Frailty, thy name is old age
Recently I watched a video of Sir Sean Connery who became famous for his role as James Bond. Unlike in bygone days, he was slow and dependent on a caregiver for mobility. Most of my rheumatology patients are slow. Some call them the “old and frail”.
Age is the number of years lived but what is being frail? Why do some 80-year-olds remain agile, youthful and strong and why do some slow down even at an “early” age of 50? Is there a miracle cure for us to remain youthful? Are there any tests to determine how frail you are?
What is being frail?
Imagine an old man struggling to get up from a seated position. If the seats do not have arm-rests the task becomes much more difficult. Walking even a few feet is tough. The arm and leg movements are slow. Turning around takes a couple of seconds. Quick reflexes are not seen. Sadly, if that person trips, he is bound to suffer injury as to prevent a fall, rapid responses using arms and feet are needed. Strangely even patients without any sort of joint disease / joint pain become frail as well.
As joint specialists/rheumatologists, we notice how frail a person is. This is because of some of the manoeuvres we ask the patient to do. In joint disease examination, I insist that the patient should get up from the seat, move towards and get on the examination bed. Careful observation of how he/she performs these tasks itself is sufficient for us to gather plenty of evidence. But mobility is just one out of many factors that we check in the “Frail index”.
Frailty is now considered as a medical condition with multiple causes and contributors.This is characterised by diminished strength, endurance, and reduced physiologic function of the body. True to its definition frail patients suffer from lack of strength. Even if strength is adequate, endurance matters a lot in this age category. According to well proven research, frailty increases the chances of an individual becoming dependent on others. And unfortunately it shortens the life span as well.
How frail are you?
There are ways to measure how frail you are. A test that incorporates your cognitive skills, how rapidly you get up from a chair; walk; turn around; get back; sit down and a few other parameters is called Frail Index. Based on the score people can be categorized with mild, moderate or severe frailty. The higher the score, the worse the outcome is in terms of lifespan, risk of falls, risk of fractures and also other diseases like heart trouble, strokes etc. Some tests check weakness as measured by low grip strength, slowness by slowed walking speed, low level of physical activity, low energy or self-reported exhaustion, and unintentional weight loss to determine frailty.
Are there ways to at least partially correct this? To understand all this, we need to know why people become frail.
Reasons for being frail
No exact reason has been discovered as the cause for being frail. Scientists think there could be a multitude of causes of which genetics, lifestyle, diseases and the environment might play a key role in causing this “slowness”. Our own immune system which combats infection might cause what we call long term inflammation in certain organs. At the end, the muscles, skeleton, heart, vessels and the blood stream are affected causing frailty.
“Sarcopenia” is lack of muscle. From the age of 20 till 90 more than 50 percent of our muscle is lost/thinned out. This is the reason why the elderly, appear thin and “wasted”. We believe that sarcopenia is also a cause for being frail.
Another reason is lack of sex hormones – oestrogen in females and testosterone in males. Rapid decline of sex hormones leads to increased frailty. Lack of Vitamin D also could also be a factor, as is obesity in midlife.
Why are we concerned about frailty?
Being frail has numerous disadvantages. Frail elderly are unfortunately considered by some as a burden to the relatives/caregivers. Full time attention is needed for some. They are at a risk of falls which are a disaster as they result in fractures or head injuries that can lessen one’s lifespan.
The geriatric population is rapidly expanding and the majority being frail, more attention needs to be given in terms of finances and human resources.
How to mend the “old and frail”?
As a consultant dealing with joint disease we encounter frail patients on a daily basis. A brief systemic review is necessary to figure out what could be amended in these patients. For sarcopenia (lack of muscle) I prefer to “prescribe” some simple exercises mainly involving stretching. If there are features of Vitamin D deficiency, ordering supplements corrects muscle power and prevents bone pain.
Joint inflammation (inflammatory arthritis like rheumatoid arthritis) is a cause for being frail. Treatment involves medication to bring down the swelling of joints. Evaluating underlying diseases like heart trouble, diabetes, anaemia, high cholesterol levels and lung disease is also extremely useful. These only require simple tests and are correctable.
What if the patient is already showing marked frailty? Then we concentrate on preventing accidents like falls. I prefer to assess how the patient mobilises himself. Prescribing walking aids is the next best step. There are various different types of walking sticks, walking frames meant for separate leg/ body disorders.
We should never forget the eyesight, hearing and the sensing capabilities of these patients. Patients who are already frail have a huge disadvantage if their senses are diminished. Again detailed history of problems will reveal most of these disabilities.
A popular query by youngsters is how to prevent frailty. The simplest remedy is to do regular non strenuous exercise and have well balanced nutrients. Doctors should lead by example.
Sri Lanka needs consultants in geriatric medicine, trained in handing the frail.
(The writer is a Consultant in Joint Disease and Rehabilitation)