“Frail” and “frailty” are words often used in relation to very old people. Looking them up in the Shorter Oxford Dictionary gives us “likely to be broken, perishable’ when applied to objects and “weak, liable to err or yield to temptation” when applied to people. Probably not too helpful! Are these concepts which can be useful in examining the situation and wellbeing of older people? Or is “frail” just another stereotype, often association with “elderly” – another term with connotations of inevitable decline? So I looked around for current definitions.
There is a growing consensus among experts that frailty does exist as a distinct syndrome in a subset of older people who are at increased risk of hospitalisation, dependency and whose life expectancy is reduced. But there is no overall agreement on indicators of frailty or how it should be defined. A common measurement is based on five specific criteria indicating adverse functioning, which include both self-reported and performance-based elements. Those who meet at least three of the criteria below are defined as “frail”, while those not matching any of the five criteria are defined as “robust”.
- Low physical activity
- Muscle weakness
- Slowed performance
- Fatigue or poor endurance
- Unintentional weight loss
It seems more helpful to clinicians to identify frailty on the basis of physical rather than psychosocial factors as these are more tangible, more objectively confirmed and are more likely to be treatable by medical means. This approach is intended to help “the development of screening tools for health workers to identify vulnerable older people and inform interventions and preventive strategies.”
But what about psycho-social factors?
Should frailty be defined purely in terms of biomedical factors? Go to:
Psychological, social and environmental factors may be important contributors to frailty and very influential in terms of care policies and service provision.
In the Survey of Older People in New Zealand (SOP) in 2000 the authors defined frailty as “a complex syndrome of underlying problems” resulting in “vulnerability to environmental challenge”. Put another way – medical, physical or mental health problems could compromise the ability to carry out key activities – washing, dressing, getting about, housework, keeping records, etc. In this concept frailty resulted from the interaction between bodily conditions and functioning.
Prevalence of frailty by personal characteristics
The findings of SOP, not unexpectedly, were that frailty increased with age, especially after 85 years. Prevalence was slightly higher for females than males and increased sharply for women from age 87.
The prevalence of frailty among Maori was higher than for New Zealand European and Pacific Island people. There was the same prevalence of frailty among Maori aged 65-70 as there is among non-Maori aged 81-84 years. This suggests a 10 to 15 year difference in the onset of frailty.
Marriage appeared to have a protective effect, with higher frailty figures for the widowed, divorced or separated. This illustrated the influence of the social environment on an older person’s ability to continue to maintain activities and functions associated with independent living. Complementary roles and coping patterns between partners develop over long periods of time together. This fits with the finding that there was a greater prevalence of frailty among older people living alone.
An interesting finding was the clear association between income and frailty– those with lower incomes had a higher prevalence of frailty – another link between health status and socioeconomic status. This highlights the cumulative effect of life events. Older people who are frail are more likely to be those with histories of lower incomes, less secure housing and social isolation. Does this suggest that home ownership has an important protective effect? “Addressing declining rates of home ownership for all groups throughout the lifespan can also be seen as contributing to housing security and wellbeing in later life, with associated health benefits.” This conclusion was arrived at getting on for 20 years ago!
Most studies on preventing frailty have been conducted after acute events such as strokes or fractures. Relatively few studies have been undertaken on intervention once frailty has developed. But these show that it is possible to prevent further functional decline.
The beneficial effects of exercise in the older population have been widely publicised. Given that inactivity and muscle weakness are major determinants of frailty, it is not difficult to imagine a simple and cost‐effective exercise‐intervention measure that may slow or reverse the process.
Positive psychological states may also be beneficial in the prevention of frailty. It has been suggested that the concept of positive health is more than simply the absence of disability or disease. Thus, approaches aimed at the production of a positive psychological state in those at risk of frailty may strengthen other interventions aimed at stopping functional decline.
Clearly, the definition and measurement of frailty cannot rely solely on bio-medical factors. The life history and environment of very old people are equally important, if not more so.