Frailty in Pulmonary and Critical Care Medicine

Abstract

Conceptualized first in the field of geriatrics, frailty is a syndrome characterized by a generalized vulnerability to stressors resulting from an accumulation of physiologic deficits across multiple interrelated systems. This accumulation of deficits results in poorer functional status and disability. Frailty is a "state of risk" for subsequent disproportionate declines in health status following new exposure to a physiologic stressor. Two predominant models have emerged to operationalize the measurement of frailty. The phenotype model defines frailty as a distinct clinical syndrome that includes conceptual domains such as strength, activity, wasting, and mobility. The cumulative deficit model defines frailty by enumerating the number of age-related things wrong with a person. The biological pathways driving frailty include chronic systemic inflammation, sarcopenia, and neuroendocrine dysregulation, among others. In adults with chronic lung disease, frailty is independently associated with more frequent exacerbations of lung disease, all-cause hospitalization, declines in functional status, and all-cause mortality. In addition, frail adults who become critically ill are more likely develop chronic critical illness or severe disability and have higher in-hospital and long-term mortality rates. The evaluation of frailty appears to provide important prognostic information above and beyond routinely collected measures in adults with chronic lung disease and the critically ill. The study of frailty in these populations, however, requires multipronged efforts aimed at refining clinical assessments, understanding the mechanisms, and developing therapeutic interventions.Keywords: frailty; body composition; disability; health-related quality of life; mortality Correspondence and requests for reprints should be addressed to Jonathan P. Singer, M.D., M.S.,

Report from the American Society of Transplantation on frailty in solid organ transplantation

“…1 Frailty symptoms have been linked to disease severity such as the model for end-stage liver disease and sodium (MELDNa) score in liver transplantation. 7,8,12 As with frailty, studies of sarcopenia are limited by the lack of universally accepted definitions and methods of measurement. IL-6, TNF-α, CXCL-10, neopterin, lower CD4:CD8 ratios, higher numbers of memory T-cells, and cell-free mitochondrial DNA are reported specific biomarkers of frailty.…”

“…[7][8][9][10][11] Sarcopenia and frailty share similar underlying mechanisms, such as physical inactivity, chronic inflammation, and endocrine dysregulation. 7,8,12 As with frailty, studies of sarcopenia are limited by the lack of universally accepted definitions and methods of measurement. 13 Sarcopenia, like frailty, may be a risk factor for worse outcomes in lung transplant candidates; however, data are conflicting, with some studies showing lower pretransplant skeletal muscle mass measured radiographically being a risk factor for worse outcomes, 9,14 and others showing risk for longer hospital stays but not mortality.…”

Frailty assessment in older adults with chronic obstructive respiratory diseases

“…Despite the fact that more than half of the older people with chronic diseases such as heart failure17 and chronic obstructive pulmonary disease (COPD) might be frail,6 most physicians often focus on specific diseases, such as diabetes, heart failure, and COPD, instead of the early diagnosis and intervention of frailty, which might lead to the occurrence of unexpected adverse outcomes in older adults. Once frailty develops, a new physiological stressor (eg, acute exacerbation of COPD [AE-COPD] or critical illness) can overwhelm the already diminished physiologic reserve, resulting in disability, severe morbidity, or even death 18. Therefore, the American Geriatrics Society (AGS), the National Institute on Aging (NIA), and the Alliance for Academic Internal Medicine held a joint conference in 2015 with the purpose to advance the field of frailty research among relevant medical specialties 19…”

Frailty and patient-reported outcomes in subjects with chronic obstructive pulmonary disease: are they independent entities?

“…6 Frailty is thought to be one of the defining features of ageing and several concise measurement tools have appeared in the literature as a consequence. 5 The Cardiovascular Health Study Index developed by Fried et al has been the most widely used to assess this biological syndrome. 6 Alternative tools such as the Frailty Index and Clinical Frailty Scale using the cumulative deficit approach have also been validated.…”