Frailty- an emerging syndrome

August 21, 2008

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