Jun. 14 2013
Call to Action Aims to Establish Frailty as Medical Syndrome and Screening as a Standard Clinical Practice

Everyone older than 70 should be checked for frailty, a condition that is both readily treated and potentially deadly, according to an article by geriatricians representing six major international and U.S. medical organizations along with other leading experts on aging. The article, titled “Frailty Consensus: A Call to Action,” appears in the June edition of the Journal of the American Medical Directors Association.

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Linda P. Fried, MD, MPH, Dean of Columbia University’s Mailman School of Public Health and one of the authors of the article said, “With ever greater numbers of older persons, it is urgent that we confront the challenge frailty by recognizing it as a medical condition that can be slowed and even reversed. Establishing a new clinical standard for screening for frailty will help preserve health and extend the lives of millions.”

For the first time, the group of geriatricians agreed on a specific medical syndrome of physical frailty that has multiple causes and contributors and is characterized by diminished strength, energy, potentially by weight loss, and can lead to difficulty carrying out normal daily activities. Those with frailty are more likely to become dependent on others or even die. Their condition is tenuous; a health problem such as flu or a fractured hip can thrust them into disability or even be deadly. Between 5 and 10% of people aged 65 and older have signs of frailty, with women and those age 80 and older more likely to have the condition.

Dean Fried was the lead author of a 2001 paper in the Journal of Gerontology: Medical Sciences that was the first to define frailty as a clinical syndrome and propose criteria for identifying the condition. Dr. Fried has led teams of scientists who have defined the biologic alterations underlying the development of fraily and the risks associated with the condition. In the new paper, the authors recommend that primary care physicians and specialists use a simple screening quesioinnaire called FRAIL, which takes less than 15 seconds to administer, or other more definitive tools based on the criteria developed by Dr. Fried and colleagues.

The FRAIL tool asks five screening questions to identify those at high risk of being frail. Those who answer yes to at least three likely are frail and should see a physician for further evaluation and treatment.

  • Fatigue: Are you fatigued?
  • Resistance: Do you have difficulty walking up one flight of steps?
  • Aerobic: Are you unable to walk at least one block?
  • Illness: Do you have more than five illnesses?
  • Loss of weight: Have you lost more than 5 percent of your weight in the past six months?

In addition to recommending that primary care and specialist physicians perform frailty screening on everyone who is older than 70, the group suggested checking “younger” older adults who have lost a significant amount of weight because of a chronic condition.

Treating Frailty

The key to treating frailty is figuring out its root cause. In many cases, once frailty is identified, it can be treated with aerobic and resistance exercise, protein and caloric supplements, vitamin D and reduced medications, the scientists agreed. Another crucial factor is identifying frailty early in its development.

  • Exercise: A number of studies show that exercise – sometimes as little as 45 to 60 minutes three times a week – has positive effects on frail older adults. It can increase walking speed, stair climbing, ability to get out of a chair and balance while decreasing depression and a fear of falling.
  • Nutrition Supplements: Weight loss often accompanies frailty, so adding a supplement can stabilize weight and reduce mortality in those who are undernourished. Protein supplements can improve strength and muscle mass.
  • Vitamin D: For those who are deficient in vitamin D, adding a supplement holds promise in reducing falls and hip fractures and improving muscle function.
  • Reducing Inappropriate Medications: Polypharmacy—or taking five or more medications—increases the potential of bad side effects from poor drug interactions and possibly contributes to frailty. Those who are taking multiple medications should ask their primary care physicians specifically about side effects, potential effects of medicine combinations and if any medications can be cut out. Sometimes fewer medications are more beneficial than many.

John Morley, MD, director of geriatrics at Saint Louis University, is lead author of the paper. The paper is the result of a meeting in December 2012 held by representatives from international and national medical societies. The conference was convened in response to a white paper by the International Association of Gerontology and Geriatrics and World Health Organization recognizing the preference for older adults to age in their own homes instead of in long-term care facilities. The conference attracted experts in the field of frailty as well as representatives from the International Association of Gerontology and Geriatrics; Society on Sarcopenia, Cachexia, and Wasting Diseases; International Academy of Nutrition and Aging; European Union Geriatric Medicine Society; American Medical Directors Association; and American Federation for Aging Research.

The article was supported by grants from Sanofi and Nutricia Advanced Medical Nutrition (Danone).

Related:

"Learning to Spot Frailty," The New York Times (June 21, 2013)

VIDEO: Aging in America. A June 12 panel discussion with Dean Linda P. Fried, Rabbi Rachel Cowan, Rabbi Leonard A. Sharzer, and moderator Mark Meridy. Sponsored by the Jewish Theological Seminary.