Frailty Syndrome: "You Know It When You See It"
The normal aging process is characterized by a progression of physical events that occur throughout the life cycle. Changes associated with aging occur throughout the body and are more pronounced in the later years. Changes in the musculoskeletal system begin to occur after the third decade and continue into the eighth and ninth decades. The frailty syndrome can be described as a culmination of the effects of these changes on the human body.
As normal aging progresses, our muscle and bone systems show declines in several different areas. The term sarcopenia describes the biochemical changes that occur within the muscle fibers as they relate to declining muscle mass and muscle function. Visible atrophy of muscle fibers results in decreased strength. These changes result from fat deposition replacing lean muscle mass, a process that begins after the third decade of life and can result in up to a 40% decrease in muscle mass by the eighth decade of life. Marked losses in muscle strength and decreased endurance become more prominent over time and correlate with an increase in falls as we get older.
The structural integrity of the skeleton plays a major role in maintaining optimal posture and gait. After the age of 40 however, the rate of bone mass and bone density starts to decrease. This process is exacerbated in women following menopause and can lead to osteopenia and osteoporosis. Independent of the development of osteoporosis, normal age related decreases in bone density result in decreased bone strength, which can increase the risk of falls and fractures.
As a result, these normal processes of aging play a significant role in the decreased mobility that is often observed in later life. The frailty syndrome is not defined by mobility alone; malnourishment, as evidenced by involuntary weight loss, also is an important component. Although it is difficult to define precisely, most healthcare professionals will concur that frailty can be easily recognized as "you know it when you see it."
As the population continues to age and the percentage of older adults over the age of 80 continues to expand, it is more important than ever to identify the frailty syndrome sooner. Several different studies have tried to identify a working definition of the common findings of frailty based on recognizable criteria and by using measureable scales of disability. A landmark study identified and defined frailty as a syndrome that is distinct and independent of medical illnesses and disability.
The frailty syndrome requires at least three of the following five characteristics:
Unintentional weight loss of at least 10 pounds or greater than 5% of body weight from the prior year
Muscle weakness, as measured by reduced grip strength
Physical slowness, based on measured time to walk a distance of 15 feet
Poor endurance, as indicated by self-reported exhaustion, and
Low physical activity, as scored using a standardized assessment questionnaire
The study found that 7% of the population aged 65 and older and 20% of the population aged 80 and over met the criteria for frailty in the absence of any acute or chronic medical conditions.
Once the frailty syndrome is recognized, the next step is to target the conditions associated with it. Developing appropriate interventions is an important multifaceted process. Factors to be considered, aside from chronic and acute medical conditions, include nutritional status and supplementation as required, mental health and depression, dental health and proper chewing and swallowing, and a thorough medication evaluation and review, to identify possible drug side effects causing weakness, slowness (both physical and mental), and falls. In addition, a comprehensive exercise program and increased physical activity have also been shown to benefit the frailty syndrome. Muscle weakness and atrophy resulting from a sedentary disposition and chronic illness respond well to physical therapy.
In conclusion, with the significant growth of the over 80 population and the increased average life expectancy, we all will no doubt encounter an increase in the prevalence of the frailty syndrome. Many of the predisposing factors of frailty occur as a result of the aging process. Many of us generally identify frail elders superficially by the "you know it when you see it" test. However, early recognition and assessment of the identified standardized criteria for the diagnosis of the frailty syndrome is an important first step that may guide the appropriate treatment interventions and improve health outcomes. Helping older adults maintain their highest level of function is the optimal goal of geriatric care.
|Nora DeVoe is a Gerontologist specializing in Eldercare and Caregiver issues. She may be reached at (716) 667-7299.|
Dr. Nora is a ....