Editorial article
Defining and understanding frailty
Definir y comprender la fragilidad
Beatriz Montero-Errasquín
, Alfonso J. Cruz-Jentoft
Corresponding author
Servicio de Geriatría, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
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Cruz-Jentoft" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Beatriz" "apellidos" => "Montero-Errasquín" "email" => array:1 [ 0 => "beatriz.montero@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Alfonso J." "apellidos" => "Cruz-Jentoft" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Geriatría, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Definir y comprender la fragilidad" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The term “frailty” began to appear in the medical literature in the 1950s, usually in relation to old age, to describe people with a serious illness or significant physical and mental impairment. These people are obviously at a very high risk of passing away or developing new medical issues. However, defining them as frail probably adds very little to their care, prognosis, or quality of life in terms of accurately characterizing their medical and functional problems.</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is therefore striking that research and publications on frailty have increased exponentially in the last two decades. Although this research was initially limited to the field of geriatrics, nowadays any specialist who treats elderly patients is familiar with the word frailty and it is beginning to be used routinely in daily clinical practice, in both primary care clinics and hospitals. However, frailty is also becoming a catch-all term for describing heterogeneous conditions based more on the clinician’s individual understanding than on the most modern scientific concepts, an issue that starts in university faculties<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and reaches the best experts in the field.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The main change that has taken place over the last two decades in our understanding of frailty has been a focus shift with respect to its purpose. Today there is a certain consensus to define frailty as a state of vulnerability of a person to both endogenous and exogenous stressors that is linked to negative health outcomes, such as functional impairment, dependence, institutionalization, hospitalization, greater health care costs, or morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is noteworthy that the ability of frailty to predict mortality has lost importance over its ability to predict disability before its onset.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Frailty is caused by a depletion of compensatory mechanisms and a loss of homeostasis secondary to a decline in multiple systems that leads to a decrease in the patients’ functional reserve.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Hence, there is a consensus that frailty is a multidimensional concept that includes not only biological or physical factors, but also psychological and social ones, all of which condition cognitive or social frailty.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> But perhaps the most relevant fact is that frailty is no longer synonymous with severe disability necessarily associated with old age and, therefore, usually irreversible, but rather a dynamic state that can be reversible either spontaneously or following an intervention.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The problem arises when the concept of frailty is brought into clinical practice, as one must determine which of the many existing definitions should be used in each clinical context. A review of the literature reveals that many diagnostic criteria are capable of predicting negative health outcomes in the elderly and are consequently useful in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Before answering this question, to understand the extensive literature available on frailty, it must be understood that there are currently at least two major schools of thought that use different approaches for measuring frailty.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A first approach is based on measuring the number of deficiencies accumulated by a given person and summarizing them in a frailty index (ratio between the number of deficiencies and the number of measurements) with scores ranging from 0 (no deficiencies) to 1 (deficiencies in all studied aspects), although considering that the person passes away with a score above 0.7 points. This approach, attributed to a Canadian researcher, Ken Rockwood,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> assesses frailty from a multidimensional prism closely related to aging and including a significant number of diseases, symptoms, disabilities, or abnormal laboratory values in the index (a minimum of 30, although the original contained 70 items), which can be automated to be extracted from clinical databases. It is based on a prior comprehensive assessment of the person and is particularly useful for its retrospective determination, although of less value in routine clinical practice or as a screening method for frailty.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A second approach, which is currently more popular in our setting, is based on the determination of a frailty phenotype and was initially proposed by Linda Fried using data from the Cardiovascular Health Study carried out in the USA.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> This phenotype uses five precisely defined features: involuntary weight loss, muscle weakness, slow walking speed, fatigue, and sedentarism to classify the person as robust, pre-frail (one or two criteria), or frail (three or more criteria). This definition is unidimensional (measuring physical frailty only) but simple to understand, and has been shown to be a powerful predictor of the risk of falls, incident disability, hospitalization, and death. Although it is used routinely in research, it is time-consuming and requires certain degree of training to obtain each of the measurements. Along the same lines of using a phenotype, Rockwood proposed another measure of frailty known as the Clinical Frailty Scale (CFS)<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> based on the clinician’s clinical judgment, who rates the patient on a scale of 1–7 (later refined to a scale of 1–9), from very healthy to terminally ill. This scale predicts a good number of health outcomes, correlates well with other frailty scales,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and proved particularly useful from a clinical standpoint during the coronavirus disease of 2019 (COVID-19) pandemic.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However, it may be arguable whether this constitutes a measure of frailty or rather more of a general measure of the patients’ overall clinical and functional status.</p><p id="par0035" class="elsevierStylePara elsevierViewall">To make things easier outside research settings, several dozen frailty screening scales have been proposed,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> with extremely variable characteristics in terms of the number of domains explored, the time required to complete them, and even the setting in which they are validated. The most recent international consensus on frailty recommends that opportunistic screening tests with a validated instrument should be offered to all people over 65 years of age.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The instruments proposed include the CFS, the Edmonton scale, and the FRAIL questionnaire.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The latter is probably the simplest one to use, as it is based on five questions on fatigue, endurance, gait, presence of certain comorbidities, and weight loss, without the need for performing physical examinations or laboratory tests. It is scored from 0 to 5 and classifies the patient as robust (0 points), pre-frail (1 or 2 points), or frail (3–5 points).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Given the complexity of the assessment and diagnosis of frailty, which is currently based on a clinical and geriatric assessment, in addition to the limitations and inconsistencies that can be caused by the different definitions and diagnostic criteria applied, interest in identifying biomarkers of frailty is growing in recent years.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Biomarkers related to genetic and metabolomic aspects, growth factors, hormones, inflammation, or oxidative metabolism have been studied, but none have been identified thus far and it seems likely that a biomarkers panel will be required to accurately characterize frailty.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In any case, clinicians should ask themselves the following question: what good does it do my patient if I diagnose their frailty status? The obvious answer is that frailty is an excellent predictor of both functional and vital prognosis, as well as of the use of health and social resources. Detecting frailty allows to guide patients on their prognosis and, therefore, to make better decisions when trying to choose a treatment indication, especially in the case of very aggressive ones. This approach is already being used in the selection of cancer treatments, the indication for certain surgeries or procedures (such as percutaneous aortic valve implantation), or the decision whether or not to initiate dialysis. The aim is never to discriminate, but rather to adapt these treatments to the patients’ needs.</p><p id="par0050" class="elsevierStylePara elsevierViewall">But what is even more important is to try to reverse frailty or prevent its consequences. A comprehensive geriatric assessment combined with interventions aimed at addressing reversible factors (uncontrolled diseases, poor oral health, polypharmacy, sarcopenia, malnutrition, depression, anemia, hypothyroidism, or others) can improve the patients’ frailty state and prognosis.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> On the other hand, the latest clinical guidelines recommend treating frail or pre-frail patients with a multicomponent exercise program including exercises to improve muscle strength and a nutritional intervention designed to increase the patients’ calorie and protein intake.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,20</span></a> The exercise prescription must be personalized, as if it were a drug, detailing the type of exercise, together with its duration and frequency, as well as dynamic, enabling its modification according to the objectives to be achieved and the patients’ own preferences. The results of the first randomized clinical trial using exercise and nutrition therapy in people with sarcopenia and frailty to prevent disability will be published in the coming months, and these may provide guidance on how to use these treatments accordingly.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Frailty, understood as vulnerability, is a concept that has appeared to stay and is going to impose itself in clinical practice as a fundamental tool for the optimal treatment of elderly patients. Any clinician treating these patients, from primary care physicians<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> to specialists treating the most complex problems, must be able to identify frail patients and implement interventions that treat, reverse, or prevent frailty and the cascade of negative events that it is associated with.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Montero-Errasquín B, Cruz-Jentoft AJ. Definir y comprender la fragilidad. Med Clin (Barc). 2021;157:438–439.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "What is meant by “frailty” in undergraduate medical education? A national survey of UK medical schools" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Winter" 1 => "M. Al-Jawad" 2 => "J. Wright" 3 => "D. Shrewsbury" 4 => "H. Van Marwijk" 5 => "H. 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