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Frailty

Frailty
Literature review current through: Jan 2024.
This topic last updated: Jun 12, 2023.

INTRODUCTION — Frailty is most often defined as an aging-related syndrome of physiological decline, characterized by marked vulnerability to adverse health outcomes. Frail older patients often present with an increased burden of symptoms including weakness and fatigue, medical complexity, and reduced tolerance to medical and surgical interventions. Awareness of frailty and associated risks for adverse health outcomes can improve care for this most vulnerable subset of patients.

Although there is no gold standard for detecting frailty, multiple frailty screening tools have been developed and utilized for risk assessment and epidemiologic study.

This topic will review the definitions, pathophysiology, prevalence, and diagnosis of frailty and clinical approaches that may attenuate vulnerability and relieve symptoms.

PREVALENCE — Many population-based studies of frailty have been performed using a variety of frailty measures. Although the prevalence of frailty varies with the tool used and with the population studied, prevalence in several studies in the United States ranges from 4 to 16 percent in community-dwelling men and women aged 65 and older [1-5] and up to 43 percent of older patients with cancer [6]. Pre-frailty (patients at risk for frailty who fulfill some, not but all, criteria for frailty) has a prevalence ranging from 28 to 44 percent in those over 65 years old [1,4,5].

A 2012 systematic review found that when frailty was defined on the basis of physical findings alone, overall prevalence in 15 studies (44,894 participants) was 9.9 percent; when psychosocial aspects were included in the definition, prevalence was 13.6 percent among eight studies (24,072 participants) [7]. In a European study (the Survey of Health, Ageing, and Retirement in Europe [SHARE]) comparing eight frailty scales, frailty prevalence ranged from 6 to 44 percent when applied to a database of individuals aged 50 to 104 years [8]. In a US study of people aged 90 and older, the prevalence of frailty was 24 percent for those aged 90 to 94 and 39.5 percent for those 95 and older [9].

In a study in the United States of nearly 6000 community-dwelling men aged 65 and older, at an average follow-up of 4.6 years, 54.4 percent of men who were robust at baseline remained robust, 25.3 percent became pre-frail, 1.6 percent became frail, 5.7 percent died, and the remainder could not be assessed [5].

HEALTH CONSEQUENCES AND MORTALITY — Frail older adults are less able to tolerate and adapt to stressors such as acute illness, surgical or medical interventions, or trauma than younger or non-frail older adults. This increased vulnerability contributes to increased risk for procedural complications, falls, institutionalization, disability, and death [10]. After adjustment for comorbidities, frailty predicts hip fractures, disability, and hospitalization [4]. Frailty also predicts adverse outcomes related to renal transplantation, general surgery (elective and emergency), and cardiac surgery interventions [11-15]. As such, frailty in older patients is considered to be the hallmark geriatric syndrome that is a forerunner to other geriatric syndromes, including frequent falls, fractures, delirium, cognitive impairment, and incontinence.

Frailty is associated with increased mortality:

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In the longitudinal Women's Health Initiative Observational Study, mortality was increased in those with baseline frailty (HR 1.71; 95% CI 1.48-1.97) [4].

In a study in men, mortality was twice as high for frail, compared with robust men (HR 2.05; 95% CI 1.55-2.72) [5].

In a European study, mortality was best predicted by the Frailty Index and Edmonton scales, with death rates three to five times higher in cases classified as frail compared with those not classified as frail [8].

In analysis of data from the Longitudinal Aging Study Amsterdam, in which 2874 adults aged 64 to 84 years were followed for 21 years, frailty (defined as ≥0.25 on the 32-item frailty index) was associated with greater four-year mortality (odds ratio [OR] 2.79, 95% CI 2.39-3.26) [16].

In a cohort study of over two  million United States veterans aged 65 years or older, the risk of suicide attempt was higher in patients with all levels of frailty (prefrailty and mild, moderate, and severe frailty) compared with those without frailty, as measured by the frailty index assessing morbidity, function, sensory loss, cognition and mood, and other functions [17].

CONCEPTS AND DEFINITIONS

Overview — It is generally recognized that the term “frailty” captures the essence of age-related vulnerability and decline, and that it can be useful in clinical practice [18,19]. At present, there are two major conceptual frameworks for the term “frailty” that have influenced the development of multiple frailty measurement tools.

Physical frailty, often termed phenotypic or syndromic frailty, was developed in part to capture representative signs and symptoms (fatigue, low activity, weakness, weight loss, and slow gait) of community-dwelling older adults that were most vulnerable to adverse health outcomes.

Deficit accumulation frailty or index frailty was developed around a conceptual framework that identifies the most frail, vulnerable older adults through cumulative comorbidities and cumulative illnesses as frail.

In both physical frailty and deficit accumulation frailty, advanced frailty is consistent with advanced vulnerability. Indeed, comparability studies have found that those who are most vulnerable can be found by either tool. However, substantial discordance at individual level classifications exists between the conceptual frameworks in the more intermediate levels of frailty [20].

Acceptance of a standardized definition for frailty in clinical practice has been slowed in part by a proliferation of frailty measurement tools with differing conceptual bases and that often fail to differentiate between disability, comorbidity, and frailty. A summary of conceptual commonalities includes [18,19,21,22]:

Multiple factors (medical, environmental, educational, and psychological background) impact frailty, functional status and physiologic reserve among older adults.

Age, chronic comorbidities, and disability, while associated with frailty, do not establish the diagnosis of frailty [1,22-24].

Frailty exists on a spectrum. The end stage of the continuum of frailty is often considered to be failure to thrive. (See "Failure to thrive in older adults: Evaluation" and "Failure to thrive in older adults: Management".)

Old age itself does not define frailty. Many older adults remain vigorous, despite advanced age, while others have gradual yet unrelenting functional decline in the absence of apparent disease states, or failure to rebound following illness or hospitalization.

Instruments developed to identify frailty — Efforts to incorporate frailty measurement tools into both subspecialty and primary care practices continue to increase [25,26]. Over the past several years, multiple frailty assessment tools have been developed to help identify frail patients. Most have been validated in their ability to identify those individuals at highest risk for adverse health outcomes in a variety of clinical settings.

A 2016 comprehensive review of the most frequently cited frailty measurement tools identified 67 different frailty instruments, capturing varying domains and criteria depending upon the intended use of the instrument [27]. A subsequent study found a wide range of agreement (no agreement to almost complete agreement) among these instruments when tested in the same population [28].

The majority of screening tools used to determine frailty status have been developed based upon one of two concepts: "physical" or "phenotypic" frailty versus "deficit accumulation" or "index" frailty [25,29,30] (see 'Overview' above). Physical or phenotypic frailty is thought to result from multisystem biological decline leading to specific symptoms such as weight loss, weakness, and walking speed. Deficit accumulation or index frailty is measured by tabulating the combination of comorbidities, social situations, and disabilities (rather than a specific biology per se) to assess risk.

The physical frailty screening tool most often cited is often called the Fried Frailty Tool or Frailty Phenotype [27]. This tool was developed to identify physical frailty in community-dwelling older adults and was validated in the Cardiovascular Health Study (CHS), which involved over 5000 men and women aged ≥65 years [1], and multiple other studies [11,12,31,32]. This tool requires patient participation and specialized equipment for grip strength and walking speed measurements and defines the frailty phenotype as meeting three or more of the following five criteria [1]. Pre-frailty is defined as one or two of these characteristics, and not frail as having none:

Weight loss (≥5 percent of body weight in last year)

Exhaustion (positive response to questions regarding effort required for activity)

Weakness (decreased grip strength)

Slow walking speed (gait speed) (>6 to 7 seconds to walk 15 feet)

Decreased physical activity (Kcals spent per week: males expending <383 Kcals and females <270 Kcal)

The deficit accumulation or index approach to measuring frailty is based on the accumulation of illnesses, functional and cognitive declines, and social situations that are added together to calculate frailty [33]. It requires answering 20 or more medical and functional-related questions. The higher the number of deficits, the higher the frailty score. The tool can be adapted to information available in the medical record and does not require a patient interview or exam for tabulation.

Although there may be biological connections between mild cognitive impairment/dementia and frailty, the most commonly utilized physical frailty measurement tools do not incorporate cognitive assessment [34]. However, frailty is associated with an increased risk of cognitive decline [35,36]. In addition, the presence of cognitive impairment increases the likelihood of adverse health outcomes in geriatric patients who meet criteria for physical frailty. In a 2011 systematic review of 22 articles addressing the definition of frailty, cognitive measurements were commonly included in frailty screening, mostly in tools assessing frailty based on cumulative deficits rather than physical frailty [21].

Rapid screening tools — Although the frailty phenotype assessment and the frailty index approach are the most commonly cited and most validated approaches to frailty measurement, clinicians and patients may benefit from using a quicker frailty screening assessment tool. Such tools allow clinicians to more quickly flag vulnerable older adults and work to alter care plans based on this vulnerability. Several studies have compared the most commonly utilized screening tools and found that these indices were comparable in predicting risk of adverse health outcomes and mortality [2,37,38].

In addition, several of the rapid screening tools described below can be utilized to identify those who might need a more formal comprehensive geriatric assessment (CGA) [39].

A tool that takes only minutes to perform, and can be incorporated into the history-taking part, is the FRAIL scale, which is presented in a slightly modified version below [40,41]. The mnemonic "FRAIL" is helpful in remembering the component questions:

Fatigue ("Have you felt fatigued? Most or all of the time over the past month?") Yes = 1, No = 0

Resistance ("Do you have difficulty climbing a flight of stairs?") Yes = 1, No = 0

Ambulation ("Do you have difficulty walking one block?") Yes = 1, No = 0

Illnesses (“Do you have any of these illnesses: hypertension, diabetes, cancer (other than a minor skin cancer), chronic lung disease, heart attack, congestive heart failure, angina, asthma, arthritis, stroke, and kidney disease?”) Five or greater = 1, fewer than 5 = 0

Loss of weight (“Have you lost more than 5 percent of your weight in the past year?”) Yes= 1, No = 0

Frail scale scores range from 0 to 5 (0 = best, 5 = worst) and represent frail (3 to 5), pre-frail (1 to 2), and robust (0) health status.

Another assessment tool known for its ease in administering in most clinical settings is The Study of Osteoporotic Fractures (SOF) frailty tool [37]. Frailty is defined as the presence of at least two of three components:

Weight loss of 5 percent in last year;

Inability to rise from a chair five times without use of arms; or

A "no" response to the question "Do you feel full of energy?"

The Edmonton Frail Scale has 14 questions that cover a variety of important domains, including cognition, general health, function, social support, and nutrition. This validated tool, while not diagnosing physical frailty or deficit accumulation frailty per se, is useful to identify a number of measurement domains that are important to the health care of older adults [42]. Indeed, this tool functions like a short version of a CGA, which in turn may be helpful in the identification of more areas that may benefit from further diagnostic efforts or care management plans.

Finally, the Clinical Frailty Scale is a rapid frailty screening tool that is scored between 1 (very fit) and 9 (terminally ill) based on self-report of comorbidities and the need for help with activities of daily living (ADLs) (figure 1) [43].

PATHOPHYSIOLOGY — There is increasing evidence that dysregulated stress response systems, including immune, endocrine, and energy response systems are important to the development of physical or syndromic frailty. The basis of this dysregulation and ultimately frailty is hypothesized to be driven by aging-related molecular changes, genetics, chronic environmental exposures, and specific disease states (figure 2) [44]. Sarcopenia, or age-related loss of skeletal muscle and muscle strength, is a key physiologic component of frailty. Decline in skeletal muscle function and mass are often consequences of age-related hormonal changes [45-48] and changes in inflammatory pathways, including increase in inflammatory cytokines [49].

Endocrine — Multiple age-related hormone changes have been associated with frailty (see "Growth hormone deficiency in adults"):

Decreased growth hormone and insulin-like growth factor (IGF)-1 [45,50,51] – Associated with lower strength and decreased mobility in a cohort of community-dwelling older women [52].

Decreased dehydroepiandrosterone sulfate (DHEA-S) [45] – DHEA-S likely plays a direct role in maintaining muscle mass and indirectly prevents the activation of inflammatory pathways that contribute to muscle decline [53].

Increased cortisol levels [54] – May impact skeletal muscle and immune system components.

Decreased sex steroids – Evidence is mixed that lower levels of reproductive hormones contribute to frailty [55-58].

Decreased 25(OH) vitamin D [59].

Inflammation and the immune system — Direct biological connections between chronic exposure to inflammatory mediators and pathophysiological tissues changes consistent with frailty are increasingly evident.

Serum levels of the proinflammatory cytokine interleukin (IL) 6 and C-reactive protein (CRP), as well as white blood cell and monocyte counts, are elevated in community-dwelling frail older adults [45,59-62]. In addition, elevated levels of these biomarkers in female long-term care residents may predict worsening physical performance and gait speed 12 months later [62]. IL-6 acts as a transcription factor and signal transducer that adversely impacts skeletal muscle, appetite, adaptive immune system function, and cognition [63] and contributes to anemia [64,65].

Immune system activation may trigger the clotting cascade, with a demonstrated association between frailty and clotting markers (factor VIII, fibrinogen and D-dimer) [60].

Frail older adults are less likely to mount an adequate immune response to influenza vaccination [31].

Other stress response and metabolic systems

Altered glucose metabolism [66]

Dysregulation of the autonomic nervous system [67]

Age-related changes in the renin-angiotensin system and in mitochondria likely impact sarcopenia and inflammation, important components of frailty [68]

PATIENT EVALUATION

Patient history and examination — Identification of frailty in a variety of clinical practice settings can guide additional assessment and aid in designing appropriate treatment plans.

A consensus group of delegates from international and US societies has recommended that all persons over age 70 and adults with chronic disease or weight loss exceeding 5 percent over a year be screened for frailty using available screening tools [19]. However, there are no available data from trials investigating whether screening an unselected geriatric population for frailty, based on age alone, will improve outcomes.

For patients in whom frailty is a potential concern, based on the clinician's observations and reports from the patient and patient's family related to activity levels, diet, cognition, and weight, the following should be ascertained:

The patient history should focus on energy levels and excessive fatigue, ability to perform or maintain physical activities like stair climbing, and the ability to get out of the home and walk at least one block.

In addition to examination appropriate to the patient's medical history and current complaints, the physical examination should include a frailty screen such as those listed above and an assessment of the patient's ability to rise from a firm chair five times without use of arms, and the ability to walk across the room. Several frailty screening tools are available. (See 'Instruments developed to identify frailty' above.)

Differential diagnosis — When considering the diagnosis of frailty, it is crucial to develop a differential diagnosis list and rule out underlying medical or psychological issues that may be driving signs and symptoms of frailty.

The most common conditions to be considered in older patients presenting with weight loss, weakness, and impaired functional abilities include:

Depression

Malignancy – Lymphoma, multiple myeloma, occult solid tumors

Rheumatologic disease – Polymyalgia rheumatica, vasculitis

Endocrinologic disease – Hyper- or hypothyroidism, diabetes mellitus

Cardiovascular disease – Hypertension, heart failure, coronary artery disease, peripheral vascular disease

Renal disease – Renal insufficiency

Hematologic disease – Myelodysplasia, iron deficiency, and pernicious anemia

Nutritional deficits – Vitamin deficiencies

Neurologic disease – Parkinson disease, vascular dementia, serial lacunar infarcts

Laboratory testing — When evaluating a frail patient for the first time, laboratory testing should be undertaken in order to rule out treatable conditions. A suggested initial screen includes:

Complete blood count

Basic metabolic panel

Liver biochemical tests, including albumin

Vitamin B12

Vitamin D

Thyroid-stimulating hormone (TSH)

Consideration of workup for other conditions, such as polymyalgia rheumatica, vasculitis, or congestive heart failure, should be based on the patient history and physical examination. (See "Clinical manifestations and diagnosis of polymyalgia rheumatica" and "Overview of and approach to the vasculitides in adults".)

MANAGEMENT — Specific care plans for frailty have not yet been extensively developed or tested. Despite this, there are emerging strategies that can be utilized to help mitigate the daily impact of frailty on quality of life and overall health status.

Establishing goals of care — Goal-setting with patients and their families is crucial in providing care for the frail individual, establishing individual priorities, weighing risks and benefits of interventions, and making decisions regarding aggressiveness of care. As the older adult progresses along the frailty spectrum and develops more severe disease and/or disability, it becomes increasingly important to tailor medical care to the needs of these vulnerable patients while keeping the individual's values and goals in mind. Comprehensive geriatric assessment (CGA) may help guide development of management and intervention plans for frail patients [39]. Potential interventions that might be beneficial along the continuum of frailty are shown in a figure (figure 3). (See "Discussing goals of care" and 'Comprehensive geriatric assessment' below.)

For robust older patients, the medical practitioner should appropriately treat known chronic diseases, manage intermittent acute illness and events, and assure age-appropriate screening measures and preventive care [69].

In the moderately to severely frail patient, often "less is more." Aggressive screening or intervention for non-life-threatening conditions may be rife with complications. Procedures or hospitalizations may bring about unnecessary burden and decreased quality of life to a patient who is already at great risk of morbidity and mortality [70]. In some cases, referral to palliative care may be the most appropriate intervention. (See 'Palliative care' below.)

Nonetheless, frail older adults may benefit from interventions targeting specific components of their frailty exam, and from CGA [71,72].

Interventions

Efficacy — A variety of interventions, particularly those including exercise, appear promising in the prevention or reduction of frailty.

A systematic review of the effectiveness of interventions to prevent frailty in older adults summarized 21 randomized trials with a total of 5275 older adults and 33 interventions [73]. The results showed that group, but not individual, physical exercise programs were effective at reducing or postponing physical frailty as measured by any validated scale or measurement or index (eg, frailty index, physical frailty measures, or Edmonton Frailty Scale). Favorable effects of physical exercise, nutritional supplementation, and cognitive training were also seen on a variety of frailty components.

A secondary analysis of data from a three-year, randomized trial of 1637 French community-dwelling older adults investigated whether a long-term multi-domain lifestyle intervention of cognitive training, nutrition counseling, and advice on physical activity was associated with severity and incidence of frailty measured by a comorbidity or deficit accumulation index [74]. Compared with usual care, the intervention group had a decreased risk of both developing increased numbers of comorbidities (hazard ratio [HR] 0.72; 95% CI 0.55-0.93) and of persistent comorbidities/deficits (HR 0.53; 95% CI 0.33-0.85).

Exercise — The benefits of exercise in older adults include increased mobility, enhanced performance of activities of daily living (ADLs), improved gait, decreased falls, improved bone mineral density, and increased general wellbeing [75-78]. Studies suggest that even the frailest older adults are likely to benefit from physical activity at almost any level that can be safely tolerated [79,80]. In a systematic review of 33 trials conducted among adults over 65 years of age, yoga improved the frailty markers of gait speed, and lower extremity strength and endurance when compared with education or inactive controls [81]. Yoga outcomes were similar to those seen with the active controls of Tai chi or other forms of exercise. While functionally limited or frail individuals may never be able to meet minimum recommended activity levels for older adults, even modest activity and muscle strengthening can impact the progression of functional limitations [79,80]. (See "Physical activity and exercise in older adults", section on 'Functionally limited or frail'.)

Occupational therapy — In addition to exercise, formal occupational therapy has been shown to be helpful, particularly in patients who are having difficulties with ADLs. A meta-analysis of home and community-based occupational therapy for frail older adults showed moderate improvements in the ability to perform ADLs, in social participation, and in mobility, compared with baseline [82].

Nutritional supplementation — For patients with weight loss as a component of frailty, attention should be focused on medication side effects, depression, difficulties with chewing and swallowing, dependency on others for eating, and use of unnecessary dietary restrictions (low-salt/low-fat) (table 1). (See "Failure to thrive in older adults: Management", section on 'Weight loss'.)

In treatment of weight loss, oral nutritional supplements between meals (low-volume, high caloric drinks or puddings) may be helpful in adding protein and calories. A meta-analysis of studies of nutritional supplements showed that providing nutritional supplements to older undernourished adults yielded small gains in weight (2.2 percent) [83].

Several meta-analyses of randomized trials show a reduction in falls with vitamin D supplementation [84-88]. Vitamin D supplementation also may improve balance and preserve muscle strength [89] and may play a role in preventing or treating frailty. In one report, lower serum levels of 25-hydroxyvitamin D (<20.0 ng/mL) were associated with a higher prevalence of frailty at baseline in a group of 1600 men over age 65 but did not predict greater risk for developing frailty at 4.6 years [90]. Given that vitamin D appears to play an important role in both muscle and nervous tissue maintenance with aging, further studies to evaluate the association between vitamin D and frailty are indicated. The daily intake of vitamin D in older adults should be at least 800 to 1000 international units. (See "Falls: Prevention in community-dwelling older persons" and "Geriatric health maintenance", section on 'Vitamin D'.)

Medication review — Periodic evaluation of a patient's drug regimen is an essential component of medical care for an older person, and it is especially important for patients who are pre-frail or frail. Such a review may indicate the need for changes to prescribed drug therapy (table 2). Changes may include discontinuing a therapy prescribed for an indication that no longer exists, discontinuing therapy with side effects that may be contributing to frailty symptoms, substituting a therapy with a potentially safer agent, changing drug dose, or adding a new medication. In reviewing medications, it is important to focus on the established goals of care with the patient and caregivers. (See "Deprescribing".)

Ineffective interventions — Although activation of inflammatory pathways and dysregulation in endocrine systems is believed to contribute to frailty (see 'Pathophysiology' above), there are limited data on hormonal and antiinflammatory interventions for frailty, and none have proven to be of significant benefit.

Several hormonal and nutritional interventions have been evaluated in related geriatric conditions.

Testosterone replacement increased muscle mass and strength in hypogonadal and eugonadal men, especially in combination with exercise. Testosterone, however, may lead to an unfavorable lipid profile and unpredictable effects on the prostate gland [91,92]. We do not suggest routine testosterone replacement, in the absence of demonstrable hypogonadism, as evidenced by clinical symptoms and signs consistent with androgen deficiency and a subnormal morning (8 to 10 AM) serum testosterone concentration on three separate occasions. (See "Testosterone treatment of male hypogonadism", section on 'Appropriate candidates'.)

Growth hormone or growth hormone releasing factor supplementation have not demonstrated efficacy in improving function or other clinical outcomes in older adults with age-related declines [93]. A systematic review found that the risks of exogenous growth hormone outweigh potential benefits [94].

Benefit from dehydroepiandrosterone sulfate (DHEA-S) supplementation in preventing or treating frailty has not been demonstrated [95-97].

Further intervention studies in frailer, older individuals will be needed to determine the effectiveness and potential harm of treatments that target endocrine or inflammatory biology in frail older adults.

Palliative care — Diagnosing frailty helps identify those older adults at highest risk of adverse health outcomes. Palliative care approaches may be helpful to alleviate symptoms of related medical conditions and to help in consideration of the appropriateness of potential medical and surgical interventions (such as chemotherapy or major surgery) and their impact on mortality and quality of life for the frail older adult [98].

For those with advanced frailty and multiple comorbidities or those with failure to thrive, the engagement of a palliative care team may help to identify methods to preserve or improve quality of life and to clarify goals of care. (See "Benefits, services, and models of subspecialty palliative care", section on 'Palliative care services'.)

Notably, in the United States, the Centers for Medicare and Medicaid Services (CMS) no longer accept either debility or adult failure to thrive as a principal diagnosis for hospice services, and these diagnoses should not be listed as the primary hospice diagnosis. However, progressive inanition is one criterion which may be used to identify a likely life expectancy of six months or less. (See "Hospice: Philosophy of care and appropriate utilization in the United States".)

MODEL SYSTEMS OF CARE — Care for frail older adults is frequently challenging, related to their increased disability and multiple chronic diseases. This is further heightened in frail individuals who lack social supports. An interdisciplinary team-based approach to care is often important in meeting the needs of frail adults, who may represent the population most likely to benefit from specialized and targeted comprehensive interventions [99].

Outcomes of interdisciplinary interventions are mixed, however. In one small randomized trial, an interdisciplinary intervention involving screening, home visits, and occupational and physical therapy tailored to the patient's support needs, compared with usual care, resulted in no difference in disability outcome at six-month, one-year, and two-year assessments [100]. However, in another randomized clinical trial, multidisciplinary approaches that focused on improvement of specific diagnostic criteria for physical frailty resulted in improvement in frailty status and the potential for reduced health care costs [71,101].

A conceptual model of care has been outlined by one gerontology group, that proposes several adjuncts and enhancements to the traditional one clinician/one patient visit [102]. Proposed practice changes include:

Comanagement involving clinician and nurse practitioner or clinician assistant

Support personnel (nurses, social workers) with specialized gerontology training available as consultants

Facilities accommodations – Adjustable height tables, clearance for wheelchair maneuvering, microphones/headsets for hearing impaired, adjustable walker

General staff education for communicating with frail older adults

Team meetings to discuss complicated patients

Full integration of electronic communications – Electronic medical records, email, secure practice website, patient health questionnaires, templated notes

Partnership and familiarity with community resources for housing, health promotion, and caregiver support

Comprehensive geriatric assessment — Frail older adults are at highest risk in the general population of older adults, and may be expected to derive maximum benefit from comprehensive geriatric assessment (CGA). The overall goals of CGA are:

To improve physical and psychological function

To optimize medication prescribing and use

To decrease nursing home placement, hospitalization, mortality risk

To improve patient satisfaction

CGA involves an interdisciplinary care team that coordinates evaluation of an older patient and develops a plan for integrated care [103]. The team usually consists of a geriatrician or other medical practitioner knowledgeable in the care of older adults, nurse, social worker, pharmacist, and an occupational or physical therapist. (See "Comprehensive geriatric assessment" and "Comprehensive geriatric assessment for patients with cancer".)

Outpatient PACE — The frailest older adults in the United States may benefit from the Medicare Program of All-inclusive Care for the Elderly (PACE). The goals of this model are to improve function, overcome environmental challenges, and keep older adults living in their communities by preventing institutionalization.

In this outpatient patient management model, primary care is delivered to community-dwelling older adults by an interdisciplinary team in a day clinic setting [104]. The interdisciplinary team includes a practitioner knowledgeable in geriatric medicine, nurses, physical and occupational therapists, and social workers. Services provided include home nursing, physical and occupational therapy, transportation, aide service, and adult day care. Patients who enter the program receive complete long-term care and are followed until the end of their lives, even if they eventually require placement in an assisted-living facility or nursing home.

PACE was designated as a permanent Medicare program in 1997 because it was successful in maintaining function and community-dwelling status and in providing lower-cost care compared with traditional fee-for-service care [105].

Hospital care and ACE — Hospitalization increases risk for institutionalization and decrease in quality of life for a frail older adult. Change in environment, exposure to new medications, and immobility, combined with acute illness, can lead to devastating outcomes for these vulnerable patients. Often, the decline in level of function and ability to care for oneself that occurs during hospitalization persists after discharge [106,107]. In one study, frail individuals had a sevenfold increased risk of progressing from no disability to mild disability within one month of hospitalization, compared with non-frail patients (35 versus 7 percent) [108].

Acute Care for Elders (ACE) is a model of care for the acutely ill hospitalized older adult designed to prevent functional decline and improve functional independence if decline has occurred. The model typically includes a specially designed environment that is a more home-like environment, patient-centered medical care that focuses on the prevention of disability, and comprehensive discharge planning and management. In a randomized controlled trial of 1531 community-dwelling adults aged 70 and older, this model decreased the likelihood of decline in activities of daily living (ADLs) or nursing home placement both at hospital discharge and at 12 months without an increase in hospital length of stay or hospital costs [109].

SUMMARY

Frailty is an increasingly recognized clinical state of vulnerability with inherent increased risk for adverse health outcomes, including functional decline and mortality. There is no gold standard for diagnosing frailty. Importantly, old age itself does not define frailty. (See 'Concepts and definitions' above.)

The physiological basis of frailty is thought to be driven in part by the activation of inflammatory pathways and dysregulation of neuroendocrine systems, which leads to skeletal muscle decline. (See 'Pathophysiology' above.)

An international consensus group has recommended that all persons over age 70, and adults with chronic disease or weight loss exceeding 5 percent over a year, be screened for frailty, though evidence supporting this approach is not robust. The FRAIL scale is one tool that can be readily incorporated into history-taking, but multiple other screening tools are available and have been validated. Physical examination should include assessment of the patient's ability to rise from a firm chair five times without use of arms and their ability to walk across the room. (See 'Patient evaluation' above and 'Instruments developed to identify frailty' above.)

Goal-setting with patients and their families is crucial in providing care for the frail individual, establishing individual priorities, weighing risks and benefits of interventions, and making decisions regarding aggressiveness of care. Interventions have focused on components of frailty, such as strength. Activity interventions have been shown to have a positive impact on even the frailest older adults. To date, no biological or pharmaceutical interventions are recommended for frailty per se, although biologically targeted interventions may play a role in the future. (See 'Establishing goals of care' above and 'Interventions' above.)

A variety of interventions, particularly those including exercise, appear promising in the prevention or reduction of frailty. However, it is important to tailor interventions to the individual, incorporating patient preferences and stage on the spectrum of frailty (figure 3). Palliative care approaches may be considered in the frailest subset of older adults. (See 'Interventions' above and 'Palliative care' above.)

Clinical geriatric evaluation teams and specialized programs can play an important role in improving the quality of life for older adults. (See 'Model systems of care' above.)

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