Management of Frailty in Older Adults
Strength-based resistance training is the single most effective intervention for managing frailty in older adults, with proven benefits in reducing mortality, improving function, and enhancing quality of life. 1
Core Management Strategy: Exercise as First-Line Therapy
Resistance and strength training should be the foundation of any frailty management program, as this intervention demonstrates the strongest evidence for reversing frailty and improving outcomes. 1 The benefits are cost-effective, with intervention costs balanced by reduced healthcare utilization. 1
Effective Exercise Modalities Include:
- Muscle power training and resistance exercises (primary recommendation) 1
- Computerized-based training and exergames 1
- Dance programs 1
- Inspiratory muscle training and whole-body vibration training 1
- Home-based exercises combined with health education and telephone support 1
Critical caveat: Improvements in activities of daily living (ADL) and quality of life only occur when physical outcomes improve first, so exercise programs must be intensive enough to produce measurable physical gains. 1
Nutritional Management
Protein supplementation alone does NOT improve physical outcomes in frail older adults and should never be prescribed as monotherapy. 1
Protein supplementation only works when combined with concurrent resistance training, making the combination therapy the evidence-based approach. 1
- HMB (β-hydroxy-β-methylbutyrate) supplementation may provide additional benefits and can be considered. 1
- All frail older adults must be screened for oral disease and referred for dental care, as poor oral health directly impacts nutritional status and frailty progression. 1
Medication Management: Deprescribing as Priority
Inappropriate medications are frequently prescribed to frail older adults, and frailty itself increases the risk of medication harm. 1, 2
Key Actions:
- Review and deprescribe inappropriate medications, particularly sedatives, analgesics, and drugs with high anticholinergic burden. 2
- Recognize that pharmacokinetics are altered in frailty (e.g., paracetamol shows high inter-individual variability). 2
- Use validated deprescribing tools specifically developed for frail populations. 1, 2
- Healthcare professionals with more experience managing frail patients are more likely to successfully deprescribe. 1, 2
Multidimensional Interventions for Those ≥80 Years
For adults 80 years and older, multidimensional interventions can prevent progression from pre-frailty to frailty. 1 These should include:
- Physical exercise programs 1
- Health education 1
- Telephone support for adherence 1
- Comprehensive geriatric assessment to identify reversible risk factors 3, 4, 5
Important limitation: Integrated care only improves physical function when usual care is NOT already of high quality, so assess baseline care quality before implementing. 1
Identification and Screening Approach
Use simple, validated frailty screening instruments rather than complex assessments, as these are showing resurgence in clinical practice. 1 Options include:
- Clinical Frailty Scale (CFS) for rapid assessment 6
- Frailty phenotype criteria (≥3 of: unintentional weight loss, exhaustion, weakness, slow walking speed, low physical activity) 7
- Artificial intelligence-based screening from electronic medical records (emerging technology) 1, 2
Be aware of stigma: Older adults may experience negative psychological effects from being labeled "frail," so use person-centered language. 1
Risk Stratification and Monitoring
Frailty status fluctuates substantially, and changes in frailty are MORE predictive of mortality than current frailty status alone. 1 Therefore:
- Monitor frailty trajectory over time, not just baseline status 1
- Identify intermediate/pre-frail states (1-2 frailty criteria), as these patients have 2.63-fold adjusted odds of progressing to frailty. 7
- Screen for geriatric syndromes (cognitive impairment, falls, incontinence, malnutrition) as these compound frailty's impact on outcomes. 6
Lifestyle and Environmental Modifications
Mediterranean diet and residing in areas with green space delay frailty progression. 1 Conversely, sedentary behavior and diets high in processed foods accelerate frailty. 1
Modifiable Risk Factors to Address:
- Reduce sedentary time through structured activity programs 1
- Promote Mediterranean dietary patterns 1
- Address environmental factors including air pollution exposure 1
- Encourage social participation and meaningful activities 1
Special Populations: Frailty with Dementia
For individuals with both frailty and dementia, the vulnerability is substantially increased compared to dementia alone, requiring even more comprehensive management. 1 These patients need:
- Early frailty diagnosis before profound cognitive deficits develop 1
- Individually tailored interventions based on geriatric assessment 1, 2
- Recognition that frailty is a risk factor for developing dementia 1
Common Pitfalls to Avoid
- Do not prescribe protein supplements without concurrent resistance training – this wastes resources and provides no benefit. 1
- Do not assume frailty equals disability or comorbidity – these overlap but are distinct conditions requiring different approaches. 7
- Do not implement integrated care programs where usual care is already excellent – you will see no additional benefit. 1
- Do not neglect oral health screening – this is consistently overlooked despite clear evidence of importance. 1
- Do not rely on technology-based interventions alone – many frail older adults lack digital literacy and access. 1, 2