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a The John Hopkins Medical Institutions, Baltimore, Maryland
b The University of Washington, Seattle
c The University of Pittsburgh, Pennsylvania
d The University of California at Davis, Sacramento
e St. Francis Hospital, Roslyn, New York
f The University of California at Los Angeles
g The University of Vermont, Burlington
h Uniformed Services University of the Health Sciences, Bethesda, Maryland
i Wake Forest University School of Medicine, Winston-Salem, North Carolina
Linda P. Fried, Director, Center on Aging and Health, The Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 2-700, Baltimore, MD 21205 E-mail: lfried{at}welch.jhu.edu.
Decision Editor: John E. Morley, MB, BCh
Background. Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established.
Methods. To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989–90 and 582 from an African American cohort recruited in 1992–93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality.
Results. Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29–2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3–4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline).
Conclusions. This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.
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T. M. Gill, E. A. Gahbauer, H. G. Allore, and L. Han Transitions between frailty States among community-living older persons. Arch Intern Med, February 27, 2006; 166(4): 418 - 423. [Abstract] [Full Text] [PDF]
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S. L. Wolf, M. O'Grady, K. A. Easley, Y. Guo, R. W. Kressig, and M. Kutner The influence of intense tai chi training on physical performance and hemodynamic outcomes in transitionally frail, older adults. J. Gerontol. A Biol. Sci. Med. Sci., February 1, 2006; 61(2): 184 - 189. [Abstract] [Full Text] [PDF]
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M. Cesari, S. B. Kritchevsky, B. J. Nicklas, B. W. H. J. Penninx, P. Holvoet, P. Koh-Banerjee, S. R. Cummings, T. B. Harris, A. B. Newman, and M. Pahor Lipoprotein Peroxidation and Mobility Limitation: Results From the Health, Aging, and Body Composition Study Arch Intern Med, October 10, 2005; 165(18): 2148 - 2154. [Abstract] [Full Text] [PDF]
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L. A. Wray, M. B. Ofstedal, K. M. Langa, and C. S. Blaum The Effect of Diabetes on Disability in Middle-Aged and Older Adults J. Gerontol. A Biol. Sci. Med. Sci., September 1, 2005; 60(9): 1206 - 1211. [Abstract] [Full Text] [PDF]
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 L. P. Fried, E. C. Hadley, J. D. Walston, A. B. Newman, J. M. Guralnik, S. Studenski, T. B. Harris, W. B. Ershler, and L. Ferrucci From Bedside to Bench: Research Agenda for Frailty Sci. Aging Knowl. Environ., August 3, 2005; 2005(31): pe24 - pe24. [Abstract] [Full Text]
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 E. W Gregg and C. J Caspersen Review: Physical disability and the cumulative impact of diabetes in older adults The British Journal of Diabetes & Vascular Disease, January 1, 2005; 5(1): 13 - 17. [Abstract] [PDF]
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T. M. Gill, H. G. Allore, T. R. Holford, and Z. Guo Hospitalization, Restricted Activity, and the Development of Disability Among Older Persons JAMA, November 3, 2004; 292(17): 2115 - 2124. [Abstract] [Full Text] [PDF]
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A. M. Payne, S. L. Dodd, and C. Leeuwenburgh Life-long calorie restriction in Fischer 344 rats attenuates age-related loss in skeletal muscle-specific force and reduces extracellular space J Appl Physiol, December 1, 2003; 95(6): 2554 - 2562. [Abstract] [Full Text]
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A. Mitnitski and K. Rockwood Help Available--Phenomenological Models for Research on Aging Sci. Aging Knowl. Environ., March 26, 2003; 2003(12): vp2 - 2. [Abstract] [Full Text]
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J. E. Morley and J. H. Flaherty Editorial It's Never Too Late: Health Promotion and Illness Prevention in Older Persons J. Gerontol. A Biol. Sci. Med. Sci., June 1, 2002; 57(6): M338 - 342. [Full Text]
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W. M. Bortz II A Conceptual Framework of Frailty: A Review J. Gerontol. A Biol. Sci. Med. Sci., May 1, 2002; 57(5): M283 - 288. [Abstract] [Full Text]
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A. M. Matsumoto Andropause: Clinical Implications of the Decline in Serum Testosterone Levels With Aging in Men J. Gerontol. A Biol. Sci. Med. Sci., February 1, 2002; 57(2): M76 - 99. [Full Text]
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J. E. Morley Editorial: Drugs, Aging, and the Future J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2002; 57(1): M2 - 6. [Full Text] [PDF]
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J. E. Morley Editorial: Andropause: Is It Time for the Geriatrician to Treat It? J. Gerontol. A Biol. Sci. Med. Sci., May 1, 2001; 56(5): 263M - 265. [Full Text]
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M. Gillick Guest Editorial: Pinning Down Frailty J. Gerontol. A Biol. Sci. Med. Sci., March 1, 2001; 56(3): 134M - 135. [Full Text]
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A. B. Newman, J. S. Gottdiener, M. A. McBurnie, C. H. Hirsch, W. J. Kop, R. Tracy, J. D. Walston, and L. P. Fried Associations of Subclinical Cardiovascular Disease With Frailty J. Gerontol. A Biol. Sci. Med. Sci., March 1, 2001; 56(3): 158M - 166. [Abstract] [Full Text]
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