In the 1980s and 1990s, doctors diagnosed frailty largely based on their intuition. \u201cWe used to say: \u2018You know it when you see it\u2019\u201d says Dr Peter Abadir, an associate professor of geriatric medicine and gerontology at the Johns Hopkins University School of Medicine.<\/p>\n
\u201cWhich is just a crude way of saying frail people look frail.\u201d<\/p>\n
Fortunately, the field has advanced since then, and there are more specific and objective methods to diagnose the condition.<\/p>\n
Here\u2019s how experts define frailty, how it differs from normal ageing, what puts someone at risk of becoming frail and what to do about it.<\/p>\n
What is frailty?<\/p>\n
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 hospitalised, needing long-term follow-up care or dying as a result of that fall is higher than in someone who is not frail.<\/p>\n
Frailty is also understood to go hand-in-hand with ageing, though not everyone who is old is frail. \u201cYou can think of frailty as rapid ageing, or more rapid ageing than your peers,\u201d says Dr Kenneth Rockwood, a professor of geriatric medicine at Dalhousie University in Canada.<\/p>\n
Estimates vary, but according to one large 2020 review, globally, about 11 per cent of adults in their 50s qualified as frail, while 51 per cent of people 90 or older were frail.<\/p>\n
Earlier this year, data from Tilda (The Irish Longitudinal Study on Ageing) showed that one in eight people (12 per cent) in Ireland aged 70+ required medical attention for a fall within a 12-month period.<\/p>\n
Doctors think of frailty as a spectrum, starting with the \u201cpre-frailty\u201d 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.<\/p>\n
How do I know if I\u2019m frail?<\/p>\n
There are two main methods of diagnosing frailty. One focuses on older adults\u2019 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.<\/p>\n
Everyone will slow down and decline a little with age, but it\u2019s those who rank in the bottom 20 per cent on these tests that doctors are most concerned about.<\/p>\n
The other diagnostic framework, called the deficit accumulation model, takes a more holistic approach. A medical professional diagnoses frailty based on the number of health conditions a patient has, such as high blood pressure or mild cognitive impairment. The model can also include a person\u2019s own view of their health and their ability to perform complicated everyday tasks, such as driving.<\/p>\n
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.<\/p>\n
\u201cThe more things you have wrong with you, the more likely you are to be frail,\u201d says Rockwood, who developed the scale.<\/p>\n
A GP or geriatrician might administer one of these assessments to a patient starting at about age 70, or if they suspect the person is frail. However, there are a few questions you can ask yourself to evaluate how you\u2019re ageing, says Dr Linda Fried, a professor of epidemiology and medicine at Columbia University. Fried developed the physical frailty measure while she was a geriatrician at Johns Hopkins.<\/p>\n
\u201cIf you feel more at risk in your environment, if you\u2019re feeling hesitant to go and do some of the things you used to do, it\u2019s worth taking stock of how you\u2019re doing,\u201d Fried says.<\/p>\n
What causes frailty?<\/p>\n
Experts think 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 ageing.<\/p>\n
\u201cNormal ageing will involve all of this,\u201d Abadir says. \u201cIt\u2019s just the pace and the trajectory\u201d of the changes and dysfunction that are accelerated in a person with frailty.<\/p>\n
That expedited deterioration could be related to a health condition that affects many functions or systems in the body \u2013 for example, kidney failure or dementia. Or it could occur organically for reasons scientists don\u2019t yet understand.<\/p>\n
\u201cAs we age, our physiological reserve across a number of the body systems declines naturally,\u201d says Dr R\u00f3n\u00e1n O\u2019Caoimh, a geriatrician at Mercy University Hospital, Cork. \u201cThe 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.\u201d<\/p>\n
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 says. Those combined changes can cause someone to \u201cpare back their exercise level\u201d.<\/p>\n
As people become less active and more deconditioned, \u201cthey actually develop more of a sense of fatigue and low energy\u201d, Fried says.<\/p>\n
Finally, as people consume fewer and fewer calories because their bodies are less active, they start to lose weight.<\/p>\n
How do I avoid becoming frail?<\/p>\n
When someone is already frail, it is difficult to reverse course, so experts emphasise early intervention and prevention, ideally starting in midlife.<\/p>\n
They generally agree the best way to stave off frailty is with strength training and aerobic conditioning. It\u2019s 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 450 grams (1lb) of body weight a day. Staying socially active and engaged can also be helpful.<\/p>\n
\u201cLong before getting older, people should maintain their strength and muscle mass,\u201d Fried says. \u201cIt\u2019s really important.\u201d<\/p>\n
One reason women may be more likely to become frail is that \u201cthey start with lower strength and less muscle mass\u201d, she says.<\/p>\n
There is some evidence these types of lifestyle interventions can also help improve pre-frailty or prevent further decline, O\u2019Caoimh says.<\/p>\n