These frail, older patients often pose a challenge to their health care provider, who may feel overwhelmed by the complex presentation of the patients’ health status.³ One of the major hurdles is that frailty does not fit the traditional medical model of single diagnosis or single organ system disease. There is almost never a chief complaint, and the manifestations of system failure within frailty occur in combination. Frailty refers to notable clinical losses in reserve in many systems that are interdependent for good health.^9–11

The medical problems of the frail patient often appear overwhelming because no single disease or organ system is involved.

Consensus does not yet exist regarding the medical components of frailty.³^,⁶^,¹² However, the term is increasingly recognized as progressively decreasing reserves in our aging population. The reserves of one system are no longer able to compensate for the decline in another system, as they do in the robust individual.

Although the recognition of frailty in a patient should not lead to decreasing care, it does generate a cascade of care needs, such as increased physician visits, hospital admissions, emergency room visits, prescription medications, and ancillary services.¹^,⁸

Primary care clinicians are well poised to identify frail patients in their practices. By identifying the frail patient, focused interventions (or avoidance of interventions), goal setting, and recommendations about medical management (Tables 29-1 and 29-2) can be made with discernment. There is good evidence that identifying frail patients will improve clinical outcomes and there is also increasing evidence that it is cost effective—in short, it is good medical care.³^,¹³^,¹⁴

TABLE 29-1

Clinical Assessment and Management of Common Frailty Symptoms

Symptom	Assessment	Treatment
Unintentional weight loss	Measure weight loss in the previous 6 months/year as a percentage of previous body weight (significant loss is >5%) Ask: “Have you lost more than 10 lbs in the past year—not on purpose?”	Inquire about food availability, preparation, and social aspects of eating Assess for dental problems Liberalized diet (encourage foods of choice) Recommend small frequent feedings Consider nutritional supplements
Exhaustion	Ask: “How often in the past week did you feel exhausted?” “How often would you say you just could not get going?”	Medication review to eliminate fatigue-causing medications Reordering tasks to conserve energy (e.g., eating first, resting, then bathing) Treat remediable conditions (COPD, CHF, anemia, insomnia) Modify daily procedures (e.g., sitting while showering rather than standing)
Weakness/low physical activity	Ask: “How often last week did you feel everything was an effort?” Measure grip strength (Jamar handheld dynamometer)	Increase physical activity (e.g., walking 20-30 min, 3-5 times per week) Strength training Modify environment to decrease energy expenditure (e.g., placement of phone, bedside commode) Adjust room temperature to patient’s comfort
Slow walking speed	Timed walking at usual pace 15 feet: slow is >6 seconds for person of normal height (7 seconds for females under 62 inches and males under 68 inches)	Recommend referral for rehabilitation evaluation or physical therapy for strength training Recommend tai chi if available
Cognition	Mini-Cog screening MMSE, SLUM, or similar testing	Exclude reversible causes (medication toxicity, metabolic changes, depression, thyroid disease, subdural hematoma, etc.) Promote brain health by exercise, diet, stress reduction, etc. Nonpharmacologic interventions (behavior modifications, scheduled toileting, music, bathing in AM) Maximize and maintain functioning
Mood	Screen for depression (Geriatric Depression Scale, PHQ-9, etc.) Assess for helplessness, hopelessness, lack of pleasure, guilt, loss of self-esteem, social withdrawal, persistent dysphoria, and suicidal ideation	Prescribe SSRI alone or in combination with cognitive-behavioral therapy Schedule frequent encounters Listen to concerns Generally avoid TCAs in older adults Consider ECT if severe
Pain	Assess pain severity on scale of 1 to 10 Ask: “Describe how pain has interfered with your activities during the past 24 hours.”	Educate on nonpharmacologic approaches to pain management (clean safe environment, decreased stimuli, back rub, therapeutic touch, etc.) If needed, prescribe oral analgesics for chronic and breakthrough pain in appropriate dosages—short-acting q3-4 hours; long-acting q8-12 hours (Initiate a stimulant laxative in all patients receiving opioids)

CHF, Congestive heart failure; COPD, chronic obstructive pulmonary disease; ECT, electroconvulsive therapy; MMSE, Mini-Mental State Examination; PHQ-9, Patient Health Questionnaire-9; SLUMS, St. Louis University Mental Status; SSRI, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants.

TABLE 29-2

Clinical Management of Frail Older Adults

Etiology of frailty

It has been proposed that aging is an accumulation of random damage to a complex system with overlapping parts. As defects accumulate with time, the organism loses its redundancy across multiple molecular, cellular, and physiologic systems.¹⁵ Resilience is lost—systems no longer have the ability to compensate for one another. The individual then becomes frail as the decline in a majority of systems results in a negative energy balance, sarcopenia, and diminished strength and tolerance for exertion.¹⁶ All systems are at or near the threshold of failure and homeostasis becomes difficult.

In healthy humans, the entire homeostatic network provides a flexible and timely response to any external threat. However, when frailty exists, the range of adaptive responses becomes much more limited. Frail adults have diminished capacity to withstand stress, which places them at risk for adverse health outcomes. This has been well known to astute clinicians throughout history.

In the frail patient, reserves and redundancy of complex systems are lost, making homeostasis difficult to maintain—the body becomes less forgiving.

Recently, frailty has been viewed as a manifestation of an impaired energy pathway.¹⁷ In other words, as persons become frail, more energy is needed to maintain homeostasis. Any pathology rapidly decreases the energy available in the system for healing, making the patient more vulnerable. In short, homeostasis becomes harder to maintain and the body becomes much less forgiving.

Models of frailty

Within disciplines focusing on care and service to the aged individual, there has been a lively discussion for at least the past two decades about whether or not the term can be used to identify a subset of older people who deserve closer clinical monitoring and support.¹⁸

Various models of frailty have been proposed to predict the risk of poor clinical outcomes. The most well-known and widely used model, as discussed in the previous section, was proposed by Fried et al. in 2001 and describes frailty as a phenotype—a clinical syndrome or set of signs and symptoms that tend to occur together, thus characterizing a specific medical condition.² Components of the phenotype include the following five conditions: unintentional weight loss, exhaustion, weak grip strength, slow walking speed, and low physical activity. The presence of three or more of these factors equals frailty. In addition to assessing physical function, many clinicians believe that the definition of frailty should also include cognition, depressed mood, pain, and perhaps even advanced age.

Another popular model of frailty was proposed by Rockwood et al. in 2007.⁹^,¹⁹ In this model a frailty index (FI) is obtained—basically by adding all the multisystem biomarkers of decline together (disabilities and comorbidities) and coming up with a number. This concept views frailty as an accumulation of deficits—a quantitative approach using the number of health problems rather than the nature of health difficulties.

Each of these models, as well as other descriptions, has its own strengths and weaknesses. Although useful in research and policy planning, neither approach, to this point in time, has significantly benefited the primary care clinician. A simple, clinical, useful tool for frailty that will improve care and value patient-centered outcomes is still to be developed.⁵^,⁶

CASE 1 Frank Mills (Part 2)

Mr. Mills requires careful broad-focused attention to his growing weakness, weight loss, and functional decline. His bladder catheter places him at risk for an occult bladder infection, which must be investigated. The status of his prostate cancer must be reviewed. Untoward effects of his medications on his appetite and well-being should be considered. The effectiveness of pain management, particularly the low back pain, must be reviewed. His ability to feed himself and swallow safely should be explored. His mood, never before a problem in his active life full of high achievements, should be assessed. With his declining gait and mental status, the possibility that a fall has led to an occult subdural bleed, particularly with his warfarin treatment, should be entertained. These issues are all addressed over the course of the following month, as is a thorough review of possible emerging new issues, but no new problems are unearthed. However, a mental status exam shows a significant decline from the previous year’s score, consistent with his growing need for the supportive services.

1. You are to meet with Mr. Mills and his daughter to summarize the findings of your investigation. What will be the major themes you will address?

Is recognition of frailty helpful to the clinician?

Increasingly, the term frailty is being used to summarize health status and to provide useful clinical information.

Frailty has clinical consequences. It is widely accepted that recognizing frailty is important clinically, but recognizing physical frailty in clinical practice may not be as straightforward as first thought.¹^,²⁰ Many patients and families, as well as clinicians, may simply attribute declines in function to “old age” and not recognize frailty as an entity. Because of the often slow gradual decline, medical attention may not be sought. Other conditions, such as chronic disease, comorbidities, and disability, may overshadow the recognition of frailty. Also, there is often a general feeling that there is no treatment or intervention that is going to help with frailty anyway.²¹

However, recognizing frailty can be of tremendous benefit to the practicing physician. Because of frail patients’ diminished capacity to withstand stress, they are at a high risk for adverse health outcomes. Not only are the decreased reserves of frailty important predictors of serious events such as falls, the presence of frailty also influences decision making about medication prescribing, and various interventions such as surgery, cancer treatments, coronary angiography, and others. As the body becomes less forgiving, the clinician must pay more attention to detail.

Timely recognition of frailty by the clinician may enable early identification of potentially treatable underlying conditions or open the possibilities of prevention and treatment. Primary care services for the oldest old are often reactive, and may not prove to have a significant impact on mortality or quality of life.¹ Identifying the frail patient may result in more proactive, preventive, or anticipatory clinical therapy decisions. Clinicians can potentially identify frail older adults by asking their older patients about declines in strength, endurance, nutrition, physical activity, fatigue or decreased energy, or slowed performance. Physical findings may include weight loss, slowed gait speed, and weakness.

Frailty is an important concept for the clinician to recognize—it is a more accurate predictor of adverse outcomes than age alone.

Another important clinical area for early recognition of frailty involves the timely introduction of geriatric and palliative care approaches to care, if treatable options have been eliminated. Although not a substitute for a diagnostic workup, timely hospice and palliative care ensures that patients and families receive care that optimizes quality of life and relieves suffering.

CASE 1 Frank Mills (Part 3)

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