In 1998, there were 34 million adults aged 65 years or older in the US.1 By 2030, that number is expected to double.1 This dramatic increase in the number of geriatric patients poses a number of challenges to the health care system and the providers who operate within it. In order to address these challenges, physicians in all fields must become familiar with some of the special considerations that accompany geriatric patients and their care.
Geriatric medicine encompasses a broad spectrum of geriatric syndromes, the most common of which include changes in sensory perception, cognition, and mobility.1 The syndrome of frailty is also highly prevalent, affecting an estimated 25% to 50% of individuals aged 85 years or older.2,3 Frailty is an important syndrome to identify, as frail patients are more likely than their non-frail counterparts to experience falls, hospitalizations, and other adverse outcomes.2
Definition of Frailty
Frailty is not identified as any individual symptom but rather as a syndrome seen in older adults. The syndrome of frailty has been described as a state of increased vulnerability to stressors, either acute or chronic, due to aging-associated physiologic decline and reduction in physiologic reserve.4,5 The resulting inability to sufficiently compensate in the setting of one or more stressors can have severe consequences, including disability, hospitalization, institutionalization, or death.4
Two main models exist for defining frailty: the phenotype model and the cumulative decline model.
The phenotype model grew out of a secondary analysis of data from the Cardiovascular Health Study, a prospective cohort study of over 5000 adults aged 65 years or older.6 Fried and colleagues defined a phenotype of frailty that satisfies at least three of the following five criteria: low grip strength, low energy, slowed walking speed, low physical activity, and/or unintentional weight loss.2 Notably, markers of cognition are not included in the phenotype. Individuals meeting criteria for frailty were observed to have poorer outcomes, namely increased falls, reduced mobility and function, and increased rates of hospitalization and death.2 Even after adjustment for clinical or subclinical disease, disability status, depressive symptoms, and socioeconomic status, frailty as defined by the phenotype model remained an independent predictor of risk of these poor outcomes.2
Frailty can also be defined with the cumulative deficit model via calculation of a patient’s Frailty Index. Based on 92 individual parameters including a variety of signs, symptoms, laboratory data, disease states, and disabilities, the Frailty Index is calculated as the percentage of parameters or deficits present in an individual.7 A higher percentage is reflective of more cumulative deficits and thus a frailer individual. Studies have identified a Frailty Index of 0.67 as a “tipping point” for patients at which further deficit accumulation is likely to result in death.8,9
The phenotype model and cumulative deficit model have both been shown to be valid predictors of frailty-associated decline with overlap in identification of frail patients and statistical convergence.10,11 The Frailty Index has demonstrated greater precision in discriminating between moderate and severe frailty, perhaps because it is a continuous rather than categorical model.12 Models derived from the original Frailty Index have reduced the number of parameters to roughly 30 without loss of predictive validity.3 Still, the Fried model is a valid tool and is used commonly in practice.
It is important to note that frailty is distinct from disease or disability, as noted by Fried and colleagues, although overlap with these other entities is commonly observed.2 Additionally, frailty is a dynamic process. Although progression to greater frailty occurs more frequently than improvement to a lesser degree of frailty, there are several interventions that have been shown to improve outcomes for frail patients.2
While exercise to promote fitness is recommended for all patients regardless of age, it is especially important in frail older adults. Exercise is one of the most effective interventions for keeping frailty at bay and maintaining the quality of life and functionality of geriatric patients. Studies have demonstrated that regular exercise in older adults improves gait and muscle strength, resulting in increased mobility and fewer falls.13,14 In a 2009 Cochrane review of 49 randomized controlled trials of exercise interventions for residents of long-term care facilities (a population that is predisposed to frailty), strength and balance exercises were particularly helpful for increasing muscle strength and improving functionality.15 The benefits of exercise interventions for older patients have been demonstrated in several home-based and group-based settings.16-18
The optimal duration and frequency of exercise for frail older adults is currently unknown on a population level.4 Exercise should be pursued at an intensity that is safe and appropriate for the patient. This determination can be made with the assistance of a trained physiotherapist.
Comprehensive Geriatric Assessment
Another important intervention in the care of frail of vulnerable older patients is the comprehensive geriatric assessment, a multidisciplinary process involving a range of health domains for the ongoing evaluation and management of frail or vulnerable older adults. These domains include physical medical conditions, mental health conditions, level of functioning, social circumstances, and environmental considerations.19 Coordination of care among all providers is key for successful comprehensive geriatric assessment. The core team of providers usually includes a primary care physician, nurse, occupational therapist, physiotherapist, and social worker.19 The primary care physician is not necessarily a geriatrician. The physiotherapist can assist with exercise to improve gait and muscle strength to increase mobility and reduce falls.
Comprehensive geriatric assessment is also iterative, meaning that assessment of the patient is ongoing and continually revisited. Comprehensive geriatric assessment has been shown to improve outcomes in frail older adults, whether initiated in the community or in a hospital setting. Meta-analysis of 22 randomized controlled trials found that frail older patients who received comprehensive geriatric assessment during a hospitalization were more likely to return home, were less likely to experience cognitive or functional deterioration, and had lower in-hospital mortality compared to patients who did not receive comprehensive geriatric assessment as inpatients.20 Additionally, when comprehensive geriatric assessment is delivered in the community, patients experience fewer falls and have an increased likelihood of continuing to live at home.21,22
Goals of Care
Finally, any discussion of geriatric care should include goals of care. As in all patients, but especially in geriatric patients, the overall mission is to avoid premature morbidity and mortality while also maintaining a good quality of life. However, the risk-to-benefit ratio of medical interventions for frail older adults can be quite different from that of other patient groups. Providers should discuss with these patients their wishes regarding aggressiveness of care for ongoing medical issues, measures of screening and prevention, and possibly end-of-life care. Current screening and prevention guidelines suggest that the utility of conventional screening tests after age 75 may be limited, but ultimately care must be individualized to the patient.23 A combination of individualized and shared decision-making with the patient can ensure that care continues to be provided in a manner that is appropriate and concordant with the patient’s wishes.24
In summary, frailty is a prevalent syndrome within the rapidly growing geriatric population, and its presence in a patient merits special consideration for that patient’s care. The benefits of exercise interventions, comprehensive geriatric assessment, and goals of care conversations are well established. It is important to remember that frailty is a unique entity and synonymous with neither disease nor disability. As such, it is our mission as providers to ensure the vitality of our older patients for years to come.
By Jessica K Qiu, 3rd year medical student at NYU School of Medicine
Peer reviewed by Nina Blachman, MD, Geriatrics, NYU Langone Health
Image courtesy of Wikimedia Commons
1. Miller KE, Zylstra RG, Standridge JB. The geriatric patient: a systematic approach to maintaining health. Am Fam Physician. 2000;61(4):1089-1104. https://www.ncbi.nlm.nih.gov/pubmed/10706161
2. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-156. https://www.ncbi.nlm.nih.gov/pubmed/11253156
3. Song X, Mitnitski A, Rockwood K. Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. J Am Geriatr Soc. 2010;58(4):681-687.
4. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-762.
5. Xue QL. The frailty syndrome: definition and natural history. Clin Geriatr Med. 2011;27(1):1-15. https://www.ncbi.nlm.nih.gov/pubmed/21093718
6. Fried LP, Borhani NO, Enright P, et al. The Cardiovascular Health Study: design and rationale. Ann Epidemiol. 1991;1(3):263-276.
7. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. Scientific World Journal. 2001;1:323-336.
8. Rockwood K, Mitnitski A. Limits to deficit accumulation in elderly people. Mech Ageing Dev. 2006;127(5):494–496. https://www.ncbi.nlm.nih.gov/pubmed/16487992
9. Scheffer M. Complex systems: Foreseeing tipping points. Nature. 2010;467(7314):411–412.
10. Cigolle CT, Ofstedal MB, Tian Z, Blaum CS. Comparing models of frailty: the Health and Retirement Study. J Am Geriatr Soc. 2009;57(5):830–839.
11. Rockwood K, Andrew M, Mitnitski A. A comparison of two approaches to measuring frailty in elderly people. J Gerontol A Biol Sci Med Sci. 2007;62(7):738–743.
12. Kulminski AM, Ukraintseva SV, Kulminskaya IV, Arbeev KG, Land K, Yashin AI. Cumulative deficits better characterize susceptibility to death in elderly people than phenotypic frailty: lessons from the Cardiovascular Health Study. J Am Geriatr Soc. 2008;56(5):898–903.
13. Daley MJ, Spinks WL. Exercise, mobility and aging. Sports Med. 2000;29(1):1-12. https://www.ncbi.nlm.nih.gov/pubmed/10688279
14. Keysor JJ. Does late-life physical activity or exercise prevent or minimize disablement? A critical review of the scientific evidence. Am J Prev Med. 2003;25(3 Suppl 2):129-136.
15. Forster A, Lambley R, Hardy J, et al. Rehabilitation for older people in long-term care. Cochrane Database of Syst Rev. 2009;1:CD004294.
16. de Vries NM, van Ravensberg CD, Hobbelen JS, Olde Rikkert MG, Staal JB, Nijhuis-van der Sanden MW. Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: a meta-analysis. Ageing Res Rev. 2012;11(1):136–149.
17. Theou O, Stathokostas L, Roland KP, et al. The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res. 2011;2011:569194.
18. Clegg A, Barber S, Young J, Forster A, Iliffe S. Do home-based exercise interventions improve outcomes for frail older people? Findings from a systematic review. Rev Clin Gerontol. 2012;22(1):68–78.
19. Welsh TJ, Gordon AL, Gladman JR. Comprehensive geriatric assessment – a guide for the non-specialist. Int J Clin Pract. 2014;68(3):290-293.
20. Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553.
21. Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet. 2008;371(9614):725–735.
22. Stuck AE, Egger M, Hammer A, Minder CE, Beck JC. Home visits to prevent nursing home admission and functional decline in elderly people: systematic review and meta-regression analysis. JAMA. 2002;287(8):1022–1028.
23. Goldberg TH, Chavin SI. Preventive medicine and screening in older adults. J Am Geriatr Soc. 1997;45(3):344-354.
24. Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285(21):2750-2756.