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RACGP aged care clinical guide (Silver Book)

Silver Book - Part A

Frailty

Silver Book - Part A
    16. Frailty
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Last revised: 30 Oct 2019

  • Frailty is best assessed annually using a validated measurement tool.
  • Prescribe appropriate physical activity that includes a resistance training component.
  • Screen all patients admitted to residential aged care facilities for the risk of malnutrition.
  • Early involvement of a physiotherapist can be helpful.
  • Early involvement of a dietitian or nutritionist can be helpful.
  • Reduction in polypharmacy can be helpful.
  • Engagement of a dentist can be helpful.
  • Engagement of a speech therapist can be helpful when necessary for swallowing difficulties.
  • Consider comorbidities that may be contributing (eg depression, cognitive impairment).
Frailty is a syndrome of physiological decline that occurs in later life, and is associated with vulnerability to adverse health outcomes.1 Older people who are frail are less resilient to stressors (eg acute illness, trauma) and at an increased risk of adverse outcomes, procedural complications, falls, institutionalisation, disability and death.2 Old age alone does not define frailty, and frailty is not an inevitable consequence of ageing.

Factors associated with increased frailty include:

  • older age3
  • current smoker3
  • lower educational level3
  • current use of post-menopausal therapy3
  • not being married4
  • depression5
  • intellectual disability6
  • being of Aboriginal and/or Torres Strait Islander descent7
  • sedentary lifestyle
  • undernutrition
  • chronic disease
  • multimorbidity
  • obesity (may contribute due to pro-inflammatory state).8,9

Pathophysiology

There is increasing evidence that dysregulated immune, endocrine, stress and energy response systems are important to the development of frailty. The basis of this dysregulation most likely relates to molecular changes associated with ageing, genetics and specific disease states, leading to physiological impairments and clinical frailty. Sarcopenia, or age-related loss of skeletal muscle and muscle strength, is a key component of frailty. Decline in skeletal muscle function and mass are consequences of age-related hormonal changes and changes in inflammatory pathways, including increase in inflammatory cytokines.10Ageing people lose height and lean body mass, but gain and redistribute fat.

Endocrine

Table 1 shows the many age-related hormone changes that have been associated with frailty.11

Table 1.

Table 1.

Age-related hormone changes associated with frailty
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Inflammation and the immune system

There is a consistent and strong correlation between frailty and biomarkers of the innate immune system:

  • Levels of pro-inflammatory interleukin (IL)-6 and C-reactive protein (CRP) are elevated in older adults.
    • IL-6 adversely affects skeletal muscle, appetite, adaptive immune system function and cognition,12 and contributes to anaemia.13
  • There is an association between frailty and clotting markers (factor VIII, fibrinogen and D-dimer).14
  • Frail older adults are less likely to mount an adequate immune response to influenza vaccination.15

Stress responses and metabolic systems

The likelihood and extent of frailty increases as abnormal physiological processes accumulate:

  • Older age leads to dysregulation of the autonomic nervous system.16,17
  • Age-related changes in the renin-angiotensin system and in mitochondria likely impact on sarcopenia and inflammation, both important components of frailty.18

Undernutrition

Undernutrition is associated with a deficiency of energy, protein and other nutrients, resulting in weight loss and changes in body composition; it may be difficult to assess in patients with fluid retention (eg ascites, oedema) and those who are overweight.19

Undernutrition results in:19

  • reduced muscle strength
  • impairment of immune function and wound healing
  • slowed recovery from illness and surgery
  • impaired psychosocial functioning
  • poorer clinical outcomes (increased mortality, longer hospital stays, increased readmission rates). 

Patients at risk of malnutrition include those with:

  • chronic disease (eg dementia, chronic obstructive pulmonary disease, cancer, gastrointestinal, kidney or liver disease)
  • acute illness, if food is not consumed for a day or more (consider patients who are fasting for a procedure and post-surgery)
  • immobility
  • frailty
  • depression (refer to Part A. Mental health)
  • social issues (eg low socioeconomic status, social isolation, inability to cook or shop).

Diagnosis

Consider assessing frailty annually. There are many instruments available, and two broad models of frailty have been described:20

  • Frailty phenotype model – hypothesised to have an underlying biological basis.
  • Frailty index – cumulative deficit model.

The most commonly used tool for the phenotypic frailty is the Physical Frailty Phenotype, also known as the Fried or Hopkins tool.21 Instruments to assess frailty include:

  • Fried frailty indicators – frailty (three or more of the below), pre-frailty (one or two of the below) and not frail (none of the below)22
    • Unintentional weight loss (≥4 kg in the past year)
    • Self-reported exhaustion
    • Weakness (reduced grip strength)
    • Slow gait speed
    • Low physical activity
  • Frailty index – based on the accumulation of illnesses, functional deficits, cognitive decline and social circumstances, it involves answering >20 medical and functional questions23
  • Clinical Frailty Scale – helpful scale that takes very little time
  • Edmonton Frail Scale1
  • other useful simple tests with variable specificity and sensitivity24
    • Slow walking speed (>5 seconds to walk 4 m)
    • Timed up and go test (>10 seconds to stand from a chair, walk 3 m, turn around, walk back to the chair and sit down again).

All patients admitted to a residential aged care facility (RACF) should be screened for risk of malnutrition and, if at risk, referred to a dietitian.25 The following tools are useful in screening for malnutrition:

Management

General approach24

Non-pharmacological

Physical frailty

Interventions with some efficacy in the treatment of frailty include:31,32

  • exercise (resistance and aerobic) – consider early involvement of a physiotherapist if possible 31,32
  • caloric and protein support31,32
  • vitamin D supplements in those found to be deficient25
  • reduction in polypharmacy.32

Weight loss

  • Assess executive function – does the patient have capacity to plan and prepare meals?
  • Is there dependency on others to eat?
  • Are there difficulties with chewing and swallowing, difficulties with feeding (eg tremor)?
  • Could medication side effects be a possible contributing factor?
  • Is depression present?
  • Are there unnecessary dietary restrictions in place (eg low salt, low fat), which make food less satisfying?
  • Are financial difficulties present? (May affect quality and quantity of food intake.)

Undernutrition and malnutrition

The management of undernutrition and malnutrition depends on the degree of malnutrition. Document the patient’s nutrition status and level of risk, agree to goals of nutrition support with the patient and/or carers, and monitor the intervention. An accredited dietitian is best placed to provide advice on the nutrition support required.

Consider nutrition support for older people who are malnourished; for example, those with:

  • unintentional loss of >10% of body weight in the past three to six months
  • a BMI <20 kg/m2 and unintentional loss of >5% of body weight in the past three to six months.

Remember that not all involuntary weight loss is due to reduced food intake.

Consider nutritional support for older people who are at risk of malnutrition; for example, those who:

  • have eaten little or nothing for more than five days, or are likely to eat little for the next five or more days (eg elective surgery)
  • are very old (consider nutrition support earlier)
  • have poor absorptive capacity, nutrient losses or increased nutritional needs.

Vitamin D supplements have been found to assist in slowing the progress of physical frailty.33,34 Oral nutritional supplements between meals may be helpful (if first-line strategies fail) in adding protein and calories to diet.35 The American Geriatrics Society’s Choosing Wisely initiative advises against the use of high-calorie supplements because of a lack of evidence, and recommends the following strategies:36

  • Review medications
  • Optimise social supports
  • Provide appealing food and feeding assistance
  • Clarify patient goals and expectations
  • Consider removal of dietary restrictions to improve palatability of food

Pharmacological

Physical frailty

Interventions with some efficacy in the treatment of frailty include:30

Medication review

  • Medications should be reviewed, and medications not required discontinued with care (refer to Part A. Deprescribing).
  • Consider dose reduction in frail older people.
  • Adjust doses for patients with renal impairment and hypoalbuminemia.
  • Review anticholinergic load – Beers Criteria.37 Anticholinergic load is associated with voiding difficulties, cognitive decline and reduced performance on instrumental activities of daily living.38
  • Refer to Part A. Medication management for more information.

Weight loss

If the patient has comorbid depression, consider using mirtazapine (may increase appetite and support weight gain) or a selective serotonin reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI) not associated with anorexia (eg citalopram, venlafaxine). There is no evidence to support use of antidepressants for weight gain in a patient without depression.

Appetite stimulants

Not currently recommended in Australia and advised against in the US.36

Osteoporosis

Refer to Part A. Osteoporosisfor more information.

Testosterone

Older men (aged ≥65 years) have lower testosterone levels. In men who are ageing, a lower testosterone concentration predicts poorer health outcomes (eg frailty, cardiovascular events, mortality). However, randomised controlled trials have not found evidence that testosterone therapy improves cardiovascular and mortality outcomes. Supplementation in the older adult frail population is debatable, and guidelines recommend testosterone therapy for hypogonadal men only, after careful risk–benefit assessment.39

Depression

The choice of treatment for patients with intact cognition will depend upon the severity, type, and chronicity of the depressive episode with antidepressants and/or psychotherapy;40,41 however, the evidence for use in patients with dementia is less robust (refer to Part A. Dementia).
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  3. Fugate Woods N, LaCroix AZ, Gray SL, et al. Frailty: Emergence and consequences in women aged 65 and older in the Women's Health Initiative Observational Study. J Am Geriatr Soc 2005;53(8):1321–30.
  4. Cawthon PM, Marshall LM, Michael Y, et al. Frailty in older men: Prevalence, progression, and relationship with mortality. J Am Geriatr Soc 2007;55(8):1216–23.
  5. Lakey SL, LaCroix AZ, Gray SL, et al. Antidepressant use, depressive symptoms, and incident frailty in women aged 65 and older from the Women's Health Initiative Observational Study. J Am Geriatr Soc 2012;60(5):854–61.
  6. Evenhuis HM, Hermans H, Hilgenkamp TI, Bastiaanse LP, Echteld MA. Frailty and disability in older adults with intellectual disabilities: Results from the healthy ageing and intellectual disability study. J Am Geriatr Soc 2012;60(5):934–38.
  7. Hyde Z, Flicker L, Smith K, et al. Prevalence and incidence of frailty in Aboriginal Australians, and associations with mortality and disability. Maturitas 2016;87:89–94.
  8. Peralta M, Ramos M, Lipert A, Martins J, Marques A. Prevalence and trends of overweight and obesity in older adults from 10 European countries from 2005 to 2013. Scand J Public Health 2018;46(5):522–29.
  9. Samper-Ternent R, Al Snih S. Obesity in older adults: Epidemiology and implications for disability and disease. Rev Clin Gerontol 2012;22(1):10–34.
  10. Schapp LA, Pluijm SMF, Deeg DJH, et al. Higher inflammatory marker levels in older persons: Associations with 5-year change in muscle mass and muscle strength. J Gerontol A Biol Sci Med Sci 2009; 64A(11):1183–89.
  11. Puts MT, Visser M, Twisk JW, Deeg DL, Lips P. Endocrine and inflammatory markers as predictors of frailty. Clin Endocrinol (Oxf) 2005;63(4):403–11.
  12. Ershler WB, Keller ET. Age-associated increased interleukin-6 gene expression, late-life diseases, and frailty. Annu Rev Med 2000;51:245–70.
  13. Ershler WB. Biological interactions of aging and anemia: A focus on cytokines. J Am Geriatr Soc 2003;51(3 Suppl):S18–21.
  14. Walson J, McBurnie MA, Newman A, et al. Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: Results from the Cardiovascular Health Study. Arch Intern Med 2002;162(20):2333–41.
  15. Yao X, Hamilton RG, Weng NP, et al. Frailty is associated with impairment of vaccine-induced antibody response and increase in post-vaccination influenza infection in community-dwelling older adults. Vaccine 2011;29(31):5015–21.
  16. Varadhan R, Chaves PH, Lipsitz LA, et al. Frailty and impaired cardiac autonomic control: New insights from principal components aggregation of traditional heart rate variability indices. J Gerontol A Biol Sci Med Sci 2009;64(6):682–87.
  17. Ogliari G, Mahinrad S, Stott DJ, et al. Resting heart rate, heart rate variability and functional decline in old age. CMAJ 2015;187(15)E442–49.
  18. Burks TN, Andres-Mateos E, Marx R, et al. Losartan restores skeletal muscle remodeling and protects against disuse atrophy in sarcopenia. Sci Transl Med 2011;3(82):82ra37.
  19. Gastrointestinal Expert Group. Gastrointestinal. Melbourne: Therapeutic Guidelines, 2018.
  20. Walston JD, Bandeen-Roche K. Frailty: A tale of two concepts. BMC Medicine 2015;13:185.
  21. Buta BJ, Walston JD, Godino JG, et al. Frailty assessment instruments: Systematic characterization of the uses and contexts of highly-cited instruments. Ageing Res Rev 2016;26:53–61.
  22. 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):M146–56.
  23. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci 2007;62(7):722–27.
  24. Turner G, Clegg A, British Geriatrics Society; Age UK; Royal College of General Practitioners. Best practice guidelines for the management of frailty: A British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing 2014;43(6):744–47.
  25. Dent E, Lien C, Lim WS, et al. The Asia-Pacific clinical practice guidelines for the management of frailty. J Am Med Dir Assoc 2017;18(7):564–75.
  26. Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 1999;15(6):458–64.
  27. Malnutrition Advisory Group. The 'MUST' Explanatory Booklet. Redditch, Worcestershire: MAG, 2003 [Accessed 9 August 2019].
  28. Rubenstein LZ, Harker JO, Salvà A, Guigoz Y, Vellas B. Screening for undernutrition in geriatric practice: Developing the short-form mini-nutritional assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001;56(6):M366–72.
  29. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr 1987;11(1):8–13.
  30. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14(6):392–97.
  31. Travers J, Romero-Ortuno R, Bailey J, Cooney MT. Delaying and reversing frailty: A systematic review of primary care interventions. Br J Gen Pract 2019;69 (678):e61–69.
  32. Ofori-Asenso R, Chin KL, Mazidi, M, et al. Global incidence of frailty and prefrailty among community-dwelling older adults: A systematic review and metanalysis. JAMA network Open 2019;2(8):e198398.
  33. Montero-Odasso M, Duque G. Vitamin D in the aging musculoskeletal system: An authentic strength preserving hormone. Mol Aspects Med 2005;26(3):203.
  34. Ensrud KE, Blackwell TL, Cauley JA, et al. Circulating 25-hydroxyvitamin D levels and frailty in older men: The osteoporotic fractures in men study. J Am Geriatr Soc 2011;59(1):101.
  35. Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev 2009;(2):CD003288.
  36. American Geriatrics Society. Choosing Wisely: Ten things clinicians and patients should question. Philadelphia: AGS, 2015 [Accessed 9 August 2019].
  37. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019. doi: 10.1111/jgs.15767. [Epub ahead of print].
  38. Han L, Agostini JV, Allore HG. Cumulative anticholinergic exposure is associated with poor memory and executive function in older men. J Am Geriatr Soc 2008;56(12):2203–10.
  39. Ali S, Garcia JM. Sarcopenia, cachexia and aging: Diagnosis, mechanisms and therapeutic options – A mini-review. Gerontology 2014;60(4):294–305.
  40. Nelson JC, Delucchi KL, Schneider LS. Moderators of outcome in late-life depression: A patient-level meta-analysis. Am J Psychiatry 2013;170(6):651–59.
  41. Areán PA, Cook BL. Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biol Psychiatry 2002;52(3):293.
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