Frailty in the elderly: How to identify it?

Early diagnosis can help preventive action and delay dependence dynamics

Along with the improvement in life expectancy in our society, we are witnessing an increase in the dependence of the elderly. Improving the number of years lived in good health is the current challenge to overcome in order to limit the avoidable loss of autonomy and improve the quality of life of seniors.

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The early identification of frailty in the elderly could help to find its determinants and take preventive actions for delaying avoidable dependence dynamics and adverse events. So how can we identify frailty at the ambulatory care level and how to manage it once it has been diagnosed?

Frailty, many definitions, and variable prevalence

The concept of frailty was developed in the field of geriatrics to better understand the health needs of older people and to be able to propose an adapted prevention strategy. There are many definitions of frailty. Claymann described an elderly person in 1990 as "never very well or very sick". For Senin (Senin et al, 2003), frailty is a situation resulting from a significant reduction in the homeostatic reserve, something that places the elderly person in the highest risk of an adverse health problem including dependence, institutionalization and even death in the outset of a minor event.

According to the French Society of Geriatrics and Gerontology (French acronym: SFGG), frailty is a clinical syndrome characterized by a decrease in physiological reserve capacities altering the body’s stress adaptation mechanisms. This potentially reversible condition is a risk factor for mortality and adverse events (e.g. falls, hospitalization, institutionalization).

Two main models are used to identify frailty in the elderly. The first model is Fried's phenotypic model, which takes into account five physical criteria. The disadvantage of this model is that it does not include cognitive and socio-environmental dimensions in the measure of fragility. The second model is the Rockwood model, based on a multidimensional approach of an elderly person taking into account the different physical, psychological, social and comorbidities factors in a particular patient.

It is also important to note that the prevalence of frailty is quite variable and highly dependent on the definition used. In the SHARE study carried out in ten European countries, the prevalence of frailty according to the Fried model was estimated for France at 15.5% among those over 65 years of age and living at home. This prevalence increases with age and is higher among women.

A dynamic and reversible syndrome

Frailty detection is a major public health issue because it allows predicting the risk of autonomy loss, dependency and other adverse events such as falls and hospitalization in people over 65 years of age. At present, the financial impact of dependency can reach a staggering 25 billion euros, while its prevention could save some 10 billion euros according to the Assembly of French Departments.

However, the reversibility of frailty is not spontaneous and requires geriatric interventions. With the cooperation of multiple stakeholders in primary care, several benefits can be derived from these interventions, such as reducing the risk of hospitalization for frail elderly people and adapting care provision in the event of hospitalization. A vigorous elderly person may also have access to certain types of care that can sometimes be denied due to their age.

By taking into account the ratio between the frailty prevalence and the benefits of possible interventions, the identification of frailty can thus be applied to people over the age of 70 years without any serious illness that could trigger dependence, at the initiative of a caregiver who suspects the presence of frailty.

Which are the available tools to detect frailty?

Arguably, a standardized Comprehensive Geriatric Assessment (CGA), which is the benchmark for diagnosing and assessing frailty, is neither feasible nor relevant for older people living at home. It is therefore important to have a tool that is easy to use in primary care and does not require specific geriatric skills.

In France, the questionnaire carried out by the Gérontopôle de Toulouse, a world-renowned clinical center researching age-related conditions, was thus selected as relevant by the SFGG and the French National Council for Geriatrics Professionals (French acronym: CNPG) for the identification of frailty in primary care. This questionnaire can be carried out by the attending physician or another primary care provider such as a nurse or a nurse's aide.

This identification is the first step in a sequence that includes a more comprehensive assessment with the GCA, which can be carried out in a geriatric day hospital or at home with the intervention of a mobile geriatric team.

Multi-domain interventions

By identifying frailty and assessing its determinants, a strategy based on targeted interventions can be put in place so that frail elderly people can be "repositioned" in a successful aging trajectory to prevent dependency. These interventions include adapted physical activity and the fight against physical inactivity, nutrition enrichment, vitamin D provision, the reduction of multi-medication and the provision of social assistance.

Sources:
1. Clayman A. (1990) Determinants of frailty [abstract]. Gerontologist, 30, 105A.
2. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Med Sci 2001 ; 56A : M146-M156.
3. Senin U, Cherubini A, Mecocci P. [Impact of population aging on the social and the health care system: need for a new model of long-term care] Ann Ital Med Int. 2003 Jan-Mar; 18 (1):6–15

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