Testing for frailty
Here is a test for frailty: Sit in an upright chair. Start your stopwatch, get up and walk 3 yards, turn round, return to your chair and sit down. A time of less than 10 seconds is normal, between 10 and 20 seconds is an indicator of encroaching frailty and more than 20 seconds is characteristic of frailty. Slightly more complicated is the five repetition chair rise test with an increased risk of falling for those who take more than a minute to achieve the five up and downs. Walking speed is also an indicator of frailty – being capable of more than 13/4 mph rules out frailty but below 11/2 mph, the slower you are the frailer you are likely to be.
Frailty and muscle loss
Frailty is closely allied to loss of muscle tissue. As we age we all lose muscle mass and strength, a condition called sarcopenia. A degree of age-related muscle loss is unavoidable but the rate at which we lose muscle is largely dependent on how much exercise we take. By the seventh and eighth decade of life, maximal voluntary muscle contractile strength is decreased, on average, by 20 to 40% for both men and women. Most of this loss of strength is caused by decreased muscle mass. The resulting progressive loss of neuromuscular function leads to increasing disability and loss of independence. The prevalence of sarcopenia increases with each 5-year age group from about 15% among the 65 to 70 year olds to as much as 50% in the over 85s and probably becoming increasingly common thereafter. It accelerates with the passing of the years. As the age of the population grows so will the numbers with sarcopenia.
Frailty and dependence
Physical capacity becomes increasingly important as age increases. For 50-year-olds, not being as fit as they should be for that age will not make a substantial difference to their daily living (unless they are really, really unfit). But for an 80 or 90 year old, poor fitness levels (relative to that age group) may mean that the individual is unable to maintain an independent life. The difference between being fit or unfit at this age may mean the difference between being able to get out of bed and dress unaided or relying on carers. Or the difference between able to get up from a chair and put the kettle on or being dependent on others to do it for them.
The social consequences of frailty
The social and financial consequences of frailty are enormous and growing. When frail people become ill they have poorer outcomes for mortality, morbidity or institutionalisation than the non-frail and if discharged from hospital have a high rate of readmission – as much as 40% over six months. Our hospitals are full of “bed blockers” who only needed admission because they were frail and who are unable to go home because of lack of carers and lack of money to pay for them. The frail elderly occupy increasing numbers of beds in residential homes and nursing homes for dependent people. If able to stay at home they require regular visits from informal or formal carers to allow them to keep a semblance of normal life. Frail elderly people are major users of emergency medical services presenting with such problems as falls, immobility, incontinence and confusion. They are at particular risk of falling. 50% of people aged over 80 fall at least once a year and about 5% of these falls result in a fracture, most seriously of the neck of the femur (the “hip”). Falls are a major threat to older adults’ quality of life, often causing a decline in self-care ability and in participation in physical and social activities. Fear of falling can lead to further limiting of activity, independent of injury. Current estimates are that falls cost the NHS more than £2.3 billion per year.
We have a growing army of dependent elderly people, with increasing social care costs, increasing difficulty in finding enough younger carers and an inability to afford them. The trajectory of this problem is inexorably upwards with the proportion of the population aged over 80 set to double over the next forty years while the number of over 85s requiring 24 hour care is also expected to double to 446,000, a staggering number. The media frequently publicise the crisis in social care funding, predicted to rise to £2.6 billion annually by 2020. The Institute for Fiscal Studies has predicted that, unless they are bailed out by the Government, local councils will have to spend up to 60% of their revenues on social care by 2034.
Frailty in old age is a serious threat for us all and for most of us it is entirely avoidable. Next time I will talk about some of the strategies for avoiding this fate.