Mr. W is an 84-year-old White retired farmer who presents at his primary care provider's office accompanied by his wife and daughter. Mr. W appears well nourished and fairly robust. Medical history includes hypertension, hyperlipidemia, hypothyroidism, benign prostatic hypertrophy, and mild-to-moderate Alzheimer disease (AD). Mr. W has no history of alcohol use/abuse but has a 60+ year history of tobacco use. Mr. W says he stopped using tobacco about a year ago.
Mr. W and his wife of 57 years live on a farm. Their daughter lives 200 miles away. Their son lives close by and helps Mr. W on the farm as needed. Mrs. W cooks his meals, provides housekeeping, and assists him with medications. She says that Mr. W's confusion is "worse" when he is inactive and unable to get outside "during bad weather." She adds that he wakes up during the night several times a week asking her about "going home." Recently, he has had trouble finding the bathroom in the house.
The patient reports a "good" appetite, but Mrs. W says that they both eat less meat than in years past. No weight loss has been noted. Mrs. W notes that her husband is not outside very often and naps in his recliner "a lot." His daily walk to the barn to feed the cows in the evening is now "exhausting to him," she states. Mr. W admits to falling several times over the last 18 months without injury but is unsure of the cause or frequency.
Mr. W's daughter reports he "came down with a bad cold" 8 months ago and was diagnosed with pneumonia by the urgent care physician. The pneumonia reportedly resolved after a few weeks of antibiotic therapy, but Mr. W was very weak and more confused for weeks. A month later, Mr. W had a "stomach bug" or virus with poor appetite and diarrhea. Two months ago, Mr. W suffered a shoulder injury while working in the garden and was diagnosed with tendonitis; a prednisone dose pack was ordered by the urgent care provider. Within 4 days of completing the dose pack, Mr. W experienced delirium that included new-onset incontinence, an inability to perform activities of daily living, and two falls without injury.
On exam, Mr. W is an alert and cooperative, obese older gentleman. Vital signs are: T 98.4[degrees] F, pulse 78, respirations 20, and BP 124/76. Height 5 feet 9 in. Weight 225 lb (102.1 kg). Body mass index 33. A complete metabolic profile, complete blood cell count, lipid panel, vitamin D level, and thyroid panel test results are within normal limits for his gender and age. He still complains of right shoulder pain and rates it an 8 on a 0-10 scale, with 0 being no pain and 10 being the worst pain. There is limited range of motion in the right shoulder. Mr. W is intact neurologically except that he is oriented to place and person only. The cognitive assessment reveals mild-to-moderate dementia. Capillary refill was noted as prompt in all four extremities, and +1 pedal edema was noted in his lower legs and feet. Respirations are effortless at rest. His timed up and go (TUG) test result was 9 seconds.
The need to recognize frailty
As the population of the world ages, the ability to recognize frailty in older adults is becoming more important than ever. Frailty has been shown to increase in both incidence and severity with age and poses a high risk for adverse health outcomes, such as falls, hospitalization, and possibly mortality.1 Frailty is not associated with a single disease, but with loss of function associated with malnutrition and inflammation.2 The prevention of frailty, when possible, along with the initiation of intervention, may slow decline, reduce the chance of adverse outcomes, and reduce healthcare costs.3,4 The recognition of prefrail and frail older adults early in clinical practice ensures that both patient and family members can be involved in discussions regarding the patient's care goals.5 Nurse practitioners (NPs) are well positioned to provide older adults with patient-centered, individualized care.
Frailty as a geriatric syndrome
Frailty is a "long-established clinical expression that implies concern about an older person's vulnerability and outlook."6 Using data from the Cardiovascular Health Study, Fried and colleagues attempted to define frailty as a syndrome.1 What emerged from the data of over 5,000 older adults were different phenotypes identified as relating to frailty. These include muscle weakness, loss of lean muscle mass (sarcopenia), unintentional weight loss, weakness, and susceptibility to falls, trauma, and infection.1 Although consensus among experts is that frailty is a condition described when a number of these impairments are present, there is no single definition of frailty.7
Current definitions of frailty syndrome
Current definitions of frailty fall within two schools of thought. One thought is that frailty is the outcome of accumulated disease states that increases the older adult's risk for mortality. This definition utilizes the concept of accumulation deficit that includes up to 75 criteria, including chronic disease and disability states. The individual's deficit scores are totaled. The higher the deficit score, the more advanced the frailty state.8
The second definition describes frailty as a distinct physiologic process resulting from the dysregulation of multiple systems within the body. Dysregulation leads to decreased muscle mass (sarcopenia) with decreased strength, low exercise tolerance with self-reported fatigue, slowed walking speed, diminished physical activity, and inadequate nutrition intake, resulting in unintentional weight loss that is greater than 5% body weight in 6 months or less. This definition of frailty stems from the work of Fried and colleagues and is most commonly accepted.1 Research has shown this definition to be consistent with that of a clinical syndrome.1 According to this criteria, the older person with three or more of these manifestations is considered to be frail. The presence of less than three criteria indicates prefrailty.1 Prefrailty is described as the state between frail and robust (nonfrail) and indicates the dynamic nature of frailty.9
While these two operational definitions of frailty are the most widely used, there are many other variations.8 Recent literature has been published that now describes chronic inflammation, poor nutrition, persistent pain, and poor social support as factors that influence the diagnosis and progression of frailty.7,10 Despite the growing interest in frailty as a syndrome over the past 25 years, there is still no uniform definition of frailty. More research is needed in order to conceptualize the definition of frailty and create standardized tools so that it may be recognized more quickly.7
The prevalence of frailty
In the 2001 Cardiovascular Health Study, participants assessed as frail were older, more likely to be female and Black, and had higher rates of disability and coexisting chronic diseases.1,11,12 In a study by Song, Mitnitski, and Rockwood, it was concluded that the prevalence of frailty increased with age and shortened survival.13
Incidence has also been repeatedly shown to be higher in females than males.8,13 This is thought to be due to the fact that women have a longer life expectancy; because frailty increases with age, women are more likely to become frail. Increased incidence of frailty in women has been theorized as being due to an increased fear of falling in women with subsequent reduced physical activity, lower average amounts of lean body mass, and muscle strength.1,13
Factors that have been found to predispose older Latin American adults to frailty include poverty and malnutrition as well as lack of education and employment.2 Incidence, however, has been noted in wide ranges. Standardized tools are needed so that research is more consistent and there is less variability among results.
The pathophysiology of frailty
Research indicates that frailty results from the dysregulation of interacting body systems in advanced age.1 This dysregulation, after a period of time, reduces reserve. This loss of reserve and resilience is the catalyst for the robust older adult to become frail. Muscle wasting, poor nutrition, inflammation, persistent pain, and comorbid disease states may predispose the older adult to frailty. The frail older adult, when faced with such stressors as infection, injury, or change in environment, is at risk for adverse events, such as falls, hospitalizations, institutionalization, and even death. With such a health status change, an independent frail older adult may become permanently dependent.6
Body and muscle mass is important in maintaining the health and robustness of an older adult. Loss of muscle mass or sarcopenia is a major component of frailty syndrome. Evidence suggests that muscle wasting is apoptosis driven at the cellular level.14 Anorexia is defined as loss of appetite or reduced food intake and can be the catalyst for muscle wasting in the older adult. This anorexia of aging is thought to be due to age-related declines in the activity of the hypothalamus and an impaired response to ghrelin and cholecystokinin-hunger hormones. These alterations may be the cause of reduced hunger and unintentional weight loss in older adults. Altered taste and smell, proinflammatory cytokines that activate neurons involving satiety and hunger, as well as inability to chew due to edentulism, delayed gastric emptying, decreases in gastric and pancreatic enzymes along with a global decrease in the intake of nutrient-rich foods play a key role in the development of cachexia and sarcopenia in the older adult.15 The progressive weakness due to muscle loss leads to loss of strength and mobility. Loss of strength and mobility may lead to dependence. (See The frailty cycle.) In addition, low serum levels of vitamins such as A, B6, B12, folate, C, D, and E, as well as mineral deficiencies of calcium, zinc, and selenium have all been independently associated with frailty indicators.2
Other conditions that have been theorized as contributing to the frail condition in the older adult include chronic disease, poor nutrition, inflammation, persistent pain, and poor psychosocial and economic support. Results from the landmark study by Fried and colleagues indicate that older persons had a greater tendency of developing frailty when two or more major chronic diseases such as cardiopulmonary disease or diabetes were present.1 Older adults may be at higher risk for coronary events and orthostatic hypotension-related falls with aggressive treatment of hypertension.16 There is accumulating evidence that supports an association between frailty, cognitive impairment, and dementia.17 Clegg and colleagues describe the "frail brain" as associated with structural and physiologic changes in the brain, especially in the area of the hippocampus that has been identified as important mediator in cognitive changes and AD.6 The hippocampus is a key area of the brain involved in regulation of the stress response.
Inflammation is individually associated with frailty. Increased levels of proinflammatory factors such as interleukin-6, a cytokine inflammatory marker, tumor necrosis factor, and C-reactive proteins have been related to frailty in older adults.2 Inflammation is now known to be associated with many chronic diseases that predispose an older person to frailty, including cardiovascular disease, anemia, diabetes mellitus, and chronic kidney disease.18 Chang and colleagues concluded that interactions may occur between certain co-occurring inflammatory diseases that heighten an older adult's risk of frailty.18 Frailty is strongly linked to sarcopenia, and these proinflammatory factors are known to cause injury and prevent muscle repair.2 Dysregulation of the cellular response to aging and stressors is thought to contribute to the sarcopenia and inflammatory process that leads to frailty.14
Moderate or higher pain has also been shown to independently be associated with frailty.10 Findings support the idea that persistent pain diminishes "physiological reserves" that may predispose the person to the development of frailty.10 Therefore, the treatment and control of persistent pain may slow progression or reverse frailty in the older adult.
Frail older adults are known to be particularly vulnerable to stressors. De Witte and colleagues concluded that frailty may be related to stressors stemming from a lack of social support or interactions, especially emotional loneliness and poor environmental surroundings.19 Addressing frailty with a more holistic approach may better guide interventions to prevent adverse outcomes, hospitalization, or even death.19 Connecting older adults with resources for social support may also slow the progression of frailty and improve the individual's quality of life.
The assessment of frailty
The recognition of prefrail and frail states is crucial in providing optimal primary care to older adults. A panel of United States and European gerontology experts urged all providers to periodically screen adults older than 70 for frailty.20 Consider the risk of frailty in older adults following physiologic and psychological stressor or exacerbation of a chronic illness.
There are numerous frailty screening tools available as clinical resources (see Frailty assessment tools).21 Tools that have been researched for efficacy and found reliable include the Fried Frailty Index (FFI), the Edmonton Frail Scale (EFS), the Clinical Frailty Scale (CFS), and the FRAIL scale.1,15 The FFI requires the presence of three or more of these five criteria: weight loss, exhaustion, weakness, slowness, and low physical activity.1 The FRAIL scale was proposed by the International Association of Nutrition and Aging and only requires answers to five simple questions.11 The Frailty Index (FI) is based on the routinely used comprehensive geriatric assessment (CGA) and involves aspects from a broader perspective, including mood, cognition, and incontinence.12 More recently, the Survey of Health, Ageing, and Retirement in Europe (SHARE-FI) frailty instrument has been developed and tested for reliability.22 The SHARE and SHARE-FI tools involve the patient or caregiver by asking questions regarding appetite, strength, exhaustion, and physical activity. In addition, the provider gives information about medications and illness.22,23 Bilotta and colleagues recognized the Study of Osteoporotic Fractures (SOF) criteria is effective in predicting adverse health outcomes.24 The Comprehensive Frailty Assessment Instrument (CFAI) was developed and its validity supported recently by De Witte and colleagues in Belgium. The CFAI includes frailty in physical, psychological, social, and environmental domains.19
There are also self-reporting screening instruments used to identify frail older adults. A study conducted by Hoogendijk et al compared five simple measurement instruments: the general practitioner's judgment, prescription of multiple medications, the Groningen Frailty Index (GFI), the Program on Research for Integrating Services for the Maintenance of Autonomy (PRISMA-7) tool, and the Functional Autonomy Measurement System (abbreviated from French as SMAF) rating scale.25 While providing valuable screening information, self-rating questionnaire-type frailty screening tools are subjective and have a risk for nonresponse.
Finding a valid and simple tool to use in primary care is the first step toward recognizing this complex syndrome among older adults. A standardized definition may give rise to such a tool. Until then, the older adult must be assessed for the presence of frailty because it is a dynamic syndrome that may be preventable.20
In the case of Mr. W, he appears strong and has experienced no weight loss. In fact, he is of the sarcopenic obese group of older adults. Despite his recent history of falls, the TUG test does not indicate a risk of falls. He does admit to being easily exhausted, and this information was confirmed by his wife. She reports that his physical activity is limited. His medical history of hypertension, hypothyroidism, and dementia put him at risk for frailty as well. The fact that in the last 6 months, Mr. W has experienced illnesses and injury that have negatively impacted his mental and physical health is also a reason to more thoroughly assess him for frailty. Mr. W is considered prefrail and is in need of close monitoring by his primary care provider in order to minimize and/or avoid adverse outcomes. Conducting a CGA is imperative to recognize the prefrail or frail older adult. This information is invaluable in decision making and care planning shared between patient, family, and provider.
Prevention and treatment
Periodic CGA and management strategies are necessary to provide the best possible outcomes for older adults. Morley and colleagues recommend to assess and intervene when frailty is identified in the older adult, provide treatment, including prescribing aerobic and resistance exercise, caloric and protein supplements, vitamin D, and reduced medications.20 An interdisciplinary approach to treatment can positively affect functional status, prevent falls and polypharmacy, hospitalization, institutionalization, and mortality.3 In a comprehensive review of the literature, Heuberger cited numerous studies with evidence that physical activity may prevent, delay, treat, and even reverse sarcopenia and frailty in older adults.2 With increased strength and physical activity, the vicious cycle of frailty may be stopped. Mr. and Mrs. W. should be instructed on the importance of regular physical activity. If the patient is unsteady or weather is inclement, the suggestion of a chair exercise video would be appropriate. Mr. W should certainly be encouraged to perform his prescribed exercises for his injured right shoulder in order to maintain range of motion and reduce pain. Adequate nutrition is also essential for increased strength. Malnutrition or dietary deficits of calories and micro- or macronutrients have been associated with poorer outcomes, poor quality of life, and mortality.2 Strategies such as supplements and flavor augmentation may improve appetite and caloric intake. Meals on Wheels, assisted feeding, improved eating environment, and/or social dining may improve nutrition status as well.2 Low serum vitamin D levels defined as less than 15 ng/mL were associated with a 3.7-fold increased risk for frailty in a study by Wilhelm-Leen and colleagues.26 Thus, vitamin D supplementation may assist in the prevention and/or treatment of frailty. Mr. W reports a good appetite, but a detailed nutritional assessment should be conducted and instructions given to Mrs. W. regarding strategies to improve protein intake within their diet. Mr. W is encouraged to continue his multivitamin supplement.
Pharmacologic intervention for frailty has been investigated with different degrees of success, but none are currently recommended. More importantly, it should be noted that frailty has been strongly associated with pharmacokinetic responses rather than chronological age.27 Prescribing medication for the prefrail or frail older adult needs to be done with caution due to an increased incidence of adverse drug reactions. Mr. and Mrs. W. should be instructed to visit the primary care provider regularly; and if an urgent care visit is necessary, then followup with the primary provider should occur as soon as possible.
Conclusion
The presence of frailty, a complex geriatric syndrome in older adults, increases the risk of adverse outcomes with the most minor of stressors. Adverse outcomes may include hospitalization, institutionalization, or death. In order to prevent or limit frailty, an ongoing CGA of older patients must be performed and multimodal interventions initiated to preserve muscle mass, strength, mobility, and physical activity. Vellas and colleagues describe the recognition and treatment of frailty as being "the new area in geriatric medicine."28 The need for the development and application of strategies to recognize and treat frailty in a timely manner is noted as one of the top priorities in both gerontology, general practice, and public health.9,24 The NP is the key person to recognize the prefrail and frail so that an individualized treatment plan may be formulated to minimize adverse events experienced by the patient.
Frailty assessment tools1,11,20-25
Provider-conducted tools
* FFI
* FRAIL scale
* EFS
* CFS
* SHARE/SHARE-FI
* SOF scale
* CFAI
Self-reporting questionnaire tools
* GFI
* Tilburg Frailty Indicator
* Sherbrooke Postal Questionnaire
* PRISMA-7 tool
REFERENCES