In search of fragility

A few days ago I gave a session in primary care on aspects to be taken into account in the early identification of fragility in the elderly, so I think it is interesting to disseminate certain current aspects of it.

In the first place, as with other concepts in geriatrics, the definition is variable, with different consensus of relevance for the homogeneity of criteria in epidemiological studies.* This is considered as a syndrome characterized by a loss of biological reserve, as a consequence of which vulnerability to stress increases and entails a risk of adverse outcomes such as disability, hospitalization or death.

It is a broad concept that can have two approaches, one more physical that emphasizes aspects such as weakness, slowness, weight loss that can be more measurable and another as accumulated deficits in physical, psychological, social variables that are detected through comprehensive geriatric assessment.

The biological substrate underlying the physiopathological changes in fragility is mainly related to neuroendocrine and inflammatory aspects, which occur during ageing itself and are conditioned by aspects related to comorbidities and socio-economic life circumstances.

Different screening scales have been developed, ** of which the most relevant may be the FRAIL Scale (Fatigue, Endurance, Ambulation, Illnessess as more than 5 diseases, Loss or weight loss >5% in one year), or the Frailty Index with a list of different risk factors. As tests that present a high sensitivity we have the speed of walking (more than 8 seconds in covering 6 meters), timed get up and go test, or the PRISMA questionnaire.

The spectrum covered is wide, from the robust individual, to pre-fragility, fragility and the permanently established dependence, with the care objectives being dynamic.

With these guidelines, epidemiological studies have been developed in which the prevalence is 10% in people over 65 years of age and in > 85 years it quadruples, being higher in men and with a higher mortality risk in women. Although, as has already been mentioned, it depends to a great extent on the population studied and the operational criteria used. It can also serve as a predictor to identify patients at risk of hip fracture, disability, institutionalisation or mortality. As a differential diagnosis, we must take into account the possibility of depression, malignancy, polymyalgia rheumatica, thyroid diseases, etc. Therefore, the high risk of adverse events must be used to make decisions that allow a better evaluation of the benefit or risks for the safety of diagnostic or therapeutic interventions.

The therapeutic possibilities are mainly through exercise that can partially reverse the effect of immobility or frequent sarcopenia in old age. Exercise about twice a week is sufficient, as well as ensuring adequate and varied nutrition, by carrying out an assessment of prescribed medicines whose indication is not currently present or that produce adverse reactions. In a multicomponent intervention trial with physical and cognitive exercise and nutritional supplementation for 12 weeks, the variables in the fragility indicator are improved at 3 and 6 months, however the results in hospitalization, disability or death, are not.***

The role of the primary care physician is essential in the early identification of the physiological decline of the pathological condition, screening all patients over 70 years of age, with various comorbidities or with significant involuntary weight loss, referring those patients who benefit from a more specific assessment to Geriatrics, agreeing on objectives between the different levels of care and especially coordinating the social and health resources.

* Morley JE, Vellas B, Van Kan GA et al. Frailty consensus: a call to action.J Am Med Dir Assoc 2013;14:392-397

**Theou O, Brothers T, Mitnitski A, Rockwood K. Operationalization of Frailty Using Eight Commonly Used Scales and Comparison of Their Ability to Predict All-Cause Mortality. JAGS 2013;61:1537.

***Ng TP, Feng L, Nyunt MS, et al. Nutritional, physical, cognitive, and combination interventions and frailty reversal among older adults: a randomized controlled trial.Am J Med 2015;128:1225.