Identification and management of frailty in the primary care setting

Abstract

F railty is a dynamic state of heightened vulnerability to stress ors. It is a multidimensional syndrome that places individuals at risk for adverse health outcomes, including falls, disability, admission to hospital and death. 1 The prevalence of frailty rises with advancing age, from 16% in people older than 65 years to rates as high as 52% in those older than 85 years. 2 It is associated with many comorbidities and is more common among women 3 and individuals with lower socioeconomic status. 4 Frailty is not an inevitable part of aging, although it is noted frequently during a person's last year of life. 5 However, frailty is a challenge for modern geriatric medicine 6 and for health services, because it is associated with unnecessary hospital admissions and visits to emergency departments, 7 leading to sub stantial costs for health care and a negative effect on quality of life. 8 Observational evidence suggests that frailty involves a slowly progressive functional deterioration over five to 10 years 9 during which there are many opportunities for early recognition and inter vention. Improved knowledge and practical case finding strategies would allow clinicians to provide better support for their patients who are living with or who are at risk of frailty better and, therefore, at increased risk of declining health and loss of independence.We review the utility of validated instruments for case finding and identifying frailty components, as well as evidence for inter ventions to prevent or reverse frailty (Box 1) and consider the application of this evidence in the nonspecialist setting. What are the many dimensions of frailty?A recent scoping review tackled the previous lack of consensus on a single view of frailty and offered a working definition that provides clinicians with a pragmatic understanding of the com plex and multidimensional nature of frailty as having psycho logical, cognitive and social aspects in addition to physical char acteristics. 12 Understanding that frailty involves complex interactions between biopsychosocial factors 13 will require that clinicians shift from a traditional diseasebased approach to a multidimensional model.Physical frailty is welldefined and characterized by reduced physiologic function. Based on the frailty phenotype model, 10 its features include unintentional weight loss, selfreported exhaus tion, weakness, slow walking speed and low physical activity. This model is anchored in a physiologic model that postulates dysregulated energy metabolism, and both cellular and molecu lar mechanisms, as summarized elsewhere. 14 Here, physical frailty is defined as an important medical syndrome that is clin ically meaningful and distinct from disability. 15

<p>Agreement of a Short Form of the Self-Administered Multidimensional Prognostic Index (SELFY-MPI-SF): A Useful Tool for the Self-Assessment of Frailty in Community-Dwelling Older People</p>

“…A self-administered tool able to evaluate frailty is currently a target for welfare and health-care systems, since the self-perception of frailty could yield a wider assessment and enable frailty to be diagnosed earlier. 29 So far, the self-assessment of frailty has been used only for screening purposes. Moreover, a systematic review found a total of 10 self-administered tools for assessing frailty in primary care and concluded that the Tilburg Frailty Indicator and the SHARE Frailty Index were the only suitable ones.…”

Frailty in family practice/primary health care: Care and management

“…The mental domain can present mental frailty with cognitive, mood or motivational consequences. Cognitive frailty should be distinguished from physical frailty and dementia (5,8,9). Social frailty depends on the loss of social or general resources, self-care skills, and social behaviours and activities that an individual needs (5,10,11).…”

Validation of the French version of the Vulnerable Elders Survey-13 (VES-13)

“…Stratification of subjects employing these instruments requires a lengthy process, comprising several questionnaires and complex physical assessments, both requiring high levels of geriatric expertise [9]. Because of these requirements, use of both instruments is limited to specialized teams which means that neither can be transposed to primary care [2,5,15]. Another instrument, the Vulnerable Elders Survey-13 (VES-13), also can be employed to predict the risk of functional decline, institutionalization, or death in the elderly, [16,17].…”