Frailty Syndrome

Frailty is a clinical syndrome of reduced physiological reserve across several organ systems, so that a minor stressor such as an infection, a new drug or a short admission causes a disproportionate and often lasting decline in function.

About 10% of community dwelling people aged 65 and over are frail, rising to more than a quarter of those aged 85 and over. It is more common in women and in people with low income, multimorbidity or poor education.

Pathophysiology. Chronic low grade inflammation (raised interleukin-6 and C-reactive protein), sarcopenia, neuroendocrine dysregulation (raised cortisol, low IGF-1, low sex hormones), mitochondrial dysfunction and immune senescence erode reserve. Small deficits in many systems accumulate until homeostasis fails under stress.

The physical phenotype is defined by five features: unintentional weight loss (4.5 kg or 5% in a year), self-reported exhaustion, weakness (low grip strength), slow gait (under 0.8 m/s) and low physical activity. Three or more features indicate frailty and one or two indicate pre-frailty. Frailty presents as falls, delirium, fluctuating function, incontinence, recurrent admissions, delayed recovery and new dependence. It predicts disability, institutionalisation and death.

Screen all people aged 70 and over, and anyone with significant weight loss or recurrent falls, with a validated frailty index or clinical frailty scale. Measure gait speed, grip strength and chair rise time. A full geriatric assessment covers medical problems, medicines, cognition, mood, nutrition, continence, vision, hearing, mobility, home and carers. Look for reversible contributors with full blood count, urea and electrolytes, glucose, thyroid function, vitamin B12, 25-hydroxyvitamin D, calcium and liver tests.

Differential diagnosis.

• Sarcopenia without wider frailty.
• Depression and cognitive impairment.
• Occult malignancy, chronic infection (including tuberculosis), heart failure, COPD and anaemia.
• Hypothyroidism, hyperthyroidism and Parkinson disease.

Offer a multicomponent exercise programme with resistance and balance training at least 3 times weekly. Aim for protein 1.0 to 1.2 g/kg daily, rising to 1.2 to 1.5 g/kg daily in acute or chronic illness. Replace vitamin D if deficient (800 to 2000 IU daily). Review every medicine and stop those without clear benefit, especially sedatives, anticholinergics and antihypertensives causing postural hypotension. Treat reversible contributors, correct sensory impairment and address social isolation.

Special groups. In frail people the targets for blood pressure and glucose should be relaxed to avoid hypotension and hypoglycaemia. Plan surgery and chemotherapy with geriatric input and shared decisions about the burden of treatment.

Monitoring. Repeat gait speed, grip strength, weight and function every 3 to 6 months and after any admission.

Referral and escalation. Refer to a geriatrician for rapid decline, complex multimorbidity, or before major interventions. Discuss goals of care and advance care planning early.