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Frailty in the young and old – shared mechanisms?
European Geriatric Medicine 1 (2010) 171
Controversies in geriatric medicine
Frailty in the young and old – shared mechanisms?
Paediatric medicine and geriatric medicine share many common features. The patients share common characteristics – dependency, functional limitation, impaired homeostasis, impaired ability to express their problems and an increased susceptibility to the external socioeconomic and immediate physical environments. The clinical assessment is also similar – requiring the interpretation of non-specific symptoms in order to formulate a diagnosis, the need to take a collateral history and involve family members or other carers in decision making. They also share common ethical scenarios – for example, the absence or loss of autonomy when considering end of life discussions. It is interesting to note that the appropriateness of resource allocation at the end of life is most often discussed for very young, and very old patients; Zweifel et al.’s [1] seminal work identified that the cost of dying was expensive, irrespective of the patients’ age. Also noteworthy is how systems of care in each speciality mirror one another – paediatricians place great emphasis on community work, and geriatricians are increasingly returning to their historical roots in the community in order to deliver integrated care. Finally, both paediatrics and geriatrics suffer from an important therapeutic limitation – the absence of a robust literature on pharmacological treatments available for their respective patients. Aside from agerelated multiple comorbidities, the paediatric patient and the geriatric patient are indeed very similar. So, it is interesting then to read that there are apparently such differences in approaches to frailty and vulnerability. Typically, geriatricians equate frailty and vulnerability, as intimately related concepts. Is it helpful to distinguish these two concepts? In the medical literature, frailty may be described as a biological phenotype which predicts adverse events in older people, such as falls, fracture or death. Or it may be described as a clinical phenotype, in which these clinical syndromes, or ‘geriatric giants’, are already manifest. The distinction is rather dependent upon perspective. For geriatricians, the clinical phenotype will be of most interest – how best to identify the client group of interest and improve outcomes. From the epidemiological or public health perspective, the biological phenotype is useful as a population at risk (‘susceptible’), in whom intervention may be considered to prevent the more severe clinical manifestations. The biological
phenotype also lends itself to research into mechanisms, such as inflammation, that may be implicated in the pathogenesis. One view might be that the biological phenotype of frailty identifies a population susceptible to developing the clinical phenotype. This is where the concept of frailty, which might be applied to paediatric and geriatric patients equally, can be examined critically. The clinical phenotype is similar in both age groups, as described above. But the biological phenotypes are quite different. In older people, lifelong health and well-being are important, but equally so are cumulative comorbidities, and their impact on, for example, muscle mass and function. However, in the younger population, the biological frailty phenotype will be less relevant, as the clinical presentation will usually be related to a catastrophic single pathology or genetic disorder – the adult physiological frailty model is less relevant. Similar environmental factors, such as socioeconomic status, will no doubt impact upon both the young and old, as this determines nutrition, healthcare and other factors that influence survival. So, it might also be argued that both age groups are susceptible to developing frailty, and both may be vulnerable, but the path to frailty will be different. It is perhaps best that any shared understanding is derived mainly from the clinical realm, rather than by investigating shared mechanisms leading to physiological frailty. Conflict of interest statement Nothing declared. Reference [1] Zweifel P, Felder S, Meiers M. Ageing of population and health care expenditure: a red herring? Health Econ 1999;8(6):485–96.
S. Conroy University of Leicester School of Medicine, Room 540, Level 5, Clinical Sciences Building, P.O. Box 65, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom E-mail address: [email protected]
DOI of original article: 10.1016/j.eurger.2010.05.002 1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.05.009
Available online 15 June 2010
Controversies in geriatric medicine
Frailty in the young and old – shared mechanisms?
Paediatric medicine and geriatric medicine share many common features. The patients share common characteristics – dependency, functional limitation, impaired homeostasis, impaired ability to express their problems and an increased susceptibility to the external socioeconomic and immediate physical environments. The clinical assessment is also similar – requiring the interpretation of non-specific symptoms in order to formulate a diagnosis, the need to take a collateral history and involve family members or other carers in decision making. They also share common ethical scenarios – for example, the absence or loss of autonomy when considering end of life discussions. It is interesting to note that the appropriateness of resource allocation at the end of life is most often discussed for very young, and very old patients; Zweifel et al.’s [1] seminal work identified that the cost of dying was expensive, irrespective of the patients’ age. Also noteworthy is how systems of care in each speciality mirror one another – paediatricians place great emphasis on community work, and geriatricians are increasingly returning to their historical roots in the community in order to deliver integrated care. Finally, both paediatrics and geriatrics suffer from an important therapeutic limitation – the absence of a robust literature on pharmacological treatments available for their respective patients. Aside from agerelated multiple comorbidities, the paediatric patient and the geriatric patient are indeed very similar. So, it is interesting then to read that there are apparently such differences in approaches to frailty and vulnerability. Typically, geriatricians equate frailty and vulnerability, as intimately related concepts. Is it helpful to distinguish these two concepts? In the medical literature, frailty may be described as a biological phenotype which predicts adverse events in older people, such as falls, fracture or death. Or it may be described as a clinical phenotype, in which these clinical syndromes, or ‘geriatric giants’, are already manifest. The distinction is rather dependent upon perspective. For geriatricians, the clinical phenotype will be of most interest – how best to identify the client group of interest and improve outcomes. From the epidemiological or public health perspective, the biological phenotype is useful as a population at risk (‘susceptible’), in whom intervention may be considered to prevent the more severe clinical manifestations. The biological
phenotype also lends itself to research into mechanisms, such as inflammation, that may be implicated in the pathogenesis. One view might be that the biological phenotype of frailty identifies a population susceptible to developing the clinical phenotype. This is where the concept of frailty, which might be applied to paediatric and geriatric patients equally, can be examined critically. The clinical phenotype is similar in both age groups, as described above. But the biological phenotypes are quite different. In older people, lifelong health and well-being are important, but equally so are cumulative comorbidities, and their impact on, for example, muscle mass and function. However, in the younger population, the biological frailty phenotype will be less relevant, as the clinical presentation will usually be related to a catastrophic single pathology or genetic disorder – the adult physiological frailty model is less relevant. Similar environmental factors, such as socioeconomic status, will no doubt impact upon both the young and old, as this determines nutrition, healthcare and other factors that influence survival. So, it might also be argued that both age groups are susceptible to developing frailty, and both may be vulnerable, but the path to frailty will be different. It is perhaps best that any shared understanding is derived mainly from the clinical realm, rather than by investigating shared mechanisms leading to physiological frailty. Conflict of interest statement Nothing declared. Reference [1] Zweifel P, Felder S, Meiers M. Ageing of population and health care expenditure: a red herring? Health Econ 1999;8(6):485–96.
S. Conroy University of Leicester School of Medicine, Room 540, Level 5, Clinical Sciences Building, P.O. Box 65, Leicester Royal Infirmary, Leicester, LE2 7LX, United Kingdom E-mail address: [email protected]
DOI of original article: 10.1016/j.eurger.2010.05.002 1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.05.009
Available online 15 June 2010