EDITORIALS

Frailty: Toward a Clinical Definition

Gabor Abellan van Kan, MD, Yves M. Rolland, MD, John E. Morley, MB, BCh, and Bruno Vellas, MD

While most clinicians believe they can recognize a frailolder person, there is a lack of consensus as to what definesfrailty and how it should be diagnosed clinically.1,2 For thisreason, a Geriatric Advisory Panel of the International Acad-emy of Nutrition and Aging has postulated a new approach todefining frailty and a case-finding tool.3 The major agreementof the group was that for frailty to be a useful clinical condi-tion, it should be considered a predisability state. Theystressed that, conceptually, frailty should exclude persons withdisability (ie, physical impairment that interferes with theability to perform activities of daily living).

Most definitions of frailty have considered it to be a statewhere there is increased vulnerability to stressors.1,4,5,6 Whena frail individual is exposed to a stressor, it is postulated thatthey are at increased risk of developing disability or otheradverse outcomes (like death, hospitalization, or institution-alization). Thus, the frailty syndrome is part of a continuumsituated between the normal physiological changes of agingand the final state of disability and death.

Commonly used definitions of frailty include the Friedcriteria.7 These criteria, which have been widely embraced,include exhaustion (fatigue), weight loss, measured gripstrength and walking speed, and low energy expenditure. Thelack of standards for some of the measurements, the difficultyin performing these tests in frail older persons especially in thenursing home,8 and the failure of this group to exclude dis-ability have limited the incorporation of these evidence-basedcriteria into general clinical practice.

Rockwood and colleagues9 have created a frailty indexbased on disability and illnesses. It appears to be predictive ofdeath and institutionalization.10 It may also predict pooroutcomes in the nursing home.

The Short Physical Performance Battery (gait speed, re-peated chair stands, and tandem balance) was found to bepredictive of disability in nondisabled community living el-

Department of Geriatric Medicine, University Hospital of Toulouse, INSERMU558 University of Toulouse III, Toulouse, France (G.A.v.K., Y.R., B. Vellas);GRECC, VA Medical Center and Division of Geriatric Medicine, Saint LouisUniversity School of Medicine, St. Louis, MO (J.E.M.).

The authors have no conflicts of interest in regards to this article.

Address correspondence to John E. Morley, MB, BCh, Division of GeriatricMedicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd.,M238, St. Louis, MO 63104. E-mail: morley@slu.edu

Published by Elsevier, Inc on behalf of the American Medical DirectorsAssociation

DOI: 10.1016/j.jamda.2007.11.005

EDITORIALS

derly.11 Rolland et al12 confirmed the utility of this approachin the EPIDOS study.

The Mini-Nutritional Assessment (MNA) has been usedin clinical practice to assess nutritional status.13 Given theimportance of weight loss as a marker for future disability, hipfracture, institutionalization, and death, it would appear thatpersons who are identified at nutritional risk by the MNA canbe considered to be frail.14 –19

Based on these definitions, the Geriatric Advisory Panel feltthat while a clear definition of frailty is not at this stage ofresearch easily created, it would be highly useful to develop asmall screening tool to identify persons at risk for frailty. Such atool should be easily utilizable by physicians in practice andrequire a minimum time for administration. Ideally, it could alsobe administered by other health professionals or even caregivers.To this end, they proposed the “FRAIL” scale, which consists of5 domains (Table 1). Validation of this simple approach is stillrequired. The panel felt that those who screened positive by thisscale would then be suitable candidates to undergo a compre-hensive geriatric assessment and targeted intervention to pre-vent the frailty-associated adverse outcomes.20 –22

With tools such as these available, the panel felt it wouldbecome easier to untangle the complex physiopathologicalpathways leading to frailty. This would allow the study of theinteraction of factors that seem to synergistically lead to frailtysuch as anemia,23,24 orthostasis,25 weight loss,26 sarcope-nia,27–29 polypharmacy,30,31 congestive heart failure,32,33

diabetes mellitus,34 –36 osteopenia,37,38 hypovitaminosisD,39 – 41 testosterone deficiency,42– 44 cytokine excess,45– 47

low-protein diets,48 and decline in executive function.49,50

We believe that identification of frail older persons at highrisk for further deterioration represents a major step forward inallowing clinicians to provide high-quality care for this vul-nerable population. The “FRAIL” screening scale will allowrapid identification of these persons with subsequent targetedintervention. It would also allow an independent methodto evaluate quality indicators such as those proposed by As-

Table 1. The “FRAIL” Scale

FatigueResistance (ability to climb 1 flight of stairs)Ambulation (ability to walk 1 block)Illnesses (greater than 5)Loss of Weight (�5%)

sessing Care of Vulnerable Elders (ACOVE).51,52

van Kan et al 71

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