Fighting frailty in older patients FRAILTY IS OFTEN thought of as a normal part of aging, but in reality it isn’t.1 Most definitions describe frailty as a condition marked by a loss of function, strength, and physiologic reserve.1 Frailty can often predict the risk of falling and possibly result in a disability related to impaired mobility and restricted activities of daily living. Other adverse consequences include the possibility of hospitalization, rehabilitative therapy, and loss of independence.1-3 Any comorbidity may contribute to the condition of frailty, particularly cardiac disease and/or osteoporosis.4-6 Unaddressed frailty is associated with risk factors for disability and complications such as infection and prolonged recovery (for example, a hip fracture due to a fall can result in less mobility, leading to pneumonia), as well as a greater financial burden on the patient and family if institutional care is indicated.2,5,7 This article will look at how to assess patients for frailty and ways to help them improve their health.

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Diagnosis The five physical signs and symptoms of frailty include weakness marked by grip strength, weight loss of 5% or more body weight in the last year, exhaustion, slow walking speed (more than 6 to 7 seconds to walk 15 ft [4.6 m]), and decreased physical activity.1-3,8 When three of these five signs and symptoms are present in an older adult (age 65 or older) or a younger, chronically ill adult, they characterize frailty.1,2 Frailty can be a middle point between independence and a “predeath” prognosis related to multisystem dysfunction and global decline, which can spiral to end-oflife complications.9 It’s thought to be driven by inflammatory pathway activation and dysregulation of neuroendocrine systems, which leads to skeletal muscle decline.1 Obesity, or even being overweight, may disguise a “core frailty” and a risk of sarcopenia (age-related decline in muscle function).1 A


By Joyce O. Hislop, RN, OCN

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

February l Nursing2014 l 65

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Finland study followed men and women ages 30 to 60 for 22 years (1978-2000) to assess the risk of developing frailty related to obesity. At the 22-year evaluation researchers concluded that the development of frailty may begin in midlife, and obesity was one of the underlying causes of frailty.10 Assessment One assessment to gauge an older adult’s independent mobility strength is the Timed Up and Go (TUG) test (see Assessing frailty with the TUG test). This test can be performed in the home by a visiting nurse. Observe for undue slowness, hesitancy, abnormal movement of trunk or upper extremities, staggering or stumbling, or dizziness.3,8 An extremely slow gait is considered the primary indicator of fall risk.7 Falls from a standing height are the most common cause of hip fractures in older adults.7,11 The cost of hip fractures is measured not only in dollars, but a minimum of 6 weeks recovery time and up to 24 physical therapy sessions.7 Complications may include infection, shock, thromboembolism, and degenerative arthritis. Initiate reasonable and appropriate interventions to improve the patient’s strength and balance and reduce fall risk.2 These interventions include reviewing medications; evaluating

cognitive status, vision, hearing, mobility, and safety risks in the home; and physical therapy if indicated.12 Treatment Randomized studies have shown that even very frail patients in long-termcare facilities benefit from resistance exercises such as weight lifting or weight-bearing exercises of the large skeletal muscle groups.13 These exercises can help them gain lean muscle mass and walking speed.2-4 Adding nutritional supplements such as vitamin D can also help them meet these goals because studies have shown its effectiveness in preventing falls and improving balance.1 Baby boomers have begun to enter their senior years, and they’re changing the current perception of the term older adult. Membership in fitness centers and activities such as bicycling and walking are a part of life for a great many older adults who’ve embraced healthy habits and physical activity programs such as cardio, yoga, and tai chi. Maintaining an exercise program throughout life can help them control chronic problems such as hypertension, diabetes, obesity, and some cancers, helping them to live longer than any previous generation.2 Combining weight loss with exercise has a greater impact on frailty than either intervention alone.1

Assessing frailty with the TUG test During the TUG test, which measures a patient’s mobility strength, the patient is instructed to rise from a chair (with or without arm rests), walk 10 ft (3 m), turn and walk back to the chair, and sit down again.3,8 The patient should wear safe footwear and prescribed glasses and/or use an assistive cane or ambulatory device if this is usual for him or her. Accomplishing this performance-based measure in under 10 seconds indicates high mobility and 10 to 19 seconds is typical mobility. These results establish unattended mobility inside and outside the home. However, 20 to 29 seconds indicates lower mobility, and 30-plus indicates a risk for falling and a dependence on assistive devices.7

Educating patients As the aging population increases, nurses will be navigators of evidencebased interventions in revising the myth of inevitable frailty. Our role will include educating our patients about proactive self-care and routine medical management, guiding these boomers through their senior years. ■ REFERENCES 1. Walston JD. Frailty. UpToDate. 2013. http:// 2. Benefield LE, Higbee RL. Frailty and its implications for care. In: Boltz M, Caepzuti E, Fulmer T, Zwicker D, eds. Evidence-Based Geriatric Nursing Protocols for Best Practice. 4th ed. New York, NY: Springer Publishing Co.; 2012. 3. Salzman B. Gait and balance disorders in older adults. Am Fam Physician. 2010;82(1):61-68. 4. Rianon N. Facts about osteoporosis and aging. Training Excellence in Aging Studies. 2010. http:// Osteo.html. 5. Thomas J. Hip fractures. Training Excellence in Aging Studies. 2010. reynolds/soundbytes/hipFracture.html. 6. Harkness K, Heckman GA, McKelvie RS. The older patient with heart failure: high risk for frailty and cognitive impairment. Expert Rev Cardiovasc Ther. 2012;10(6):779-795. 7. MD Guidelines. Fractured pelvis. http://www. 8. American College of Rheumatology. Timed up and go test. 2011. 9. Agarwal K. Failure to thrive elder adults: management. UpToDate. 2012. http://www. 10. Stenholm S, Strandberg TE, Pitkälä K, Sainio P, Heliövaara M, Koskinen S. Midlife obesity and risk of frailty in old age during a 22-year follow-up in men and women: The Mini-Finland Follow-up Survey. J Gerontol A Biol Sci Med Sci. 2013;May 2. [Epub ahead of print]. 11. Mayo Clinic. Hip fracture. 2012. http://www. 12. Fairhall N, Langron C, Sherrington C, et al. Treating frailty: a practical guide. BMC Med. 2011; 9:83. 13. Randall RL. Baby boomers’ defining characteristics could help them redefine aging in America. 2012. rhonda-l-randall-do/baby-boomers-redefiningaging_b_1448949.html.

Joyce Hislop is a retired nurse and freelance writer in Breinigsville, Pa. The author has disclosed that she has no financial relationships related to this article.


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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Fighting frailty in older patients.

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