Frailty and Pre-Frailty in Older Adults

Topics in Geriatrics: Frailty and Pre-Frailty in Older Adults

Frailty and pre-frailty are syndromes found in the elderly population that foretell disability, morbidity, and mortality.5 Screening to identify pre-frailty and treating the cluster of symptoms before they progress to frailty are crucial to ensuring longevity in the older adult.

Objectives:

            1. Understand frailty and pre-frailty and how they affect the older adult population

            2. Be able to evaluate whether a patient is pre-frail, frail, or non-frail

            3. Identify limitations in knowledge in the current literature on frailty

            4. Be able to implement interventions that target the older adult at risk for frailty holistically

What is Frailty?

Frailty is a clinical state of “increased vulnerability” resulting from age-related degeneration of multiple physiologic systems and functional abilities, and limited ability to be resilient against stressors to the system as a result.1 The consequences of frailty may include functional decline, disability, and loss of independence.2

What is Pre-Frailty?

Because frailty is a reversible state, the term pre-frailty has been created to identify an individual that has not yet reached the the level of disability of a frail individual, but is at a high risk of progressing to frailty. 1,2

In a cross sectional study that screened patients 70 years and older at primary care clinics for frailty, it was found that pre-frailty is more common than frailty, with 49% of people indicating characteristics of pre-frailty and only 31% indicating frailty.It was also found that pre-frail individuals were more likely to be obese, have diabetes, report pain, or have polypharmacy than non-frail individuals and that pre-frailty has also been linked to increased risk of hospitalizations, transitioning to longer term care, and death.2,3 Knowing these possible risk factors should alert the clinician that a patient should be screened for frailty.

How do I measure Frailty?

Frailty can be identified using a phenotypic chart generated by Fried et al. that has been since been adapted in several instances in the literature. Three out of five phenotypic characteristics must be identified in order to classify a patient with having frailty, and one or two characteristics must be identified in order to classify a patient with having pre-frailty. The following are the identifying characteristics: low grip strength, low energy, slowed waking speed, low physical activity, and/or unintentional weight loss.1 Patients' subjective report as well as the physical therapist’s assessment are required in order to complete this outcome measure. Below are the full criteria adapted by the Women’s Health and Aging Studies and Cardiovascular Health Study.

Identifying symptoms of frailty and pre-frailty is pivotal to the prevention of further deterioration of the patient’s condition. It has been noted that weakness is usually the first observable symptom, while exhaustion and weight loss are usually identified later in the process of decline.1,2

What Are Some Interventions for Frailty?

According to one systematic review by Frost et al., the consensus on best treatment practices to treat pre-frailty and frailty has not been made due lack of large and high quality studies. While no individual treatment recommendation can currently be made, studies show that exercise alone may not be enough to improve functional abilities, but behavioral and psychosocial factors may also need to be taken into account.3

Another systematic review by Apóstolo et al. showed that group physical exercise programs were found to be “generally effective” for postponing or preventing the progression of frailty. This may suggest that a group exercise setting not only improves physical fitness and functional capabilities but also allows patients to interact with one another, thereby creating social connections and improving accountability.4 This proposition supports the idea of Frost and colleagues, who also mention that mood, cognitive state, and loneliness can be additional determinants of frailty.3 The group exercise programs that showed improvement in frailty status included Tai Chi, resistance training with and without nutrition consultation, and comprehensive multicomponent training. These positive findings were found to be effective in community dwelling older adults, older adults aged 80-90 years contacted through the primary care center, and institutionalized older adults aged 85 and older, but not in housebound older adults.4

Besides exercise to prevent the progression of frailty, the provision of nutritional supplements like milk fat globule membrane and protein energy formula, increasing protein calorie intake, and increasing micronutrient intake also showed favorable results.4  Bonnefoy et al. encourage adopting the Mediterranean diet to promote healthy aging and prevent age-linked disability, and show that supplementing with fish oil in conjunction with strength training can enhance functional muscle strength. The Mediterranean diet often consists of raw vegetables, fruits, nuts, raw cereals, fish, and olive oil, with less emphasis on red meat compared to the traditional Western diet. It has also been shown that individuals with frailty were found to have lower levels of vitamin D, and supplementation is encouraged to prevent functional decline and muscle function.5 Education on nutrition and help with diet adherence may be an essential part of preventing or stopping the progression of frailty in the older adult.

Additional Resources:

1. Iowa Geriatric Education Center

https://igec.uiowa.edu/frailty

2. Fit for Frailty

http://www.bgs.org.uk/campaigns/fff/fff\_full.pdf

3. National Frailty Education Programme

https://tilda.tcd.ie/ppi/frailty-education/

4. Prevention of Frailty

https://www.merckmanuals.com/professional/geriatrics/prevention-of-disease-and-disability-in-the-elderly/prevention-of-frailty

5. Four Ways to Beat the Frailty Risk

https://www.hopkinsmedicine.org/health/healthy\_aging/healthy\_body/stay-strong-four-ways-to-beat-the-frailty-risk

References:

1. Xue, Q. (2011). The Frailty Syndrome: Definition and Natural History. *Clinics in Geriatric Medicine,27*(1), 1-15. doi:10.1016/j.cger.2010.08.009

2. Serra-Prat, M., Sist, X., Saiz, A., Jurado, L., Domenich, R., Roces, A., & Papiol, M. (2016). Clinical and functional characterization of pre-frailty among elderly patients consulting primary care centres. *The Journal of Nutrition, Health & Aging,* *20*(6), 653-658. doi:10.1007/s12603-016-0684-3

3. Frost, R., Belk, C., Jovicic, A., Ricciardi, F., Kharicha, K., Gardner, B., . . . Walters, K. (2017). Health promotion interventions for community-dwelling older people with mild or pre-frailty: A systematic review and meta-analysis. *BMC Geriatrics,* *17*(1). doi:10.1186/s12877-017-0547-8

4. Apóstolo, J., Cooke, R., Bobrowicz-Campos, E., Santana, S., Marcucci, M., Cano, A., . . . Holland, C. (2018). Effectiveness of interventions to prevent pre-frailty and frailty progression in older adults. *JBI Database of Systematic Reviews and Implementation Reports,* *16*(1), 140-232. doi:10.11124/jbisrir-2017-003382

5. Bonnefoy, M., Berrut, G., Lesourd, B., Ferry, M., Gilbert, T., Guerin, O., . . . Rolland, Y. (2014). Frailty and nutrition: Searching for evidence. *The Journal of Nutrition, Health & Aging,* *19*(3), 250-257. doi:10.1007/s12603-014-0568-3