Geriatric medicine is all about frailty these days. But what is the concept of frailty and how can we measure it? I heard about frailty before but I never paid too much attention.
Here is what I learn about frailty very recently.
Everything there is to know about frailty is summarized in a seminar published in the Lancet by Kent Rockwood (1).
Here is there definition. Frailty is a state of vulnerability to poor resolution of homeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime. This definition is fairly simple and easy to understand but does not give any clear information about how to measure it.
There are two different way to evaluate the concept of frailty:
- The phenotype of frailty: that was developed by Linda Fried (2). It describes five different aspect of frailty. If you have three of them, you are considered frail, one or two, pre-frail, and zero, you are a robust person.
Frail elderly people according to this definition are associated with adverse outcomes (fall, hospitalisation, death, mobility and function) at 3-5 years. There are some negative aspects with this index though. The prospective cohort that they used was not previously designed to measure frailty (which to me is not a problem because that is mostly what we do today. We use large database and create research questions afterward that the database can answer). But the major point is that this frailty tool does not include Parkinson (not a problem because I really think they are a special population and there characteristics are not generalizable), depression (fair enough) and cognitive impairment. This could be a problem. Elderly with cognitive impairment: are they more likely to by frail? This is debatable. I can understand though why they excluded them because this tool is a series of questions that you have to be able to recall from memory.
Finally, to complete the phenotype index, we need to measure the gait and the grip strength in a specific way, which could be a problem in a primary care setting and surely in the emergency department.
Bottom line: interesting, but not perfect.
- The cumulative frailty index: developed by Kent Rockwood (3). This index is very mathematical:
Number of deficits of the patient/ Number of deficits possible to measure
This definition seems very simple. The more deficits you have, the more frail you are until you reach a point not compatible with life. At first, the total number of deficit was 90. They used a non-exhaustive geriatric assessment and labs values to get to this 90 number. Again, this frailty index was associated with adverse outcomes. I could not find a specific cut-off that was ideal to integrate a dichotomic answer (frail or not frail). Fortunately, another study showed that if we use a total of 30 deficits, we have the same results (4).
Finally, this index is very interesting, but how can we measure it in the emergency department? We need a GEM nurse to do this work. That is the simple answer. But the question is far more complicated than that. When the GEM nurse is involved in a case, it is usually because we suspect that this elderly person is at risk for adverse outcomes; aka frail. Then, do we need the frailty index? One of the particularly interesting parts of the frailty is to use this concept at the beginning of the medical evaluation: the triage. Is this realistically doable at triage? The philosophy of triage is to do a quick evaluation in less than 2 minutes to rapidly categorize a level of priority. Should we re-think this?
Now, we know more about frailty, but we still don’t know what is to best way to measure it in the emergency department.
Who will find the answer? Welcome to the frailty competition…may the more robust searcher win!
- Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013 Mar 2;381(9868):752-62. PubMed PMID: 23395245. Pubmed Central PMCID: 4098658.
- Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. The journals of gerontology Series A, Biological sciences and medical sciences. 2001 Mar;56(3):M146-56. PubMed PMID: 11253156.
- Jones DM, Song X, Rockwood K. Operationalizing a frailty index from a standardized comprehensive geriatric assessment. Journal of the American Geriatrics Society. 2004 Nov;52(11):1929-33. PubMed PMID: 15507074.
- Song X, Mitnitski A, Rockwood K. Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. Journal of the American Geriatrics Society. 2010 Apr;58(4):681-7. PubMed PMID: 20345864.