Preventing and Reversing Frailty

“Frailty, thy name is woman”. Hamlet said this when his mother remarried suddenly and though Hamlet meant that his mother was not strong enough to resist marriage, Shakespeare could as well have written, “Frailty, thy name is human”. As Michael Crichton says, “And I think the answer is that we are, in reality, terribly frail animals. And we don't like to be reminded of how frail we are—how delicate the balances are inside our own bodies, how short our stay on Earth, and how easily it is ended.”

Frailty in medicine has a specific definition, characterized by a decline in functioning across multiple physiological systems, accompanied by an increased vulnerability to stressors [1].

It is an evolving concept and hence there are many different definitions and classification systems in play. One of the more commonly used systems defines frailty when one or more of these five conditions is present

1. Weakness (defined by grip strength)
2. Slow gait speed
3. Low physical activity
4. Exhaustion
5. Unintentional weight loss

Frailty is commoner as we grow older, though it can be seen in younger individuals, especially following chronic, debilitating illnesses. The prevalence varies depending on the populations studied and the definitions used, ranging from 11-40% in elderly Western populations [1]. In India, it ranges from 20% in the urban elderly in Hyderabad [2] to 47% in rural Northern India [3]. The poorer the person, the lower the nutritional status, the more prevalent is frailty.

Diagnosing frailty is important. The presence of frailty predisposes to a decline in both physical and mental functions, increased hospitalizations, increased incidence of falls and earlier mortality. More importantly, since there is a greater deterioration of physical and mental functions as compared to the rest of the population, any stress can destabilize the body much more than in a person who is not frail. We often call it the “tip of the iceberg” syndrome. A person is plodding along at the of 75, living within a narrow band of activity and routine, when let’s say a fall causes a fracture, leading to pain and immobility, which in turn cascades into cardiac, renal and other problems, some perhaps medication related, and then perhaps accelerated death, as against the situation in a non-frail person, whose organs may have much more slack to withstand the fall and its effects.

There are 3 aspects to frailty management. The first is to prevent frailty from occurring (primary prevention), the second is to reverse frailty if it occurs (secondary prevention) and the third, which we will not address today is improving the quality of life in those where the frailty itself cannot be reversed (tertiary prevention) [4].

Frailty can be prevented. If frailty does occur and is picked up in time, it is potentially reversible, too.  However, the primary care physician or any physician who sees an elderly patient / person at any time for any indication, should be able to and/or make the effort to identify the presence of frailty or pre-frailty so that steps can be taken to prevent or reverse the decline. In India, there are very few geriatric physicians and hence this needs to be done by family physicians and any other physician who sees elderly patients on a regular basis.

Interventions fall into the following categories [4].

1. Physical activity

Physical activity prevents frailty and in those who have become frail, it can help reverse frailty. PA works as a definitive method of prevention and treatment. However in a setting where there are physical and mental challenges, the PA has to be structured and supervised and individualized to the patient’s unique situation.

2. Pharmacologic

Drugs that treat diseases that hasten frailty (cardiac conditions, high blood pressure, diabetes, etc.) can help prevent or reverse frailty. Polypharmacy on the other hand, can cause frailty and should be controlled.

3. Food and Nutrition

The nutritional status of each individual has to be studied in detail. If nutritionally deficient, then the calorie intact has to be increased. If obesity is a predisposing factor, then steps to reduce obesity with sensible eating strategies need to be introduced.

4. Cognitive

Reading, learning and other activities that require mental agility can hopefully prevent and reverse frailty though the data is not particularly strong at this point in time.

5. Psychosocial

As we have seen earlier, relationships, friends and families can make a big difference to our happiness quotient…these also help in preventing and reversing frailty and help us live longer.

In short, the older we grow or see those around us age, we need to test and be tested for the possibility of frailty, especially with respect to our grip strength, gait and the presence of low energy, exhaustion and unexplained weight loss, during our doctor visits or as part of our annual health check-ups. If one or more of these is present, we need to take steps to prevent or reverse frailty, starting with structured, graded physical activity and the other points mentioned earlier.

In our atmasvasth quest to live long, healthy, recognizing, preventing and reversing frailty is an important part of our goal towards an improved healthspan and lifespan.

Footnotes

1. Hoogendijk EO et al. Frailty: implications for clinical practice and public health. Lancet. 2019 Oct 12;394(10206):1365-1375.

2. Shalini T et al. Frailty and Nutritional Status among Urban Older Adults in South India. J Aging Res. 2020 Jul 10;2020:8763413.

3. Rath RS et al. Frailty, Disability, and Mortality in a Rural Community-Dwelling Elderly Cohort from Northern India. Indian J Community Med. 2021 Jul-Sep;46(3):442-445.

4. Ijaz N et al. Interventions for Frailty Among Older Adults With Cardiovascular Disease: JACC State-of-the-Art Review. J Am Coll Cardiol. 2022 Feb 8;79(5):482-503.