Age and Ageing 1997; 26: 245-246
EDITORIAL
Frailty and ageing
...Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.
William Shakespeare, As You like it.
Most elderly people are not at all sans everything and
lead full and active lives at home. However, as any
organism ages it becomes less and less able to adapt
to challenges from the internal and external environment. Initially this may manifest itself only under
circumstances of extreme stress and be reflected in an
increased likelihood of death following major events
such as severe trauma, overwhelming sepsis or heroic
surgery. As adaptability fails even more with
progressive ageing, minor events—such as less
severe injury, relatively trivial infections or injudicious
use of drugs—may precipitate catastrophic functional
failure.
Over the years, gerontological researchers have
attempted to separate the effects of 'true' ageing from
the effects of age-related disease, although the practical
usefulness of these efforts has been questioned by
several authorities [1]. In addition, geriatricians have
recogni2ed a clinical presentation characterized by 'a
multisystem reduction in physiological capacity' and
not necessarily related to a specific single disease
process. A variety of terms have arisen to describe this
or similar syndromes [2, 3], but 'frailty' is perhaps the
most commonly used.
Two problems arise with the concept of frailty: the
first is one of definition—whilst most doctors use the
term 'frail', there is considerable variation in what they
mean by it. In particular, a geriatrician's concept of
'frail' may be very different to that of a gastroenterologist or an orthopaedic surgeon. The second
problem is one of quantification—exactly how frail is
'frail'?: clearly it is not an all-or-none phenomenon
and different patients will exhibit different degrees
of frailty.
These issues are well demonstrated in the field of
geriatric pharmacology. Many early studies of drug
metabolism in elderly people used geriatric patients
and demonstrated a dramatic reduction in drug
clearance compared to young volunteers (see [4] for
review). It was soon realised that these changes were
due more to concurrent disease and 'frailty' than to age
per se [5]. As a result, more recent studies have used
well-screened 'fit' older people — the problem here
being that the screening is sometimes so stringent that
we are investigating the 'super-old', who really do not
represent the general elderly population at all.
hi an attempt to overcome at least some of these
problems, a group of geriatricians and pharmacologists
proposed a working definition of 'frail' and 'fit' almost
10 years ago [6]. This definition was based almost
entirely on function and the ability (or not) to perform
activities of daily living (ADL). It did not pretend to
quantify frailty, merely defining the ends of a spectrum;
similarly it did not purport to identify the multiplicity of
physiological deficits underlying the condition. Nonetheless, this simple and pragmatic definition has
provided a useful tool to investigate the factors
which are important in determining drug handling in
elderly subjects.
The problems mentioned above are compounded by
the fact that 'frailty' may not be static—again, using
drug metabolism as an example, events that increase
'frailty' may have a profound effect on some drug
metabolizing enzymes, with a return towards normality
on recovery [7].
Over the past decade, various groups have advanced
the concept of frailty, hi particular, attempts have been
made to more clearly conceptualize and define the
problem [8-10], to quantify the level of defined,frailty
and to use such quantified measures to predict either
risk of disability or medico-social outcome [10-12].
The paper by Campbell and Buchner in this issue of
Age and Ageing [13] usefully extends the debate on
'frailty'. They define frailty in a systematic way and
emphasize the difference between the frail patient and
someone who is simply disabled. They argue that the
condition of frailty can be diagnosed clinically by
measuring certain parameters which are essential for
successful interaction with the environment. Their
measures include several measures of physical performance, an exercise test, Mini-Mental State
Examination (MMSE) and anthropometric measurements. However, a scoring system based on this
combination of specific measurements has yet to be
evaluated in a widespread manner.
Recent cohort studies have begun to evaluate the
usefulness of various combination scores of 'frailty' in
predicting outcome and in identifying at-risk patients.
In a prospective multi-centre cohort study of patients
aged 70 years and older hospitalized for acute medical
illness, Sager and co-workers identified three patient
characteristics that were independent predictors of
functional decline: increasing age, lower admission
MMSE scores and lower pre-admission levels of ADL
scores [14]. A scoring system based on these three
245
Editorial
predictor variables allowed patients to be classified
into low-, intermediate- and high-risk categories. The
rates of ADL decline at discharge for these categories
were 17, 28 and 56% in the development cohort and
19, 31 and 55% in the validation cohort [14]. Another
cohort study of i486 men and 2630 women aged 71
years and older, followed for a mean of 3.7 years, found
that a 15-level combination score derived from serum
albumin and disability levels revealed a strong gradient
in mortality risk [11]. Combination scores such as these
can thus be useful in characterizing older populations.
No discussion of frailty would be complete without
consideration being given to psycho-social aspects of
an individual's interactions with his or her environment. Schulz and Williamson emphasize the importance of psycho-social and behavioural aspects of
physical frailty in determining the impact of illness
and disability on patient and family [15]. Not only do
psycho-social factors predict adverse outcomes, including death, in older adults but many of these factors are
modifiable and could be targeted in intervention
programmes. Psycho-social factors known to determine adverse outcomes for elderly people range from
patient factors (including depression [2]), to caregiver
problems [16] and housing conditions [17].
Widespread agreement on the concept of 'frailty' is
long overdue. The issue certainly merits further
discussion. The paper in this issue of Age and Ageing
forms a sound basis for such, and the correspondence
columns of the journal would seem to be a most
appropriate forum for this debate.
Ken W. Woodhouse, M. Sinead O'Mahony
Department of Geriatric Medicine, University of
Wales College of Medicine
Uandough Hospital, Penlan Road, Penarth
CF64 2XX, UK
Fax: (+44) 1222 716986
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246
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