As a medical resident 30 years ago, Ava Kaufman remembers puzzling over some of the elderly patients who came to the primary-care practice at George Washington University Hospital. They weren't really ill, at least not with any identifiable diseases. But they weren't well, either.
"The symptoms are causally linked together in a vicious cycle,'' says Linda Fried, a geriatrician who is dean of the Columbia University Mailman School of Public Health. In 2001, Fried and research colleagues were the first to define the physical characteristics of frailty in a
landmark paper published in the Journal of Gerontology. "These are people at risk of very bad outcomes."
The signs of frailty can be obvious, even to the layperson. The frail often look "as if a puff of wind could blow them over," Fried says. Their gait is slow and unsteady. Over the years, they seem to shrink in size, the result of muscle wasting that occurs naturally as people age. Everyone loses muscle mass as they approach their 90s, although studies have shown that resistance training — weightlifting — can slow this process.
Because it typically worsens over time, frailty often leads to more serious consequences, such as a disabling fall, even death. Frail people are, in fact, at higher risk of falls, and have a much more difficult time recovering if they become ill or enter the hospital. "Putting a frail person in the hospital often is the beginning of the end,'' Kaufman says.
How to stay healthy longer
To be sure, many older Americans continue to lead active and productive lives. However, the nation's increasing longevity is bringing new challenges for health and social programs. Americans' life span in 2009 was 78.5 years, according to the Centers for Disease Control and Prevention, about three decades more life than in 1900, when the average was 47.3 years.
"We've added 30 years to the human life span, which is an unparalleled success story for public health, medicine and education,'' Fried says. "As a result, it is critically important that we help these people who are living longer stay healthy.''
Of those living alone or with families, not in nursing homes or hospitals, about 4 percent of men and 7 percent of women older than 65 were frail, according to the parameters used by Fried and her colleagues in the 2001 study. The researchers, who studied more than 5,000 adults aged 65 and older, also found that the chances of frailty rose sharply after age 85, to about 25 percent. These numbers, the most recent data available, reflected conditions prior to 2001, leaving "an important but unanswered question as to whether the frequency of frailty is the same, increasing or decreasing" today, Fried said.
Also, women are more likely than men to be frail, possibly because women typically outlive men and "start out with less muscle mass than men and, once they lose it, they may cross the frailty threshold more rapidly than men,'' Fried says.
Stephanie Studenski, principal investigator at the Claude D. Pepper Older Americans Independence Center at the University of Pittsburgh, has been practicing in the
geriatrics field for more than 30 years and sees "older people across the full spectrum, from frail 60-year-olds to vigorous 95-year-olds,'' she says. For the younger group, who usually are frail because of multiple chronic conditions, "sometimes medications can worsen frailty with their side effects, so adjustments can help,'' she says. "I tell these patients I can often make you better, give you more reserve and increase your resilience although not totally cure you. We can't change from black to white, but often can push the black into gray.''
For those in their 80s or older, however, the causes of frailty are sometimes less obvious.
Barbara Resnick, a geriatric nurse-practitioner in Baltimore, remembers an 85-year-old woman, living at home, who "stopped going out to dinner with friends; she would say she was too tired and didn't have the energy. She wasn't walking out to get her mail anymore. She was eating less and losing weight rapidly."
Her adult daughter became concerned and brought her mother to Resnick "and asked us to fix the problem," recalls Resnick, who chairs the board of the American Geriatrics Society.
But there often is no quick fix. Clinicians checked the woman for underlying disease — they found none — and adjusted her medications. They also urged the woman to increase her physical activity, Resnick says. "That's really the best way to manage frailty: Engage as much as you can; optimize what you can do. What's important is resilience.''
Similarly, Kaufman recalls "a wonderful gentleman'' in his 80s who had been doing quite well until his wife fell, broke her hip and had to enter a nursing home. The couple had been married 60 years. After she left, he began to slow down physically, and he stopped eating.
"He just gave up,'' Kaufman says. "There was no one specific thing. But within a few months, he died. What do you put on a death certificate? If it was a pediatric case, we'd say 'failure to thrive.' He died of frailty.''
An inflammatory problem?
Jeremy Walston, a geriatrician and molecular biologist who co-directs the Biology of Healthy Aging Program at Johns Hopkins University School of Medicine, believes that frailty may, in part, be related to the body's inability to regulate its normal inflammatory response. His research has found that frail people suffer from a constant low-grade inflammatory state.
"When something attacks the body, it sends out a number of inflammatory signals to fight an infection or heal a wound,'' says Walston, who also is principal investigator for Hopkins's Older Americans Independence Center. "In frailty, these pathways get turned on, and they don't get turned off." Such chronic inflammation can lead to weakening of skeletal muscles and the immune system.
Frail people also are less able to process glucose properly, he says, and they secrete more cortisol, a hormone that over time, as with chronic inflammation, also can damage skeletal muscles and the immune system.
Scientists don't yet understand how these findings relate to the more predictable changes associated with aging, or whether they are a cause — or a consequence — of frailty.
Researchers also
are studying the impact of moderate physical exercise in preventing the most powerful indicator of frailty: slow walking speed. An ongoing
study of 1,600 people between the ages of 70 and 89 is comparing the effects of a moderate-intensity walking and weightlifting to a program of health education only. The exercise group walks for 30 minutes several times a week and uses ankle weights to improve lower-body strength. The education group receives information on diet, managing medications and other health-related matters, but not about physical exercise.
A smaller, earlier phase of the study suggested that physical activity was key, with a 26-percent reduction in walking problems among those who worked out regularly.
"You don't have to go to an exercise program at the gym,'' Kaufman says. "Clean your house. Walk to the mailbox to get your mail, or work in your garden. The greatest common denominator of frailty is muscle loss and slowing of gait, and it's amazing what
physical exercise can do.''
Walston agrees. "Growing old may be inevitable, but growing frail is not,'' he says.
The author's most recent Op-Ed was "U.S. Military Prepares for Global Unrest Amid Climate Fears." This article is adapted from "Frailty is a Medical Condition, Not an Inevitable Result of Aging," which appeared in the Washington Post. The views expressed are those of the author and do not necessarily reflect the views of the publisher. This version of the article was originally published on LiveScience.
Stay Strong: Four Ways to Beat the Frailty Risk
A factor known as frailty can predict bigger health problems down the road. So how is frailty defined, and how can you stay healthy through your senior years? Here’s what Johns Hopkins experts want you to know.
Make Healthy Meals Easier
If weakness prevents you or a loved one from buying and preparing healthy foods, ask a family member for help. Or connect with local groups like Meals on Wheels or a senior center that offers healthy meals and transportation.
The spring in your step, the healthy foods on your plate and the optimistic feeling in your heart all help you feel great today. But did you know that nurturing these factors could also help you sidestep or even reverse frailty—the loss of strength, speed and energy that can whittle away at independence as a person ages?
An estimated 7 to 12 percent of Americans age 65 and older are considered frail. Risk rises with age—from one in 25 people between ages 65 and 74 to one in four of those older than age 84. That’s a concern, because frailty increases the risk of infections, illnesses that have to be treated in the hospital, falls and even disabilities. In a study of 594 older adults, Johns Hopkins researchers have found that frailty doubles the risk of surgical complications, lengthens hospital stays, and increases the odds of leaving independence behind (and moving to a nursing home or
assisted-living facility) after a surgical procedure by as much as twentyfold.
Pioneering research at Johns Hopkins is helping doctors and their patients spot frailty sooner, for better health outcomes. “If we understand the underlying biomedical processes that create frailty, we can develop better interventions—from medications to lifestyle changes,” says
Samuel Durso, M.D., director of geriatric medicine and gerontology at Johns Hopkins. “And fortunately, research already shows that some lifestyle steps can help.”
Identify frailty early.
You or a loved one may be considered frail if three or more of these criteria, developed by Johns Hopkins, apply to you:
You’re shrinking. You’ve unintentionally lost 10 or more pounds in the past year.
You feel weak. You have trouble standing without assistance or have reduced grip strength.
You feel exhausted. Everything you do takes a big effort, or you just can’t get going three or more days most weeks.
Your activity level is low. This includes formal exercise plus household chores and activities you do for fun.
You walk slowly. Your pace is considered slow if the time it takes you more than six or seven seconds to walk 15 feet.
Discuss frailty with your doctor if you have concerns. “It’s also important to keep chronic conditions like high blood pressure, cholesterol and diabetes under control,” Durso notes.
Be active most days of the week.
“One cause of frailty is the age-related loss of
muscle mass,” Durso explains. Research suggests that activities like walking and easy strength-training moves improve strength and reduce weakness – even in very old, frail adults. Every little bit helps, at any age.
Eat well.
Aim for three healthy meals a day that provide fruit, vegetables, protein, good fats,
whole grains and low-fat dairy products. In one study, people who followed this approach (also known as the
Mediterranean diet) faithfully were 74 percent less likely to become frail. Be sure to include enough muscle-nurturing protein. Women need about 46 grams per day, men about 56 grams—but many older people don’t get quite enough. Good sources include:
Low-fat milk (8 grams per 8 ounces)
Meat, fish or poultry (about 21 grams in 3 ounces)
Cooked dried beans (about 16 grams in a cup)
Yogurt (11 grams in 8 ounces of regular yogurt, 23 grams in 8 ounces of Greek yogurt)
Keep your mind active, your attitude optimistic.
Positive feelings were shown to translate into a lower risk of frailty in one study. “Staying socially connected with others and continuing to learn may also help,” Durso says. “Johns Hopkins research has found that those factors may explain why older volunteers who tutor in elementary schools sharpen their own thinking skills and improve their physical functioning too.”
Definitions
Assisted living: A place for adults to live who do not need full-time nursing care but do need help with everyday tasks, such as dressing, bathing, eating or using the bathroom. Residents often need help due to memory disorders, incontinence or mobility issues. Centers offer a homelike atmosphere, providing meals, housekeeping, laundry, recreational activities, transportation and assistance 24 hours a day.
Mediterranean diet: Traditional cuisine of countries bordering the Mediterranean Sea, shown to reduce the risk for heart disease, diabetes, some cancers and dementia. On the menu: Plenty of fruits, vegetables and legumes, along with olive oil, nuts, whole grains, seafood; moderate amounts of yogurt, cheese, poultry and eggs; small amounts of red meat and sweets; and wine, in moderation, with meals.
Muscle mass: Your muscles contract to power movements, and their mass refers to their size. The greater your muscle mass, the larger and denser your muscles are. The related term lean body mass is the weight of your muscles, bones, ligaments, tendons and internal organs.
Whole grains: Unlike refined grains, grains—such as whole wheat, brown rice and barley—that still have their fiber-rich outer shell, called the bran, and inner germ. It provides vitamins, minerals and good fats. Choosing whole grain side dishes, cereals, breads and more may lower the risk for heart disease, type 2 diabetes and cancer and improve digestion, too.
