What is Frailty?
"Growing old may be inevitable, but growing frail is not."
Dr Sarah Turpin, ED Geriatric Fellow
Frailty is a clinical syndrome. It can be defined. It can be measured. Most importantly, it can be prevented and even reversed.
The two most well known concepts of frailty are the Cumulative Deficit Model (Rockwood) and Frailty Phenotype (Fried). A simple way of viewing frailty, is the idea that minor stressors can cause major functional and physical decline with associated adverse outcomes. These include dependency, institutionalisation and premature death.
The formal international definition is:
"A medical syndrome with multiple causes and contributors that is characterised by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death."
The emergency presentation of a frail patient to acute or emergency care is both a risk and an opportunity. A risk, because as a “stressor” an acute admission is a moment when those who don’t appear frail can become frail. An opportunity, because should their frailty be revealed to a clinician who can identify and manage it, then deterioration and further decline in health and function can be prevented or slowed.
How Do We Recognise Frailty? (The Frailty Phenotype1)
Look for:
Unintentional weight loss (10 lbs in past year)
Self-reported exhaustion
Weakness (grip strength)
Slow walking speed
Low physical activity
No criteria = Robust
1-2 criteria = Pre-frail
3 or more criteria = Frail
Who Should We Assess For Frailty?
Patients who present with a frailty syndrome:
| Falls | Delirium & Dementia | Immobility |
| Polypharmacy | End of Life | Incontinence |
Patients from a nursing home
Consider it in everyone who is >85 years old
What Happens To Frail Patients?
Frail patients are at higher risk of becoming increasingly dependent and requiring institutionalisation; they are also at increased risk of dying during a hospital stay. The likelihood of adverse events occurring relates to how frail somebody is; the frailer the patient, the higher risk they are for experiencing an adverse event.
There are now national guidelines aimed at middle aged adults to try to reduce the chances of becoming frail. If a patient is already living with frailty, considered approaches such as maintaining physical activity whilst in hospital, rationalising inappropriate medications and optimising nutrition can help prevent somebody becoming more frail.
The phrase “sit out, get out” can be a genuine life saver for frail patients in acute care – getting out of bed every day during a hospital stay helps prevent deconditioning and the associated risks of reduced muscle strength, falls, hypostatic pneumonia, thromboembolism and constipation.
(Fig. 1) The Cycle of Frailty ²
(Fig. 2) The Frailty Trajectory ³
What Can Be Done?
Recognition is essential, since this allows you to flag up frail patients early. Frailty should be managed alongside acute medical and surgical conditions, and comprehensive geriatric assessment of acutely sick patients to prevent or reverse deterioration of their frailty as a consequence of their acute illness is an important aspect of providing good quality care in the acute hospital and ED setting.
Once identified, frail patients can be referred to a service where the multifaceted process of comprehensive geriatric assessment can be initiated – ideally from the moment they cross the threshold of the emergency department.
References:
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Dalhousie University – Canadian Frailty Scale
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The Cycle of Frailty – Image from: Xue, Q.L., Bandeen-Roche K., Varadhan, R., Zhou, J., & Fried, L.P. (2008). Initial manifestations of frailty criteria and the development of frailty phenotype in the Women’s Health and Aging Study II. Journal of Gerontology A: Biologic Science, Medical Science, 63(9), 984-90.
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The Frailty Trajectory – Image from: Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013 Jun;14(6):392–7.
Edit and Peer Review by R. Prest, J. Sillett and J. Banerjee
