Skip to Content
Internal MedicineGeriatricsFrailty In The Elderly

Frailty In The Elderly

Introduction to Frailty for MCCQE1

Frailty is a state of increased vulnerability to poor resolution of homoeostasis after a stressor event, which increases the risk of adverse outcomes, including falls, delirium, and disability. For MCCQE1 preparation, understanding frailty is crucial as it represents a shift from disease-oriented medicine to patient-centred, functional medicine—a core tenet of the CanMEDS framework (specifically the Medical Expert and Health Advocate roles).

In the Canadian context, with an aging population, recognizing frailty allows for better resource allocation, appropriate care planning, and the implementation of the Comprehensive Geriatric Assessment (CGA).

🍁

Canadian Context: Over 1.6 million Canadians are considered medically frail. The concept of frailty as a cumulative deficit model was pioneered in Canada by Dr. Kenneth Rockwood at Dalhousie University (Clinical Frailty Scale).

Pathophysiology and Etiology

Frailty is considered a multisystem dysregulation. It is not an inevitable part of aging, but rather a distinct clinical syndrome.

The Cycle of Frailty

The pathophysiology is often described as a cycle of energy dysregulation:

  1. Sarcopenia (loss of muscle mass)
  2. Reduced metabolic rate
  3. Decreased total energy expenditure
  4. Chronic undernutrition
  5. Physiological vulnerability

Key Distinctions for MCCQE1

  • Frailty ≠ Disability: Disability is difficulty performing tasks; frailty is the vulnerability leading to disability.
  • Frailty ≠ Comorbidity: While they overlap, a patient can be frail without multiple comorbidities, and vice versa.

Screening and Diagnosis

For the MCCQE1, you must be familiar with the two primary models of frailty used in Canada.

Fried’s Physical Phenotype

Frailty is diagnosed if 3 or more of the following 5 criteria are present (1-2 indicates “Pre-frail”):

  1. Unintentional Weight Loss: >10 lbs or >5% of body weight in the past year.
  2. Exhaustion: Self-reported (“Everything I did was an effort”).
  3. Low Physical Activity: Based on kcals expended per week.
  4. Slowness: Slow walking speed (standardized cut-offs).
  5. Weakness: Low grip strength (dynamometer measurement).

Mnemonic: W.E.A.K.S. (Weight loss, Exhaustion, Activity low, K-slow walking, Strength low)

The Clinical Frailty Scale (CFS)

Developed at Dalhousie University, the CFS is a 9-point scale used to summarize the overall level of fitness or frailty.

LevelCategoryDescription Summary
1Very FitRobust, active, energetic, motivated.
2WellNo active disease symptoms but less fit than level 1.
3Managing WellMedical problems are well controlled; not regularly active.
4Vulnerable”Pre-frail.” Symptoms limit activities; complain of being “slowed up.”
5Mildly FrailNeed help with high-order IADLs (finances, transportation, heavy housework).
6Moderately FrailNeed help with all outside activities and keeping house; help with bathing.
7Severely FrailCompletely dependent for personal care due to physical or cognitive issues.
8Very Severely FrailApproaching end of life; completely dependent; recovering from minor illness.
9Terminally IllLife expectancy <6 months, but not otherwise evidently frail.

Management: Comprehensive Geriatric Assessment (CGA)

The gold standard for managing frailty is the Comprehensive Geriatric Assessment (CGA). This is a high-yield topic for the MCCQE1. It is a multidimensional, multidisciplinary diagnostic process.

Step 1: Medical Assessment

Review comorbidities. Crucially, perform a Medication Review to identify polypharmacy and potential adverse drug reactions.

  • Checklist: Visual acuity, hearing, nutrition, pain.

Step 2: Functional Assessment

Evaluate the patient’s ability to function in their environment.

  • ADLs (Activities of Daily Living): DEATH (Dressing, Eating, Ambulating, Toileting, Hygiene).
  • IADLs (Instrumental ADLs): SHAFT (Shopping, Housekeeping, Accounting, Food prep, Telephone/Transportation).

Step 3: Psychological Assessment

Screen for the “3 Ds” of Geriatrics:

  • Dementia: (e.g., MMSE, MoCA).
  • Depression: (e.g., Geriatric Depression Scale).
  • Delirium: (e.g., CAM - Confusion Assessment Method).

Step 4: Social Assessment

Evaluate social support systems, caregiver burden, and financial stability.

  • Home Safety: Stairs, rugs, lighting.
  • Advance Care Planning: Goals of care discussions.

Polypharmacy and Deprescribing

Polypharmacy is a major contributor to frailty.

MCCQE1 High-Yield: Deprescribing

Always consider if a new symptom is a side effect of a medication (“Prescribing Cascade”).

  • Beers Criteria: List of potentially inappropriate medications in older adults.
  • STOPP/START Criteria: Screening Tool of Older Persons’ Prescriptions.
  • Canadian Resource: Refer to Deprescribing.org (Bruyère Research Institute) for algorithms on stopping PPIs, Benzodiazepines, and Antipsychotics.

Canadian Guidelines

Choosing Wisely Canada

Relevant recommendations for Geriatrics:

  1. Don’t use benzodiazepines or other sedative-hypnotics in older adults as a first choice for insomnia, agitation, or delirium.
  2. Don’t use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.
  3. Don’t prescribe antibiotics for asymptomatic bacteriuria in non-catheterized patients.

Canadian Geriatrics Society (CGS)

The CGS emphasizes the “5 Ms” of Geriatrics:

  1. Mind (Cognition, Depression, Delirium)
  2. Mobility (Falls, Gait)
  3. Medications (Polypharmacy)
  4. Multi-complexity (Frailty, Multimorbidity)
  5. Matters Most (Goals of Care)

Key Points to Remember for MCCQE1

  • Reversibility: Frailty is dynamic. Early intervention (exercise, nutrition) can reverse frailty or delay progression.
  • Falls: Frailty is the single strongest predictor of falls.
  • Atypical Presentation: Frail elderly often present atypically (e.g., pneumonia presenting as delirium or a fall, rather than fever and cough).
  • Hospitalization: Hospitalization itself is a major risk factor for functional decline (“Hospital-associated disability”).
  • Vitamin D: Canadian guidelines recommend Vitamin D supplementation (800-2000 IU daily) for those at high risk of falls or fractures.
// Common Abbreviations in Geriatrics
ADL   = Activities of Daily Living
IADL  = Instrumental Activities of Daily Living
CGA   = Comprehensive Geriatric Assessment
CFS   = Clinical Frailty Scale
MoCA  = Montreal Cognitive Assessment
MMSE  = Mini-Mental State Examination

Sample Question

Clinical Scenario

A 79-year-old male presents to his family physician accompanied by his daughter. The daughter reports that her father has “slowed down” significantly over the past 6 months. He has lost 5 kg unintentionally during this period and reports feeling exhausted most days. He has stopped attending his weekly bowling league because he feels too weak. His past medical history includes hypertension and osteoarthritis. Physical examination reveals a slow gait speed and reduced grip strength. He is cognitively intact.

Which one of the following is the most appropriate initial step in the management of this patient?

  • A. Prescribe a high-calorie protein supplement immediately
  • B. Perform a Comprehensive Geriatric Assessment (CGA)
  • C. Order a CT scan of the head to rule out occult malignancy
  • D. Prescribe an SSRI for presumed depression
  • E. Refer to a long-term care facility for placement

Explanation

The correct answer is:

  • B. Perform a Comprehensive Geriatric Assessment (CGA)

Explanation: This patient exhibits classic signs of the Frailty Phenotype (Fried’s criteria): unintentional weight loss, self-reported exhaustion, low physical activity (quit bowling), slow gait, and weakness.

  • Option B is correct: The Comprehensive Geriatric Assessment (CGA) is the gold standard for managing frailty. It is a multidimensional process designed to determine a frail older person’s medical, psychological, and functional capability to develop a coordinated and integrated plan for treatment and long-term follow-up. It identifies reversible causes and targets interventions (e.g., exercise, medication review, nutrition).
  • Option A is incorrect: While nutrition is part of the management, prescribing supplements without a full assessment (including dental status, swallowing, social factors, and diet history) is premature.
  • Option C is incorrect: While weight loss can signal malignancy, the clinical picture strongly points to frailty. A CT head is not the initial step without other focal neurological signs, although investigations may be part of the CGA.
  • Option D is incorrect: While depression is a differential diagnosis (or comorbidity), diagnosing it requires meeting specific criteria (SIGECAPS). Treating with medication without assessment is inappropriate, especially given the risks of polypharmacy.
  • Option E is incorrect: Institutionalization is a last resort. The goal of treating frailty is to maintain independence and function in the community for as long as possible.

References

  1. Medical Council of Canada. MCC Objectives for the Qualifying Examination Part I. Available at: mcc.ca 
  2. Rockwood K, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-495.
  3. Fried LP, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.
  4. Choosing Wisely Canada. Geriatrics. Available at: choosingwiselycanada.org/geriatrics 
  5. Deprescribing.org. Deprescribing Algorithms. Bruyère Research Institute. Available at: deprescribing.org 
  6. Public Health Agency of Canada. Aging and Chronic Diseases: A Profile of Canadian Seniors.
Last updated on
FallsAnemia