Treating Frail Patients Requires 'Precision Gerontology'

An estimated 15% of Americans over age 65 years who aren't living in institutions are considered frail — a complex geriatric syndrome that raises the odds of disability, hospitalization, the need for nursing care, and death.

But while the word frailty may conjure images of wizened and weakened men and women, the clinical picture is far less clear.

Dr George Kuchel

"We've made a lot of progress in some ways, but still a lot of work to be done in others," said George A. Kuchel, MD, CM, the chair in Geriatrics and Gerontology and director of the UConn Center on Aging in Farmington, Connecticut.

"You have to be very careful about generalizations," Kuchel said during a presentation on frailty in the primary care setting at the 2022 American College of Physicians Internal Medicine meeting. "This is very important when you are thinking about managing it."

One of the key take-home messages, Kuchel said, "and one of the first things I learned as a geriatrics fellow, is that when you have seen one older person, all you have seen is one older person."

What this means is that while all people age, there is tremendous variance in how they age. "Some become quite frail and disabled and need to be in a nursing home, while some age gracefully and are living well," he said. "Most fall somewhere in-between."

The second major take-home is that frailty is multifactorial — a critical consideration when it comes to managing elderly patients.

"Unlike other conditions, there is no single medication, there is no one single thing you can do — it is really multifactorial," he said. "What it means is to match the components to target unique needs, and that is something that we are calling 'precision gerontology,' as opposed to precision medicine."

The definitions of frailty vary but can involve:

Increased vulnerability
Enhanced risk of declining function, disability, and death
Decline in functioning across multiple physiologic systems, accompanied by an increased vulnerability to stressors

Key features that clinicians should emphasize include multifactorial etiology with each risk factor contributing only modestly:

Multidimensional nature, with physical and psychosocial factors playing a part
Frailty represents an extreme consequence of the normal aging process
The process is dynamic, and individuals can fluctuate between frailty states

Diagnosing Frailty

Diagnosing frailty in the average clinical setting can be a challenge. Unlike other disorders, no single test or assessment tool exists for the condition. Most settings or patients, for example, do not even have the device to measure hand grip strength, Kuchel said. Other obstacles include a lack of time and reimbursement.

What it means is to match the components to target unique needs — and that is something that we are calling ‘precision gerontology,' as opposed to precision medicine. Dr George A. Kuchel

However, clinicians can quickly and easily assess patients for several warning signs. These include the presence of multimorbidity (>5 diseases), slow walking speed (<1 m/sec), inability to climb a flight of stairs, and/or walk a block or rise from chair five times with arms folded.

"These are simple questions that can be asked by a medical assistant or even over the phone ahead of time," he said.

Frailty and sarcopenia are closely linked but are not equivalent. As a result, dual-energy x-ray absorptiometry (DXA), which can measure both bone mineral density and muscle mass, is not a good assessment of frailty because muscle mass by itself is not necessarily tied to weakness. Instead, Kuchel said, measuring muscle function and quality is much more effective at identifying frail patients.

"Gait velocity is potentially the greatest single measure, and if there is one thing you should do with your patient, it is to check gait velocity," Kuchel said. Researchers at his facility are working on radio technology identification-based device that allows for measuring gait when a patient walks down the hallway.

"Measuring gait should be the sixth vital sign, and you need to have that information in front of you when working with older patients," he said. "We are working on integrating it into our system."

Managing Frailty

Although no single intervention for frailty exists, physical activity has been shown to delay its onset. Still, Kuchel said, clinicians can try a range of approaches, both biologic and social, to address the condition.

Assessing for and treating depression, for example, may help reduce frailty fatigue, as can stopping medications — including benzodiazepines, and corticosteroids — that might be worsening the condition. Another step is to check for low vitamin D levels and hypothyroidism, he said.

Some patients have unexplained anemia that could be corrected, as well as correcting basal and orthostatic hypotension, which can arise from overtreatment, Kuchel added.

People with HIV can experience accelerated aging, as can adults who were treated with chemotherapy and radiation as children. "We are also beginning to see some of this with long COVID, so there seems to be some overlap," he said.

Finally, socioeconomic considerations include the possibility of elder neglect and/or abuse, and the effects of poverty on nutrition and the ability to pay for needed medications.

The bottom line, Kuchel said, is that managing frailty is possible, but doing so effectively may require stops and starts.

"Correct what is correctable, such as nutrition, vitamin D, depression, and stopping offending meds," he said. "Match multicomponent interventions with deficits and interventions targeting healthcare systems will include better care coordination. A comprehensive geriatric assessment is important in the care of this geriatric syndrome.

Kuchel has disclosed no relevant financial relationships.

American College of Physicians Internal Medicine Meeting 2022: Frail Patients in Primary Care: I Know It When I See It, but Then What? Presented April 28, 2022

Roxanne Nelson is a registered nurse and an award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.

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