Frailty in Older Adults Frailty is a multidimensional geriatric syndrome associated with physiologic decline, including sarcopenia, or loss of lean body mass.1 As a complex immune and neuroendocrine condition, frailty contributes to increased vulnerability in older adults and a decrease in physiologic reserves. Frailty has been characterized as the inability to respond to external stressors and is associated with adverse health outcomes, including an increased risks of falls, fractures, disability, and all-cause mortality in older adults.1 It is estimated that 15% of older adults in the United States, who are not living in a long-term care facility, are considered frail.2 Frailty is one of the key health indicators, frequently resulting in poor outcomes, hospitalizations, and higher mortality rates.2 Frailty can be the single-most important clinical intervention that nurse practitioners (NPs) can identify to improve the health of older adults. As the number of older adults increases, it is important for NPs to diagnose those at greatest risk of declining health and frailty. EPIDEMIOLOGY
Epidemiologic trends indicate that the growth in the number of adults 65 years old is unprecedented in the history of the US.3 This trend results from adults living longer due to advanced medical technology and the aging baby boomer generation. The number of Americans, age 65 living in the US in 2013 was 44.7 million, accounting for 14.1% of the total population.3 As the number of older adults increases, so will the incidence of frailty, placing a strain on the US health care system. DIAGNOSIS
To make the frailty diagnosis, health care providers should monitor older adults for major indicators, or markers, that reﬂect a change in health status. The 5 major markers of frailty are: low or declining level of physical activity; muscle weakness, including poor balance; slowed performance; fatigue or poor endurance; change in cognitive status; and weight loss.4 For an older adult to be considered frail, they need to have at least 3 of the 5 markers. www.npjournal.org
Frailty is associated with vulnerability when physical and psychological stressors are occurring. This becomes a vicious cycle, resulting in decline and debilitation, with the older adult becoming weaker over time. A loss of homeostasis may cause physical decline, including multiple comorbidities, resulting in an increased risk of mortality.4 Signals of systemic abnormalities in frailty include inﬂammation, weight loss, anemia, ﬂuctuating heart rate, low vitamin levels, and insulin resistance.4 As the number of systematic abnormalities increases, a synergistic effect occurs that accelerates the incidence of frailty.4 A frail older adult has little reserve to recover from multisystem disruptions. Inadequate nutritional intake, especially protein, contributes to a loss of muscle mass and disruption of coordination. A loss in muscle mass has an impact on physical activity level, including slowed motor performance. The disrupted motor performance hinders the ability to safely perform the activities of daily living.
DIAGNOSTIC TIPS Angela K. Wooton, PhD, FNP-C Frailty is a complex condition that places older persons at risk of poor outcomes, especially when the body is under stress. It is associated with declining health, complex clinical management, and increased health care costs.4 Early detection of frailty, in an aging population, may prevent or slow disability and improve the health of older adults. SCREENING AND ASSESSMENT
Routine screening includes monitoring for a decline in health status. Indicators, such as a drop in baseline weight or a change in mental status, signal the need for further investigation. The Journal for Nurse Practitioners - JNP
Screening for sarcopenia and inﬂammation is advisable using the following tests: interleukin-6; complete blood count with differential; albumin level; and C-reactive protein.4 Monitoring testosterone and insulinlike growth factor-1 levels may be predictors of loss off muscle mass. Both tests should be ordered when the provider or the patient report a loss of muscular strength. Thyroid studies and a urinalysis can be ordered to eliminate the more common diagnosis of hypothyroidism or urinary tract infection. A comprehensive metabolic proﬁle provides indicators of liver and kidney status. C-reactive protein and interleukin-6 test results are also associated with cognitive decline in older adults.4 Additional testing for vitamin B12 and vitamin D deﬁciencies can identify potential problems. If dementia is suspected, a heavy metal and rapid plasma reagin test is indicated. Last, declining levels of dehydroepiandrosterone sulfate may signal low levels of the pituitary hormones that regulate the production and secretion of adrenal hormones.4 Additional diagnostics may be warranted, depending on the initial testing results. INTERVENTIONS AND MANAGEMENT
Nutritional interventions may improve an older adult’s stamina and ability to complete activities of daily living.4 Exercise and balance interventions have been shown to improve outcomes of mobility and functional performance skills in frail older adults.4 Key management strategies of frailty include resistance and strengthening exercises supported by protein and nutritional supplementation. Intervening in times of additional stress may prevent
The Journal for Nurse Practitioners - JNP
frailty. Maintaining a level of physical activity is the cornerstone in the prevention of frailty. CONCLUSION
Falls are an independent predicator for frailty. The effects of underlying frailty are often the reasons an older adult has difﬁculty with balance and performing activities of daily living. Frailty can ultimately lead to loss of independence and deterioration in physical function, increasing the risk in sustaining a life-altering fall. Frailty is a marker for detecting adverse health issues. However, early detection and remedying the adverse effects at an early stage can improve mortality and morbidity in older adults. References 1. Tom SE, Adachi JD, Anderson FA Jr, et al. Frailty and fracture, disability and falls: a multiple country study from the global longitudinal study of osteoporosis in women. J Am Geriatr Soc. 2013;61(3):327-334. 2. Bandeen-Roche K, Seplaki CL, Huang J, et al. Frailty in older adults: a nationally representative proﬁle in the United States. J Gerontol A Biol Sci Med Sci. 2015;70(11):1427-1434. 3. US Census Bureau News: The Older Americans Month Facts for Feature. May 8, 2015. https://www.census.gov/newsroom/facts-forfeatures/2015/cb15-ff09.html. Accessed April 25, 2016. 4. Flaherty E, Resnick B, eds. GNRS Geriatric Nursing Review Syllabus: A Core Curriculum in Advanced Practice Geriatric Nursing. 4th ed. New York: American Geriatrics Society; 2014.
Angela K. Wooton, PhD, FNP-C, is a nurse practitioner and an assistant professor of graduate nursing at the University of Southern Indiana in Evansville. She can be reached at [email protected]
. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conﬂict of interest. Department Editor Mellisa Hall, DNP, AGPCNP-BC, who would like to hear your ideas for future columns, can be reached at [email protected]
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