Introduction to Frailty

Key Points Frailty increases the risk of adverse outcomes such as disability, falls and death. Frailty has a strong association with chronic disease states commonly seen in older people such as hypertension, chronic kidney disease, osteoarthritis and depression. Comprehensive functional assessment identifies areas to further investigate and provides the clinician with an overview of the health and social care needs of an older individual.

Definition of Frailty It is a state of increased vulnerability to stressors secondary to decreased physiological reserve in multiple systems. This causes a limited capacity to maintain homeostasis and increases the risk of adverse outcomes such as disability, falls and death (1, 2).

Phenotype Model of Frailty Fried and colleagues devised criteria for diagnosing Frailty, based on secondary analysis of data from a prospective study (Cardiovascular Health Study). This is known as the Phenotype Model (3) . Self reported exhaustion Unintentional weight loss Gait speed Low energy expenditure/Physical activity (PA) Weak grip strength Linda Fried and colleagues in 2001 analysed secondary data from the prospective cohort Cardiovascular Health Study. From this, they proposed that Frailty has a phenotype, based on the 5 determined criteria of self reported exhaustion, unintentional weight loss, gait speed, low energy expenditure and weak grip strength. The Cumulative Deficit model is another model of frailty. This proposes that frailty is as a result of the cumulative effect of individual deficits. The term ‘deficits’ includes symptoms (low mood), signs (elicited from physical examination), laboratory test results, disease states and disabilities. Rockwood and colleagues in 2008 also developed the Rockwood frailty index which relates deficit accumulation to risk of death (8).

Phenotype Model of Frailty Linda Fried and colleagues in 2001 analysed secondary data from the prospective cohort Cardiovascular Health Study. From this, they proposed that Frailty has a phenotype, based on the 5 determined criteria of self reported exhaustion, unintentional weight loss, gait speed, low energy expenditure and weak grip strength. The Cumulative Deficit model is another model of frailty. This proposes that frailty is as a result of the cumulative effect of individual deficits. The term ‘deficits’ includes symptoms (low mood), signs (elicited from physical examination), laboratory test results, disease states and disabilities. Rockwood and colleagues in 2008 also developed the Rockwood frailty index which relates deficit accumulation to risk of death (8).

Phenotype Model of Frailty Measures within each indicator of frailty. Self reported exhaustion Agree with the statement ‘ I felt that everything I did was an effort during the past week’ Unintentional weight loss In the last year >4.5kg Gait speed Time to walk 4.57 m (adjusted for gender and height) Low energy expenditure/Physical Activity (PA) Does the patient perform PA less than or equal to: Male - <383kcal/week (<2.5 hours/week) Female - <270kcal/week (2 hours/week) Weak grip strength Assessed by a dynamometer (adjusted for gender and age)

Phenotype Model of Frailty Listed in this slide are specific measures required to diagnose each criteria. Self reported exhaustion – if a patient agrees with the statement ‘I felt that everything I did was an effort during the past week’ or ‘I could not get going’. YES to either/both statements = 1 point. 2) Unintentional weight loss. YES ( = 1 point) if the patient has lost weight >4.5kg this year. 3) Gait speed. This measures the time to walk 4.57m. This is adjusted for gender and height. Point(s) allocated is/are dependent on speed produced. 4) PA. If patient falls below this level of activity then 1 point each. 5) Weak grip strength. This is measured by a dynamometer. Point(s) allocated is/are dependent on strength measured by the dynamometer.

Definition of Frailty using the Phenotype Model and Fried’s Criteria PRE FRAIL FRAIL DISABILITY 1 – 2 out of 5 Fried Criteria are suggestive of a Pre – Frail state. A pre disability state. A reversible and dynamic process. 3 out of 5 Fried Criteria suggest Frailty is present. This image also implies that a patient may progress from Pre frail, to Frail, to Disabled over a non specified time period. However, it is extremely important to consider that Frailty as a state, is dynamic, and therefore reversible process.

Frailty and Sarcopaenia Sarcopaenia is defined as a syndrome characterised by progressive loss of skeletal muscle mass and muscle strength with an increased risk of adverse outcomes such as physical disability (4). A key component in the development of frailty. Leads to a decline in functional ability. Assessed for in Fried Criteria (5).

Prevalence of Frailty based on the Phenotype Model and Fried’s Criteria Based on a systematic review investigating the prevalence of frailty using the Fried criteria (5, 6). 9.9% Frail prevalence. 44.2% Pre frail prevalence. More prevalent in women than men. It increases steadily with age.

Frailty and Chronic Disease Frailty has a strong association with chronic disease states commonly seen in older people such as hypertension, chronic kidney disease, osteoarthritis and depression. Chronic diseases (individually or cumulatively) or treatments for a disease process or processes may predispose an individual to frailty. Frailty, however, is not disease specific (7).

Comprehensive assessment Frailty screening and assessment tools form a key part of comprehensive functional assessment of older people. Comprehensive functional assessment identifies areas to further investigate and provides the clinician with an overview of the health and social care needs of an older individual. Important areas to assess include cognition, activities of daily living, performance measures, nutritional status and mood. Please view the ‘Comprehensive Functional Assessment for Older People’ video on the Vivifrail website.

Comprehensive assessment In addition to the video, Diabetes Frail have created a pocket book called ‘Comprehensive Functional Assessment for Older People’. Pocket Book.pdf If would like a copy of this book please do not hesitate to contact us. This book is intended for educational purposes only.

References Sinclair AS, Dunning T, Rodrigues – Manas L. Diabetes in older people: new insights and remaining challenges. Lancet Diabetes Endocrinology 2014; Published online November 2014. Published in paper 2015; 3 (4) 275 – 285. Atienzar P, Abizanda P, Guppy A, Sinclair AJ. Diabetes and Frailty: An Emerging Issue. Part 1: Sarcopaenia and factors affecting lower limb function. British Journal of Diabetes and Vascular Disease 2012; 12 (3) 110 – 116. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56(3) 146–56. Santilli V, Bernetti A, Mangone M, Paoloni M. Clinical definition of Sarcopenia. Clinical Cases in Mineral and Bone Metabolism 2014; 11(3): 177-180. Clegg A, Young J, Iiiffe S, Rikkert MO, Rockwood K. Frailty in Older People. Lancet 2013; 381 (9868) 752 – 762. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community- dwelling older persons: a systematic review. J Am Geriatr Soc. 2012; 60(8):1487–92. Weiss CO. Frailty and Chronic Diseases in Older Adults. Clin Geriatr Med 2011; (27) 39–52. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol Biol Sci Med Sci 2007; (62A) 722-727.