Frailty has been defined according to the bio-psycho social paradigm in coherence with its different dimensions (physical, psychological, social and economic). This definition was developed through a process of literature review and in-depth discussions with major stakeholders from the scientific community, policy makers and services providers.

Frailty

Population ageing is accelerating rapidly worldwide, from 461 million people aged over 65 years in 2004 to an estimated 2 billion people by 2050, which has profound implications for the planning and delivery of health and social care. The most problematic expression of population ageing is the clinical condition of frailty.

Frailty is often conceptualised by health care providers as a state of late life decline and extreme vulnerability, characterised by weakness and decreased physiological reserve contributing to an increased risk of falls, institutionalisation, disability, and death. Frailty develops as a consequence of age-related decline in many physiological systems, which collectively results in vulnerability to a sudden change in health status, triggered by minor stressor events.

While it is recognised that the term “frailty” captures the essence of age-related vulnerability and decline, no single clinical definition of frailty is universally agreed upon and translated into clinical practice.

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Biomedical and bio-psycho social paradigms

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Frailty is generally defined within two main paradigms: biomedical and bio-psycho social. According to the biomedical paradigm, frailty is defined as a “physiological syndrome characterised by reduction of functional reserves and resistance to ‘stressors’ due to a cumulative decline of physiological systems causing vulnerability and adverse events”.

The bio-psycho social paradigm on the other hand, defines frailty as “a dynamic state affecting individuals with losses through one or more functional domains (physical, psychological and social), increasing overall the risk of adverse outcomes”. This approach requires an overall holistic viewpoint of patients and their predicament by taking into account, the medical, environmental, educational, economical and psychological factors.

While frailty commonly refers to the biomedical dimension, taken in charge by health services, pre-frailty refers to the bio-psycho social dimension of this condition, implying an integrated preventive approach among health and social services.

Prevalence of frailty

The estimated prevalence of biomedical or physical frailty in the ageing population varies greatly due to the different criteria applied in defining frailty. A prevalence of frailty of 7.9% was found in the United States, 8.5% in Spain, 7% in France and 8.8% in Italy.

The cross-sectional analysis of data from the Survey of Health, Aging and Retirement in 10 European Countries (SHARE) allowed to estimate a global prevalence of frailty of 17% (including disability) in the population over 65. A higher frequency of frailty was identified in southern Europe (especially in Spain 27.3%, Italy 23.0%, Greece 14.7% and France 15.0%), than in Northern Europe (about 11.3% in Netherlands, 12.4% in Denmark and 12.1% in Germany).

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Selected references

Avila-Funes JA, Helmer C, Amieva H, et al. (2008) Frailty among community-dwelling elderly people in France: the three-city study. J Gerontol A Biol Sci Med Sci. Oct; 63(10):1089-96.

Clegg, A. et al. Frailty in elderly people (2013), Lancet 2 March, Volume 381, No 9868, 752-762

Sternberg, SA, et al. (2011) The identification of frailty: a systematic literature review. Journal of the American Geriatrics Society, Nov;59(11):2129-38

Fried, L. P. et al. (2004). Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 59(3), 255-263.

Cesari, M. et al. (2006) Frailty syndrome and skeletal muscle: results from the Invecchiare in Chianti study. The American Journal of Clinical Nutrition May; 83(5): 1142-8.

Jürschik, P. et al. (2010) Frailty criteria in the elderly: a pilot study (Spanish). Atención Primaria, Apr;43(4):190-6

Frailty and Multimorbidity

Over the last 20 years, research has progressively demonstrated the importance of the concurrence of multimorbidity, i.e. the co-occurrence of two or more chronic diseases, and frailty.

Chronic diseases are responsible for poor quality of life, poor functional capacity and represent the main cause of death in Europe, affecting more than 80% of people aged over 65. Moreover, multimorbidity is more frequently found in the ageing population and poses new challenges to the health services, in terms of professional’s skills, resources and organisational aspects.

Frailty and multimorbidity have been found in 46.2% of the population and there is a frequent overlapping with ADL and mobility- disability. Therefore, it has become extremely important to develop interventions aimed at the early detection, prevention and management of frailty.

Due to the complexity of the problem, frailty and multimorbidity need to be considered with a more holistic approach, requiring an integrated, multi-sectoral and multi-professional strategy, focusing on community based settings and primary care services. To develop methods to detect and measure frailty in routine clinical practice, and especially in primary care, utilising existing patient data records represents a current challenge, as well as to develop effective preventive and curative measures.

Selected references

World Health Organisation (2011), Global Report: noncommunicable diseases country profiles 2011

World Health Organisation (2011), Global status report on noncommunicable diseases 2010 – Description of the global burden of NCDS, their risk factors and determinants

Prados-Torres, A. et al. (2014), Multimorbidity patterns: a systematic review, Journal of Clinical Epidemiology, 67(3): 254-66  

Clegg, A. et al. (2013) Frailty in elderly people, Lancet 2 March, Volume 381, No 9868, 752-762

Fried, L. P. et al. (2004) Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care, Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 59(3): 255-263