2016

1. Colin M. Thomas MD, MPH
Clinical Professor of Medicine
Division of Geriatric Medicine
University of California, San Diego, School of Medicine
Associate Chief of Medicine, VA San Diego Healthcare

2. What is Frailty?

3. What is Frailty?
 Cumulative decline in many
physiological systems
 A state of vulnerability where minor
stressors may result in significant
decline in health status
 Associated with adverse outcomes like
falls, disability, nursing home placement
and mortality

4. Frailty is Vulnerability
Lancet 2013; 381: 752–62

5.  Decline in
multiple systems
 Decreased
Physical Activity
 Inadequate
Nutrition
 Intolerance of
stressor events
 Increasing
dependence
Lancet 2013; 381: 752–62

6. Models of Frailty
 Cumulative Deficit Model
 Musculoskeletal function
 Aerobic capacity
 Cognitive function
 Nutrition
 Phenotype model
 Weight loss
 Exhaustion
 Energy expenditure
 Gait speed
 Grip strength

7. Frailty is common
 Prevalence
 15% of non-institutionalized elders are frail
 45% are pre-frail
Journals of Geronology A Biol Sci Med Sci, 2015. 70(11), 1427-1434.

8. Frailty is associated with
adverse outcomes
Outcome Hazard Ratio 95% CI Study
Falls 2.44 (1.95-3.04) SOF
Disability 2.79 (2.31-3.37) SOF
Hospitalization 1.27 (1.11-1.46) CHS
Nursing Home
Placement
2.60
23.98
(1.36-4.96)
(4.45-129.2)
CSHA
WHAS
Mortality 3.69 (2.26-6.02) CSHA
SOF: Arch Intern Med 2008; 168: 382–89.
CHS: J Gerontol A Biol Sci Med Sci 2001; 56: M146–56.
CSHA: J Gerontol A Biol Sci Med Sci 2004; 59: 1310–17.
WHAS: J Gerontol A Biol Sci Med Sci 2006; 61: 262–66.

9. Dimensions of Frailty
 Physical
 Nutrition
 Cognitive
 Psycho-social

10. Physical Frailty
 Muscle mass
 Strength
 Balance
 Bone density
 Increased risk of falls and injury

11. Normal aging and muscular
function
 By the age of 70, the cross-sectional area of
skeletal muscle is reduced by up to 25–30%
and muscle strength is reduced by 30–40%
 Excretion of urinary creatinine, reflecting total
muscle mass, decreases by nearly 50%
between the ages of 20 and 90 yr
 Loss of strength continues to fall at a rate of 1–
2% per year
 Irreversible decrease in the total number of
individual muscle fibers and (reversible?)
atrophy of the remaining fibers
A. McArdle et al. Ageing Research Reviews 1 (2002) 79–93

12. Sarcopenia
A. McArdle et al. Ageing Research Reviews 1 (2002) 79–93

13. Nutritional frailty
 Appetite
 Taste and smell
 Oral health
 Digestion
 Economic factors
 Ability to acquire and prepare food
 Chronic illness
Annu. Rev. Nutr. 2002. 22:309–23

14. Cognitive Frailty
 Cognition not included in commonly
used frailty phenotype measures
 Non-frail older adults with impaired
cognition are more likely to become frail
 Frail adults with impaired cognition are
more likely to become disabled or die
JAGS 56:2292–2297, 2008

15. Psycho-social Frailty
 Mental health measures are not included in
common frailty phenotype measures
 Depression and frailty frequently co-occur
in the elderly population
 Social vulnerability is associated with
higher mortality, lower educational level and
lower income
J Am Geriatr Soc 62:500–505, 2014.
J Frailty Aging. 2013; 2(3): 121–124.
Gerontol B Psychol Sci Soc Sci 2009;64B:105-117.

16. But what can we do about
frailty?
 Can we prevent or
reverse frailty?

17. Evidence based interventions for
frailty
 Resistance exercise interventions for
physical frailty
 Strength training resulted in a 30% increase
in muscle fiber size
 Resistance training can slow or partially
reverse the process of aging atrophy of
skeletal muscles
 Strength training can improve VO2 max and
exercise treadmill time
Journal of Gerontology:BIOLOGICAL SCIENCES. 2000, 55A(7), B347–B354
Arch Intern Med. 2002 Mar 25;162(6):673-8

18. ASK WELL
Is it true that the muscle mass we lose at, say, 60 years
old cannot be regained?
Reader Question • 217 votes
I'm a 77-year-old man in good health. I've dropped 10
pounds over the last 40 years, all muscle. Is there any
way for someone my age to regain muscle mass
without resorting to steroids?
Reader Question • 510 votes
Can You Regain Muscle Mass After Age 60?
By GRETCHEN REYNOLDS
DECEMBER 2, 2016 6:21 AM

19. Evidence based interventions
for frailty
 Intensive training intervention for pre-frail
older adults compared to home exercise
program
 Structured program includes
 Flexibility, light resistance, balance
 Resistance
 Endurance
 Results
 Improve physical performance
 Increase in VO2 max
 Improve functional status score
J Am Geriatr Soc 50:1921–1928, 2002.

20. Evidence based interventions for
frailty
 Bone Mineral Density
 Demonstrated to increase with
weight bearing activity and high
intensity resistance exercise
 Effective in elderly men and
women
 Fracture risk may also be
improved by
○ Remodeling
○ Improved strength and balance
Scand J Med Sci Sports 2004: 14: 16–23

21. Evidence based interventions for
frailty
 Nutrition
 Demonstrated to increase body weight and lean
body mass
 Preponderance of trials show no effect on
functional status
 Cognitive
 Limited evidence of benefit of cognitive rehab
therapies
 Psychosocial
 Caregiver burden associated with increased risk
of nursing home admission
The Journal of Nutrition, Health & Aging 19, 3, 250-257.
Neuropsychol Rev (2013) 23: 63.
J Gerontol (1992) 47 (2): S73-S79.

22. Technology and potential frailty
interventions
 Physical
 Nutritional
 Cognitive
 Psycho-social

23. Technology interventions for physical
frailty
 Exercise games
 Require adaptation for balance, strength, vision
and mobility deficits
 Team games can capitalize on social interactions
Activities, Adaptation and Aging, 32(3-4), 238-239.

24. Technology interventions for physical
frailty
 Self monitoring tools
 Can define goals and provide positive feedback
and reminders
 Adapt interfaces to accommodate common
deficits
Journal of Behavioral Medicine, 26(4), 333.

25. Technology interventions for
nutritional frailty
 Smart scales
 Body weight
 Kitchen scales
 Integrate calorie intake and expenditure
The American Journal Of Clinical Nutrition, 41(4), 810-17.

26. Technology interventions for
cognitive impairment
 Exercise
 Cognitive training games
 Gains are specific and limited
to the area being trained
 Cognitive training does not
measurably improve
functional capacity
J Geriatr Psychiatry Neurol. 2007;20(4):239-249.
JAMA. 2002;288(18):2271-2281.

27. Technology interventions for
social isolation
 Telephone and video live
interaction
 E-mail
 Social networks
 Limitations
 Cost
 Adoption rates
 Accessibility
 Risks
The Gerontologist, 55(3), 412-421.

28. Summary
 Cumulative decline in multiple systems
 Increased vulnerability to stressors
 Increased rates of complications,
institutionalization and mortality
 Some effective interventions to mitigate
and reverse declines
 Promising technology that needs to be
assessed

29. Questions?