Frailty – The what, why and how to manage

Ever heard the expression "old and frail"? Have you ever wondered what frail means? Is it just another word for old, or is it something else?

Frailty is a delicate issue. But an important one.

What is frailty?

Frailty is formally defined as a "state of increased vulnerability to poor resolution of homeostasis after a stressor event" (Clegg, 2013). We all experience minor setbacks from time to time, ranging from a simple papercut to a common cold. While many of us bounce back from these quite quickly, a frail person may not fully recover from them quickly or ever. 

Another way to think about it is that we all have a certain physical capacity. Normally, our everyday tasks only require a fraction of this capacity and there is plenty left over in the tank. However, in someone experiencing frailty, that tank is much smaller. The difference between the energy they spend in everyday tasks and their total capacity is quite small.  

Figure 1. Effects on physical capacity following minor setback in frail vs non-frail people. Having a higher level of physical capacity at baseline means a person is likely to recover well and remain independent following a minor setback. However, a minor setback may result in worse outcomes for a frail individual with lower physical capacity at baseline. [Figure adapted from Clegg (2013)].

Why is it important to understand frailty?

Understanding frailty is important so we can identify and address it as early as possible.

While someone may appear to be healthy and independent, if doing everyday tasks feels like running a marathon to them, then they may be suffering from frailty. This means, a minor setback is likely to have a much greater impact on their health and may lead to a rapid decline in their health. 

A frail person is also more likely to have a major setback (what many call an adverse event). For health professionals, it is important to identify such patients and monitor more closely and routinely.

Is frailty just a part of ageing?

No. 

Just because someone is old, doesn't mean they have to be frail. 

However, frailty is quite common among older people. Estimates suggest that ~10 % of older people are frail and ~44% of them are pre-frail (at risk of frailty). To put it in perspective, this suggests that over 2 million older Australians are either frail or pre-frail. 

Can we reduce frailty?

Yes. Fortunately there are ways of reducing frailty. 

However, properly addressing frailty requires a number of health professionals to work together. The process will typically include:

1. A comprehensive geriatric assessment by a GP or geriatrician (specialist in older people's health). They will conduct the assessment with a holistic view of health and identify specific areas requiring attention. This may include a review of current medication, vision, hearing and other factors affecting your health.

2. A tailored exercise program designed by a specialist in exercise prescription (Exercise Physiologist). Exercises will increase the individual's strength and fitness and improve their overall physical capacity. This means they can perform the same tasks with less effort. 

3. A tailored diet plan by a dietician may also be needed to address weightloss and weakness. 

What can I do?

Firstly, recognize that frailty is common but not normal. We need to educate ourselves and each other about frailty and what it looks like. If we then notice any of these signs in ourselves or the people around us, we need to take action.

What does frailty look like? 

There are some common signs of frailty: 

1. Weight loss – more than 5% per year

2. Exhaustion – feeling unusually tired most of the time

3. Low energy – doing less activity during the day

4. Slow walk – a decrease in one's walking speed

5. Hand weakness – a decrease in grip strength

While helpful, this list is not exhaustive. There are other signs which may point towards frailty.

Key references

1. Chen, C. Y., Gan, P., & How, C. H. (2018). Approach to frailty in the elderly in primary care and the community. Singapore Medical Journal, 59(5), 240–245.

2. Clegg, A., Young, J., Iliffe, S., Rikkert, M. O., & Rockwood, K. (2013). Frailty in elderly people. The Lancet, 381(9868), 752–762.

3. Fried, L. P., Tangen, C. M., Walston, J., Newman, A. B., Hirsch, C., Gottdiener, J., … McBurnie, M. A. (2001). Frailty in Older Adults Evidence for a Phenotype. The Journals of Gerontology. Series A, 56(3), M146–M157.

4. Xue, Q. L. (2011). The frailty syndrome: definition and natural history. Clinics in Geriatric Medicine, 27(1), 1–15.

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ABOUT THE AUTHOR

Hassan Qureshi is the founder and AEP of Holistic Exercise Physiology. He believes educating and communicating good science to the wider public is not only important but is the responsibility of every clinician. For this reason he started the Holistic blog.

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If you would like to see Hassan Qureshi, you can meet him online or visit him at a clinic.