frailty

see also:

• geriatrics
• exercise for health

• frailty is the accumulation of deficits with ageing resulting in mobility issues, loss of independence
• the level of frailty is an important factor in:
  • falls risk
  • depression due to mobility issues, loss of independence
  • need for emergency department attendance - 20-40% of ED attendances are said to be for those who are frail
  • impaired ability to return to prior baseline levels after an acute illness or even following ED processes - each episode likely to further increase long term frailty
  • mortality risk

• there appear to be genetic risk factors
  • a 2025 study suggested there were many genes that affect how our immune system, brain and metabolism work which contribute to risk of frailty ¹⁾
• ageing
• cognitive deterioration
  • reduced sleep with age - less repair processes, less consolidation of memories, impaired glymphatic system of the brain with reduced waste removal from the brain, etc.
  • ageing related gastric achlorhydria from atrophic gastritis compounded by proton pump inhibitors (PPIs) may have important metabolic effects particularly from “subclinical” or clinical vitamin B12 (cobalamin) deficiency along with other malabsorptions - there is building evidence that multivitamin supplements over the age of 60yrs may indeed be beneficial
  • medications
• psychological deterioration
  • falls result in increased risk of falls partly due to loss of confidence, possibly depression leading to inattention
• physical deterioration
  • musculoskeletal
    • chronic pain or physical disability
      • osteoporosis and fractures
      • arthritis - osteoarthritis, rheumatoid arthritis, etc
      • neurologic disabilities - stroke, etc
    • sarcopenia / generalised muscle wasting
      • reduced protein intake
      • alcohol
      • smoking
      • exercise
      • hormonal
      • pathologic
      • genetic factors account for ~50-60% of sarcopenia variability - see sarcopenia / generalised muscle wasting
      • ageing related factors risking sarcopenia especially from age 60yrs onwards:
        • greater degree of muscle loss following prolonged bed rest
        • higher protein intake required to rebuild muscle
          • perhaps 35-40g quality protein three times a day including breakfast (eg. eggs) - having it just at dinner in the evening won't be enough to rebuild or retain muscle
        • greater need for resistance exercise to rebuild muscle - at least twice a week
          • walking up stairs or up hills, carrying weights, etc
        • increased chronic systemic inflammation may also reduce muscle bulk?
  • cardiovasular fitness / capacity
  • impaired vision/hearing may lead to increased risk of falls, social isolation, depression, etc

• 1. “very fit”
• 2. “well” - no active disease symptoms, occasionally very active or exercise
• 3. “managing well” - well controlled medical symptoms but are regularly active beyond regular walking
• 4. “vulnerable” - symptoms limit activities, “slowed up” or “tired during day” but not dependent upon others
• 5. “mildly frail” - more evident slowing and may need help with higher level IADLs (usually unable to walk outside alone or go shopping)
• 6. “moderately frail” - need help with all outdoor activities and with keeping house. Have problems with stairs and bathing.
• 7. “severely frail” - completely dependent for personal care
• 8. “very severely frail” - approaching end of life - may not recover from a minor illness.
• 9. “terminally ill” - end of life with life expectancy < 6 months even if not otherwise evidence of frailty

• Fatigue - are you fatigued?
• Resistance - cannot walk up 1 flight of stairs?
• Aerobic - cannot walk 1 block
• Illnesses - more than 5 illnesses
• Loss of weight - > 5kg LOW in past 6 months

score: 0 = robust; 1-2 = prefail; 3-5 = frail

• score 0-2 on 11 domains:
  • cognition
  • hospital admissions past year
  • self-reported general health status
  • functional independence - number of activities need help with
  • social support availability
  • 5 or more medications
  • do you forget to take medications
  • nutrition - weight loss
  • mood - sad or depressed?
  • continence
  • functional performance - how long to get out of chair, walk 3m and get back to sitting in chair (0 = <10sec, 1 = 10-20sec, 2 = >20secs or unable)
• score 0-5 not frail
• score 6-7 = vulnerable
• score 8-9 = mildly frail
• score 10-11 = moderate frailty
• score 12-17 = severe frailty

• mobilising as soon as possible
• high protein meals
• glasses of water
• encourage families to visit
• encourage self washing, dressing, etc
• enure night rest
• early discharge planning

• regular aerobic and muscle bulk maintenance exercises
• risk mitigation to prevent trauma and its associated long term disabilities which lead to frailty
  • risk assess activities and manage appropriately even when young adults
    • don't be stupid
    • take extra care in high risk situations
  • falls risk prevention
• maintenance of social networks
• healthy lifestyle to reduce cardiovascular, stroke, obesity, diabetes and osteoporosis risks in particular
• no smoking
• adequate protein in diet - the body does not store protein except in muscles - you don't want these wasting away