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Frailty Syndrome

For today’s guest arti­cle I’d like to thank Lau­rie G. Jacobs, M.D., direc­tor of the Jack and Pearl Resnick Geron­tol­ogy Cen­ter, Albert Ein­stein Col­lege of Med­i­cine and Vice Chair, Clin­i­cal and Edu­ca­tional Pro­grams, Mon­te­fiore Med­ical Center.

This blog post first appeared in The Doctor’s Tablet, the offi­cial blog of Albert Ein­stein Col­lege of Med­i­cine.

 

Frailty: How a Con­stel­la­tion of Symp­toms Leads To Risk

by Lau­rie G. Jacobs, M.D. on March 12, 2013

Elderly Man Walking with Son

Frailty Syn­drome

Frag­ile: This Side Up. Few of us find much ambi­gu­ity when faced with a mail par­cel marked with those four words. Yet the related word “frailty” often causes con­fu­sion among doc­tors and patients alike. The word “frail” applies to peo­ple, not things—and that’s where the topic becomes tricky.

Mer­riam Web­ster defines frailty as “being phys­i­cally weak; eas­ily bro­ken or destroyed,” with syn­onyms listed as “break­able, del­i­cate, and frag­ile.” Most peo­ple asso­ciate this qual­ity with aging, although frailty is not unique to aging, and is not nec­es­sar­ily part of aging.

Frailty usu­ally appears as a state of decreased phys­i­cal func­tion and dis­abil­ity, but that is not always the case. Frail older adults, how­ever, do have a higher risk of falling, of being insti­tu­tion­al­ized and even of dying sooner than non­frail indi­vid­u­als of the same age.

Physi­cians, par­tic­u­larly geri­a­tri­cians who spe­cial­ize in the care of older adults, have increas­ingly focused on try­ing to char­ac­ter­ize frailty in the hope of pre­vent­ing or treat­ing it—and help­ing pre­pare patients and fam­i­lies for its poten­tially dis­abling effects.

Frailty is often viewed as a con­tin­uum of changes in an indi­vid­ual, not as a sin­gle qual­ity that is present or absent. That makes its def­i­n­i­tion even more chal­leng­ing. Although con­sen­sus sur­round­ing the phys­i­o­logic def­i­n­i­tion of frailty has not yet been achieved, a work­ing def­i­n­i­tion has been estab­lished. It includes the pres­ence of three or more of the fol­low­ing qualities:

  • Weight loss
  • Weak­ness
  • Exhaus­tion
  • Low activ­ity level
  • Slow gait (walk­ing) speed

Let’s take a closer look at each quality:

Weight loss

Frailty can be indi­cated by a loss of more than 10 pounds or 5 per­cent of total weight in the past year. This change rep­re­sents sar­cope­nia, the tech­ni­cal term describ­ing a decline in mus­cle mass, although it may also rep­re­sent inad­e­quate nutri­tional intake even when phys­i­cal activ­ity is low.

Weak­ness

Weak­ness is deter­mined by grip strength as mea­sured by a dynamome­ter. Nor­mal results vary by body-mass index—a mea­sure of one’s size—which is impor­tant in strength measurements.

Exhaus­tion

Wors­en­ing exer­cise tol­er­ance may be mea­sured using a self-reported scale. Doc­tors often use a slid­ing scale to record patient responses to the fol­low­ing two state­ments: “I felt that every­thing I did was an effort in the last week” and “I could not get going in the last week.”

Low Activ­ity Level

Activ­ity level is mea­sured by calo­ries burned for activ­i­ties in a given period of time. Var­i­ous inves­ti­ga­tors have estab­lished a cut­off point—for exam­ple, activ­i­ties requir­ing fewer than 270 or 383 kilo­calo­ries per week.

Gait

A slower walk­ing speed is an indi­ca­tion of a gen­eral slow­ing in motor per­for­mance. It has been mea­sured using sev­eral stan­dard­ized tests that ask indi­vid­u­als to start walk­ing at their usual pace from a stand­ing start. They are timed for a stan­dard dis­tance and their speed is cal­cu­lated as meters per sec­ond, mod­i­fied for height. For a 15-foot walk, six to seven sec­onds is a stan­dard pace.

There are other ele­ments of frailty that may or may not be asso­ci­ated with the term, such as changes in cog­ni­tion, which have not been included in this list but should be monitored.

The def­i­n­i­tion of frailty still con­tains ambi­gu­i­ties; some indi­vid­u­als who appear frail do not meet these cri­te­ria, and still oth­ers who do not appear frail will be char­ac­ter­ized as such by this work­ing definition.

Indeed, unlike the fragility of glass, frailty remains in the eye of the beholder—but we are slowly get­ting closer to the mirror.

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