The frailty syndrome in the public health agenda Fernando Rodríguez-Artalejo,1,2 Leocadio Rodríguez-Mañas3 A PubMed search of articles in this journal using the text word ‘frailty’ found only two manuscripts, published in 2010 and 2012.1 2 Thus, many readers of the journal may not be familiar with the concept and public health implications of the frailty syndrome.3 4 This is notable for several reasons. First, because frailty is a frequent condition, with a prevalence of about 10% in the population over age 60 years, reaching 25% in those aged 80 years and older.5 6 Also, in a well-known prospective study among community-dwelling older persons, the most common condition leading to death was frailty (27.9%), followed by organ failure (21.4%), cancer (19.3%) and dementia (13.8%).7 Additionally, frailty shows an important social gradient, so that women and less educated persons are more likely to be frail and to have an increased risk of worsening frailty status.3 4 8 Second, because the process of frailty can potentially be prevented and treated.4 This is important because frailty is a strong risk factor for mobility loss, falls, dependence, institutionalisation and death after exposure to even minor stressors.3 4 Moreover, frailty is a recognised predictor of outcomes after medical and surgical interventions, and should be taken into account before prescribing them to older patients.9 Given the accelerated ageing of the population in most countries, and the expected increase in the number of individuals with disability and dependence, interventions on frailty may be a good avenue to prevent or delay disability, which is a major cause of usage of healthcare and social services. And ﬁnally, because in 2003 the Institute of Medicine identiﬁed frailty as 1 of 20 priority areas, selected from several hundred candidates, in need of improvements in healthcare quality.10 Moreover, the European Medicines Agency acknowledges 1
Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/Idipaz, Madrid, Spain; 2CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain; 3Division of Geriatric Medicine, Hospital Universitario de Getafe, Madrid, Spain Correspondence to Dr Fernando Rodríguez Artalejo, Departamento de Medicina Preventiva y Salud Pública. Universidad Autónoma de Madrid, C/ Arzobispo Morcillo, 2, 28029 Madrid, Spain; [email protected]
that depending on patients’ frailty and disability status, the desirable outcome and treatment choices might vary, and that this should be taken into account in the development and approval of drugs for older adults11; also in the 2012 Ageing report, the European Commission and the Economic Policy Committee stated that coping with the challenge posed by an ageing population and trend, increases in age-related spending will require determined policy action in Europe, particularly in reforming pension, healthcare and longterm care systems.12 Therefore, the reduction of disability and dependence through appropriate action on the frailty process should be at the forefront of all policies to tackle the challenge of population ageing. Why, then, is frailty not at the top of the public health agenda? One main reason is that frailty is not yet a common clinical diagnosis, or at least it is not frequently recorded in clinical charts. Accordingly, frailty does not rank high in hospital discharge data, in vital statistics or among the main causes of disease burden, thus, it is ‘invisible’ for public health practitioners. However, given that frailty usually results from several diseases (eg, heart failure, diabetes, cancer, chronic respiratory disease, depression, etc) acting jointly, and frequently leads to disability, a substantial portion of the death toll and disease burden assigned to those diseases is also related to frailty. There is consensus on the concept of frailty, which is deﬁned as a ‘medical syndrome with multiple causes and contributors, that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependence and/or death’.4 13 However, the fact that the conceptual deﬁnition of frailty rests partly on its consequences rather than on its ontological characteristics, and that there are many ways to evince a reduced physiologic function, has hampered agreement on a single operational deﬁnition or diagnostic tool.11 13 This has hindered the adoption of frailty as a common diagnosis in clinical care. There are two popular approaches to evaluate the frailty process, but none of them is optimum. The ﬁrst approach was developed in the Cardiovascular Health
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Study (CHS), and identiﬁed a frailty phenotype which was deﬁned with ﬁve variables: unintentional weight loss, selfreported exhaustion, self-reported lowenergy expenditure ( physical activity), and measured slow walking speed and weak grip strength.14 The presence of each variable is assessed by comparison with a norm, which usually is the lowest quintile in the CHS or in the speciﬁc study sample. Those with three or more of these variables are judged to be frail, and those with one or two as prefrail. Although these frailty criteria are the most widely used in the literature, they are difﬁcult to apply in clinical care because they require a dynamometer and a walking test, and because in some settings (eg, emergency departments, intensive care units), the patients’ clinical condition does not allow for assessing them. Moreover, the CHS criteria are based on norms derived from selected patient samples and may vary with ethnicity. Furthermore, it has been argued that these criteria should be reﬁned by also considering cognition and mood, which are well-known risk factors of dependence and death. The second approach was developed within the Canadian Study of Healthy Ageing and deﬁnes frailty as the cumulative effect of individual deﬁcits in many physiological systems, as manifested by the total number of symptoms, signs, abnormal laboratory values, disease states and disabilities comprising the so-called frailty index.15 This index probably measures clinical domains other than frailty, such as the so-called biological age, as it also includes disability and disabling conditions. In fact, the frailty index is a good predictor of death, but it is possibly less accurate for predicting disability. Moreover, although short versions of this index have been developed, it is impractical in most clinical settings because it includes a large number of variables. There are a few screening instruments for frailty, such as the FRAIL scale (which only includes self-reported data),16 but a simple, validated and widely agreed diagnostic tool usable in primary and hospital care is still needed. This instrument should be able to discriminate which patients are at increased risk of adverse outcomes (eg, dependence or death) resulting from common medical interventions, such as an invasive diagnostic procedure, an oncological treatment or a minor surgical intervention. A key issue to be elucidated in the future is whether a single performance measure, such as grip strength or gait speed, may sufﬁce for frailty detection or diagnosis, although 703
Editorial recent research supports that the whole syndrome has more robust properties than any of their components.17 Of note is that population-based surveys (eg, NHANES) are starting to collect data on muscle strength using a handgrip dynamometer; this might serve to monitor the progress on the prevention and control of frailty in the older adult population. Another reason why frailty is not yet high in the public health agenda is the paucity of well-conducted clinical trials to assess the short-term and long-term efﬁcacy of medical interventions on frailty. Exercise programmes, nutritional supplements (total energy, protein, vitamins) and the reduction of polypharmacy appear to have some efﬁcacy in the treatment of frailty,4 but in most cases the clinical trials did not use a validated or established model to assess frailty at baseline and at follow-up.3 Thus, it is dubious whether the effects of these interventions apply to most frail individuals in the community; most importantly, in many cases, the outcomes in these studies corresponded to improvement in functional ability or reduction of falls, but no comprehensive evaluation has been made for each intervention on all relevant outcomes (which also include hospitalisation, incident dependence, institutionalisation and death). Also, given that frailty may be caused by different types of diseases, it is uncertain if the same types of interventions ﬁt all types of frailty and their components (eg, weight loss, gait speed, etc). Last, several scientiﬁc organisations have agreed that all persons older than 70 years, and all individuals with signiﬁcant weight loss due to chronic disease should be screened for frailty.4 This recommendation was grounded on the effectiveness of treatments for components of the frailty syndrome, and on the assumption that the screening tests produce more beneﬁcial than harmful outcomes. While this may prove true, the public health community usually requires sound clinical trial evidence that a certain screening and treatment intervention produces better outcomes than no intervention. Moreover, the cost of an intervention should compare
well with the cost of other healthcare alternatives, and the budget impact should be acceptable. All the above explains why frailty is not currently a hot topic in public health. But it also shows an urgent need to enhance our knowledge on the natural history of frailty and, particularly, on the most appropriate diagnostic tools, and the effectiveness and efﬁciency of its treatment and screening procedures; thus, the frailty syndrome should be ranked high in the research agenda. In fact, in the European Union, frailty was a frequent topic in the calls by the recently concluded seventh framework research programme, and has emerged as a true priority in Horizon 2020. As the research results are delivered, frailty will surely reach a higher position in the list of public health priorities. Contributors Both authors contributed equally to the planning and writing of this editorial. Funding This work has been supported by grants from the Instituto de Salud Carlos III (PI/12/1166 and RD12/ 0043/0001 RETICEF) and the European Commission (FRAILOMIC Initiative FP7-HEALTH-2012-Proposal No: 305483-2).
Competing interests None. Provenance and peer review Commissioned; externally peer reviewed.
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