In the 1980s and ’90s, doctors diagnosed frailty largely based on their intuition.
“We used to say, ‘You know it when you see it,’” said Dr. Peter Abadir, an associate professor of geriatric medicine and gerontology at the Johns Hopkins University School of Medicine. “Which is just a crude way of saying frail people look frail.”
Fortunately, the field has advanced since then, and there are more specific and objective methods to diagnose the condition. Here’s how experts define frailty, how it differs from normal aging, what puts someone at risk of becoming frail and what to do about it.
What is frailty?
Doctors generally define frailty as having more vulnerability and less resilience to health events. A person who is frail is more likely to fall, for instance, and the risk of being hospitalized, needing long-term follow-up care or dying as a result of that fall is higher than in someone who is not frail.
Frailty is also understood to go hand-in-hand with aging, though not everyone who is old is frail. “You can think of frailty as rapid aging, or more rapid aging than your peers,” said Dr. Kenneth Rockwood, a professor of geriatric medicine at Dalhousie University in Canada.
Estimates vary, but according to one large 2020 review, globally, about 11 percent of adults in their 50s qualified as frail, while 51 percent of people 90 or older were frail. In the United States, frailty rates tended to be higher among women, Black and Hispanic Americans and people with low income, according to a 2015 study.
Doctors think of frailty as a spectrum, starting with the “pre-frailty” stage. People who are pre-frail fare worse than their more robust peers, but they are in better shape than those who are fully frail. Interest in pre-frailty has grown in recent years in part because it is easier to intervene and improve at that stage. Pre-frailty also affects a much broader swath of the population: In the 2020 review, nearly half of adults 50 and older were considered pre-frail.
How do I know if I’m frail?
There are two main methods of diagnosing frailty. One focuses on older adults’ physical abilities. It uses a series of short tests, including grip strength and walking speed, to evaluate five key traits: weakness, slowness, exhaustion, physical inactivity and unintentional weight loss. If people have three, four or five of these traits, they are diagnosed as frail; having one or two qualifies them as pre-frail.
Everyone will slow down and decline a little with age, but it’s those who rank in the bottom 20 percent on these tests that doctors are most concerned about.
The other diagnostic framework, called the deficit accumulation model, takes a more holistic approach. A provider diagnoses frailty based on the number of health conditions a patient has, like high blood pressure or mild cognitive impairment. The model can also include a person’s own view of their health and their ability to perform complicated everyday tasks, such as driving.
The score is presented as a decimal: the number of conditions or symptoms a person has divided by the total number of conditions or symptoms a doctor evaluated them on. A score of 0.1 to 0.24 is generally considered pre-frail and 0.25 and above is considered frail.
“The more things you have wrong with you, the more likely you are to be frail,” said Dr. Rockwood, who developed the scale.
A general practitioner or geriatrician might administer one of these assessments to a patient starting around age 70, or if they suspect the person is frail. However, there are a few questions you can ask yourself to evaluate how you’re aging, said Dr. Linda Fried, a professor of epidemiology and medicine at Columbia University. Dr. Fried developed the physical frailty measure while she was a geriatrician at Johns Hopkins.
“If you feel more at risk in your environment, if you’re feeling hesitant to go and do some of the things you used to do, it’s worth taking stock of how you’re doing,” Dr. Fried said.
What causes frailty?
Experts think that frailty is the result of a decline in multiple organ systems, particularly the musculoskeletal, immune and metabolic systems. At the cellular level, frailty is associated with increased inflammation, impaired mitochondrial functioning and other hallmarks of aging.
“Normal aging will involve all of this,” Dr. Abadir said. “It’s just the pace and the trajectory” of the changes and dysfunction that are accelerated in a person with frailty.
That expedited deterioration could be related to a health condition that affects many functions or systems in the body — for example, kidney failure or dementia. Or it could occur organically for reasons scientists don’t yet understand.
“As we age, our physiological reserve across a number of the body systems declines naturally,” said Dr. Ronan O’Caoimh, a geriatrician at Mercy University Hospital and University College Cork in Ireland. “The more illness you experience, there is a more rapid decline in that physiological reserve. But there is an underlying natural rate that we will all have.”
Dr. Fried thinks too much muscle loss may cause a domino effect that leads to frailty. As people get weaker, they also typically move slower, she said. Those combined changes can cause someone to “pare back their exercise level.” As people become less active and more deconditioned, “they actually develop more of a sense of fatigue and low energy,” Dr. Fried continued. Finally, as people consume fewer and fewer calories because their bodies are less active, they start to lose weight.
How do I avoid becoming frail?
When someone is already frail, it is difficult to reverse course, so experts emphasized early intervention and prevention, ideally starting in midlife.
They generally agreed that the best way to stave off frailty is with strength training and aerobic conditioning. It’s also important to consume enough protein to help maintain muscle mass. According to some recommendations, older adults should aim for at least 0.45 to 0.54 grams of protein per pound a day. Staying socially active and engaged can also be helpful.
“Long before getting older, people should maintain their strength and muscle mass,” Dr. Fried said. “It’s really important.” One reason women may be more likely to become frail is that “they start with lower strength and less muscle mass,” she added.
There is some evidence that these types of lifestyle interventions can also help improve pre-frailty or prevent further decline, Dr. O’Caoimh said.
“Aging is inevitable,” he said, “but aging well is not inevitable.”
- Credits: The New York Times
- Author: Dana G. Smith
- Illustration: Bianca Bagnarelli
