John E. Morley, MB, BCh
Division of Geriatric Medicine and Endocrinology
Saint Louis University School of Medicine
St. Louis, Missouri, USA

In 2013 a consensus meeting of 6 societies (IAGG, EUGMS, AMDA, IANA, AFAR and SCWD) called for screening by health professionals of all persons 70 years and older for frailty [1]. Whether or not this approach was feasible or useful has been questioned [2]. This question has now been answered in the resounding affirmative by a large study from the Toulouse Gérontopôle on their Geriatric Frailty Clinic [3]. This study demonstrated that general practitioners can screen for frailty and when these frail persons are referred for a full geriatric assessment, a variety of treatable conditions are identified.

The concept of physical frailty as a precursor for disability was identified by Fried et al [4,5]. Since then numerous studies have shown that frailty is highly predictive of a variety of poor outcomes [6,7]. The study from the Gérontopole represents the first study showing that aggressive management of frailty can potentially reduce that progression to disability and other negative outcomes.

The causes of frailty are multifactorial requiring a interdisciplinary geriatric group to optimally identify and treat the frail individual [8,9]. A major cause of frailty is sarcopenia [10,11]. There is increasing evidence that aerobic and resistance exercise will successfully improve this aspect of frailty [12,13]. In addition, a high protein diet (or supplementation) also appears to have some utility [14]. Persons with sarcopenia are at high risk of falls and should also be screened with the Toulouse-St. Louis University Minifalls Assessment and have a focused treatment on other falls risk factors [15]. A number of pharmaceutical agents, such as selective androgen receptor molecules, are under development for treatment of sarcopenia, but the evidence for their utility is limited [16,17].

The other major cause of frailty is the anorexia of aging, leading to protein energy malnutrition [18,19]. Screening for anorexia and being at risk for protein energy malnutrition can be effected with a combination of the Simplified Nutrition Assessment Questionnaire (SNAQ) and the MiniNutritional Assessment (MNA) [20,21,22,23]. Utilization of the “MEALS-ON-WHEELS” mnemonic to identify treatable causes of anorexia, together with caloric supplements between meals are readily available treatment strategies [24,25].

The other components of frailty re fatigue where depression is a major treatable component [26]. Other causes of fatigue include sleep apnea, anemia, vitamin B12 deficiency, hypothyroidism and Addison’s disease. Finally, inappropriate polypharmacy often decreases function in older persons and a careful review of medicines can lead to an improvement in frailty [27,28].

The FRAIL questionnaire has now been well validated in multiple populations [29,30,31]. It consists of 5 simple questions and can be answered before a physician visit. Simple approaches such as this make it easy for healthy professionals to rapidly screen for physical frailty.

Finally, it should be recognized that there is increasing evidence that cognitive decline acts synergistically with physical frailty to accelerate the trajectory to disability [32,33,34,35,36]. This concept of “cognitive frailty” or “the frail brain” is becoming well recognized. The Toulouse Gérontopole had the prescience to include a screen for cognitive defects in their screening questionnaire [37,38,39,40]. This will markedly increase the value of future studies from this group as they validate the utility of general practitioner screening for frailty and early cognitive decline.

1. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392-7.
2. Xue QL, Varadhan R. What is missing in the validation of frailty instruments? J Am Med Dir Assoc 2014;15:141-2.
3. Tavassoli N, Guyonnet S, Abellan van Kan G, et al. Description of 1,108 older patients referred by their physician to the “Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability” at the Gerontopole. J Nutr Health Aging 2014. In Press.
4. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146-56.
5. Walston J, Fried LP. Frailty and the older man. Med Clin North Am 1999;83:1173-94.
6. Morley JE. Frailty: Diagnosis and management. J Nutr Health Aging 2011;15:667-70.
7. Morley JE. Developing novel therapeutic approaches to frailty. Curr Pharm Des 2009;15:3384-95.
8. Hoogendijk EO, van Hout HP. Investigating measurement properties of the Groningen Frailty Indicator: A more systematic approach is needed. J Am Med Dir Assoc 2012;13:757.
9. Gobbens RJ, van Assen MA, Luijkx KG, Wijnen-Sponselee MT, Schols JM. Determinants of frailty. J Am Med Dir Assoc 2010;11:356-64.
10. Morley JE, Abbatecola AM, Argiles JM, et al. Sarcopenia with limited mobility: An international consensus. J Am Med Dir Assoc 2011;12:403-9.
11. Landi F, Liperoti R, Fusco D, et al. Sarcopenia and mortality among older nursing home residents. J Am Med Dir Assoc 2012;13:121-6.
12. Singh NA, Quine S, Clemson LM, et al. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: A randomized controlled trial. J Am Med Dir Assoc 2012;13:24-30.
13. Pillard F, Laoudj-Chenivesse D, Carnac G, et al. Physical activity and sarcopenia. Clin Geriatr Med 2011;27:449-70.
14. Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE Study Group. J Am Med Dir Assoc 2013;14:542-59.
15. Morley JE, Rolland Y, Tolson D, Vellas B. Increasing awareness of the factors producing falls: The mini falls assessment. J Am Med Dir Assoc 2012;13:87-90.
16. Paponicolaou DA, Ather SN, Zhu H, et al. A phase IIA randomized, placebo-controlled clinical trial to study the efficacy and safety of the selective androgen receptor modulator (SARM), MK-0773 in female participants with sarcopenia. J Nutr Health Aging 2013;17:533-43.
17. Dalton JT, Barnette KG, Bohl CE, et al. The selective androgen receptor modulator GTx-024 (enobosarm) improved lean body mass and physical function in health elderly men and postmenopausal women: Results of a double-blind, placebo-controlled phase II trial. J Cachexia Sarcopenia Muscle 2011;2:153-61.
18. Morley JE. Anorexia of aging: A true geriatric syndrome. J Nutr Health Aging 2012;16:422-5.
19. Soenen S, Chapman IM. Body weight, anorexia, and undernutrition in older people. J Am Med Dir Assoc 2013;14:642-8.
20. Salva A, Coll-Planas L, Bruce S, et al. Nutritional assessment of residents in long-term care facilities (LTCFs): Recommendations of the Task Force on Nutrition and Ageing of the IAGG European region and the IANA. J Nutr Health Aging 2009;13:475-483.
21. Vellas B, Villars H, Abellan G, et al. Overview of the MNA—Its history and challenges. J Nutr Health Aging 2006;10:456-63.
22. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: Simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr 2005;82:1074-81.
23. Rolland Y, Perrin A, Gardette V, Filhol N, Vellas B. Screening people at risk of malnutrition or malnourished using the Simplified Appetite Questionnaire (SNAQ): A comparison with the Mini-Nutritional Assessment (MNA) tool. J Am Med Assoc 2012;13:31-4.
24. Silver AJ, Morley JE, Strome LS, Jones D, Vickers L. Nutritional status in an academic nursing home. J Am Geriatric Soc 1988;36:487-91.
25. Morley JE. Weight loss in older persons: New therapeutic approaches. Curr Pharm Des 2007;13:3637-47.
26. Morley JE. Depression in nursing home residents. J Am Med Dir Assoc 2010;11:301-3.
27. Fitzgerald SP, Bean NG. An analysis of the interactions between individual comorbidities and their treatments—implications for guidelines and polypharmacy. J Am Med Dir Assoc 2010;11:475-84.
28. Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle-aged African Americans. J Nutr Health Aging 2012;16:601-18.
29. Woo J, Leung J, Morley JE. Comparison of frailty indicators based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation. J Am Geriatr Soc 2012;60:1478-86.
30. Hyde Z, Flicker L, Almeida OP, et al. Low free testosterone predicts frailty in older men: The health in men study. J Clin Endocrinology Metab 2010;95:3165-72.
31. Ravindrarajah R, Lee DM, Pye SR, et al. European Male Aging Study Group. The ability of three different models of frailty to predict all-cause mortality: Results from the Euopean Male Aging Study (EMAS). Arch Gerontol Geriatr 2013;57:360-8.
32. Dartigues JF, Amieva H. Cognitive frailty: Rational and definition from an (I.A.N.A/I.A.G.G.) international consensus group. J Nutr Health Aging 2014;18:95.
33. Kelaiditi E, Cesari M, Canevelli M, et al. Cognitive frailty: Rationale and definition from an (I.A.N.A./I.A.G.G.) international consensus group. J Nutr Health Aging 2013;17:726-34.
34. Malmstrom TK, Morley JE. Frailty and cognition: Linking two common syndromes in older persons. J Nutr Health Aging 2013;17:723-5.
35. Malmstrom TK, Morley JE. The frail brain. J Am Med Dir Assoc 2013;14:453-5.
36. Shimada H, Makizako H, Doi T, et al. Combined prevalence of frailty and mild cognitive impairment in a population of elderly Japanese people. J Am Med Dir Assoc 2013;14:518-24.
37. Vellas B, Balardy L, Gillette-Guyonnet S, et al. Looking for frailty in community-dwelling older persons: The Gerontopole Frailty Screening Tool (GFST). J Nutr Health Aging 2013;17:629-31.
38. Rougé Bugat ME, Cestac P, Oustric S, Vellas B, Nourhashemi F. Detecting frailty in primary care: A major challenge for primary care physicians. J Am Med Dir Assoc 2012;13:669-72.
39. De Souto Barreto P, Vellas B, Morley JE, Rolland Y. The nursing home population: An opportunity to make advances on research on multimorbidity and polypharmacy. J Nutr Health Aging 2013;17:399-400.
40. Vellas B, Cestac P, Morley JE. Implementing frailty into clinical practice: We cannot wait. J Nutr Health Aging 2012;16:599-600.