Frailty Searching for a Relevant Clinical and Research Paradigm by she20208


									   28th Canadian Geriatrics Society Annual Meeting: Academic Career Day

Frailty: Searching for a Relevant Clinical and Research Paradigm
                                                     The 2nd International Working              healthfully or not. This research and clin-
Speaker: Howard Bergman, MD, The Dr.
                                                Meeting on Frailty and Aging held in            ical approach attempts to elucidate the
Joseph Kaufmann Professor and Director
                                                Montreal in March of 2006 sought to             heterogeneity of functional decline in
Division of Geriatric Medicine, McGill
                                                address key issues and controversies            older people.
University, Montreal, QC; Co-Director:
                                                related to the concept of frailty. The core
Solidage Research Group, Montreal, QC;
                                                features agreed upon are presented in           Ongoing Controversies in
Director, Quebec Research Network in Age-
                                                Table 1. Participants concurred that frailty
ing/Fonds de Recherche en Santé du                                                              Defining and Using the Frailty
                                                is “an increased vulnerability to stressors
Québec, Montreal, QC; Chair, Advisory                                                           Concept
                                                due to impairments in multiple, inter-          Frailty is not yet a clinical instrument.
Board, Institute of Aging, Canadian
                                                related physiologic systems.” These             Controversies and grey areas that persist
Institutes of Health Research, Ottawa, ON.
The term frailty, observed Dr. Howard           impairments are believed to lead to             include disentangling chronic disease
Bergman, is widely used by health pro-          declining homeostatic reserve and               states from frailty. Dr. Bergman described
fessionals who treat aging adults.              resiliency. The working group acknowl-          the two as bearing a complex relation-
Nonetheless, the concept remains ill-           edged that while frailty and disability         ship: there is some overlap, but the key
defined. What is it, what are its compo-        have overlap, they remain distinct con-         distinction is that while most frail persons
nents, and how is it measured in the            cepts (Figure 1). A key feature of frailty is   have chronic disease, most people with
clinical setting? Does the term add             that it is associated with increased risk of    chronic disease are not frail. There is a
something to the effort to mitigate             morbidity and mortality, stated Dr.             distinct increase in the prevalence of
adverse health outcomes among older             Bergman.                                        frailty when the number and severity of
adults?                                              Frailty has been described with var-       chronic diseases increase. Whether frailty
                                                ious combinations of components includ-         is a secondary condition rather than an
Conceptualizing Frailty and                     ing physiological abnormalities,                underlying state is still being explored.
Understanding the Aging                         impairments in physical, cognitive,             Further, being frail and having a high
Process                                         and/or psychological function, and other        index of comorbidities are not equivalent.
The challenge of studying frailty, Dr.          features such as advanced age.                  It is important to consider contextual
Bergman maintained, is the lack of clear             According to Dr. Bergman, research         issues in health care—for example, stud-
criteria to designate it. How frailty differs   strategies that use the life-course             ies suggest that patients with poor access
from disability, and how researchers and        approach can significantly contribute to        to health care will show higher degrees
clinicians define effects of aging versus       the current understanding of frailty. This      of frailty.
markers of frailty are areas of evolving        individualized, integrative approach con-             Dr. Bergman highlighted that there
medical knowledge. The result is that cli-      ceives that how one ages is a product of        is a spectrum of frailty models. At one
nicians are utilizing the concept without       factors across the whole life span—             extreme of the spectrum frailty is repre-
agreement on its meaning, a problem             including environmental exposures,              sented as a medical syndrome and at the
exacerbated by the fact that frailty is a       genetic predispositions, and health             other it is a group of risk factors (Table 2).
nonmedical term circulating in popular          behaviours. Critical factors across the life          In viewing frailty as a syndrome
language.                                       course may determine whether one ages           with defining core features, Dr. Bergman
                                                                                                suggested that there may be important
                                                                                                lessons to be learned from the metabolic
 Table 1: 2nd International Working Meeting on Frailty and Aging (2006)—                        syndrome. As with frailty, there is debate
 Principle Features of Frailty                                                                  and controversy about the clinical defini-
                                                                                                tion of the metabolic syndrome. As syn-
 The core feature of frailty is increased vulnerability to stressors due to impairments in      dromes, the presence of multiple
 multiple, inter-related systems that lead to decline in homeostatic “reserve” and              components are expected have a stronger
 resiliency                                                                                     association with adverse outcomes than
                                                                                                the sum of the individual components.
                                                                                                      Dr. Bergman acknowledged the dis-
 The main consequence is an increased risk for multiple adverse health-related outcomes:

                                                                                                advantages associated with increasing
 disability, morbidity, falls, hospitalisation, institutionalisation, death

                                                                                                utilization of the frailty concept. For
                                                                                                example, physicians may overvalue the
 Frailty is a syndrome encountered in older persons with diverse predisposing,

                                                                                                symptom cluster, thereby overlooking
 precipitating, enabling, and reinforcing factors
 Frailty and disability, while related and overlapping, are distinct concepts                   the possible value of a single symptom.

Frailty: Searching for a Relevant Clinical and Research Paradigm

In addition, some of the measures pro-
posed for frailty such as gait velocity or
                                                    Table 2: Spectrum of Frailty Models
grip strength do not have established cut-
offs, thereby making it difficult to deter-
                                                    Common features: Age-related vulnerability to stressors, clinically identifiable,

mine how to classify individuals. Further,
                                                    multisystem impairment

introducing “frailty” as a diagnosis in             Medical syndrome                      Risk factor approach
clinical practice carries the potential dan-
ger of inappropriate labeling, which can
                                                    • Hypothesis-driven                   • Variable pathway and pathophysiology

have various negative effects on a
                                                    • Limited number of components linked • Unlimited number of deficits

patient’s health state and health-related
                                                      to defined underlying biologic/     • Geriatric syndrome: accumulated effects

                                                      physiologic pathway                   of impairments in multiple domains

     However, Dr. Bergman stated, the
                                                    • Medical syndrome: aggregate of Sx     resulting in a particular adverse outcome:
concept of frailty also holds great potential         and signs associated with morbid      falls
value for physicians, as it has functional            process constituting picture

10 CONFERENCE REPORT DISTRIBUTED WITH • November/December 2008 • Volume 11, Number 10
                                                                   Frailty: Searching for a Relevant Clinical and Research Paradigm

utility in clinical practice. The term iden-   nicians’ ability to characterise the hetero-   Conclusions and
tifies a subset of vulnerable older adults     geneity in the health of older persons.        Recommendations
at high risk of adverse outcomes. The          With an aging population, the capacity to      Dr. Bergman concluded that while
health needs of older persons who are          better target and remediate risk in            research and debate on frailty has
functionally independent, with apparent-       nondisabled older adults with chronic          improved understanding of aging adults,
ly normal cognitive function, may be           disease could lead to better tailoring of      the concept retains at present more
overlooked if clinicians disregard identi-     health interventions, and corresponding-       potential than practical and acknowl-
fiable frailty markers.                        ly, improved health outcomes. For exam-        edged utility. Ultimately the test of
     Frailty markers provide health care       ple, Dr. Bergman cited a study that found      frailty’s relevance will lie in further
planners with the ability to make valu-        that patient care measures that delayed        research initiatives on frailty and whether
able predictions, according to Dr.             the onset of disability and/or depend-         medical professionals succeed in improv-
Bergman. A wider clinical application of       ence by only 1 or 2 years reduced needs        ing health promotion, prevention, treat-
the concept could improve understand-          for long-term care and institutional           ment, rehabilitation, and care
ing of the aging process and enhance cli-      resources significantly.                       interventions for aging adults.


To top