JECH Online First, published on April 29, 2014 as 10.
1136/jech-2014-203863
The frailty syndrome in the public
health agenda
Fernando Rodríguez-Artalejo,1,2 Leocadio Rodríguez-Mañas3
A PubMed search of articles in this journal
using the text word ‘frailty’ found only two
manuscripts, published in 2010 and
2012.1 2 Thus, many readers of the journal
may not be familiar with the concept and
public health implications of the frailty syn-
drome.3 4 This is notable for several reasons.
First, because frailty is a frequent condition,
with a prevalence of about 10% in the
population over age 60 years, reaching 25%
in those aged 80 years and older.5 6 Also, in
a well-known prospective study among
community-dwelling older persons, the
most common condition leading to death
was frailty (27.9%), followed by organ
failure (21.4%), cancer (19.3%) and demen-
tia (13.8%).7 Additionally, frailty shows an
important social gradient, so that women
and less educated persons are more likely
to be frail and to have an increased risk of
worsening frailty status.3 4 8
Second, because the process of frailty
can potentially be prevented and treated.4
This is important because frailty is a
strong risk factor for mobility loss, falls,
dependence, institutionalisation and death
after exposure to even minor stressors.3 4
Moreover, frailty is a recognised predictor
of outcomes after medical and surgical
interventions, and should be taken into
account before prescribing them to older
patients.9 Given the accelerated ageing of
the population in most countries, and the
expected increase in the number of indivi-
duals with disability and dependence,
interventions on frailty may be a good
avenue to prevent or delay disability,
which is a major cause of usage of health-
care and social services.
And finally, because in 2003 the Institute
of Medicine identified frailty as 1 of 20 pri-
ority areas, selected from several hundred
candidates, in need of improvements in
healthcare quality.10 Moreover, the
European Medicines Agency acknowledges
1 istics, and that there are many ways to
Department of Preventive Medicine and Public Health,
Universidad Autónoma de Madrid/Idipaz, Madrid,
Spain; 2CIBER of Epidemiology and Public Health
(CIBERESP), Madrid, Spain; 3Division of Geriatric
Medicine, Hospital Universitario de Getafe, Madrid,
Spain
Correspondence to Dr Fernando Rodríguez Artalejo,
Departamento de Medicina Preventiva y Salud Pública.
Universidad Autónoma de Madrid, C/ Arzobispo
Morcillo, 2, 28029 Madrid, Spain;
fernando.artalejo@uam.es
Copyright F,Article
Rodríguez-Artalejo author
et al. J Epidemiol (or their
Community Healthemployer)
Month 2014 Vol2014.
that depending on patients’ frailty and dis-
ability status, the desirable outcome and
treatment choices might vary, and that this
should be taken into account in the devel-
opment and approval of drugs for older
adults11; also in the 2012 Ageing report,
the European Commission and the
Economic Policy Committee stated that
coping with the challenge posed by an
ageing population and trend, increases in
age-related spending will require deter-
mined policy action in Europe, particularly
in reforming pension, healthcare and long-
term care systems.12 Therefore, the reduc-
tion of disability and dependence through
appropriate action on the frailty process
should be at the forefront of all policies to
tackle the challenge of population ageing.
Why, then, is frailty not at the top of
the public health agenda? One main
reason is that frailty is not yet a common
clinical diagnosis, or at least it is not fre-
quently recorded in clinical charts.
Accordingly, frailty does not rank high in
hospital discharge data, in vital statistics
or among the main causes of disease
burden, thus, it is ‘invisible’ for public
health practitioners. However, given that
frailty usually results from several diseases
(eg, heart failure, diabetes, cancer, chronic
respiratory disease, depression, etc) acting
jointly, and frequently leads to disability, a
substantial portion of the death toll and
disease burden assigned to those diseases
is also related to frailty.
There is consensus on the concept of
frailty, which is defined as a ‘medical syn-
drome with multiple causes and contribu-
tors, that is characterized by diminished
strength, endurance, and reduced physio-
logic function that increases an individual’s
vulnerability for developing increased
dependence and/or death’.4 13 However,
the fact that the conceptual definition of
frailty rests partly on its consequences
rather than on its ontological character-
evince a reduced physiologic function, has
hampered agreement on a single oper-
ational definition or diagnostic tool.11 13
This has hindered the adoption of frailty
as a common diagnosis in clinical care.
There are two popular approaches to
evaluate the frailty process, but none of
them is optimum. The first approach was
developed in the Cardiovascular Health
0 No 0 Produced by BMJ Publishing Group Ltd under licence.
Editorial
Study (CHS), and identified a frailty
phenotype which was defined with five
variables: unintentional weight loss, self-
reported exhaustion, self-reported low-
energy expenditure (physical activity),
and measured slow walking speed and
weak grip strength.14 The presence of
each variable is assessed by comparison
with a norm, which usually is the lowest
quintile in the CHS or in the specific
study sample. Those with three or more
of these variables are judged to be frail,
and those with one or two as prefrail.
Although these frailty criteria are the most
widely used in the literature, they are dif-
ficult to apply in clinical care because they
require a dynamometer and a walking
test, and because in some settings (eg,
emergency departments, intensive care
units), the patients’ clinical condition does
not allow for assessing them. Moreover,
the CHS criteria are based on norms
derived from selected patient samples and
may vary with ethnicity. Furthermore, it
has been argued that these criteria should
be refined by also considering cognition
and mood, which are well-known risk
factors of dependence and death.
The second approach was developed
within the Canadian Study of Healthy
Ageing and defines frailty as the cumula-
tive effect of individual deficits in many
physiological systems, as manifested by
the total number of symptoms, signs,
abnormal laboratory values, disease states
and disabilities comprising the so-called
frailty index.15 This index probably mea-
sures clinical domains other than frailty,
such as the so-called biological age, as it
also includes disability and disabling
conditions. In fact, the frailty index is a
good predictor of death, but it is possibly
less accurate for predicting disability.
Moreover, although short versions of this
index have been developed, it is impracti-
cal in most clinical settings because it
includes a large number of variables.
There are a few screening instruments
for frailty, such as the FRAIL scale (which
only includes self-reported data),16 but a
simple, validated and widely agreed diag-
nostic tool usable in primary and hospital
care is still needed. This instrument
should be able to discriminate which
patients are at increased risk of adverse
outcomes (eg, dependence or death)
resulting from common medical interven-
tions, such as an invasive diagnostic pro-
cedure, an oncological treatment or a
minor surgical intervention. A key issue to
be elucidated in the future is whether a
single performance measure, such as grip
strength or gait speed, may suffice for
frailty detection or diagnosis, although
1
 Editorial
recent research supports that the whole
syndrome has more robust properties than
any of their components.17 Of note is that
population-based surveys (eg, NHANES)
are starting to collect data on muscle
strength using a handgrip dynamometer;
this might serve to monitor the progress
on the prevention and control of frailty in
the older adult population.
Another reason why frailty is not yet
high in the public health agenda is the
paucity of well-conducted clinical trials to
assess the short-term and long-term effi-
cacy of medical interventions on frailty.
Exercise programmes, nutritional supple-
ments (total energy, protein, vitamins) and
the reduction of polypharmacy appear to
have some efficacy in the treatment of
frailty,4 but in most cases the clinical trials
did not use a validated or established
model to assess frailty at baseline and at
follow-up.3 Thus, it is dubious whether
the effects of these interventions apply to
most frail individuals in the community;
most importantly, in many cases, the out-
comes in these studies corresponded to
improvement in functional ability or
reduction of falls, but no comprehensive
evaluation has been made for each inter-
vention on all relevant outcomes (which
also include hospitalisation, incident
dependence, institutionalisation and
death). Also, given that frailty may be
caused by different types of diseases, it is
uncertain if the same types of interven-
tions fit all types of frailty and their com-
ponents (eg, weight loss, gait speed, etc).
Last, several scientific organisations have
agreed that all persons older than 70 years,
and all individuals with significant weight
loss due to chronic disease should be
screened for frailty.4 This recommendation
was grounded on the effectiveness of treat-
ments for components of the frailty syn-
drome, and on the assumption that the
screening tests produce more beneficial
than harmful outcomes. While this may
prove true, the public health community
usually requires sound clinical trial evi-
dence that a certain screening and treat-
ment intervention produces better
outcomes than no intervention. Moreover,
2 Rodríguez-Artalejo F, et al. J Epidemiol Community Health Month 2014 Vol 0 No 0
the cost of an intervention should compare
well with the cost of other healthcare alter-
natives, and the budget impact should be
acceptable.
All the above explains why frailty is not
currently a hot topic in public health. But
it also shows an urgent need to enhance
our knowledge on the natural history of
frailty and, particularly, on the most
appropriate diagnostic tools, and the
effectiveness and efficiency of its treat-
ment and screening procedures; thus, the
frailty syndrome should be ranked high in
the research agenda. In fact, in the
European Union, frailty was a frequent
topic in the calls by the recently con-
cluded seventh framework research pro-
gramme, and has emerged as a true
priority in Horizon 2020. As the research
results are delivered, frailty will surely
reach a higher position in the list of
public health priorities.
Contributors Both authors contributed equally to the
planning and writing of this editorial.
Funding This work has been supported by grants from
the Instituto de Salud Carlos III (PI/12/1166 and RD12/
0043/0001 RETICEF) and the European Commission
(FRAILOMIC Initiative FP7-HEALTH-2012-Proposal No:
305483-2).
Competing interests None.
Provenance and peer review Commissioned;
externally peer reviewed.
To cite Rodríguez-Artalejo F, Rodríguez-Mañas L.
J Epidemiol Community Health Published Online First:
[please include Day Month Year] doi:10.1136/jech-
2014-203863
J Epidemiol Community Health 2014;0:1–2.
doi:10.1136/jech-2014-203863
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