By Ryan DuBosar
Precision medicine is coming of age for the ironically young field of gerontology, while different definitions of "frailty" compete in physicians' minds.
At Internal Medicine Meeting 2022, ACP Member George A. Kuchel, MD, CM, addressed frailty's definitions, diagnostic pathway, and quick ways to incorporate targeted treatments in a busy clinic.
Frailty is a state of flux—by definition, by state of function, by etiology, by risk factors, said Dr. Kuchel, who is the Travelers Chair in Geriatrics and Gerontology at UConn Health and director of the University of Connecticut Center on Aging in Farmington, Conn.
For example, if an internist defines frailty by phenotype, there are five criteria: weakness, slow gait speed, low physical activity, exhaustion, and unintentional weight loss (5% or more in the past year).
"Basically, if you have three or more, you're considered to be frail; to be at one or two, you're pre-frail," he said.
But when frailty is defined as a process, the score is an accumulation of an index comprising health deficits (such as signs and symptoms), the prevalence of which increase with age. The frailty score is the sum of deficits (at least 30) divided by the total number measured.
"Frailty doesn't occur in isolation from other things that occur with aging," he added. "And this illustrates something that all of you see in our offices every day. … The vast majority of people over the age of 65 have one or more chronic conditions and about three-quarters who have two or more. And that's the nature of the average general internal medicine practice."
To link definitions of frailty to clinical outcomes, Dr. Kuchel first discussed how little homogeny exists among elderly people and their presentations.
"Trajectories of aging are actually highly, highly variable," he said. "We all know that there are some older adults who become quite frail or disabled." Some patients go to nursing homes while others maintain mobility, "growing old gracefully," he said.
Dr. Kuchel tells his medical students, "Look around the room today. You are as similar to one another as you will ever be."
Just as no patient presents the same, no one intervention treats all the many factors that can cause frailty.
"There's a role for what we call a multicomponent intervention," Dr. Kuchel said "And what you really need to do is match the components of that intervention target. We need something that we're beginning to call precision gerontology."
The desired outcome of precise targeting is to maintain function—mobility, behavior, and cognition, then voiding and continence—and then to improve outcomes such as independence and quality of life, he said.
Dr. Kuchel discussed how to boil down these concepts in the physician's office in a way that is compatible with a busy practice.
A simple frailty questionnaire screening tool (FRAIL) has been validated with five elements: fatigue, resistance, ambulation, illnesses, and loss of weight, although Dr. Kuchel acknowledged the implications of yet another score to capture during an office visit.
"Every second counts in the office, I realize that," he said. "But again, it's the kind of thing that either you or your medical assistant or somebody in your office can ask."
He added that while frailty and sarcopenia are not the same thing, they are closely linked. While a DXA scan can measure bone mineral density and muscle mass, as well as be used to diagnose osteoporosis and assess response to treatment, it can't be used for slow gait speed because muscle mass is not a great predictor of frailty.
Fortunately, gait speed is an easily administered measure. "If you could do only one thing on your older patient to predict how well they're going to do … The one thing is how they engage speed. And mobility performance is probably the most reliable and validated," Dr. Kuchel said.
Because fatigue can be difficult to differentiate, always consider depression as a contributor to frailty, he said. Many internists are comfortable prescribing antidepressants, which are very well tolerated by older adults.
Dr. Kuchel also suggested correcting low vitamin D levels and hypothyroidism. "We can't be prisoners of the meta-analysis you have to do if your patient has low 25-hydroxyvitamin D levels. You have to correct that." Similarly for hypothyroidism, it's very important to check for orthostatic hypotension in frail patients, he said.
In addition, internists can always fall back on fundamental principles of geriatrics to consider altered presentations in patients, such as occult infections like acute cholecystitis and pyelonephritis.
Similarly, individuals who have undergone chemotherapy or radiotherapy as children are much more likely to become frail and to develop chronic diseases of aging in midlife, Dr. Kuchel said.
"Also … think of the social dimension of your patient, which you have to do with older patients," he said. "And then, obviously, we cannot ignore the contribution of poverty in terms of cost of food and medication that may be contributing to frailty in your patient."
Exercise intensity was a question raised by the audience.
Dr. Kuchel said exercise certainly works for many disabilities and for sarcopenia. In terms of how much exercise a patient needs, "The short answer is a little bit is better than nothing. … We need to get away from the idea that it's all about strength. … To prevent falls, to prevent disability, you need to focus on three things: Strength is important, and balance, balance, balance is incredibly important. And so's flexibility," he said. "[T]o look at programs that could target all three, this is my advice." ■