Recent advances – Frailty Part 1

Frailty of old age is an under-recognised pandemic in Westernised societies. So what is it?

The definition of frailty

It is a clinically recognisable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors is compromised.

Quite a mouthful – but taken slowly it makes sense.

“increased vulnerability”: frail people are very prone to all sorts of things going wrong and when they do go wrong they suffer more than the non-frail.

“aging-associated decline in reserve”: frail people are functioning at a much greater percentage of their abilities just to keep going – they have limited reserves for upping their game.

“and function”: frail people are weaker and move more slowly than the non-frail.

“multiple physiologic systems”: frail people have diminished resistance to infection and diminished ability to withstand relatively minor physical insults.

“ability to cope with every day acute stressors”; frail people have a reduced ability to fight off minor infections and if they fall over are much more likely to suffer debilitating injury – or be unable to get up off the floor.

“Death is not the enemy”

“Death is not the enemy. Human death is normal; we all die. The real enemies are premature death, disability, pain, human suffering and the prolongation of dying. All the rest is mostly noise.” George Lundberg (1).  These “real enemies” have one common factor – frailty.

How common is frailty?

Around 10% of people aged over 65 live with frailty. This figure rises to between 25% and a 50% for those aged over 85. Frailty isn’t the same as living with multiple long-term health conditions though it is such conditions which underlie the development of frailty. These conditions are the “non-communicable diseases (NCDs)” and, according to WHO, the principal causes are tobacco use, physical inactivity, the harmful use of alcohol, unhealthy diets and air pollution (2). Trials of modification of any of these factors compared with any of the others have not been performed – just too difficult. For my money the one factor which, if corrected, would produce the greatest benefit would be lack of physical activity.

Why is frailty important?

Increasing frailty is closely related to increasing age and, as we all know, the number of old people in our society is increasing steadily. So frailty is getting more common. The main ill effects of frailty include  debility, dependency, increased risk of falls, need for regular carer, increased risk of hospitalisation, delayed discharge, need for residential care and enormous social and financial costs.

Imagine this scenario. Granny lives alone but just about copes. She develops a bad cough after a URTI. One morning she phones her daughter (who lives 100 miles away) for help because she feels so bad that she can’t get out of bed. Daughter calls the ambulance and is told that there are none available just now but one will be along as soon as possible. Three hours later the ambulance arrives and takes Granny to the nearest A&E department – and joins the queue of ambulances waiting to discharge their patients (3). The Department is full and it is four hours before Granny is eventually transferred onto an A&E trolley. A few more hours pass before Granny is seen, examined and x-rayed – still on the trolley. The decision is taken that she needs admission but there are no beds (4). Granny stays on the trolley overnight and is eventually transferred to the ward the following morning. After a week of antibiotics and some physiotherapy Granny is ready to go home – but after a week’s bed-rest is too weak and feeble to be able to look after herself. She will need a care package to be set up – that takes another ten days to achieve.

When Granny eventually leaves the hospital a bed is freed up to take one of the patients waiting on a trolley in A&E, another patient can be transferred from an ambulance into the Department, another ambulance is now available to attend Grandad who has just fallen and broken his hip! It can be a relentless cycle.

Next time:

I will talk about what causes frailty and is it preventable and/or treatable?

References:

1. Lundberg GD. Death is not the enemy. Medscape June 26, 2023.
2. World Health Organisation. https://www.who.int/health-topics/noncommunicable-diseases#tab=tab_1
3. Last year in England almost 2 million hours of ambulance time was lost in hand-over delays. https://aace.org.uk/hospital-handovers/
4. In one week of January last year over 14,000 beds were taken up by patients who no longer needed to be there. https://www.england.nhs.uk/2023/01/nhs-pressure-continues-as-hospitals-deal-with-high-bed-occupancy/