The Journey Starts Now

Wanted to share an interesting paper I was reading on frailty.

For many, 'frailty' is hard to define but we know it when we see it: The little old lady with a kyphotic back and tennis ball decorated walker, slowly traversing the crosswalk of a busy street, seemly in need of a 1950s boy scout to expediter her crossing before the walk sign expires. The old man who now begrudgingly accepts help from the neighbor to take out the trash because he just can't do it himself anymore. The great uncle that can't play with his great nephew because it is simply too difficult to get back up from the floor.

In an attempt to capture this state more formally, there are now several models that have formulated objective criterial for what frailty is. These are helpful guideposts as we will soon see. They also are helpful when exploring the physiology underlying the development of these criteria.

In this paper Chen, Mao, and Leng lay out what is known about the current state of frailty. They start with a great overview of frailty saying that, "Frailty is a common and important geriatric syndrome characterized by age-associated declines in physiologic reserve and function across multiorgan systems, leading to increased vulnerability for adverse health outcomes". They go on to describe the criteria as well as the proposed underlying physiology that drive the process. Definitely worth a read.

But, why are we talking about this here?

Understanding frailty becomes incredibly relevant to how we go about health. Frailty is the boogie man that not only heralds the coming of the grim reaper, but leads to an enormous degradation in the quality of life. By knowing how it comes, we can begin planning on ways to avoid it. Specifically, we can come up with discrete and actionable interventions that directly address both the outcomes as well as the underlying process. Again our mentality here is to build reserve and delay decline.

Let's look at the 5 criteria in the frailty model and how this helps to inform us:

1) Weakness

We know about anabolic resistance and about predictable muscle mass and strength declines over time. We also know that no matter your age you can train strength and power (power being generating strength over time). There are a myriad of studies showing how muscle mass and strength are directly related to all cause mortality and dementia. You can also see this with your own eyes by viewing older individuals. The starkness with which being physically weak limits one's freedom and independence is sobering.

No matter if you are 13, 40, or 85 we can do things in real time to directly battle this specific frailty criteria. In a 13 year old this could manifest as setting up intentional health routines around exercise, nutrition, and sleep; getting them on the right track early so it becomes the norm. In a 40 year old it could manifest as a deep discussion about triaging the duties on their very full docket, deciding which they need to sacrifice so that they can then replace it with time for healthier habits. In an 85 year old it might manifest as a very in depth evaluation of where they are starting from, what their functional goals are, and building confidence in them through education that they can make a meaningful change to their strength. In all cases we can map out one's current strength and predicted trajectory, then come up with a game plan to put them in the top 75%ile of their peer group, keeping them well above the 20%ile weakness cut off.

2) Slowness

Similar to the weakness criteria above, this is a 'use it or lose it' category. Many patients I have encountered in their 70s and beyond are fully aware of the potentially devastating consequences of a fall. In responsem, they load up on Calcium and Vitamin D supplements, they take their bisphosphonates, and they intentionally do everything 'very very slowly.'

I get it, be cautious stepping off curves and be careful about those hazardous area rugs that scream tripping hazards. But taking it slow might not be the right mentality. Instead, by intentionally evaluating and training movement, leaning in and increasing both proprioception, strength, and reaction time, patient's can regain the confidence of moving at normal speeds. The key is to be able to catch themselves mid-trip preventing the fall from occurring. By gaining well founded confidence in this ability, they regain meaningful quality of life through regained functional capacity.

3) Low level of physical activity

This as with the prior two criteria can be educated and trained. In addition to building stamina, strength, and better body awareness through focused and specific training, there are additional factors to consider.

Giving a patient a reason to be physically active is imperative. Perhaps this is a senior walking group that meets weekly, perhaps it is grandchildren or great-grandchildren to interact with, perhaps it is a neighbor that needs a bit more help, perhaps it is a volunteer position at the local library or the individual's church. It is a reason that gives them something to get out of bed and get out of the house to do. Getting to the core of this driving factor for staying active is essential. To authentically get to the 'why' to be physically active I find it best to explore the areas of social health, sexual health, and life philosophy. From these pillars comes well defined 'whys' deeply resonate with the patient.

4) Exhaustion

Again, hitting on the same points as before. Building reserve and delaying decline in cardiopulmonary function can be trained at any age. It starts as always with meeting the patient where they are and slowly building from there. This in addition to exploring underlying disease processes, hormonal health, and understanding specific organ by organ dysfunction. An absolutely essential part of getting a bit more pep in the step, and helping people in their golden years truly enjoy life.

5) Weight Loss

At the risk of repeating myself, again this is a criterial that can be focused on to build reserve and delay decline. Major modifiable factors that contribute to this in a big way are lean muscle mass retention, nutritional input, organ function preservation, and hormonal balance. As before all of these factors are able to be measured and have interventions that are shown to improve outcomes no matter the age.

The Pathophysiology

In addition to listing several of the criteria for frailty, the authors of the paper explore what might be driving these criteria. They make the claim that chronic inflammation is likely one of the drivers for the frailty phenotype. Great! We can measure, monitor, and reduce that too.

Let's keep in mind the adage that 'what gets measured get managed'. Let's make sure the things we know are coming down the line, the things we know we want to avoid get consciously measured so they can be consciously managed.

When you know exactly what is coming, you can prepare for it. This process of preparation needs to start happening now. I am conscious of this process not only in my own health decision, but I have started consciously thinking about this as I make decisions for my kids. It is never to early to start and never to late to integrate and keep going.

Chen X, Mao G, Leng SX. Frailty syndrome: an overview. Clin Interv Aging. 2014 Mar 19;9:433-41. doi: 10.2147/CIA.S45300. PMID: 24672230; PMCID: PMC3964027.

LINK to paper PDF