The New England Journal of MedicineFrailty in Older Adults

Frailty in Older Adults: A Complex Interplay of Biological Mechanisms and Clinical Manifestations

Frailty, a clinically identifiable state of diminished physiological reserve and increased vulnerability to adverse health outcomes, becomes more prevalent as populations age. This comprehensive review explores the definitions, biological underpinnings, measurement approaches, and clinical management strategies for frailty in older adults. The article emphasizes the importance of assessing frailty to predict outcomes, target interventions, and tailor clinical management, while highlighting the challenges in implementing effective frailty screening and management programs in routine care settings.

Key Points:

• Frailty prevalence ranges from 11% among those 50-59 years old to 51% among those 90 years or older in community-dwelling populations across 62 countries.
• Two predominant concepts of frailty exist: the Fried frailty phenotype (a syndrome) and frailty as a state of accumulated health deficits.
• Biological mechanisms of frailty include chronic inflammation, cellular senescence, mitochondrial dysfunction, and deregulated nutrient sensing.
• Frailty measurement tools range from brief screening instruments to comprehensive geriatric assessments.
• Exercise, nutritional supplementation, and comprehensive geriatric assessments have shown efficacy in reducing frailty and improving associated outcomes in clinical trials.
• The effectiveness of routine frailty screening in primary care and acute care hospital settings remains uncertain.
• Frailty screening before stressful treatments (eg, chemotherapy, surgery) has demonstrated benefits in improving outcomes and reducing complications.
• Management should focus on increasing physiological reserve and preventing or mitigating stressors.
• Frailty assessment should not be used to withhold potentially effective treatments but to facilitate patient-centered care.
• Evidence gaps exist in strategies for identifying frailty, choice of screening tools, and approaches to intervention in routine care.
• Future research directions include hybrid effectiveness-implementation studies and knowledge translation efforts to adapt and advance evidence in various clinical settings.

HCN Medical Memo
Frailty assessment and management offer a promising approach to improving care for older adults. By incorporating frailty evaluation into clinical practice, physicians can better predict outcomes, tailor interventions, and provide more personalized care. However, challenges remain in implementing effective frailty screening and management programs in routine care settings, highlighting the need for continued research and innovative approaches to translate evidence into practice.

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