The topic of frailty in older adults is the focus of this edition of Topics in Geriatric Rehabilitation. Frailty is an under-recognized concept as it has not received the attention in the rehabilitation literature that it requires; therefore, frailty is an under-recognized concept, and yet is critical to rehabilitation outcomes. A global perspective of frailty-its consequences, assessment, and intervention-is provided from esteemed authors from Singapore, Canada, Australia, and the United States.
Frailty, defined as an increased vulnerability to stress (eg, surgery or illness), is common in rehabilitation settings because energy, strength, and physical activity are key variables of frailty. The Fried's 5 criteria, the most popular way of assessing frailty, are particularly relevant to therapists because of their emphasis on the physical presentation of frailty. While therapists routinely assess strength, gait speed, and aerobic capacity (a proxy for energy), too often the findings are not seen as a pattern, much less a pattern with consequences. In this era of COVID and post-COVID where most older adults reduced their activity, prefrailty and frailty are conditions seen so commonly as to be accepted, rather than seen as red flags, as threats to quality of life and health.
The consequences of having frailty are highly relevant to the therapist, including longer hospitalization, less robust recovery from surgery, longer and poorer rehabilitation outcomes, failure to achieve a prior level of function, and rehabilitation recidivism. Additionally, individuals who are frail often have difficulty tolerating the level of intensity that denotes skilled care. Because of this difficulty, rehabilitation may not be successful, with the onus placed on the frail individual, rather than on inappropriate placement. For example, Flint and colleages1 call out the practice of calling postacute care facilities "rehab." They explain that the process of being "rehabbed to death," one of cycling between hospital and the postacute care facility while health and function are declining, is a way of avoiding the conversation about preparing for the end of life. The authors cite the statistic of "nearly one-third of Medicare decedents used the SNF benefit in the last 6 months of life."1 When "rehab" (which implies improvement and restoration of physical function) is used instead of palliative care, rehab can build unjustified hope for families and patients while implying an expectation of improvement, which requires great effort on the part of the patient. I am sure all of us have experienced the referral of the frail patient and wondered at the appropriateness of skilled rehabilitation, especially when the family is pushing the patient to participate, and the patient is less than enthusiastic. The cycling of patients between hospital and postacute facility is a function of Centers for Medicare & Medicaid Services payment policy that does not require comprehensive end-of-life care-care that could help patients and their caregivers prepare for the kind of end of life that is planned and anticipated. Instead, we experience an expensive pattern that places therapists in the middle of this cycle, with no good outcomes.
Because of these consequences and patterns, frailty needs to be recognized as a common pattern that can predict outcomes. The state of prefrailty (having 1-2 of Fried's 5 criteria) is the window of opportunity to avoid frailty, which is having 3 to 5 of the criteria. Evidence cited in several of the articles in this issue demonstrates that only 1 in 4 people move from the prefrail to robust (nonfrail) state, and 1 in 3 move from the frail to prefrail or robust state.2 Therefore, if the frail state is found through an assessment of the Fried criteria (see the Ciolek, Prevett, and Perazza articles), appropriate counseling can be conducted with the patient and family to prepare them for the downward trajectory that frailty most often implies. Appropriate discharge plans can be made that may result in a higher quality of life, one that the patient and family design.
Chia and colleagues of Singapore discuss the consequences of the frail condition on common abdominal surgical procedures, advocating for assessment of frailty to provide a context for decision-making regarding the type of surgery and/or use of more conservative therapeutic regimens. The authors discuss the options of conservative care on specific types of surgical conditions and why assessing frailty is so important. The authors also discuss prehabilitation as a protective factor for reducing postoperative complications in high-risk patients undergoing elective abdominal surgery and share their remarkable outcomes. They provide an overview of 10 years' experience in their hospital in Singapore that demonstrate shortened length of stays and returning patients to their baseline function.
Perazza and Thompson provide a thorough overview of assessment methods for frailty. They discuss the complexity of the physiological features of frailty and their consequences on the development of varied assessment tools. Therapists will find their article helpful in selecting the most appropriate assessment tool for their patients.
Auais' background as a scholar of geriatrics and a clinical therapist in Canada provides him with an excellent perspective of the intersection between frailty and fragility fractures, namely hip fractures. He discusses this relationship with a thorough review of the literature presented in an easy-to-read table and then discusses clinical considerations for acute and postacute care.
His recommendations for future research on hip fracture and frailty are particularly valuable for other scholars. Interestingly, the World Health Organization is recognizing that intrinsic capacity, another term for frailty, may provide a holistic picture of the individual's reserves before and after a fragility fracture, providing an opportunity to optimize that intrinsic capacity and thus provide a model for prevention.3
Ciolek and Ross address the topic of cognitive frailty in a thorough description of the nuances of cognitive changes that may be due to frailty. They introduce 2 relatively new predementia syndromes of motoric cognitive risk and cognitive frailty that should be considered by any therapist working with individuals who are frail so as to address the cognitive changes as early as possible. The concept of early recognition of cognitive changes is similar to the importance of recognizing prefrailty in its earliest stages so as to have the most impact. They provide many helpful tables and tools with which to assess cognitive changes.
Treacy and Sherrington in Australia contribute their expertise to this issue with their article on frailty's impact on mobility. Having just completed a systemic review on this topic,4 this article is a wonderful synthesis of rehabilitation interventions for improving mobility in individuals with frailty. They found that for additional improvements to be made through exercise, the increase in dosage needs to be significant, to the order of 240% of additional practice (eg, from 25 to 90 minutes) to have a beneficial effect.
Cabrera, a clinical therapist and director of a geriatric residency, has extensive experience with individuals who are frail. She writes an excellent article on the physical therapist management of frailty across multiple settings. She discusses the background of frailty, assessment, and intervention in clear terms that will benefit every therapist reading her article.
Prevett and Tang, in Canada, focus their article on prefrailty, the aspect of frailty that every therapist needs to be thoroughly indoctrinated in, as it is the window of opportunity for intervention. They discuss the identification of individuals in the prefrail classification of frailty, why prefrailty matters, and then what to do about the condition. They explore the interventions not only of resistance exercise but exergaming and nutrition.
Each article in this edition can be read without the context of the others, but taken together, the reader should be well-versed in the topic of frailty, recognizing that the continuum of frailty is a critical lens in which to view all older adults to optimize outcomes and quality of life.
-Dale Avers, PT, DPT, PhD, FAPTA
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