PPwOA Week 7 Notes – Frailty and Fragility Fractures

Frailty: Concept

  • Frailty is not the same as normal ageing. While ageing is a normal process with associated risks, frailty is a distinct syndrome indicating reduced ability to cope with stressors (acute illness, surgery, trauma, bereavement).

  • Frailty increases risk of falls, institutionalisation, disability, and death compared with age-matched peers.

  • Emerged as a clinical/ research focus in the last ~20 years following Fried and colleagues’ frailty phenotype work; still an area with many unknowns.

  • Many voices on how to conceptualise frailty; no single gold standard, but the two most common approaches are the phenotype model and the accumulation of deficits model.

Frailty Conceptualisations

  • Phenotype approach (biological syndrome model): measures include weight loss, fatigue, exhaustion, weakness, low physical activity, slowness, and mobility impairment.

    • Fried et al. frailty phenotype (five variables; yes/no scoring):

      • Weakness

      • Slowness

      • Low levels of physical activity

      • Exhaustion

      • Weight loss

    • Scoring: if a person has three or more criteria -> frail; one or two -> pre-frail; none -> non-frail.

  • Accumulation of deficits approach (frailty index): counts health deficits (symptoms, signs, diseases, disabilities, lab tests) and divides by the total number of deficits measured.

    • Formula: Frailty index=number of health deficits presenttotal number of deficits measured\text{Frailty index} = \frac{\text{number of health deficits present}}{\text{total number of deficits measured}}

    • Example: 15 of 30 deficits present -> Frailty index=1530=0.5\text{Frailty index} = \frac{15}{30} = 0.5

    • Typically ≥30 deficits are measured, though often 70–80 characteristics are considered; comprehensive geriatric assessment is needed to generate the index (multidisciplinary and time-consuming).

  • Clinical Frailty Scale (Rockwood et al., 2005): a global clinical grading from very fit to terminally ill based on impairments, activity limitations, and participation restrictions.

  • Commonly, operational definitions of frailty specify impairments in: mobility, muscle strength, balance, motor processing, physical functioning, disability, cognition, nutrition, endurance, and physical activity.

  • Impairments, activity limitations, and participation restrictions are linked to adverse outcomes: falls, malnutrition, hospitalisation, institutionalisation, disability, death.

Causes and Pathophysiology

  • Frailty develops from a complex interplay of factors; ageing is a risk factor but not the sole cause.

  • Interacting determinants: age, genes, diseases, lifestyle, environment.

  • Genetic influences may affect susceptibility to diseases that contribute to frailty.

  • Whole-of-life approach: environmental and lifestyle risk factors include (alphabetical):

    • Depression

    • Fair/poor self-rated health

    • Heavy drinking

    • Low levels of education

    • Physical inactivity

    • Prevalence of chronic health conditions

    • Prevalence of chronic symptoms

    • Smoking

    • Being unmarried

  • Prenatal environment may influence frailty risk later in life.

  • Birth weight and later grip strength associations suggest early life muscle fibre endowment may influence sarcopenia risk and frailty; higher early infection exposure and chronic stress may drive chronic inflammation, a key pathway to frailty.

  • Cytomegalovirus infection has been linked to frailty via increased interleukin-6 (IL-6).

  • Chronic stress → increases in IL-6 and accelerated telomere shortening.

  • Inadequate nutritional intake (low energy, protein, vitamin D, vitamin E, vitamin C, folate) is associated with frailty.

  • Both underweight and overweight states can be frail.

  • Chronic inflammation is a central pathophysiological process affecting musculoskeletal, endocrine, cardiovascular, and hematologic systems, contributing to the frailty syndrome and its adverse outcomes.

  • Common consequences of frailty include: falls, malnutrition, hospitalisation, institutionalisation, disability, death, cognitive impairment, mood disorders, prolonged recovery from stressors, and worsening of chronic illnesses.

Frailty Screening and Assessment

  • There are more than 75 frailty tools; no consensus on an optimal screening/assessment tool.

  • Tools fall into five categories: judgement-based, physical performance tests, physical frailty determinants, multidimensional instruments, and frailty indices.

  • Choice of tool depends on the clinician, setting, client, resources, and data availability.

  • Physiotherapists frequently use physical performance tests and contribute to multidisciplinary screen/assess processes.

  • If screening suggests likely frailty, a Comprehensive Geriatric Assessment (CGA) is recommended.

Comprehensive Geriatric Assessment (CGA)

  • CGA is a multidimensional, multidisciplinary diagnostic and therapeutic process to determine the medical, mental, and functional issues of the older person.

  • Goal: develop a coordinated, integrated care plan with follow-up.

  • Multidisciplinary team often includes: geriatricians, nurses, social workers, physiotherapists, occupational therapists, dietitians, pharmacists, speech pathologists, audiologists, optometrists, dentists, psychologists, psychiatrists.

  • Physiotherapist role in CGA:

    • Assess physical functioning, environment, functional capacity, mobility, balance.

    • Evaluate posture, joint range of motion, neurological status, falls history, feet/footwear, gait patterns, balance, motor processing (coordination, movement planning, speed).

    • Consider neurocognitive processing (e.g., dual-task ability) and activities of daily living.

    • Identify individual profile and issues; contribute to a personalised care plan; implement interventions; regular review.

Management of Frailty (Physiotherapist focus)

  • Frailty is dynamic; prevention or delaying progression is possible, and reversal is feasible in some cases.

  • Core approach: physical interventions, ideally combined with nutritional interventions; further research needed on the best mix.

  • Multi-component exercise programs are recommended for pre-frail and frail older adults to improve strength, gait speed, balance, and physical performance.

  • Program design principles:

    • Start with accessible, safe activities (chair-based exercises, non-weight-bearing work, walking, elastic bands).

    • Progress intensity according to individual capability and performance.

    • Progression should occur to match activities of daily living (ADL) performance to promote independence.

    • There are no specific contraindications to physical activity in frail older adults beyond general safety precautions; adverse events in trials are rare.

    • Frail older adult trials show very low adverse events and no greater risk compared with inactive controls for events like fractures, tendonitis, muscle soreness, back pain, musculoskeletal injuries, and falls.

  • Key components and evidence:

    • Resistance training is essential and improves muscle strength, gait speed, and overall physical performance; important given sarcopenia’s role in frailty.

    • The exact mix of strength, power, and endurance training is still being studied; clinical judgment is needed per individual.

  • Exercise prescription considerations:

    • Resistance training: typically ~2–3 times per week; intensity ranges from 35%to40% 1RM35\% to 40\%\,\text{1RM} up to 70%to80% 1RM70\% to 80\%\,\text{1RM}; volume around 8−15 reps8-15\text{ reps} for lower intensities and 6−12 reps6-12\text{ reps} for higher intensities.

    • Aerobic training: 2–3 times per week; intensity at a level described as somewhat hard; start at 5–10 minutes and progress.

    • Types of aerobic options vary (e.g., walking, cycling, low-impact modalities).

    • Stretching and flexibility are essential components of a multi-domain program.

    • Balance, agility, proprioception, and coordination are crucial; recommended 2–3 days per week, 8–20 minutes per session; include both static and dynamic balance; start with static and progress to dynamic balance as tolerated.

    • Session characteristics: typically 45–60 minutes, individualized, progressive, and supervised when possible.

    • Duration for benefits: programs should run for at least ~2.5 months; some gains persist beyond 12 months.

    • Adherence strategies: supervision, individualisation, involvement of family; use of exercise diaries, activity trackers (e.g., Fitbits) to enhance engagement.

    • Important principle: maintain gains; continue exercising after goals are met because gains can decline quickly without ongoing activity (use it or lose it).

Fragility Fractures: Definition, Epidemiology, and Outcomes

  • Definition: fractures resulting from a fall from standing height or less, or fractures occurring without obvious trauma.

  • Prevalence and burden:

    • Fragility fractures are common; about half of women and one third of men over age 50 experience one.

    • Common sites: hip (neck of femur, NOF), spine, and wrist.

    • Osteoporosis context: ~2 million2\,\text{million} Australians diagnosed; many cases undiagnosed.

    • Hospital admission rate: every 5−6 minutes5-6\text{ minutes}, someone is admitted with an osteoporotic fracture.

  • Outcomes after hip fracture:

    • Approximately 25%25\% die in the first 12 months following the fracture.

    • About 50%50\% never regain their pre-fracture mobility.

  • Dementia comorbidity: among those with NOF fracture and pre-existing dementia, about 62%62\% die within the first 12 months after surgery.

  • Vertebral fractures: only about 30%30\% are diagnosed; under-recognition depends on patient presentation, clinician suspicion, and imaging.

  • Falls as a risk factor: many fragility fractures arise from falls from standing height; falls assessments are not routinely performed after fragility fracture.

  • Hip protectors: very low uptake; some literature suggests only ~4%4\% of patients are advised to use hip protectors after a fragility fracture.

Osteoporosis Prevention and Management

  • Prevention focuses on: diet (calcium and vitamin D), regular exercise, limiting alcohol, and avoiding smoking.

  • Vitamin D: important for bone and muscle health; assess serum levels of 25(OH)D; supplement if low; vitamin D status is linked to muscle strength and fall risk.

  • Exercise remains central to bone health and fracture prevention; rapid short bursts of high-intensity, high-impact exercise with longer rest periods may be more effective for bone remodelling than continuous long bursts.

  • Evidence from systematic reviews on bone density:

    • Neck of femur (proximal femur): non-weight-bearing high-force resistance training is most effective for improving or maintaining bone mineral density (BMD).

    • Spine: a combination of exercises is most effective for maintaining or increasing BMD.

  • Adverse events in exercise studies for fragility fracture populations: fractures and falls reported, but overall no clear increase in fracture risk due to exercise; safety improved with proper supervision and progression.

  • Practical exercise prescriptions (guidelines): a combination of progressive resistance training, weight-bearing exercises, and challenging balance/step/mobility activities.

  • Overall goal: maximise bone health, prevent subsequent fractures, and reduce fall risk through integrated exercise and nutrition strategies.

Practical Implications for Clinicians

  • Recognise frailty as a dynamic condition that may be preventable or reversible with appropriate interventions.

  • Use appropriate screening tools to identify frailty and refer for CGA when indicated.

  • Implement multi-component, individually tailored exercise programs for frailty, with emphasis on resistance training, aerobic exertion, balance, flexibility, and mobility.

  • Prioritise ongoing engagement and adherence strategies to sustain benefits over the long term.

  • In fragility fracture care, screen for osteoporosis, optimise nutrition and vitamin D status, promote safe physical activity, and consider pharmacologic therapies as indicated.

  • Be mindful of high-risk periods post-fracture (mortality and mobility implications) and coordinate multidisciplinary care to mitigate risks.

Summary Takeaways

  • Frailty is a distinct, dynamic health state distinct from normal ageing, characterised by reduced resilience to stressors and higher risk of adverse outcomes.

  • Two main frailty models exist: phenotype (Fried criteria) and accumulation of deficits (frailty index); CGA and the Clinical Frailty Scale are commonly used clinical tools.

  • Causes of frailty reflect a life-course interplay of genes, diseases, lifestyle, and environment, with chronic inflammation a key pathophysiological mechanism.

  • Assessment in physiotherapy involves physical performance tests