Commentary by David Sutin MD, NYU Section 0f Geriatric Medicine
The Annual American Geriatric Society meeting, held May 2008, in Washington DC, was as usual fascinating. The meeting highlights included a lively discussion of the treatment of hypertension in the very elderly, and a talk on the emerging syndrome of frailty. Frailty was the selected subject for the Henderson State-of-the Art lecture, delivered by Dr Linda Fried, which I will summarize below.
The Syndrome of Frailty is characterized by at least 3 of the following 5 criteria-weakness, low energy and exhaustion, slow walking speed, low physical activity and weight loss. In the Cardiovascular Health study 7.3% of women over age 65, and 4.9% of men over 65 years of age were frail, with frailty being especially common in those over 80 years of age. Subjects who were frail had a Hazard Ratio, over 3 years, of 1.98 for worsening ADL disability and 2.24 for death. (Fried LP, Tangen CM, Walston J. et al. Frailty in older adults: evidence for a phenotype, Journal of Gerontology Series A-Biological Sciences and Medical Sciences. 2001, 56(3):M146-56.)
Dysregulation and deficits of multiple systems are associated with frailty including sarcopenia, inflammation, decreased heart rate variability, altered clotting, altered insulin resistance, anemia, higher levels IL-6, CRP, cortisol and lower levels DHEA-S and the presence of micronutrient deficiency.
It is felt that there are 3 major courses of death in adults. In 20% there is a fatal illness, with a rapid decline prior to death (median age 65 years). In 25% there is a slow decline in physical capacities that is punctuated by serious exacerbations of different pathologies such as congestive heart failure or COPD (median age 75 years). In 40% there is a long term decline of function, requiring many years of assistance due to progressive fraility and cognitive impairment with death generally occuring after a physiological challenge, (median age 85 years).
Preventing frailty is obviously a major focus of geriatrics and includes the treatment of sarcopenia, which is modifiable. Data have shown that in frail nursing home patients resistance exercise increased muscle mass by 180% and strength by 100%. Nutritional supplementation may also be helpful. Further research on all aspects of frailty is needed. Among several comprehensive reviews of frailty, we suggest the following:
Ahmed N, Mandel R, Fain MJ, Frailty: An emerging Geriatric Syndrome, The American Journal of Medicine. 2007, Vol 120, pg 748-753