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frailty

A multifactorial state of decreased physiologic reserves & increased vulnerability to stress, including fragility, or weakness in physical or mental health, with decreased reserves in multiple organ systems. The concept of frailty has extended to include social frailty [47] Etiology: - secondary to acute event - hospitalization - surgery - immobility - acute illness - extreme heat exposure or cold exposure [31] - end-stage of chronic disease(s) - risk factors - older age* - female gender - heavier weight at baseline, metabolic syndrome - general & abdominal obesity during adulthood increases risk of frailty in older age [46] - lower self-assessed health status - presence of > 5 illnesses [32] - osteoarthritis - cognitive impairment* - lower education level - proinflammatory diet with high dietary inflammatory index [69] - medications [31] - glinides (repaglinide, nateglinide) - SGLT-2 inhibitors - insulin [66] - depression - hearing loss [33] - poor oral hygiene [45] - HIV1 infection [7,39] (largely driven by comorbidities [41]) - risk factor even when HIV1 is well controlled [7] - predictors of frailty - sarcopenia - fatigue (exhaustion) - multiple contibutory factors stronger predictor than any one factor [7] - in patients with osteoarthritis, fatigue is the strongest predictor of reduced activity & frailty > weight loss, decreased strength, or diminished walking speed - idiopathic * not all elderly are frail [32] * frailty able to improve with good cognitive function [56] Epidemiology: - 3-7% of individuals 65-75 years of age [4] - 20-40% of individuals > 80 years of age Pathology: 1) decline in neuromuscular function 2) sarcopenia - decreased grip strength 3) osteoporosis 4) diminished ability to respond to stress (homeostenosis) a) decline in maximal oxygen consumption [3] - fatigue, easy exhaustion b) psychomotor slowing - slow walking speed* if ambulatory 5) comorbidities a) 7% of frail elderly have no known comorbidity b) 25% of frail elderly have 1 comorbidity c) > 5 comorbidities is a risk factor [32] 6) inflammation may play role * best predictor of disability, long-term nursing home placement, mortality History: - activities of daily living [31] - support system - alcohol, tobacco, physical activity [31] Physical examination: - standard exam - attention to orthostatics, rigidity, muscle strength, vision, hearing * frailty state likely to decline with poor physical function but able to improve with good cognitive function [56] Clinical manifestations: 1) presents with multiple aspects of functional decline [7] 2) weight loss, unintentional* (> 10 lbs or 5%) over past year) 3) muscle weakness* - grip strength using hand dynamometer 4) fatigue, exhaustion, low energy* 5) bradykinesia* 6) dyspnea on exertion 7) loss of mobility - gait speed is a useful performance measure [14] - slow walking speed* - inability to walk 6 meters in < 8 seconds [27]; < 0.8 m/sec [7] - best predictor of disability, long-term nursing home placement, mortality - timed get-up & go test is another useful performance measure [7] - difficulty climbing a flight of stairs* - difficulty walking one block* 8) low activity level* 9) anorexia 10) >= 5 illnesses* 11) develops in slow, stepwise process [4] * any 3 of criteria define frailty [7,16] * different sources provide different criteria * fatigue predicts low activity level [7] * also see frailty score [16] * no gold standard for screening for frailty in clinical practice [7] Laboratory: - serum 25-hydroxyvitamin D: [7,19,20] - both low & high levels associated with increased likelihood of frailty - high serum IL6 is common [12] - high serum cortisol may play a role [12] - as indicated [31] - serum albumin, serum total cholesterol - complete blood count (CBC) - basic metabolic panel - serum phosphate - serum magnesium - serum vit B12, serum folate - serum TSH - low serum creatinine is associated with sarcopenia & frailty [49] - serum cystatin C/creatine ratio more accurately assesses renal function (not directly affected by muscle mass) [65] - association between Toxoplasma gondii IgG ELISA serointensity & frailty [59] * frailty state likely to decline with low serum albumin, high serum CRP but able to improve with good cognitive function [56] Special laboratory: - comprehensive geriatric assessment is gold standard - in-hospital bedside use problematic [48] - frailty score - Clinical Frailty Scale Complications: 1) inability to perform activities of daily living, fluctuating disability 2) recurrent falls - transient impairment in cerebral oxygenation due to impaired diastolic BP recovery at 30 seconds after standing [44] - increased risk of fracture, especially in more sedentary elderly [71] - missteps after hip fracture contributing to the death of a 77 year old geriatrician with multiple well-controlled comorbidities [72] 3) diminished mobility 4) spiraling decline in vitality, diminished quality of life [32] 5) delirium is common 6) increased risk of mild cognitive impairment & dementia [29] 7) hospitalization - increased risk for hospitalization [32] - longer hospital stay [32] - has not been associated with nursing home placement (GRS) [7] - increased likelihood of discharge to skilled nursing facility (MKSAP) [32] - frailty predicts higher 30 day mortality, longer hospital stay, & 30-day emergency department visits in hospitalized elderly [7] - not associated with increased length of hospital stay [7] - frail patients unlikely to survive to hospital discharge following in-hospital cardiopulmonary arrest [28] - no benefit for routine PCI after NSTEMI in frail elderly [54] - common among hospitalized elderly with community-acquired pneumonia [58] - associated with increased mortality, longer hospitalization, & duration of antibiotic therapy [58] 8) frailty predicts postoperative complications including postoperative delirium [68] (see frailty score) [7] - even low-risk procedures are hazardous for frail patients [50] 9) excess risk of death - frailty is associated with excess risk for postoperative mortality after elective surgery [13] - RR = 36 in the first few postoperative days - RR = 2.0 at 90 days - excess risk for 1 year postoperative mortality after specific surgeries: - total knee replacement, 4% vs 1% - total hip replacement, 9% vs 2% - large bowel surgery, 21% vs 10% - peripheral artery bypass, 24% vs 12% - esophagectomy or gastrectomy, 43% vs 21% Management: 1) exercise may be of benefit [9,25] - multicomponent exercise with a resistance-based training component is associated with improved physical function (muscle strength, balance) & better health outcomes (less disability, fewwer falls) in frail elderly (GRS11) [7] - multicomponent exercise consisting of balance, flexibility, resistance training & aerobic activity is more effective than resistance training or aerobic exercise alone (GRS9) [7] - resistance training - group exercise programs are effective in improving function in frail elderly [7] - aerobic exercise - adherence to exercise is high, risk of adverse events low (GRS9) [7] - higher intensity exercise feasible, but effects similar to lower intensity exercise (GRS9) [7] - frail elderly may benefit from a moderate-intensity exercise [25] - exercise continued for > 5 months results in greater benefits (GRS9) [7] - stretching - tai chi [4] - yoga may benefit frail elderly but may not offer benefit over exercise [55] - multicomponent & resistance exercises may prevent & reverse frailty among middle-aged (40-65 years) adults, but clinical significance is uncertain [67] 2) minimize polypharmacy [31] - risks of anticoagulation for atrial fibrillation in demented frail elderly may exceed benefits [52] 3) treat depression [31] - frailty able to improve with good cognitive function [56] 4) hormone replacement of little benefit - testosterone replacement may benefit elderly men with low serum testosterone - growth hormone of no benefit - DHEA of no benefit 5) calcium & vitamin D may improve sarcopenia (if vitamin D deficiency) [37] 6) zinc supplementation (10-21 mg/day) may reduce risk of impaired lower-extremity function & frailty among community-dwelling older adults [35] 7) no proven role of antioxidants 8) if frailty associated with sarcopenia, an increase in high-quality protein + calories of benefit [7] - formerly, caloric intake &/or increased protein intake of no benefit [7] 9) increased consumption of fruits & vegetables reduces later life frailty in middle-age African Americans [7] - dietary quercetin is associated with lower risk of frailty [64] 10) adherence to a Mediterranean-style diet & higher total carotenoid intake may delay or prevent later life frailty, especially in adults < 60 years [42] 11) in elderly (mean age 84 years) better quality diet is inversely associated with incidence of frailty [61] 12) exercise & nutritional intervention improves physical function in prefrail elderly [42] 13) positive attitude attenuates physical & mental decline associated with frailty [4] === Hospitalization & Surgery === 1) frailty assessment & frailty score for hospitalized elderly 2) frail elderly benefit the most from intensive physical cardiac rehabilitation after hospitalization for acute heart failure [53] 3) Hospital Elder Life Program (HELP) may be of benefit in reducing risk of postoperative frailty 4) in-hospital multicomponent intervention targeted to frailty is safe & improves health-related quality of life [57] 5) limited vidence suggests comprehensive geriatric assessment benefits independence & mortality in hospitalized frail elderly [70] 6) surgery: - preoperative evalution with a frailty score >= 42 resulting in surgeons re-evaluating the benefits of elective surgery &, if continuing, to engaging in frailty-informed shared decision lowers postoperative mortality [51] === prognosis === - whether or no it may be possible to reverse frailty, may depend on how frailty is assessed [60] - it may be possible to improve a severely frail state to a pre-frail or mildly frail stat [60] - frailty by itself is not considered a hospice diagnosis [63] Notes: - also see frailty score [16] - no gold standard in screening for frailty [7] - electronic frailty tools not useful for primary care-based population screening [62]

Interactions

disease interactions

Related

frailty score; FRAIL scale, frailty index, Edmonton Frail Scale Hospital Elder Life Program (HELP) osteoporosis prefrailty sarcopenia

Specific

cognitive frailty social frailty

General

geriatric disorder; disease of old age; geriatric syndrome syndrome

References

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