Review
Frailty: An Emerging Geriatric Syndrome

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Abstract

Frailty is a new and emerging syndrome in the field of geriatrics. The study of frailty may provide an explanation for the downward spiral of many elderly patients after an acute illness and hospitalization. The fact that frailty is not present in all elderly persons suggests that it is associated with aging but not an inevitable process of aging and may be prevented or treated. The purpose of this article is to review what is known about frailty, including the definition, epidemiology, and pathophysiology, and to examine potential areas of future research.

Section snippets

Frailty Defined

Frailty, a fairly common biological syndrome in the elderly, is identified by decreased reserves in multiple organ systems. It may be initiated by disease, lack of activity, inadequate nutritional intake, stress, and/or the physiologic changes of aging. Frailty develops slowly in a stepwise process, with increments of decline precipitated by acute events. It is manifested as loss of skeletal muscle mass (sarcopenia), abnormal function in inflammatory and neuroendocrine systems, and poor energy

Background

Contrary to popular belief, not all elderly are frail.5 Only 3% to 7% of elderly persons between the ages of 65 to 75 years are frail.6 The incidence of frailty increases with age, reaching more than 32% in those aged more than 90 years.7 Furthermore, once a person is pre-frail, he or she is more likely to progress to frailty, thus emphasizing the downward spiral affect of this syndrome.8

Frailty can be a primary or secondary diagnosis. Notably, 7% of the frail elderly have no illness, and 25%

Significance

Why is frailty important? Currently 20% of the population of the United States are aged more than 65 years, and the most rapidly growing segment of our population are those aged more than 85 years. The incidence of frailty increases with age and will become more prevalent as our population continues to grow old.13 Studies show that 3% to 7% of people aged more than 65 years are frail6; this percentage increases to 20% to 26% for elderly persons in their 80s5, 6 and to 32% for those in their 90s.

A Working Diagnosis of Frailty

The diagnosis of frailty has taken time to evolve. Initial studies showed a decrease in strength and balance to be predictors of frailty.16, 17 However, in the elderly, multiple causes can lead to such a state, including immobility, decreased appetite, poor nutrition, and chronic illness. On this basis, a “cycle of frailty” was hypothesized. The Figure helps conceptualize this cycle and highlights the interdependence of various factors that may cause patients to enter this cycle. For example,

Clinical Research

Research also has begun in the clinical realm. Although a detailed discussion of clinical research is beyond the scope of this article, a general overview is provided.

Atherosclerosis contributes to frailty by decreasing blood flow and oxygenation to muscles, leading to sarcopenia. It indirectly contributes to cognitive impairment, through strokes, and to decreased physical activity in congestive heart failure and myocardial infarction.31 The Cardiovascular Health Study showed that

Conclusion

An understanding of what Eli Metchnikoff once referred to as the “intimate details” of the mechanisms behind an “utterly pathological” old age has just begun. It is now known that old age is not synonymous with the frailty syndrome. Still, frailty has only recently been defined, and frailty research is in its early stages. Acceptance of a formalized set of criteria for the diagnosis of frailty will facilitate studies. Potential areas of investigation include the underlying pathophysiology of

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