Monday, 25 July 2016

Frail, cracked or broken?

Marco Inzitari

The concept of frailty historically has been the object of a lot of debate among those who work in the field of elderly health, with differences between epidemiological and clinical outlook.


For geriatricians the frail have for a long time been people with multiple health problems and often with an already advanced disability, such as those that can be found in hospitals or nursing homes. Epidemiological Revolution introduced by Linda Fried, a most prominent geriatrician and epidemiologist that I have already quoted in the post "Thinking differently in healthy aging", changed the paradigm in early 2000.

In plain language, she indicated as "frail" something at risk of breaking, not already "broken", as in the case of people with advanced disabilities that we mentioned. So a frail person, in this view, is a person with apparent good health, and even without a disability, which has reduced physiological reserves of different organs and systems that makes them particularly susceptible to descend towards disability in case of injuries of a different nature (clinical, such as illness, or social, as a widow, etc). Detection of frailty in this sense is mainly based on measures of physical or cognitive performance, with a clear objective of prevention, since it is proven that the frailty is reversible and targeted interventions (exercise, nutrition, geriatric assessment) can prevent disability.


However, from the outset different epidemiological and clinical research voices have tried to reconcile the view of the frailty of a glass jar that is intact but very delicate with the glass jar that already is cracked, as a continuous or a "spectrum of fraily" with different nuances from the pre-disability to advanced disability (Whitson HE et al, J Gerontol a Biol Sci Med Sci 2007) or as two sides of the same coin (Cesari M et al, Age and Ageing 2013). Two recent reviews in the Lancet (signed by Clegg A 2013 and the Spanish Rodriguez-Mañas, this month) again come to focus on the concept of clinical frailty or as to say the concept of the cracked jar. In practice, they say, the frailty has great value because it indicates a state of greater reversibility when it comes to disability in people with relatively good health, on the one hand, and, on the other hand, in elderly patients has more predictive power over the chronic disease (including mortality prediction).

Goes on breaking

But the frailty clinical detection, based substantially on appreciating an accumulation of preclinical and clinical aspects of deficits and disabilities through a comprehensive assessment (Rockwood model) makes us wonder: what's the point? In other words, how can it help us in day to day life? In fact there’s still no single operational definition of frailty nor much evidence on interventions in frail patients in the clinical setting. In a recent publication in the European Journal of Geriatric Medicine, where I have been fortunate to participate as co-author, my friend Jordi Amblàs, geriatrician at the Hospital de la Santa Creu de Vic, proposes to apply the concept of frailty even in the management of the end of life phase.

Specifically, he proposes that: 1) the frailty, reflected by accumulated deficits in overall geriatric assessment along with 2) the seriousness of the main pathology and 3) the typical progression of disease (cancer disease vs chronic medical disease vs dementia) constitute the pillars of diagnosis of patient's condition at the end of life; and that the decision is based on 1) the diagnosis of combined situation 2) the preferences and needs of the patient within a framework of shared decision making. In future studies, the practical impact of this type of approach should be evaluated.

In short, from a semantic point of view what gives meaning to this continuum of frailty is the expression of the risk of rapid evolution towards worsening. And above all, as we see, the concept of fragility acquires a sense that is quite practical as a base for interventions in elderly people, whether directed to carefully manage a delicate glass jar, to preserve a cracked one or to glue together the glas of jar that is already breaking but is still full of history and character.

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