Commentary by Antonella Surbone MD PhD FACP, Department of Medicine, New York University Medical School, Clinical Correlations Ethics Section Editor
According to the Institute of Medicine (IOM) report of April 14th, 2008, the elderly comprise 12% of the U.S. population, and their number is projected to almost double between 2005 and 2030, from 37 million to 70 million. The elderly currently account for more than one third of all hospital stays and of prescriptions, and more than a fourth of all office visits to physicians in the U.S. The average 75 year old American has three or more comorbidities and takes at least four medications.  Thus, delivering optimal geriatric care has become a medical and ethical priority in our aging society.
In western countries, old age tends to be represented mostly in terms of decreased productivity, functional impairment, co-morbidity, cognitive limitations and the burden of care placed on the family and the health care system. Healthcare providers thus tend to view the older population through a skewed “ageist” prism, acting on assumptions of uniform frailty and cognitive impairment. This distorted appraisal continues to limit the appropriateness of care and the adequacy of research and education in geriatrics. The older adult population, however, is physiologically, psychologically, socially and culturally heterogeneous. 
Aging involves a progressive decline in the functional reserve of multiple organs and systems that modulate the person’s adaptation to stress.  The word “frailty” has been often used improperly to refer to elderly patients’ increased vulnerability, when compared to younger adults. As reported by Dr. Sutin, research has lead to a precise conceptualization of frailty as the result of the interplay of physical, psychological, cognitive, functional, social and environmental factors [4,5]. Comorbidity, disability and frailty may occur in elderly patients as separate or concomitant entities, and their multidimensional assessment should guide clinical decision making in geriatrics.
In geriatric oncology, for example, the patient’s frailty often limits the safety of administration of standard and experimental treatments. Frailty, however, may result from the patient’s underlying cancer, and it can be improved or even reversed by active oncologic treatment. [6,7] Studies show that the frequent under-treatment of elderly cancer patients and their under-representation in clinical trials frequently stems from misconceptions about an inevitable correlation between aging, vulnerability and frailty. By contrast, available data suggest that age itself, in the absence of severe concomitant illnesses or psychological, cognitive or functional impairment, is not an independent risk factor for either increased toxicity or lack of cancer treatment efficacy. 
The distorted cultural perception of age that dominates most western societies, known as ageism, has a major influence on our attitudes toward, and practices of, providing health care to elderly patients, who often suffer from social isolation due to the loss of their past former productive roles. Poverty is especially common in the elderly, and socioeconomic, combined with cultural, factors in ethnic minorities in western countries limit their access to medical care and research.  Frailty is worsened by lack of social support and elderly patients are at risk for diminished quality of life and increased psychological stress.
In conclusion, when offering specific treatments to elderly patients, we must take into consideration different medical, psychological, functional and social factors. Understanding the determinants of frailty and learning how to recognize and measure it in the clinic is essential to achieve the objective of basing our clinical judgments on sound evidence, rather than on cultural myths, biases, or prejudices that rather endanger quality and effectiveness of geriatric care.
1. Institute of Medicine. Retooling for an aging America: Building the health care workforce. Committee on the Healthcare Workforce for older Americans- Washington, D.C.: The National Academies Press, 2008.
2. Lipsitz LA. Physiological complexity, aging, and the path to frailty. Sci Aging Knowl Envir 2004; p. pe16.
3. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol 2004; 59: 255-263.
4. Balducci L. Aging, frailty and chemotherapy. Cancer Control 2007; 14: 7-14.
5. Monfardini S, Basso U. Oncological causes of frailty in older cancer patients. Eur J Cancer 2007; 43:1230-1231.
6. Surbone A, Kagawa-Singer M, Terret C, Baider L. The illness trajectory of elderly cancer patients age across cultures: SIOG position paper. Ann Oncol 2006; 18:633-638.
7. Surbone A. Ethical considerations in conducting clinical trials for elderly cancer patients. Aging Health 2008; 4: 253-260.
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