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The cornerstone, even raison d'etre, of geriatric medicine concerns the identification, evaluation, and treatment of frail older adults and prevention of loss of independence and other outcomes for which they are at risk. The proportion of frail within the older population is high and will increase with the aging of society. A focus on frailty has been a consistent theme in geriatric theory and practice. In 1990, Fretwell stated “frailty in an individual (is) defined as an inherent vulnerability to challenge from the environment.” Because of the high-risk status of frail older adults, geriatric medicine seeks to intervene in frail patients to prevent or minimize illness and dependency. In 1992, a conference on the physiologic basis of frailty agreed that controversy on definition and limited understanding of etiology hindered preventive strategies. In 1993, W. Bortz stated that “A major threat to active life expectancy is the development of frailty…. Despite absence of easy categorization, there is no question as to the immense participation of frailty in both individual and composite morbidity and mortality. Recognizing this pervasive impact on well-being, it is strange to note the lack of critical insight that attends it.” Baltes and Smith observed that the oldest old, those in the “fourth age” after 85 years (in developed countries), are particularly biologically vulnerable and frail and have compromised ability to tolerate stressors. As a result, their well-being is increasingly dependent on the use of extrinsic compensations to maintain life and autonomy, because there is such diminished ability to compensate physiologically. These observations frame the conceptual understanding that aging is associated with increased likelihood of frailty, and that older persons have reduced physiological reserve than younger persons and these changes are likely independent of disease. Over the past 15 to 20 years since the statements above, we have attained increasing clarity about the definition and characteristics of frailty and its import and etiology, and a new basis for prevention and interventions. This chapter seeks to synthesize this knowledge.

Geriatric medicine has found the concept of frailty compelling for several reasons (Table 52-1). First, frail individuals are perceived to constitute those older adults at highest risk for a number of adverse health outcomes, including disability, dependency, institutionalization, falls, injuries, acute illness, hospitalizations, slow or incomplete recovery from illness and/or hospitalization, and mortality.

Table 52-1 Frailty Is at the Core of Geriatric Medicine

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