A practical approach to frailty
Incorporating simple assessments into routine consultations can help general practice nurses identify the overlapping syndromes of frailty, sarcopenia and malnutrition
There are an estimated 1.8 million people in the UK aged 60 and over living with frailty.1 Prevalence is expected to rise as people live longer with multiple long-term conditions.2 With an annual cost to the NHS of around £5.8 billion a year,3 and a detrimental impact on an individual’s well-being and quality of life, strategies to optimise nutrition and function are key components of prevention and treatment. Frailty has been identified as an NHS priority.4
‘A Guide to Managing Frailty, Sarcopenia and Malnutrition’, developed by the Malnutrition Pathway, aims to enable healthcare professionals to recognise the signs of frailty, sarcopenia and malnutrition, and encourage action to identify and tackle contributory nutritional issues.
Frailty, sarcopenia and malnutrition are overlapping syndromes, which can perpetuate each other. Unintended weight loss, slow gait speed, low energy expenditure, self-reported exhaustion and poor grip strength are all typically associated with frailty, but are equally present in sarcopenia and in malnutrition.5 Malnutrition plays a key role in the pathogenesis of sarcopenia and frailty, and the prevalence of malnutrition increases with increasing severity of frailty.6
SARCOPENIA
Sarcopenia is defined as loss of muscle mass, function or strength. It is common among older adults but can also occur earlier in life, from the fourth decade. Disease, especially inflammatory conditions, inactivity, and poor nutrition can all contribute.7 Sarcopenia can arise in the absence of malnutrition from muscle disuse or a lack of muscle stimulation (e.g. as a result of acute or progressive disease, bed rest, immobility), and may be present, although not as obviously, in individuals with obesity. However, malnutrition is associated with an approximately three to four times risk of developing sarcopenia compared with those without malnutrition.8,9
In primary care, practical evidence-based tools e.g. the SARC-F questionnaire – a 5-item questionnaire – can be used to determine the likelihood of sarcopenia.10 A score of ≥4 suggests sarcopenia is likely. The SARC-F questionnaire should be followed by simple strength measurements, such as hand-grip strength and the 30 second chair stand test.
MANAGEMENT
By incorporating a number of simple assessments into consultations all health and care professionals can assist in identifying frailty, sarcopenia and malnutrition. Although these conditions are often considered to be an in inevitable part of ageing, all can respond to interventions around nutrition, exercise and medicines usage.11 The combination of muscle strength training and protein supplementation has been found to be the most effective intervention to delay or reverse frailty and the easiest to implement in primary care.12
Protein quantity and quality are both important determinants in the capacity of protein to influence muscle health,13 and the resource outlines considerations for protein consumption while also highlighting the importance of exercise to enhance protein uptake. In addition, consider vitamin D supplementation, hydration, medicines management, social support, cognitive function, co-morbidity optimisation and falls and fragility fracture prevention.
- ‘A Guide to Managing Frailty, Sarcopenia and Malnutrition’ is available at www.malnutritionpathway.co.uk/frailty_guide
Production of the frailty resource has been made possible by an unrestricted educational grant from Abbott.
REFERENCES
1. NIHR Dissemination Centre. Themed Review—Comprehensive Care: Older People Living with Frailty in Hospitals. National Institute of Health Research, 2017.
2. Kingston A, et al. Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Age and Ageing. 2018; 47 (3): 374-380.
3. NHS Confederation. Supporting People with Frailty. 12 March 2024. www.nhsconfed.org/publications/supporting-people-frailty
4. NHS Long Term Plan. 2019. www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
5. Dodds R, Sayer AA. Sarcopenia and frailty: new challenges for clinical practice. Clin Med (Lond). 2016 Oct;16(5):455-458
6. Verlaan S, et al. High Prevalence of Physical Frailty Among Community-Dwelling Malnourished Older Adults-A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2017 May 1;18(5):374-382.
7. Cruz-Jentoft A, Sayer A. Sarcopenia. The Lancet. 2019; 393(10191): 2636-2646.
8. Beaudart C, et al. Malnutrition as a strong predictor of the onset of sarcopenia. Nutrients. 2019; 11(12): 2883.
9. Batsis JA, Villareal DT. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies. Nat Rev Endocrinol. 2018; 14(9): 513-537.
10. Malmstrom TK, Morley JE. SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. J Am Med Dir Assoc.2013;14(8):531-532.
11. Morley J, et al. Frailty Consensus: A Call to Action. J Am Med Dir Assoc 2013;14(6):392-3973
12. Travers J et al. Delaying and reversing frailty: a systematic review of primary care interventions. British Journal of General Practice 2019; 69 (678): e61-e69.
13. Deutz and Wolfe. Is there a maximal anabolic response to protein intake with a meal? Clin Nutr. 2013; 32:309–13.