Frailty in the
Older Adult
Cynthia J. Brown, MD, MSPH
Associate Professor
Director, Geriatric Medicine Section
Birmingham/Atlanta VA GRECC
University of Alabama at Birmingham
Learning Objectives
• Identify key features of frailty as currently defined
• Define sarcopenia
• Understand changes in body composition associated with
aging
• Describe how a multidisciplinary team might approach frailty
in the older adult
Case Presentation
Case 1: An 82-year old man with a history of heart
failure, knee osteoarthritis, and hypertension presented
for elective knee replacement.
Case 2: An 82-year-old man with a history of heart
failure, knee osteoarthritis, and hypertension presented
for elective knee replacement.
Case 3: An 82-year-old man with a history of heart
failure, knee osteoarthritis, and hypertension presented
to the ED after being found by a neighbor on the floor.
• These three patients demonstrate different
levels of susceptibility and clinical stability,
which strongly affected clinical outcomes.
• There appears to be a spectrum of resilience,
from highly independent and robust to the
most frail and vulnerable.
Defining Frailty
Break into your small groups and answer the
following questions:
• How would you define the term “frail”?
• What makes a person frail?
• Are there key components to frailty?
Frailty Definitions
• A variety of definitions have been used
defining frailty as synonymous with:
– Disability
– Comorbidity
– Advanced Old Age
• However, while there is some overlap,
frailty appears to encompass more than
disability or comorbidity.
Overlap of Frailty with ADL Disability
and Comorbidity
Disability: > 1 ADL
N=67
21.5%
N=2131
46.2%
5.7%
26.6%
N=98
Comorbidity
Frailty
Fried LP, J Gerontol Med Sci, 2001
Frailty Definition
• Clinicians have begun to define frailty as:
“a syndrome of decreased reserve and
resistance to stressors, that result in
cumulative declines across multiple physiologic
systems, causing vulnerability to adverse
outcomes.”
• It has been postulated that there are key
components of frailty, and multiple components
must be present to constitute frailty.
Fried LP, J Gerontol Med Sci, 2001
Fried’s Model of Frailty
Fried’s Model of Frailty
Definitions of Components of Frailty
– Shrinking
• > 10 pounds lost unintentionally in past year
– Self-reported exhaustion
• Self-report of exhaustion on CES-D questions
– Weakness (grip strength)
• Grip strength lowest 20% adjusted for gender &
BMI
– Slow walking speed
• Slowest 20% to walk 15 feet
– Low physical activity
• Lowest quintile of weighted kilocalorie expended
per week
Sarcopenia in the Older Adult
Sarcopenia
• Sarcopenia: age-related loss of muscle
mass and strength.
• Changes in the muscle fiber itself, and an
increase in infiltration of fat into the
muscle (myosteatosis) also common with
aging.
• Changes all lead to a decline in muscle
function.
Sarcopenia and Myosteatosis
Petrella et al. Eur J Appl Physiol 2007
Top: Young Female, age 27
Bottom: Older Female, age 65
Height and weight matched
Top: Young Male, age 25
Bottom: Older Male, age 63
Height and weight matched
Muscle Aging
Strength
Difficulty
with weight
bearing tasks
Power
Risk of falls
and fracture
Physical activity
Disability
Muscular
Endurance
Fatigability
Age-related Loss of Muscle Mass
7.5
10.0
A. Men
N=211
B. Women
2
Skeletal muscle index (kg/m )
9.5
7.0
9.0
*‡
8.5
6.5
*‡
*‡
*‡
8.0
6.0
7.5
5.5
7.0
25 y
37 y
61 y
25 y
72 y
72 y
D. Women
2
C. Men
omen (SMI < 5.67 kg/m )
2
61 y
50
50
men (SMI < 7.25 kg/m )
37 y
Values are mean ± SE. Main age group effects, P<0.001.
40
*Different
from 25 y, P<0.05. ‡Different40from 37 y, P<0.05.
DXA-determined limb muscle mass.
MM Bamman, et al.
30
30
Functional
Consequences
Evaluation of Function
• Walking fundamental mobility task.
• Variables that influence walking speed
include:
–
–
–
–
Musculoskeletal status
Sensory function
Motor control
Cognitive status
• Walk speed a general summary indicator;
could be useful single-item screening tool
Gait Speed
Predicted Median Life Expectancy
by Age and Gait Speed
Studenski S, et al. JAMA. 2011;305(1):50-58.
Timed Chair Stands
• Used to evaluate lower body strength and
endurance
• Instruct to stand from chair without using arms
5 times while being timed.
• Normative values available, can identify which
older persons may have problems with
strength.
Get Up and Go Test
• The get up and go test asks a person to:
–
–
–
–
stand from a chair without using their arms
walk 10 feet
turn around and walk back
and sit in the chair
• Can be timed with a time of ≥ 20 seconds
indicating risk for adverse outcomes.
• Can also observe for unsteady gait.
Now it is your turn to try these
easy clinical assessments
Health Literacy in
Older Adults
Contributing Factors in Older Adults
• Fewer years of schooling, poorer—fixed
incomes
• > 50% do not take meds as directed
• 68% cannot interpret blood sugar value
• 76% cannot follow Upper GI instructions
• 100% could not understand Medicaid rights
in one study
Related Cultural/Language Barriers
•
•
•
•
•
•
Non-English speaking
Immigrant status
Ethnic interpretation of illness
Spiritual and religious beliefs
Default answers
Lack of insurance/transportation
Testing in a Busy Practice
• Always assume and ask in sensitive way
– ”How do you get your information?”
– “What things do you like to read?”
– “How satisfied are you with how you read?”
• Eyes wandering over page, very slow to
finish, sounding out words, look confused
• Remember the “pill bottle” prop
– Ask questions about the dosage and frequency
Nutrition Problems in
the Older Adult
Changes in Body Composition
• There is a net decrease in:
– Bone mass
– Lean muscle mass
– Water content
• There is a net increase in:
- Total body fat
- Especially intra-abdominal (fat located
inside the belly area/abdominal cavity)
Physiological Changes Accounting for
Nutrition Risk in Elderly
 Changes in taste, and smell
 Changes in the gastrointestinal system
 Impaired thirst sensation
 Atrophic gastritis (chronic inflammation
of stomach with reduced stomach
secretions.
Pathologic Changes Common in Aging
• Chronic diseases and restrictive diets
• Dental problems
• Depression
• Alcohol abuse
• Medication side effects