Recently I watched a video of actor Sir Sean Connery. Unlike the bygone days, he was slow and dependent on a care giver for mobility. Most of my rheumatology patients are slow. Some call them the “Old and Frail”. Age amounts to the number of years lived, but what is being frail? Why do some elderly eighty-year-olds remain agile, youthful and strong? And why do some slow down even at an ‘early’ age as fifty? Is there a miracle cure for us to remain youthful? Are there  any tests to determine how frail you are? This article is aimed at identifying and correcting some of the reasons for typical old age behaviour.  

What is being frail?
Imagine an old gent struggling to mobilise himself. Getting up from a seated position itself is a challenge. If the seats do not have armrests the task becomes more difficult. And then, walking even for a few feet is a tough task. The swinging arm and leg movements are slow. Turning around takes a couple of seconds. All quick reflexes are absent. Sadly, if that person trips over an object, he is bound to suffer an 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 too.  

Being a joint specialist/rheumatologist, I belong to a group of doctors who are usually the first to notice how frail a person is. This is because of some of the maneuvers we ask the patient to perform. 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 ‘Frail index’.  
Frailty is now considered as a medical condition with multiple causes and contributors. This is characterized 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 to become dependent on others. And unfortunately it shortens lifespan 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 to 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.  

Even careful observation is sometimes enough to determine how frail a person is. But are there ways to at least partially correct this? To understand all this, we need to know why people become frail.  

Reasons 
No exact reason has been discovered as the cause for being frail. Scientists think there could be a multitude of causes out of which genetics, lifestyle, diseases and the environment might play key roles in causing this ‘slowness’. Our own immune system which combats infections might cause what we call long term inflammation in certain organs. In the end, the muscles, skeleton, heart, vessels and the blood stream are affected and causes frailty.  

‘Sarcopenia’ is lack of muscle. From the age of 20 till 90 more than fifty percent of 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. These are oestrogen in females and testosterone in males. Rapid decline of sex hormones leads to an increase in frailty. Lack of Vitamin D also could contribute to frailty. Obesity in midlife is another reason for being frail, according to research.  

Why are we concerned?
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 of these patients. They are at a risk of falling. A fall is by itself a disaster associated with the elderly resulting in fractures or head injuries and can lessen lifespan.  

As you might be aware the geriatric population is rapidly expanding. There are many causes for this out of which better hi-tech health care is a key factor. Needless to say if the majority of these people are 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 with regard to 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 reduce the swelling of joints. Evaluating underlying diseases like heart trouble, diabetes, anaemia, high cholesterol levels and lung disease is also extremely useful. For this simple tests are required and the problem can be corrected.   

What if the patient is already showing marked frailty? Then we concentrate with 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 a 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. I urge the doctors to lead by example.  

Sri Lanka is yet to produce consultants in geriatric medicine. This is a timely need as our elderly population is rapidly increasing. Although there are doctors who are interested in practicing geriatrics, we need consultants who specialize in this field. Geriatricians are exclusively trained in handing the frail. I hope our medical fraternity sets aside the different opinions to focus on creating and training as many geriatricians as possible.