndrome of growing importance among the geriatric population, occurring in 5% to 17% of older adults.1,2 Clinicians need to recognize the signs and symptoms of frailty as the average life expectancy of the population continues to increase. Several studies have demonstrated that frail adults are at increased risk of adverse health outcomes.35 However, there is no unifying definition for frailty. It is a syndrome recognized primarily in older adults that affects health, energy, and physical abilities by increasing a patient's vulnerability to stressors (e.g., falls, infection) and risk of further decline.1,6,7 Recognizing frailty and understanding its progression will help physicians develop treatment plans and better discuss prognosis with patients and their families.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Consider screening men older than 60 years; women; current and former smokers; patients who are single, socially isolated, and of low socioeconomic status; and those who have lower levels of education.2,13,14,1719

C

Systematic reviews on prevalence and risk factors

Consider screening patients diagnosed with diabetes mellitus, chronic obstructive pulmonary disease or respiratory disease, stroke, dementia, multiple sclerosis, connective tissue disease, osteoarthritis, or chronic fatigue syndrome.15,21,22

C

Prospective study and observational studies on associated conditions

Use a validated frailty assessment tool to diagnose frailty.39

C

Expert opinion and review

Frailty management should be individualized for each patient based on their degree of frailty, goals of care, and life expectancy.49,50

C

Expert opinion

Patients diagnosed as prefrail or frail who have no contraindications to physical activity should be offered a multicomponent physical activity program.5056

B

Expert opinion, reviews, and lower-quality randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Consider screening men older than 60 years; women; current and former smokers; patients who are single, socially isolated, and of low socioeconomic status; and those who have lower levels of education.2,13,14,1719

C

Systematic reviews on prevalence and risk factors

Consider screening patients diagnosed with diabetes mellitus, chronic obstructive pulmonary disease or respiratory disease, stroke, dementia, multiple sclerosis, connective tissue disease, osteoarthritis, or chronic fatigue syndrome.15,21,22

C

Prospective study and observational studies on associated conditions

Use a validated frailty assessment tool to diagnose frailty.39

C

Expert opinion and review

Frailty management should be individualized for each patient based on their degree of frailty, goals of care, and life expectancy.49,50

C

Expert opinion

Patients diagnosed as prefrail or frail who have no contraindications to physical activity should be offered a multicomponent physical activity program.5056

B

Expert opinion, reviews, and lower-quality randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://ww

The Authors

show all author info

ROBERT ALLISON II, DO, is an assistant professor in the Department of Family Medicine at West Virginia University, Morgantown....

SHAUNA ASSADZANDI, MD, is a resident in the Department of Family Medicine at West Virginia University.

MEGAN ADELMAN, PharmD, is a family medicine pharmacy specialist at Cleveland Clinic Akron (Ohio) General. At the time this article was written, she was a clinical assistant professor in the School of Pharmacy and a clinical pharmacy specialist in the Department of Family Medicine, both at West Virginia University.

Address correspondence to Robert Allison II, DO, 6040 University Town Centre, Morgantown, WV 26501 (email: robert.allison.m@wvumedicine.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. Fried LP, Tangen CM, Walston J, et al.; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–M156....

2. Collard RM, Boter H, Schoevers RA, et al. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):1487–1492.

3. Gill TM, Gahbauer EA, Allore HG, et al. Transitions between frailty states among community-living older persons. Arch Intern Med. 2006;166(4):418–423.

4. Graham JE, Snih SA, Berges IM, et al. Frailty and 10-year mortality in community-living Mexican American older adults. Gerontology. 2009;55(6):644–651.

5. Ensrud KE, Ewing SK, Cawthon PM, et al.; Osteoporotic Fractures in Men Research Group. A comparison of frailty indexes for the prediction of falls, disability, fractures, and mortality in older men. J Am Geriatr Soc. 2009;57(3):492–498.

6. Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–495.

7. Xue QL, Bandeen-Roche K, Varadhan R, et al. Initial manifestations of frailty criteria and the development of frailty phenotype in the Women's Health and Aging Study II. J Gerontol A Biol Sci Med Sci. 2008;63(9):984–990.

8. Lipsitz LA. Dynamics of stability: the physiologic basis of functional health and frailty. J Gerontol A Biol Sci Med Sci. 2002;57(3):B115–B125.

9. Fried LP, Xue QL, Cappola AR, et al. Nonlinear multisystem physiological dysregulation associated with frailty in older women: implications for etiology and treatment. J Gerontol A Biol Sci Med Sci. 2009;64(10):1049–1057.

10. Clegg A, Young J. The frailty syndrome. Clin Med (Lond). 2011;11(1): 72–75.

11. Chen X, Mao G, Leng SX. Frailty syndrome: an overview. Clin Interv Aging. 2014;9:433–441.

12. Walston JD. Connecting age-related biological decline to frailty and late-life vulnerability. Nestle Nutr Inst Workshop Ser. 2015;83:1–10.

13. Siriwardhana DD, Hardoon S, Rait G, et al. Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Open. 2018;8(3):e018195.

14. Ofori-Asenso R, Chin KL, Mazidi M, et al. Global incidence of frailty and pre-frailty among community-dwelling older adults: a systematic review and meta-analysis. JAMA Netw Open. 2019;2(8):e198398.

15. Hanlon P, Nicholl BI, Jani BD, et al. Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants. Lancet Public Health. 2018;3(7):e323–e332.

16. Puts MTE, Lips P, Deeg DJH. Sex differences in the risk of frailty for mortality independent of disability and chronic diseases. J Am Geriatr Soc. 2005;53(1):40–47.

17. Chamberlain AM, St Sauver JL, Jacobson DJ, et al. Social and behavioural factors associated with frailty trajectories in a population-based cohort of older adults. BMJ Open. 2016;6(5):e011410.

18. de Labra C, Maseda A, Lorenzo-López L, et al. Social factors and quality of life aspects on frailty syndrome in community-dwelling older adults: the VERISAÚDE study. BMC Geriatr. 2018;18(1):66.

19. Fhon JRS, Rodrigues RAP, Santos JLF, et al. Factors associated with frailty in older adults: a longitudinal study. Rev Saude Publica. 2018;52:74.

20. Gobbens RJJ, van Assen MALM, Luijkx KG, et al. Determinants of frailty. J Am Med Dir Assoc. 2010;11(5):356–364.

21. Lee JSW, Auyeung T-W, Leung J, et al. Transitions in frailty states among community-living older adults and their associated factors. J Am Med Dir Assoc. 2014;15(4):281–286.

22. Espinoza SE, Jung I, Hazuda H. Frailty transitions in the San Antonio Longitudinal Study of Aging. J Am Geriatr Soc. 2012;60(4):652–660.

23. Aprahamian I, Biella MM, Vano Aricó de Almeida G, et al. Polypharmacy but not potential inappropriate prescription was associated with frailty in older adults from a middle-income country outpatient clinic. J Frailty Aging. 2018;7(2):108–112.

24. Saum KU, Schöttker B, Meid AD, et al. Is polypharmacy associated with frailty in older people? Results from the ESTHER cohort study. J Am Geriatr Soc. 2017;65(2):e27–e32.

25. Tatum PE III, Talebreza S, Ross JS. Geriatric assessment: an office-based approach. Am Fam Physician. 2018;97(12):776–784. Accessed August 10, 2020. https://www.aafp.org/afp/2018/0615/p776.html

26. 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674–694.

27. Rieckert A, Trampisch US, Klaaßen-Mielke R, et al. Polypharmacy in older patients with chronic diseases: a cross-sectional analysis of factors associated with excessive polypharmacy. BMC Fam Pract. 2018;19(1):113.

28. Gobbens RJJ, Luijkx KG, Wijnen-Sponselee MT, et al. In search of an integral conceptual definition of frailty: opinions of experts. J Am Med Dir Assoc. 2010;11(5):338–343.

29. Stenholm S, Ferrucci L, Vahtera J, et al. Natural course of frailty components in people who develop frailty syndrome: evidence from two cohort studies. J Gerontol A Biol Sci Med Sci. 2019;74(5):667–674.

30. Welsh TJ, Gordon AL, Gladman JR. Comprehensive geriatric assessment—a guide for the non-specialist. Int J Clin Pract. 2014;68(3):290–293.

31. Hamaker ME, Jonker JM, de Rooij SE, et al. Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review. Lancet Oncol. 2012;13(10):e437–e444.

32. Partridge JSL, Harari D, Dhesi JK. Frailty in the older surgical patient: a review. Age Ageing. 2012;41(2):142–147.

33. Freiheit EA, Hogan DB, Patten SB, et al. Frailty trajectories after treatment for coronary artery disease in older patients. Circ Cardiovasc Qual Outcomes. 2016;9(3):230–238.

34. McIsaac DI, Taljaard M, Bryson GL, et al. Frailty as a predictor of death or new disability after surgery: a prospective cohort study. Ann Surg. 2020;271(2):283–289.

35. van Kempen JAL, Melis RJF, Perry M, et al. Diagnosis of frailty after a Comprehensive Geriatric Assessment: differences between family physicians and geriatricians. J Am Board Fam Med. 2015;28(2):240–248.

36. National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults. March 20, 2020. Accessed August 3, 2020. https://www.nice.org.uk/guidance/ng159

37. Bellelli G, Rebora P, Valsecchi MG, et al. Frailty index predicts poor outcome in COVID-19 patients. Intensive Care Med. 2020;46(8):1634–1636.

38. Van de Voorde P, Monsieurs K, Renier W, et al. Ethical principles and guidance with regard to ethical decisions in pre-hospital and emergency medicine in Belgium during the COVID-19 pandemic. A joint statement of the Belgian Society of Emergency and Disaster Medicine and the Belgian Resuscitation Council. March 22, 2020. Accessed August 10, 2020. https://www.brc-rea.be/wp-content/uploads/2020/03/Ethical-decision-making-in-emergencies_COVID19_22032020_final.pdf

39. Dent E, Martin FC, Bergman H, et al. Management of frailty: opportunities, challenges, and future directions. Lancet. 2019;394(10206):1376–1386.

40. Hoogendijk EO, van Kan GA, Guyonnet S, et al. Components of the frailty phenotype in relation to the frailty index: results from the Toulouse frailty platform. J Am Med Dir Assoc. 2015;16(10):855–859.

41. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.

42. Ainsworth BE, Haskell WL, Leon AS, et al. Compendium of physical activities: classification of energy costs of human physical activities. Med Sci Sports Exerc. 1993;25(1):71–80.

43. Taylor HL, Jacobs DR Jr, Schucker B, et al. A questionnaire for the assessment of leisure time physical activities. J Chronic Dis. 1978;31(12):741–755.

44. Woods NF, LaCroix AZ, Gray SL, et al.; Women's Health Initiative. Frailty: emergence and consequences in women aged 65 and older in the Women's Health Initiative Observational Study [published correction appears in J Am Geriatr Soc. 2017;65(7):1631–1632]. J Am Geriatr Soc. 2005;53(8):1321–1330.

45. Vermeiren S, Vella-Azzopardi R, Beckwée D, et al. Frailty and the prediction of negative health outcomes: a meta-analysis. J Am Med Dir Assoc. 2016;17(12):1163e1–1163e17.

46. Trevisan C, Veronese N, Maggi S, et al. Factors influencing transitions between frailty states in elderly adults: The Progetto Veneto Anziani Longitudinal Study. J Am Geriatr Soc. 2017;65(1):179–184.

47. Dent E, Lien C, Lim WS, et al. The Asia-Pacific clinical practice guidelines for the management of frailty [published correction appears in J Am Med Dir Assoc. 2018;19(1):94]. J Am Med Dir Assoc. 2017;18(7):564–575.

48. Dent E, Morley JE, Cruz-Jentoft AJ, et al. Physical frailty: ICFSR international clinical practice guidelines for identification and management. J Nutr Health Aging. 2019;23(9):771–787.

49. Moorhouse P, Mallery LH. Palliative and therapeutic harmonization: a model for appropriate decision-making in frail older adults. J Am Geriatr Soc. 2012;60(12):2326–2332.

50. Palliative and Therapeutic Harmonization. Implementation: frailty within the health system. Accessed June 4, 2020. https://pathclinic.ca/implementation/

51. Liu X, Hui-Min Ng D, Wei-Ting Seah J, et al. Update on interventions to prevent or reduce frailty in community-dwelling older adults: a scoping review and community translation. Curr Geriatr Rep. 2019;8:72–86.

52. Puts MTE, Toubasi S, Andrew MK, et al. Interventions to prevent or reduce the level of frailty in community-dwelling older adults: a scoping review of the literature and international policies. Age Ageing. 2017;46(3):383–392.

53. Hsieh TJ, Su SC, Chen CW, et al. Individualized home-based exercise and nutrition interventions improve frailty in older adults: a randomized controlled trial [published correction appears in Int J Behav Nutr Phys Act. 2019;16(1):136]. Int J Behav Nutr Phys Act. 2019;16(1):119.

54. Arrieta H, Rezola-Pardo C, Gil SM, et al. Effects of multicomponent exercise on frailty in long-term nursing homes: a randomized controlled trial. J Am Geriatr Soc. 2019;67(6):1145–1151.

55. Ng TP, Feng L, Nyunt MSZ, et al. Nutritional, physical, cognitive, and combination interventions and frailty reversal among older adults: a randomized controlled trial. Am J Med. 2015;128(11):1225–1236.e1.

56. Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, et al.; American College of Sports Medicine. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510–1530.

57. Lee PG, Jackson EA, Richardson CR. Exercise prescriptions in older adults. Am Fam Physician. 2017;95(7):425–432. Accessed June 5, 2020. https://www.aafp.org/afp/2017/0401/p425.html

58. Huguet LG, González MN, Kostov B, et al. Pre frail 80: multifactorial intervention to prevent progression of pre-frailty to frailty in the elderly. J Nutr Health Aging. 2018;22(10):1266–1274.

59. Serra-Prat M, Sist X, Domenich R, et al. Effectiveness of an intervention to prevent frailty in pre-frail community-dwelling older people consulting in primary care: a randomised controlled trial. Age Ageing. 2017;46(3):401–407.

60. Luger E, Dorner TE, Haider S, et al. Effects of a home-based and volunteer-administered physical training, nutritional, and social support program on malnutrition and frailty in older persons: a randomized controlled trial. J Am Med Dir Assoc. 2016;17(7):671e9–671e16.

61. Ruikes FGH, Zuidema SU, Akkermans RP, et al. Multicomponent program to reduce functional decline in frail elderly people: a cluster controlled trial. J Am Board Fam Med. 2016;29(2):209–217.

 

 

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