The frailty syndrome in the “frail” healthcare systems
Matteo Cesari, MD, PhD is Chargé de Mission at the Gérontopôle of the Centre Hospitalier Universitaire de Toulouse, researcher at the INSERM UMR1027, and Professor at the Université de Toulouse III Paul Sabatier (Toulouse, France). He is Editor-in-Chief of the Journal of Frailty & Aging. He Tweets at @macesari
Our societies are ageing. The number of older people is steadily growing, threatening the sustainability of public services including healthcare. Age-related chronic and disabling conditions not only adversely influence older people’s quality of life, but also represent a burden for public health expenditures. It is a fact that something has to be done in order to prevent the (often irreversible) loss of physical function that occurs with advancing age. If we are to accomplish such an ambitious task, a major revision is needed in our approach to older people and, consequently, in the concept of geriatric medicine.
Today, a person aged 65 years or older is completely different from a person of the same age twenty years ago, from both a clinical and societal viewpoint. A significant number of individuals now reach the traditional threshold of 65 years of age in perfect health. It’s not unusual to see older people acting as caregivers of their parents or, sometimes, even their children. This means that the common criterion of “chronological age” to define a person as “old”, and thus identify a possible “geriatric patient”, is inadequate. This issue affects how we organise our healthcare systems. Several medical specialties are today engaged in a rethink about how to avoid possible “ageism” and better take into account the age-related conditions today affecting large part of their patients. If we are to avoid using chronological age, different criteria are needed which allow us to more objectively describe an individual’s biological state of vulnerability. Only through such an approach will it be possible to personalize care for older people and ensure the most effective distribution of resources.
One possibility for measuring the “biological age” of the older individual is offered by the so-called frailty condition. The concept of frailty in older persons has been extensively studied in geriatrics and gerontology over the last two decades. To translate the theoretical definition of frailty (i.e. a multi-systemic syndrome of increased vulnerability to stressors) into clinical practice, several models have been proposed. In particular, two have emerged over the others and are commonly adopted in clinics and research.
The first one was proposed by Fried and colleagues in 2001. The so-called frailty phenotype based on the evaluation of five defining criteria: involuntary weight loss, sedentary behavior, weakness, exhaustion, and slow gait speed. Subjects presenting three or more of these criteria are defined as frail. The other was developed by Rockwood and colleagues few years later and is called Frailty Index. It is simply calculated by dividing the number of clinical conditions presented by the individual into the total number of conditions listed in the instrument (up to 70 items). This score (ranging between 0 and 1) provides an objective estimate of the deficits accumulated by the patient. The higher is the score, the more compromised is the overall health status of the subject.
Both models are well validated and equally capable of predicting major negative health-related events. Unfortunately, although the frailty concept underlying their structures is quite different, the two instruments are too often considered as alternatives. In our contribution published in Age Ageing, we have tried to highlight what the frailty phenotype and the Frailty Index exactly measure and why they should be considered as complementary rather than interchangeable. Only through the in-depth understanding and correct use of available instruments, will we be able to develop the needed healthcare services to adequately face the ageing-related socio-demographical changes in our societies.