Frailty, identification, treatment, and clinical practice

The demographics shift of the average age of the population worldwide mandates that careful attention be paid to the nutritional and health needs of all segments of our older adult population. Well-defined changes in body composition occur with advancing age. Characteristic of this change is the age-associated decline in skeletal muscle mass and function, sarcopenia. Sarcopenia has been linked to declines physical function, loss of independence and mortality. The functional declines associated with sarcopenia are factors that contribute to the syndrome of frailty with advancing age. Frailty has been defined as a geriatric syndrome that is characterized by a reduction physiologic reserve required for an individual to respond to endogenous and exogenous stressors (1). Using a discrete definition of frailty that includes: sedentariness, involuntary weight loss, fatigue, poor muscle strength, and slow gait speed, Fried and her colleagues have been able to associate states of frailty with increased disability, post-surgical complications and increased mortality (2). Despite the strong associations between frailty and subsequent poor outcomes, limited attention to this common geriatric condition has been paid in clinical settings.

In this issue of the Journal, Tavasolli and colleague report on the design and establishment of a frailty screening tool and comprehensive frailty assessment center developed in Toulouse France (3). The authors describe the structure, design and initial progress of the Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability. The GFC was established to provide a comprehensive evaluation of the frailty type in older adults who are identified as being “at risk” for frailty using a screening tool (“Gerontopole Frailty Screening Tool” (GFST)) (4). Patients identified by this screening instrument as frail are referred to the GFC for further assessment and tailored treatment.

In this report of the first 2 years of GFC operation, the authors report on successfully evaluating a total of 1,108 patients referred from primary care providers who had been identified as “frail” (3). Of these initial patients, virtually all met the established criteria of pre-frailty (39%) or frailty (54%) upon evaluation at the GFC. In addition to modifications to existing medical conditions and medical specialty referral, a majority of patients were prescribed physical activity (57%) and/or a nutritional intervention (26%).

The GFC represents the first clinically based evaluation center that is specifically tartgetting and treating frailty has a number of unique features. Patients are initially identified for frailty evaluation using a simple easily administered screening tool. This initial screening is further enhanced by the ability of the patient's personal physician to independently evaluate the patient's frailty status. The GFC evaluation is comprehensive and directly evaluates a wide range of domains and risk factors for frailty. Finally, based on this comprehensive evaluation, a menu of treatment options can be provided to individual patients based on the clinical findings and frailty evaluation.

Future work should be directed towards evaluating the ability of the GFC assessment and interventions to modify the frailty phenotype. In addition, an important area of investigation should be to evaluate the cost-effective of this model system for evaluating and treating frailty compared to the current standard of care for most older functionally-limited patients.