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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #21, #25, #72

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LEARNING OBJECTIVES

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Learning Objectives

  • Gain perspective about the general concept of frailty in older persons.

  • Understand alternative operational definitions of frailty.

  • Recognize frailty in older persons.

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Key Clinical Points

  1. Frailty is an important predictor of serious adverse outcomes, such as disability, health care utilization, and death. The phenotype of frailty includes the five following characteristics: unintentional weight loss, weakness, slow gait, exhaustion, and low activity. In addition there is a complex relationship between frailty and cognitive functioning.

  2. Aging phenotypes that are closely related to frailty and late-life decline include (1) signalling networks that maintain homeostasis, (2) body composition, (3) balance between energy availability and energy demand, and (4) neurodegeneration/neuroplasticity.

  3. A pervasive biological feature of aging and frailty is the presence of a chronic and mild proinflammatory state.

  4. Multimorbidity is the clinical manifestation of frailty.

  5. Frailty has become a key feature in evaluation of a number of specific medical conditions.

  6. The paradigm of precision medicine provides an almost ideal entry for the frailty concept into the mainstream of modern medicine.

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INTRODUCTION

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Over the past century, the science of clinical medicine based on the identification of risk factors and pathophysiologic mechanisms of diseases has accomplished outstanding results. Since 1960, death rates for chronic diseases have changed dramatically, mainly as a consequence of smoking reduction and treatment of hyperlipidemia and hypertension. For example, heart disease death rates declined by almost two-thirds during the past 50 years, and stroke rates declined by more than three-quarters (http://www.cdc.gov). In spite of the relative success in performing early diagnosis, slowing down the clinical development and moderating the symptoms of many chronic diseases, the witnessed gain in longevity has helped to push older adults into the part of life characterized by multimorbidity and disability, unfortunately with very little expansion of the period of life free from any illness (Figure 46-1).

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Figure 46-1.

Life expectancy and active life expectancy at age 65 and 85, US population, 1935 to 2080, selected years (redesigned from published data). (Data from Manton KG, Gu X, Lamb VL. Long-term trends in life expectancy and active life expectancy in the United States. Popul Dev Rev. 2006;32(1):81–105.)

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Geriatrics is the medical specialty that first perceived the limitations of traditional medicine: that a specific disease diagnosis or an assemblage of diagnoses could not encompass the substantial heterogeneity and complexity of the health problems presented by many older patients. Knowing the diseases and their clinical stage is not enough to explain presence and severity of physical and cognitive limitations. It has become more and more evident that the traditional biomedical principles that had been so effective in the care of patients with single disease were not similarly effective in the care ...

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