Frailty syndrome R69.8

"Frailty" or infirmity is understood to mean the simultaneous occurrence of various, sometimes disease-related limitations that make older people less resilient (in terms of health) and thus more susceptible to illness, disability or falls (Xue QL 2011). The age syndrome "Frailty" is defined by a decrease in performance in the different organ systems, which causes increased vulnerability due to a negative outcome. The older organism increasingly loses its ability to perform or compensate. It becomes more susceptible to diseases, possibly with repeated hospital stays, with the need for care, with increased mortality. Frailty" as a syndrome is now accepted worldwide (see below Clegg A et al. 2013).

The best known measurement scale for "Frailty" is from Fried LP et al (2001). Here, a distinction is made between a beginning "Frailty" ("Prefrailty") and the actual "Frailty". If only 2 of the criteria are met, the condition is referred to as prefrailty syndrome; if 3 or > 3 criteria are met, the condition is referred to as frailty syndrome. The definition according to Fried (Fried LP et al. 2001) focuses on physiological criteria (e.g. strength, endurance), which is justified for the assessment of risks such as falls or medical interventions. However, frailty can also include a social or psychological "frailty".

Another clinically useful classification is the CSHA (Clinical Frailty Scale), which distinguishes 7 levels. Its validity corresponds approximately to that of more complex scales (Buta BJ et al. 2015).

Frailty criteria according to Fried (2001). According to Fried, frailty can be assumed if at least 3-5 of the following leading symptoms are present:

• Unintended weight loss of > 5 kg/year, or according to the German Nutrition Society defined as weight loss of > 5% in 3 months or > 10% in 6 months.
• Decrease in gross body strength (hand strength measurement 20% compared to the reference population)
• Subjectively felt exhaustion
• Reduced walking speed (5 m walking distance with 20% of the speed of the comparable population), in terms of reduced mobility
• Reduced general activity

If there are only 1 or 2 criteria, one speaks of so-called prefrailty.

The prevalence of "Frailty" increases with age. 2.8% of women aged 65-79 and 2.3% of men of the same age are physically frail; overall, this is 2.6% of older adults. The overall prevalence of pre-frailty is 38.8% (40.4% of women; 36.9% of men). There are no significant gender differences for either indicator (Robert Koch Institute 2016).

An important cause of frailty is the decline in physical performance, which is characterized by several functional declines: e.g. in the reduction of strength, vision, hearing, kidney function, mental performance, etc. With increasing "Frailty" the loss of function becomes so great that the remaining reserves can no longer cope with the daily demands.

The occurrence of "frailty" was associated with a variety of risks in old age. A high degree of frailty is associated with a shorter life expectancy. For example, only 40% of people classified in the frailty categories of levels 6-7 survived the next 5 years, but 80% in categories 1-3 (Rockwood K et al. 2005). "Frailty" was associated with increased falls (Kojima G et al. 2015). Other risks include the threat of nursing home admission or need for care. A graduated "Frailty" assessment can also be used in the evaluation of intervening medical therapies. For example, "frailty" is associated with higher perioperative mortality in oncological patients or a higher risk of side effects of chemotherapy. It also reduces the vaccination response (e.g. in the case of influenza vaccination). In seniors with 3 or >3 frailty criteria according to Fried, a low antibody titer builds up after vaccination, combined with an increased rate of influenza infections.

Frailty scales are therefore used as aids to medical decisions, e.g. on the question of whether an elderly patient is fit for surgery (Kraiss LW et al. 2015) or whether he can be treated with aggressive chemotherapy. Frailty" can also be used to avoid adverse drug effects (Cullinan S et al. 2015). Thus, frail elderly people would leave the guideline-based therapy of hypertension treatment and a risk-adapted blood pressure adjustment would be recommended according to the assessment of the treating physician (Mancia G et al. 2013). It is crucial to recognise a development of the patient towards "prefrailty" or "frailty" in good time.

"Frailty" is ultimately a complex syndrome that involves a wide variety of components (e.g. strength, gait, endurance, weight). Each of these components is treatable. Frailty" can therefore be treated in its complex totality by improving its individual components. For example, an improvement in nutrition can delay weight loss and thus also muscle mass loss. Strength or endurance training is still possible even at an advanced age. Since various services are involved, multidisciplinary geriatric intervention (physiotherapy and occupational therapy, social services, provision of aids, etc.) should also have a positive effect on the condition of "Frailty". An accepted holistic drug treatment does not yet exist, but does not appear to be completely excluded (e.g. hormone therapy or anabolic steroids) (O'Connell MD et al. 2014)

The following criteria apply in practice:

• Early detection of impending "frailty", social intervention (expansion of social networks)
• Start prevention as early as possible
• No therapeutic nihilism
• Treat additional diseases
• Make patients and relatives aware of the risks of "frailty" (e.g. falls)
• Recommend multifactorial intervention (e.g. diet, exercise, mental activity)
• Frailty" is an individual and risk-adapted decision (this also means adapting existing guidelines to the personal profile of a patient, if necessary).

Every doctor knows the signs of frailty. The patients appear weak, slower, may have lost weight and have no physical reserves. Complications such as falls and a limited life expectancy are imminent.

Many physiological systems, such as muscle mass, build up during adolescence, reach a maximum in young adulthood and then gradually decrease during life. Eventually, performance becomes so low that coping with everyday life becomes difficult or even impossible (Buckinx F et al. 2015). People are becoming increasingly "frail", i.e. fragile. Since "frailty" usually occurs at an advanced age, it is primarily a geriatric syndrome.

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