frailty is the accumulation of deficits with ageing resulting in mobility issues, loss of independence
the level of frailty is an important factor in:
falls risk
depression due to mobility issues, loss of independence
need for emergency department attendance - 20-40% of ED attendances are said to be for those who are frail
impaired ability to return to prior baseline levels after an acute illness or even following ED processes - each episode likely to further increase long term frailty
mortality risk
Aetiology
there appear to be genetic risk factors
a 2025 study suggested there were many genes that affect how our immune system, brain and metabolism work which contribute to risk of frailty 1)
reduced sleep with age - less repair processes, less consolidation of memories, impaired glymphatic system of the brain with reduced waste removal from the brain, etc.
ageing related factors risking sarcopenia especially from age 60yrs onwards:
greater degree of muscle loss following prolonged bed rest
higher protein intake required to rebuild muscle
perhaps 35-40g quality protein three times a day including breakfast (eg. eggs) - having it just at dinner in the evening won't be enough to rebuild or retain muscle
greater need for resistance exercise to rebuild muscle - at least twice a week
walking up stairs or up hills, carrying weights, etc
increased chronic systemic inflammation may also reduce muscle bulk?
cardiovasular fitness / capacity
impaired vision/hearing may lead to increased risk of falls, social isolation, depression, etc
Frailty scales
Clinical Frailty Scale (CFS)
1. “very fit”
2. “well” - no active disease symptoms, occasionally very active or exercise
3. “managing well” - well controlled medical symptoms but are regularly active beyond regular walking
4. “vulnerable” - symptoms limit activities, “slowed up” or “tired during day” but not dependent upon others
5. “mildly frail” - more evident slowing and may need help with higher level IADLs (usually unable to walk outside alone or go shopping)
6. “moderately frail” - need help with all outdoor activities and with keeping house. Have problems with stairs and bathing.
7. “severely frail” - completely dependent for personal care
8. “very severely frail” - approaching end of life - may not recover from a minor illness.
9. “terminally ill” - end of life with life expectancy < 6 months even if not otherwise evidence of frailty
Gleason and Lauren Jan et al Frail Scale
Fatigue - are you fatigued?
Resistance - cannot walk up 1 flight of stairs?
Aerobic - cannot walk 1 block
Illnesses - more than 5 illnesses
Loss of weight - > 5kg LOW in past 6 months
score: 0 = robust; 1-2 = prefail; 3-5 = frail
Edmonton Frail Scale
score 0-2 on 11 domains:
cognition
hospital admissions past year
self-reported general health status
functional independence - number of activities need help with
social support availability
5 or more medications
do you forget to take medications
nutrition - weight loss
mood - sad or depressed?
continence
functional performance - how long to get out of chair, walk 3m and get back to sitting in chair (0 = <10sec, 1 = 10-20sec, 2 = >20secs or unable)
score 0-5 not frail
score 6-7 = vulnerable
score 8-9 = mildly frail
score 10-11 = moderate frailty
score 12-17 = severe frailty
Interventions in hospital
mobilising as soon as possible
high protein meals
glasses of water
encourage families to visit
encourage self washing, dressing, etc
enure night rest
early discharge planning
Prevention of frailty
What doesn't kill you makes you stronger is a MYTH
this may be useful in some psychologic situations but in general most trauma, especially if it involves articular surfaces of joints, leaves long term sequelae which may limit activities life long and this may be severe enough to create a vicious downward spiral of poor health, frailty, obesity, depression.
frailty tends to beget further frailty
PREVENTION is MUCH BETTER THAN CURE!
regular aerobic and muscle bulk maintenance exercises
risk mitigation to prevent trauma and its associated long term disabilities which lead to frailty
risk assess activities and manage appropriately even when young adults
don't be stupid
take extra care in high risk situations
falls risk prevention
maintenance of social networks
healthy lifestyle to reduce cardiovascular, stroke, obesity, diabetes and osteoporosis risks in particular
no smoking
adequate protein in diet - the body does not store protein except in muscles - you don't want these wasting away