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

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

This clinical content conforms to AAFP criteria for CME.

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.

RecommendationSponsoring organization
Do not recommend aggressive or hospital-level care for a frail older person without a clear understanding of the patient's goals of care and the possible benefits and harms.Society for Post-Acute and Long-Term Care Medicine

Pathophysiology

The normal aging process is a cumulative result of molecular and cellular damage that leads to a loss of physiologic reserve. A patient's physiologic reserve provides the ability to compensate for disease-related changes and maintain a homeostatic balance in the natural aging process. There is no one specific organ system that causes frailty but rather an aggregate loss across multiple systems.811 On the cellular level, altered processes in mitochondria and protein processing, increased free radical concentrations, and amplified sensitivity to apoptosis contribute to systemic changes.12 Key age-related changes include hormonal dysregulation (e.g., increased cortisol levels), sarcopenia (i.e., loss of skeletal and muscle mass), and increased immune system activation and proinflammatory cytokines.10,11 These changes cause a loss of homeostasis and a significantly decreased physiologic reserve, making patients who are frail more vulnerable to functional decline. As a result, these patients do not adapt to the stress of systemic disease as well as patients who are not frail.

Risk Factors

The estimated prevalence of frailty in the community setting is inconsistent in the literature, and incidence is likely underreported.2,13,14 Prevalence is hard to estimate because frailty is multifactorial, with older age, female sex, unhealthy lifestyle, and lower economic status identified as potential risk factors.2,1316 Social factors such as marital status, smoking history, social isolation, and lower levels of education also put people at risk.1720 Research suggests that frailty increases with the number of health deficits and presence of multiple comorbidities.2 Patients diagnosed with diabetes mellitus, respiratory disease, stroke, dementia, multiple sclerosis, connective tissue disease, osteoarthritis, and chronic fatigue syndrome have higher documented frailty rates.15,21,22

The relationship between medication use and frailty is not well defined. Some studies demonstrated that polypharmacy (taking five or more medications) was associated with frailty; however, potentially inappropriate medication use as defined by the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults was not associated.2326 One study indicated that frailty can be a risk factor for polypharmacy.27

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