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:
- Early discussions should be had about end-of-life goals and appropriate limitation of invasive therapies to avoid iatrogenic harm (refer to Part A. Palliative and end-of-life care).
- Early involvement of other health professionals, including
- nutritionist or dietitian
- speech therapist, when appropriate.
- Vigilance and early recognition and intervention of complications of acute illness that are common in frailty, such as
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
- 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
Interventions with some efficacy in the treatment of frailty include:30
- 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.
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.
Not currently recommended in Australia and advised against in the US.36
Refer to Part A. Osteoporosisfor more information.
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
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