As advances in medicine and pharmacology have extended the human lifespan, frailty has been the price of longevity. Frailty in the elderly is easily recognized by geriatric specialists, but has many different, overlapping definitions. Frailty is often paired with, but is not the same as, disability. It is always associated with muscle weakness and usually with unintentional weight loss and difficulty in performing one or more activities of daily living. Frailty often coexists with so many concurrent medical conditions that it is difficult for researchers to tell if frailty is a separate and distinct disease process. In the last 10 years, geriatricians and allied health care professionals who work with the elderly have learned a great deal about the complexities of frailty. Most researchers agree that a full understanding of frailty will be achieved only when the multiple interactions among all the body's systems, and the interaction of the person with his or her physical and social environment, are understood.
With coauthor Bob Thomas, I have reviewed the literature and presented an overview of definitions of frailty, coexisting conditions, and suggestions for ameliorating frailty, including exercise and treatment approaches for those who work with this vulnerable population. Katie Farrell describes selected assessment tools that can give information about the frail adult including degree of frailty, risk for falls, and endurance. In addition, screening tools are reviewed for their usefulness in referring the patient to other disciplines. Care of the frail patient is so complex that no one discipline has the knowledge or skill to provide comprehensive assessment and treatment. An interdisciplinary approach is essential.
Cognitive deficits place a person at high risk for frailty and dependence, and communication and instruction to those with cognitive loss is a particular challenge. Mike Studer writes about many aspects of cognitive rehabilitation in the frail elderly patient. He provides an overview of the effects of normal aging on cognition, then links safe mobility to cognitive skills, and presents a framework for evaluating and treating the person with cognitive deficits.
Alzheimer's disease and other dementias affect the majority of residents in long-term care facilities. Kim Warchol presents an interdisciplinary model of dementia care for long-term care. She explains the many different levels of cognition and function in people with dementia and advocates educating therapists and facility staff in adjusting activities and communication to match these levels. The goals of dementia care are to reduce unnecessary (excess) disability, reduce behaviors, and improve the resident's function and sense of well-being.
For the frail, disabled adult living in the community, adult day care provides medical services, socialization, and meaningful activity as well as a respite for family caregivers. Beverly Horowitz and Pei-Fen Chang describe a pilot study, conducted at a medical model day care center, which highlights the key role of occupational therapists in facilitating engagement in life and meaningful activity.
Good nutrition is vitally important to health, yet it can be difficult to maintain for frail elderly people. Weight loss is very common and leads to fatigue, muscle weakness, and difficulty participating in rehabilitation programs. Janelle Asai explains the many causes of loss of appetite, malnutrition, and weight loss in the elderly, and explains the role of the registered dietitian in assessing and solving nutritional problems.
No amount of studying about frailty or working with the frail elderly has taught me as much as my own father's experience. At 88 he enjoyed walking 2 to 4 miles, drove, and did yard work. He started to become frail at 89, when his arthritic knees began to wobble and he could no longer maintain his balance on the lawn. In 2002, at 90, he fell and fractured his hip, had an ORIF, and spent a month in a skilled nursing facility for rehabilitation. In the 5 weeks after his injury he lost 20 lb, remained pale and weak in spite of excellent physical therapy and occupational therapy, and suffered pain and the indignity of needing assistance for the first time in his life. At 7 months postop he was at a healthy weight and finally regained independent transfers and household ambulation with a walker. Fortunately, he never suffered any cognitive loss. He misses walking outdoors and depends on my mother for many activities of daily living. My father's experience taught me that rehabilitation cannot succeed without good nutrition, that exercise helps, that a clear mind goes a long way, and that quality of life is more important than length of life.
It is hoped that this issue of Topics in Geriatric Rehabilitation will be helpful to students and clinicians alike in furthering their understanding of the many issues surrounding frailty, and provide solid ideas for broadening their scope of intervention as well as encouraging referral to practitioners in other disciplines. It is also hoped that this issue will stimulate interest in following the intense research efforts now being conducted to elucidate the biologic, physiologic, genetic, psychosocial, and functional aspects of frailty, dementia, and related disorders. We can look forward to a time when new treatments to delay or prevent frailty will be discovered. Until then, patients and their loved ones can benefit from the variety of skilled interventions presented in this issue.