6/16/2016
Juanita (Nita) Reigle MSN, ACNP, CHFN
University of Virginia Health System
Charlottesville VA
Frailty
Frailty is theoretically defined as a clinically
recognizable state of increased vulnerability
resulting from aging-associated decline in
reserve and function across multiple physiologic
systems such that the ability to cope with
everyday or acute stressors is comprised.
Xue,Q-L. Clin Geriatr Med 2011;27(1):1-15
Why do we care about frailty?
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High rates of hospitalization
High rates of re-hospitalization
Higher mortality
More functional decline
Cost
Worse outcomes: delerium, iatrogenic
complications, functional decline, caregiver
stress
Wo F, et al. Age and Aging 2013;42:776-781
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Conditions that Contribute to Frailty
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HTN
CAD
Asthma
Pneumonia
Arthritis
Osteoporosis
Diabetes
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Malnutrition
Cancer
Alzheimer’s disease
Cataracts
Hearing disorders
Anxiety disorders
Depression
Do we “just know” who is frail?
Common Criteria for Frailty
(Fried Criteria)
• Meet three out of five phenotypic criteria:
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Unintentional weight loss
Exhaustion, low energy
Low levels of physical activity
Slowed walking speed
Poor grip strength
• Frailty Categories
– 3-5 is “frail”
– 1-2 is “intermediate”
– 0 is “not frail”
Fried LP, et al. Frailty in older adults: evidence for a phenotype. J Geron Med Sci 2001;56(3):M146–M156.
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Weight Loss
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Unintentional
> 10 lbs (4.5 kg); or
Loss of 5% of previous years body weight
Decrease muscle mass
Grip strength
• Reflects general weakness
• Grip strength of dominant hand
• Mean of 3 measurements using hand held
dynamometer
• Use dominant hand
Handgrip Strength as a Predictor of
Functional, Psychological and Social Health
Taekema DG, et al. Age and Aging 2010;39:331-337
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Poor Endurance
• Two statements from CES-D scale:
– I felt that everything I did was an effort
– I could not get going
• Criterion is positive if at least one of the
statements is true for 3 days or more during
the week
Gait Speed
• Time to walk 15 feet (Fried criteria)
• Gait Speed
Gait Speed (self selected)
Test Protocol: Measure and mark a standard distance (e.g., 15 or 20 feet, or use 5 or 6 meters for easier math). Then
measure and mark 5 feet (2 meters) before the start and 5 feet (2 meters) at the end of this middle section
2 meters
2 meters
5 or 6 meters
 Starting line
 begin timing
stop timing 
Finish line 
Instructions: “Walk at a comfortable pace”. Have the person perform 3 repetitions and calculate the average time.
Gait Speed = distance / time
e.g. 5 meters / __ sec.
Walking Speed
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Walking Speed and Functional Ability
Fritz S. Lusardi M. (2010). White Paper: Walking Speed: the Sixth Vital Sign. Journal of Geriatric Physical Therapy 32(2): 2-5. Figure 1.
Get Up and Go
• Instruct to get up from a chair, walk 10 feet
turn around; walk back and sit down.
• Usually takes 10 seconds.
• Frail elderly usually < 20 sec
• If >20 sec needs PT eval
Low Activity
Inactivity or
sedentary lifestyle
results in sarcopenia
and frailty
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Sarcopenic Obesity
• Increase in fat mass and reduction in lean
mass
• Associated with increase in caloric intake,
decrease in physical activity, low-grade
inflammation, insulin resistance, and changes
in hormonal milieu
Stenholm S, et al. Curr Opin Clin Nutr Metab Care. 2008;11(6):693-700.
Look for Risks for Fraility
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Advanced age
Multiple hospitalizations
Poor social support
History of depression or falls
Multiple co-morbid conditions
Sensory impairments
Cognitive impairments
Interventions while Hospitalized
• Treat impairments: visual aides, hearing
devices, remove earwax, etc
• Cognition: memory aides, open blinds
• Sleep: minimize interruptions
• Mobility: OOB ASAP, PT/OT consults
• Dehydration
• Discharge Plan to address unique needs
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Treating Strength and Conditioning
• Range of Motion and Flexibility exercises to start
• Exercise – resistance training to improve strength
and increase lean body mass
• Strength and physical movement is necessary to
increase exercise tolerance and walking speed
• Attention to balance to reduce risk of falls
• Attention to sensory changes
• Improve self-esteem and increase socialization
Assess Causes of Weight Loss
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Consider poor dentition
Dysphagia
Delayed gastric emptying in diabetic patients
Early satiety from heart failure
Medications cause altered taste
Depression
Anemia
Vitamin D levels and the role in Ca absorption
Palace ZJ & Flood-Sukhdeo J. Today’s Geriatric Medicine Jan/Fen 2014 Vol 7, No.1
Tools to Assess Frailty
• Not routinely used in practice
• Role in decision-making/predicting outcomes is
questioned
• Rockwood, Frailty Index
– State of vulnerability that arises in relation to the
accumulation of health deficits
– Requires rating of at least 30 health states
– Difficult to apply in practice
• Edmonton
Wou F, et al. Age Ageing. 2013;May 10
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Summary
• Frailty is a common condition in the HF
population
• The presence of frailty increases risks for
worse outcomes, including hospitalizations
and mortality
• Interventions to stabilize or reduce frailty are
possible but prevention is the best strategy
How to Avoid Becoming Frail or
Living Longer and Stronger
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Choose your parents well
Positive Family and Social Engagement
Cope with Stress
Get enough rest
Exercise
Preventative Health Practices
Healthy Diet, Floss Teeth
Minimize Caffeine, Smoking, Alcohol
Optimistic Attitude
From: Livingto100 Website
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