Frailty: what it means and what can change

The most widely used bedside description is the Clinical Frailty Scale, a clinician’s overall judgement of how fit or frail a person is. In the study that introduced it, 2,305 older Canadians were followed for five years. Each step up the scale was associated with a 21% higher risk of death and a 24% higher risk of entering institutional care, and the scale predicted death better than measures of cognition, function or comorbidity ³³.

People usually move into residential care because frailty has reached the point where living at home is no longer manageable. The useful question in aged care is how frail a person is, because that shapes what a treatment is likely to offer and what it is likely to cost them.

Frailty affects how a person responds to almost any treatment. An operation, a hospital admission or a new medicine tends to carry more risk as frailty increases. This is why a treatment that is clearly right for a fit 75-year-old may be the wrong choice for a very frail 90-year-old, and why trial results from fitter, younger people do not transfer automatically.

Frail residents were excluded from the main osteoporosis trials, for example, and the one trial run in frail women in long-term care did not show fewer fractures ²⁹.

In a randomised trial of 100 frail nursing home residents with a mean age of 87, ten weeks of high-intensity resistance training increased muscle strength by 113%, compared with 3% in those who did not exercise. Walking speed improved by about 12% and stair-climbing power by 28%. A nutritional supplement given without exercise had no effect on any primary outcome ³⁴.

The falls trials tell the same story from another direction. Exercise reduces falls while it continues, and the benefit is lost when it stops ². In the Australian Sunbeam trial, physical performance improved alongside the fall in falls ⁶.

Residents in the comparison arm of a large Australian trial were eating about 0.9 g of protein per kilogram of body weight and 700 mg of calcium a day. Raising this to 1.1 g per kilogram and about 1,140 mg with extra dairy foods reduced fractures and falls ⁸.

Taken with the exercise trial above, the pattern is that food and exercise work together, and that a supplement drink is not a substitute for either ^8,34.

Frailty usually progresses. Exercise and food can slow the loss of strength and, for some people, win some of it back. They do not make a very frail person robust.

Knowing roughly where someone is on that path helps a resident, a family and a clinical team choose well: which treatments to pursue, which trips to hospital are worth making, and when comfort becomes the main aim.