January/February 2014

The Frailty Syndrome

By Zachary J. Palace, MD, CMD, and Jennifer Flood-Sukhdeo, MS, RD, CDN
Today’s Geriatric Medicine
Vol. 7 No. 1 P. 18

Although it lacks a standardized clinical definition, older adults’ frailty warrants special considerations in terms of treatment and nutritional needs.

The normal aging process is characterized by a progression of physiologic events that occur throughout the life cycle. Changes associated with aging occur throughout the body and are most prominent in the later years. Changes in the musculoskeletal system begin to occur after the third decade and continue into the eighth and ninth decades. The frailty syndrome can be described as a culmination of the effects of these changes on the human body.

As normal aging progresses, the musculoskeletal system shows declines in several different areas. The term “sarcopenia” describes the biochemical changes that occur within the muscle fibers as they relate to declining muscle mass and muscle function. Visible atrophy of muscle fibers results in decreased strength. These changes result from fat deposition replacing lean muscle mass, a process that begins after the third decade of life and can result in up to a 40% decrease in muscle mass by the eighth decade of life. Marked losses in muscle strength and decreased endurance become more prominent over time and correlate with an increased risk of falls.1

The structural integrity of the skeleton plays a major role in maintaining optimal posture and gait. The body’s peak bone density occurs during an individual’s late 20s. An ongoing process of bone formation and resorption occurs throughout life in healthy bones. After the age of 40, however, the rate of bone resorption increases, resulting in decreased bone mass and bone density. This process is exacerbated in women following menopause and can lead to osteopenia and osteoporosis.2

Independent of the development of osteoporosis, normal age-related decreases in bone density result in decreased structural bone strength, which can increase the risk of falls and fractures. Compression fractures of the anterior cervical spine result in kyphosis, a stooped posture that often is referred to as a dowager’s hump. This forward shift of the center of gravity increases the risk of the loss of balance and falls.2

Recognizing Frailty
These normal processes of aging affect both the muscular and skeletal systems and, as a result, play a significant role in the decreased mobility that often is observed in later life. Nevertheless, the frailty syndrome is not defined by mobility alone; malnourishment, as evidenced by involuntary weight loss, also is an important component. Although it’s difficult to define precisely, most clinicians will concur that frailty can be easily recognized as “you know it when you see it.” The following clinical vignettes illustrate this point:

• Herb is an 86-year-old retired attorney residing with his wife in their home. He has a medical history significant for mild hypertension and degenerative joint disease with severe kyphosis of the thoracic spine. He underwent a right hip hemiarthroplasty at the age of 80 and continued to remain mobile and physically active postoperatively.

Recently, as a result of the progression of kyphosis, he cannot hold his head upright and walks with a severe forward-stooped posture. This posture has significantly shifted his center of gravity anteriorly, resulting in two to three falls per day while ambulating. He has difficulty in rising unassisted from a seated position and has become more sedentary.

• Betty is a 78-year-old retired teacher. She lives in her apartment in the community with a home health aide who spends several hours per day assisting her with shopping and household chores. She is independent in her activities of daily living. Her medical history is significant for insulin-dependent diabetes mellitus, hyperlipidemia, hypertension, and cataracts. She also suffers from chronic pain due to severe bilateral knee osteoarthritis, which greatly limits her mobility and keeps her sedentary much of the day. Although she has no recent fall history, she describes herself as feeling weak and fatiguing easily.

• Rita is a 96-year-old widow who resides in a nursing home. She has a medical history of dementia and was admitted to long term care three years ago. Having outlived all of her other family members, Rita lived in an apartment in the community, where she was found to have poor hygiene and was wandering frequently, often becoming lost.

Her stay in long term care has been unremarkable, and she receives assistance with her activities of daily living. She has a hearty appetite, attends activities, and continues to wander through the hallways of the nursing facility.

Although these three individuals present quite differently, most clinicians likely would agree that both Herb and Betty would be considered to manifest frailty. Physical limitations due to severe kyphosis and frequent daily falls would cause most clinicians to label Herb as frail. Betty’s clinical picture that includes multiple comorbidities and a limited level of physical activity also would be consistent with frailty.

However, most clinicians would not consider Rita as manifesting the frailty syndrome. Although she’s 96 years old, cognitively impaired, and living in long term care, her level of physical activity, as manifest by her frequent wandering, would be less consistent with a frailty diagnosis.

As the population continues to age and the percentage of older adults over the age of 80 continues to expand, it is now more important than ever to identify the frailty syndrome sooner. To do so, it is necessary to codify into a working definition the common findings associated with the frailty syndrome. Several different studies have attempted to identify frailty based on recognizable operational criteria or by incorporating measurable scales of disability. In a landmark study analyzing multiple commonly observed characteristics of frailty, Fried et al identified and defined frailty as a syndrome that is distinct and independent of medical comorbidities and disability.3

The frailty syndrome requires at least three of the following five characteristics:

• unintentional weight loss, as evidenced by a loss of at least 10 lbs or greater than 5% of body weight in the prior year;

• muscle weakness, as measured by reduced grip strength in the lowest 20% at baseline, adjusted for gender and BMI;

• physical slowness, based on measured time to walk a distance of 15 ft;

• poor endurance, as indicated by self-reported exhaustion; and

• low physical activity, as scored using a standardized assessment questionnaire.

Among the study population of more than 5,300 participants, several significant findings about frailty were observed. Those who met the criteria for frailty syndrome were more likely to be older and in poorer health and had higher rates of comorbid chronic disease and disability.3 Diagnoses of cardiovascular disease, pulmonary disease, diabetes, and arthritis as well as impaired cognition and depression were found to be more prevalent in this group.3 Studies also have identified obesity as a significant risk factor for frailty in women.4

Nevertheless, 7% of the population aged 65 and older and 20% of the population aged 80 and over meet the criteria for frailty in the absence of any acute or chronic medical conditions.5

Nutritional Considerations for Frailty
Nutrition is an important component to consider in the evaluation of frailty. Physicians should assess and evaluate nutritional status in discussions with family members and other caregivers. Weight should be measured at each visit to identify unintended or unexplained weight changes.

Many factors contribute to poor nutritional status in the elderly. Weight loss often occurs secondary to an underlying condition that may be either physical or psychological and can affect a patient’s ability to consume adequate calories or protein on a daily basis to maintain optimal functional status. For example, poor dentition can affect the ability to chew and swallow foods of a firm consistency. Patients with diabetes may have delayed gastric emptying, which can result in early satiety. Depression can present with poor appetite and a malnourished state. Prescribed medications can cause dysgeusia, an alteration in the perceived taste of foods, resulting in anorexia and weight loss.

Physicians need to periodically monitor diagnostic lab tests, including blood chemistries. These tests can be used to determine electrolyte imbalances, macro- or micronutrient deficiencies, and anemia. In particular, vitamin D levels should be checked and supplemented if they are low because of vitamin D’s role in calcium absorption and its important aspect in the prevention and treatment of osteoporosis and overall bone health.

Primary care physicians, in conjunction with other health care providers, should be aware of physical limitations that may impede food purchasing and preparation. In these situations, a referral to community-based programs that may provide meals at senior centers or deliver meals to homebound elders should be considered.

Frail elders are at greater risk of skin breakdown caused by protein malnutrition or unintended weight loss. Meeting specific nutrition requirements may play an integral part in preventing further deterioration in status and may in fact show positive outcomes.6

Another factor contributing to frailty may be the ability to adequately and safely chew and swallow,7 known as dysphagia. Nutrition interventions to ease chewing and swallowing difficulties include mechanically altering the consistency of food and/or liquids. Other nutritional recommendations that are appropriate for frail elders may include smaller more frequent meals, supplementation use, and referrals to speech pathologists, occupational therapists, and dietitians.

Supplementation can play a major role in positively impacting the nutritional status of a frail individual, particularly when diet alone fails to meet daily dietary needs. Specific indications for the use of supplements may include difficulty chewing or swallowing, unintended weight loss, protein/calorie malnutrition, or increased calorie needs secondary to a hypermetabolic state. Contraindications for supplementation may include unintended weight gain, renal conditions, and nutrient-drug interactions.

Treating Frailty
Once the frailty syndrome is recognized, the next step is treatment. The key in treating frailty lies in targeting the conditions associated with it. Developing appropriate interventions is an important multifaceted process.

As previously mentioned, frailty is not defined by medical diagnoses. Nevertheless, common chronic comorbidities have been noted with higher prevalence in this population. Evidence-based medication management of congestive heart failure results in better outcomes, fewer exacerbations, and an overall improvement in physical function and quality of life. Optimized management of chronic pulmonary disease as well as improved glycemic control of diabetes results in improved health status, fewer hospitalizations, and reductions in the physical declines associated with the frailty syndrome.

Consistent with the fundamentals of geriatric medicine, a thorough medication review should be performed during periodic office visits to inventory all medications, including prescription and over-the-counter medications. Unrecognized drug side effects as well as drug-drug interactions can cause unexpected adverse effects that can predispose patients to weakness, slowness (both physical and mental), and falls. Frequent medication review can identify opportunities for medication reduction and avoid polypharmacy.

A comprehensive exercise program and increased physical activity have been shown to benefit the frailty syndrome. Muscle weakness and muscle disuse atrophy resulting from a sedentary disposition and chronic illness respond well to physical therapy. Studies have demonstrated positive outcomes in increased muscle strength and muscle mass as a result of participating in a physical fitness program focused on resistance training.8 Studies also have supported the beneficial effects of tai chi on reducing frailty as well as reducing the occurrence of falls in the elderly.9

In Conclusion
With the significant growth of the over-80 population and the increase in average life expectancy, clinicians will no doubt encounter an increase in the prevalence of the frailty syndrome. Many of the predisposing factors of frailty occur as a result of the aging process. Most clinicians generally identify frail elders superficially by the “you know it when you see it” test.

However, early recognition and assessment of the identified standardized criteria for the diagnosis of the frailty syndrome is an important first step that will guide the appropriate treatment interventions and improve outcomes. Helping older adults attain and maintain their highest level of function is the goal of optimal geriatric care.

— Zachary J. Palace, MD, CMD, is a board-certified geriatrician and the medical director, and Jennifer Flood-Sukhdeo, MS, RD, CDN, is a clinical dietitian and the director of nutrition at The Hebrew Home at Riverdale in New York.

References
1. Dharmarajan TS, Norman RA (eds). Clinical Geriatrics. New York, NY: CRC Press; 2002.

2. Ham RJ, Sloane PD, Warshaw GA, Bernard MA, Flaherty E. Primary Care Geriatrics: A Case-Based Approach. 5th ed. Philadelphia, PA: Mosby; 2006.

3. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-156.

4. Blaum CS, Xue QL, Michelon E, Semba RD, Fried LP. The association between obesity and the frailty syndrome in older women: the Women’s Health and Aging Studies. J Am Geriatr Soc. 2005;53(6):927-934.

5. Ahmed N, Mandel R, Fain M. Frailty: an emerging geriatric syndrome. Am J Med. 2007;120(9):748-753.

6. Dorner B, Posthauer ME, Thomas D; National Pressure Ulcer Advisory Panel. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care. 2009;22(5):212-221.

7. National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association; 2002: 43

8. Fiatarone MA, O’Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med. 1994;330(25):1769-1775.

9. Wolf SL, Barnhart HX, Kutner NG, et al. Reducing frailty and falls in older persons: an investigation of tai chi and computerized balance training. J Am Geriatr Soc. 2003;51(12):1794-1803.