Advertisement

Should Frailty Include Multidimensional and Dynamic Factors?

  • Darryl B. RolfsonEmail author
Chapter

Abstract

The models and measures for frailty are multiple, and their relationships are complex. A dichotomous view frames frailty models as a heightened state of vulnerability (i.e., deficit accumulation) or as a physiologic syndrome (i.e., frailty phenotype). However, these two models are insufficient to explain many aspects of frailty. Other constructs for frailty capture the multidimensional, functional, and dynamic aspects of frailty. Geriatric syndromes have these features and may be a more authentic phenotype. An integrated view of frailty that resists unnecessary reduction in definition invites researchers and clinicians to employ a family of frailty measures in a coordinated way.

Frailty measures can be grouped into the frailty phenotype, biological markers, the frailty index, judgment-based measures, self-report measures, performance-based measures, and multidimensional measures. Selection of measures for a context could be based on test characteristics (diagnostic test accuracy, reliability, content and criterion validity, and sensitivity to change), intended use (risk modelling, outcome measure, research or opportunistic clinical use, policy), practical considerations (need for special equipment, administration time, need for prior training, need for a previously prepopulated database), interpretability (ability to grade severity, define dimensions, or detect dynamic changes), and operator training.

Implementation efforts should focus on the needs of citizens, policy-makers, clinicians, and researchers within their own contexts. If this is true, then frailty must include multidimensional and dynamic factors.

Keywords

Frailty Multidimensional Dynamic Models Measures Function Geriatric syndrome Implementation 

References

  1. 1.
    Hogan DB, MacKnight C, Bergman H. Models, definitions, and criteria of frailty. Aging Clin Exp Res. 2003;15(3 Suppl):1–29.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004;59(3):255–63.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Rockwood K, Hogan DB, MacKnight C. Conceptualisation and measurement of frailty in elderly people. Drugs Aging. 2000;17(4):295–302.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Mitnitski AB, Mogilner AJ, MacKnight C, Rockwood K. The mortality rate as a function of accumulated deficits in a frailty index. Mech Ageing Dev. 2002;123(11):1457–60.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Kulminski AM, Ukraintseva SV, Kulminskaya IV, Arbeev KG, Land K, Yashin AI. Cumulative deficits better characterize susceptibility to death in elderly people than phenotypic frailty: lessons from the Cardiovascular Health Study. J Am Geriatr Soc. 2008;56(5):898–903.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Rodríguez-Mañas L, Féart C, Mann G, Viña J, Chatterji S, Chodzko-Zajko W, et al. Searching for an operational definition of frailty: a Delphi method based consensus statement. The frailty operative definition-consensus conference project. J Gerontol A Biol Sci Med Sci. 2013;68(1):62–7.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Buta B, Leder D, Miller R, Schoenborn NL, Green AR, Varadhan R. The use of figurative language to describe frailty in older adults. J Frailty Aging. 2018;7(2):127–33.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Warmoth K, Lang IA, Phoenix C, Abraham C, Andrew MK, Hubbard RE, et al. ‘Thinking you’re old and frail’: a qualitative study of frailty in older adults. Ageing Soc. 2016;36(7):1483–500.CrossRefGoogle Scholar
  10. 10.
    Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):1487–92.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Soong J, Poots A, Scott S, Donald K, Woodcock T, Lovett D, et al. Quantifying the prevalence of frailty in English hospitals. BMJ Open. 2015;5(1):e008456.Google Scholar
  12. 12.
    Joosten E, Demuynck M, Detroyer E, Milisen K. Prevalence of frailty and its ability to predict in hospital delirium, falls, and 6-month mortality in hospitalized older patients. BMC Geriatr. 2014;14(1):1.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Rockwood K, Howlett SE, MacKnight C, Beattie BL, Bergman H, Hebert R, et al. Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian study of health and aging. J Gerontol A Biol Sci Med Sci. 2004;59(12):1310–7.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Kim DH, Kim CA, Placide S, Lipsitz LA, Marcantonio ER. Preoperative frailty assessment and outcomes at 6 months or later in older adults undergoing cardiac surgical procedures: a systematic review. Ann Intern Med. 2016;165(9):650–60.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Carpenter CR, Shelton E, Fowler S, Suffoletto B, Platts-Mills TF, Rothman RE, et al. Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis. Acad Emerg Med. 2015;22(1):1–21.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet (London, England). 2013;381(9868):752–62.CrossRefGoogle Scholar
  17. 17.
    Cesari M, Prince M, Thiyagarajan JA, De Carvalho IA, Bernabei R, Chan P, et al. Frailty: an emerging public health priority. J Am Med Dir Assoc. 2016;17(3):188–92.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Gill TM, Gahbauer EA, Han L, Allore HG. Trajectories of disability in the last year of life. N Engl J Med. 2010;362(13):1173–80.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60(8):646–9.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Theou O, Cann L, Blodgett J, Wallace LM, Brothers TD, Rockwood K. Modifications to the frailty phenotype criteria: systematic review of the current literature and investigation of 262 frailty phenotypes in the Survey of Health, Ageing, and Retirement in Europe. Ageing Res Rev. 2015;21:78–94.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Lang PO, Michel JP, Zekry D. Frailty syndrome: a transitional state in a dynamic process. Gerontology. 2009;55(5):539–49.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Xue QL. The frailty syndrome: definition and natural history. Clin Geriatr Med. 2011;27(1):1–15.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Howlett SE, Rockwood MR, Mitnitski A, Rockwood K. Standard laboratory tests to identify older adults at increased risk of death. BMC Med. 2014;12:171.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Soong J, Poots AJ, Scott S, Donald K, Bell D. Developing and validating a risk prediction model for acute care based on frailty syndromes. BMJ Open. 2015;5(1):e008457.Google Scholar
  25. 25.
    Ahmed N, Mandel R, Fain MJ. Frailty: an emerging geriatric syndrome. Am J Med. 2007;120(9):748–53.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Alexa ID, Ilie AC, Morosanu A, Voica A. Approaching frailty as the new geriatric syndrome. Rev Med Chir Soc Med Nat Iasi. 2013;117(3):680–5.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Chen LK, Hwang AC, Liu LK, Lee WJ, Peng LN. Frailty is a geriatric syndrome characterized by multiple impairments: a comprehensive approach is needed. J Frailty Aging. 2016;5(4):208–13.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Kaufman SR. The social construction of frailty: an anthropological perspective. J Aging Stud. 1994;8(1):45–58.CrossRefGoogle Scholar
  29. 29.
    Fried LP. Conference on the physiologic basis of frailty. April 28, 1992, Baltimore, Maryland, U.S.A. Introduction. Aging (Milano). 1992;4(3):251–2.Google Scholar
  30. 30.
    Keevil VL, Romero-Ortuno R. Ageing well: a review of sarcopenia and frailty. Proc Nutr Soc. 2015;74(4):337–47.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Fried LP, Hadley EC, Walston JD, Newman AB, Guralnik JM, Studenski S, et al. From bedside to bench: research agenda for frailty. Sci Aging Knowledge Environ. 2005;2005(31):pe24.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Vina J, Tarazona-Santabalbina FJ, Perez-Ros P, Martinez-Arnau FM, Borras C, Olaso-Gonzalez G, et al. Biology of frailty: modulation of ageing genes and its importance to prevent age-associated loss of function. Mol Asp Med. 2016;50:88–108.CrossRefGoogle Scholar
  33. 33.
    Bouillon K, Kivimaki M, Hamer M, Sabia S, Fransson EI, Singh-Manoux A, et al. Measures of frailty in population-based studies: an overview. BMC Geriatr. 2013;13(1):64.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Lahousse L, Maes B, Ziere G, Loth DW, Verlinden VJ, Zillikens MC, et al. Adverse outcomes of frailty in the elderly: the Rotterdam Study. Eur J Epidemiol. 2014;29(6):419–27.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Shamliyan T, Talley KM, Ramakrishnan R, Kane RL. Association of frailty with survival: a systematic literature review. Ageing Res Rev. 2013;12(2):719–36.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Kiely DK, Cupples LA, Lipsitz LA. Validation and comparison of two frailty indexes: the MOBILIZE Boston Study. J Am Geriatr Soc. 2009;57(9):1532–9.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Jones DM, Song X, Rockwood K. Operationalizing a frailty index from a standardized comprehensive geriatric assessment. J Am Geriatr Soc. 2004;52(11):1929–33.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62(7):722–7.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr. 2008;8:24.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Drubbel I, de Wit NJ, Bleijenberg N, Eijkemans RJ, Schuurmans MJ, Numans ME. Prediction of adverse health outcomes in older people using a frailty index based on routine primary care data. J Gerontol A Biol Sci Med Sci. 2013;68(3):301–8.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Hoover M, Rotermann M, Sanmartin C, Bernier J. Validation of an index to estimate the prevalence of frailty among community-dwelling seniors. Health Rep. 2013;24(9):10–7.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Jones D, Song X, Mitnitski A, Rockwood K. Evaluation of a frailty index based on a comprehensive geriatric assessment in a population based study of elderly Canadians. Aging Clin Exp Res. 2005;17(6):465–71.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Clegg A, Bates C, Young J, Ryan R, Nichols L, Ann Teale E, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing. 2016;45(3):353–60.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Hominick K, McLeod V, Rockwood K. Characteristics of older adults admitted to hospital versus those discharged home, in emergency department patients referred to internal medicine. Can Geriatr J. 2016;19(1):9–14.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Theou O, Park GH, Garm A, Song X, Clarke B, Rockwood K. Reversing frailty levels in primary care using the CARES model. Can Geriatr J. 2017;20(3):105–11.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Vetrano DL, Palmer K, Marengoni A, Marzetti E, Lattanzio F, Roller-Wirnsberger R, et al. Frailty and multimorbidity: a systematic review and meta-analysis. J Gerontol Biol Sci Med Sci. 2019;74(5):659–66.Google Scholar
  47. 47.
    St John PD, Montgomery PR, Tyas SL. Social position and frailty. Can J Aging. 2013;32(3):250–9.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Woo J, Goggins W, Sham A, Ho SC. Social determinants of frailty. Gerontology. 2005;51(6):402–8.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Theou O, Brothers TD, Rockwood MR, Haardt D, Mitnitski A, Rockwood K. Exploring the relationship between national economic indicators and relative fitness and frailty in middle-aged and older Europeans. Age Ageing. 2013;42(5):614–9.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Peek MK, Howrey BT, Ternent RS, Ray LA, Ottenbacher KJ. Social support, stressors, and frailty among older Mexican American adults. J Gerontol B Psychol Sci Soc Sci. 2012;67(6):755–64.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Andrew MK, Keefe JM. Social vulnerability from a social ecology perspective: a cohort study of older adults from the National Population Health Survey of Canada. BMC Geriatr. 2014;14:90.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Rolfson D. Successful aging and frailty: a systematic review. Geriatrics (Basel). 2018;3(4):79.CrossRefGoogle Scholar
  53. 53.
    Beard JR, Officer A, de Carvalho IA, Sadana R, Pot AM, Michel JP, et al. The World report on ageing and health: a policy framework for healthy ageing. Lancet. 2016;387(10033):2145–54.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Cesari M, Araujo de Carvalho I, Amuthavalli Thiyagarajan J, Cooper C, Martin FC, Reginster JY, et al. Evidence for the domains supporting the construct of intrinsic capacity. J Gerontol A Biol Sci Med Sci. 2018;73(12):1653.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Campbell AJ, Buchner DM. Unstable disability and the fluctuations of frailty. Age Ageing. 1997;26(4):315–8.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Theou O, Brothers TD, Mitnitski A, Rockwood K. Operationalization of frailty using eight commonly used scales and comparison of their ability to predict all-cause mortality. J Am Geriatr Soc. 2013;61(9):1537–51.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ = journal de l’Association medicale canadienne. 2005;173(5):489–95.PubMedCrossRefPubMedCentralGoogle Scholar
  58. 58.
    Wallis SJ, Wall J, Biram RW, Romero-Ortuno R. Association of the clinical frailty scale with hospital outcomes. QJM. 2015;108(12):943–9.PubMedCrossRefPubMedCentralGoogle Scholar
  59. 59.
    Afilalo J, Eisenberg MJ, Morin JF, Bergman H, Monette J, Noiseux N, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol. 2010;56(20):1668–76.PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Studenski S, Perera S, Patel K, Rosano C, Faulkner K, Inzitari M, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50–8.PubMedPubMedCentralCrossRefGoogle Scholar
  61. 61.
    Sepehri A, Beggs T, Hassan A, Rigatto C, Shaw-Daigle C, Tangri N, et al. The impact of frailty on outcomes after cardiac surgery: a systematic review. J Thorac Cardiovasc Surg. 2014;148(6):3110–7.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Handforth C, Clegg A, Young C, Simpkins S, Seymour MT, Selby PJ, et al. The prevalence and outcomes of frailty in older cancer patients: a systematic review. Ann Oncol. 2015;26(6):1091–101.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Jha SR, Ha HS, Hickman LD, Hannu M, Davidson PM, Macdonald PS, et al. Frailty in advanced heart failure: a systematic review. Heart Fail Rev. 2015;20(5):553–60.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Muscedere J, Waters B, Varambally A, Bagshaw SM, Boyd JG, Maslove D, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Med. 2017;43(8):1105–22.PubMedPubMedCentralCrossRefGoogle Scholar
  65. 65.
    Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275(11):852–7.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157–65.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Jarrett PG, Rockwood K, Carver D, Stolee P, Cosway S. Illness presentation in elderly patients. Arch Intern Med. 1995;155(10):1060–4.PubMedCrossRefPubMedCentralGoogle Scholar
  68. 68.
    Piechocinska B. Physics from wholeness: dynamical totality as a conceptual foundation for physical theories: Acta Universitatis Upsaliensis; 2005.Google Scholar
  69. 69.
    Kuchel GA. Frailty and resilience as outcome measures in clinical trials and geriatric care: are we getting any closer? J Am Geriatr Soc. 2018;66(8):1451–4.PubMedPubMedCentralCrossRefGoogle Scholar
  70. 70.
    Clegg A, Rogers L, Young J. Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review. Age Ageing. 2015;44(1):148–52.PubMedCrossRefPubMedCentralGoogle Scholar
  71. 71.
    de Vries NM, Staal JB, van Ravensberg CD, Hobbelen JS, Olde Rikkert MG, Nijhuis-van der Sanden MW. Outcome instruments to measure frailty: a systematic review. Ageing Res Rev. 2011;10(1):104–14.PubMedCrossRefPubMedCentralGoogle Scholar
  72. 72.
    Sternberg SA, Wershof Schwartz A, Karunananthan S, Bergman H, Mark Clarfield A. The identification of frailty: a systematic literature review. J Am Geriatr Soc. 2011;59(11):2129–38.PubMedCrossRefPubMedCentralGoogle Scholar
  73. 73.
    Hogan DB, Maxwell CJ, Afilalo J, Arora RC, Bagshaw SM, Basran J, et al. A scoping review of frailty and acute care in middle-aged and older individuals with recommendations for future research. Can Geriatr J. 2017;20(1):22–37.PubMedPubMedCentralCrossRefGoogle Scholar
  74. 74.
    Abbasi M, Rolfson D, Khera AS, Dabravolskaj J, Dent E, Xia L. Identification and management of frailty in the primary care setting. CMAJ = journal de l’Association medicale canadienne. 2018;190(38):E1134–e40.PubMedCrossRefPubMedCentralGoogle Scholar
  75. 75.
    Rolfson DB, Heckman GA, Bagshaw SM, Robertson D, Hirdes JP. Implementing frailty measures in the Canadian healthcare system. J Frailty Aging. 2018;7(4):208–16.PubMedPubMedCentralGoogle Scholar
  76. 76.
    Cawthon PM, Marshall LM, Michael Y, Dam TT, Ensrud KE, Barrett-Connor E, et al. Frailty in older men: prevalence, progression, and relationship with mortality. J Am Geriatr Soc. 2007;55(8):1216–23.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Raîche M, Hébert R, Dubois MF, and the PRISMA partners. User guide for the PRISMA-7 questionnaire to identify elderly people with severe loss of autonomy. In: Integrated service delivery to ensure persons’ functional autonomy. Quebec: Edisem. p. 147–65.Google Scholar
  78. 78.
    Gobbens RJ, van Assen MA, Luijkx KG, Wijnen-Sponselee MT, Schols JM. The Tilburg Frailty Indicator: psychometric properties. J Am Med Dir Assoc. 2010;11(5):344–55.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012;16(7):601–8.PubMedPubMedCentralCrossRefGoogle Scholar
  80. 80.
    Cesari M. Role of gait speed in the assessment of older patients. JAMA. 2011;305(1):93–4.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Division of Geriatric Medicine, Department of MedicineUniversity of AlbertaEdmontonCanada

Personalised recommendations