Frailty in Older Adults

Author: Kathleen Pace Murphy, PhD., MS, GNP-BC

Overview

Frailty is an age related alteration in physiology and pathology that leads to vulnerability, loss of physiological reserve, and a range of poor medical and functional outcomes (Bergman, Ferrucci, Gurainki, et al, 2007).

Frailty prevalence is uncertain. Lekan (2009) reported a 3-7% prevalence in older adults aged 65 to 75 years. Newman Gottdiener, McBurnie, et al (2001) reported in the Cardiovascular Health Study a prevalence of 25% in adults over the age of 85 years. Variations in frailly definitions and the mixing of community versus institutionalized sample cohorts have contributed to the lack of reliable frailty prevalence data (Espinoza & Walston, 2005).

Frailty etiology includes an array of diseases such as malignancy, heart failure, COPD, dementia, stroke, Parkinson’s disease, diabetes mellitus, hypothyroidism, depression, and rheumatic diseases. Other etiologies include inflammatory and immune responses with elevated proinflammatory biomarkers (elevations of Interleukin-6 and C-reactive protein), clotting cascade activation (elevated levels of factor VIII, fibrinogen and D-dimer), serum cortisol elevations, diminished vitamin D levels, growth and sex hormones (decrease in insulin-like growth factor-1(IGF-1), decrease in dehydroepiandosterone sulfate) have all been indicated (Espinoza & Walston, 2005).

 

Key Points

Frailty is a syndrome, not a disease, whose prevalence increases with age.

Utilization of Fried’s criteria (Fried, Tangen, Watson et al. (2001) may help a healthcare provider recognize frailty in older adults.

Older adults at risk for frailty include: advanced age, chronic disease, physical inactivity, poor nutritional status, social isolation, psychological distress (depression) and physical stressors (smoking, polypharmacy).

Frail older adults are less able to tolerate disruptions in homeostasis and have poorer outcomes with medical illness exacerbation and hospitalization.

Interprofessional geriatric teams utilizing comprehensive geriatric assessment and modeling are an important intervention in the care of frail older adults.

 

Diagnosis

The frailty index is one measurement used to assess this syndrome in the older adult (Fried, Tangen, Walston, et al, 2001). An older adult must have at least 3 of the 5 indices.

The frailty indices include:

If frailty is suspected, healthcare providers are encouraged to conduct a comprehensive geriatric assessment. Assessment should include a functional history (ability to conduct Activities of Daily Living, Instrumental Activities of Daily Living, and history of falls); medications review (i.e. polypharmacy); sensory (visual and hearing), impairments nutritional status (i.e. recent weight loss, eating difficulties, and dietary habits); geriatric depression; cognitive impairment; and social resources.

Review of systems should review current medical conditions. Physical examination should include weight, orthostatic blood pressure checks (supine, sitting and standing), examination of their mouth/dentition, cardiovascular assessment, neuromusculoskeletal assessment and strength testing (grip strength, core truncal strength, quadriceps strength), Get Up and Go test, postural balance, proprioception, and tests for lower extremity sensory impairment.

 

Intervention

Frailty is a syndrome which requires an interprofessional geriatric team approach and a comprehensive plan of care. The interprofessional geriatric team is comprised of a geriatrician, advanced practice nurse or physician assistant, geriatric dentist, dietician, occupational therapist, physical therapist, social worker and speech therapist.

Physical and occupational therapy are instrumental in providing a plan of care to improve gait, muscle strength, and improve functional independence (i.e. activities of daily living).

Dietician consult will provide a nutritional assessment and plan of care to address dehydration, inadequate caloric intake; dietary counseling may be needed for various co-morbidities (i.e. diabetes mellitus, renal disease).

Speech therapy consult will evaluate swallowing problems which may contribute to diminishing weight.

Dental consult will evaluate dental caries, poor fitting dentures and other dental disease which prevent the older adult from adequately eating.

Social work consult provides a social assessment and plan of care as it relates to patient and family support, referrals to community agencies and financial resources.

Frailty is a prognostic indicator for poor clinical outcome. When indicated, requesting a Palliative Care Team consult will provide additional resources (i.e. Chaplain Services and home health nurses who can provide quality of life and comfort support).

 

Helpful web-based sites to visit include:

 

References

Bergman, H., Ferrucci, L. Gurainki, J., et al. (2007). Frailty: An emerging research and clinical paradigm-issues and controversies. Journals of Gerontology; 64A: 731-737. 

Espinoza, S., & Walston, J.D. (2005). Frailty in older adults: Insights and interventions. Cleveland Clinic Journal of Medicine, 72(12): 1105-1112. 

Fried, L.P., Tangen, C.M., Walston, J., et al. (2001). Frailty in older adults: Evidence for a phenotype. Journal of Gerontology; 56A: M1-M11. 

Lekan, D. (2009). Frailty and other emerging concepts in the care of the aged. Southern Online Journal of Nursing Research, 9:3. 

Newman, A.B., Gottdiener, J.S., McBurnie, M.A., et al. (2001). Associations of subclinical cardiovascular disease with frailty. Journal of Gerontology: Medical Sciences, 56A: M158-M166.