SALT LAKE CITY — Diagnosing frailty in a nursing home resident is often easier said than done.
At the annual symposium of the American Medical Directors Association, Dr. John E. Morley called a generally accepted definition of frailty useful but not practical for most nursing homes because they don't have the time or the staff to test for the criteria that constitute that definition. “Unless someone's reimbursing you, you probably don't have the time to do this in your practice,” said Dr. Morley, professor of gerontology at St. Louis University.
He was referring to the criteria set forth by Dr. Linda P. Fried of the Johns Hopkins Medical Institutions and her associates in 2001. They characterized frailty in older adults as a clinical syndrome occurring when three or more of the following criteria are present: unintentional loss of at least 10 pounds in the past year, self-report of exhaustion, extremely weak grip strength, slow walking speed over 15 feet, and low physical activity as measured by calories expended per week (J. Gerontol. A Biol. Sci. Med. Sci. 2001;56:M146–57).
Instead, Dr. Morley suggested a frailty screening tool developed by the International Academy of Nutrition and Aging, based on simpler answers to questions suggested by the mnemonic FRAIL. F stands for fatigue (Is the person fatigued?); R for resistance (Can the person walk up at least one flight of stairs?); A for aerobic (Can the person walk at least one block?); I for illness (Does the person have more than five illnesses?); and L for loss of weight (Has the person lost more than 5% of his or her weight in the past year?) (J. Am. Med. Dir. Assoc. 2008;9:71–2).
“If you want to measure for frailty quickly in the nursing home setting, this is a nice way to do it,” said Dr. Morley, who is editor in chief of the Journal of the American Medical Directors Association. He noted that validation studies of the screening tool are currently underway. He said it's already clear that the tool “is far more useful than an echocardiogram” in revealing frailty.
Measuring frailty is important because of its direct link to poor nutrition, said Dr. Morley. Recent studies have demonstrated that frail older people consume fewer than 21 kcal/day and have lower than normal intake of protein, vitamin D, vitamin E, vitamin C, and folate.
“We should be pushing for a balanced diet,” rather than just administering multivitamins, he said. “Much of the literature that's coming out suggests that balanced diet is what matters.”
Eating right is hard to do for anyone, let alone a frail elderly person, he added. “If you look at what the average American eats, we often don't come close to five servings of fruits and vegetables a day.”
Weight loss in nursing home residents is a matter of major concern. A study of underweight nursing home residents found that 30% of residents who continued to lose weight died over the next 6 months, while the 6-month mortality rate was 20% among those whose weight stabilized, and 10% among people whose weight loss was reversed (J. Nutr. Health Aging 2002;6:275–81).
The causes of weight loss include anorexia, cachexia, rheumatoid cachexia, sarcopenia, malabsorption, hypermetabolism, and dehydration. “It is now well recognized that not only is weight loss bad for nursing home residents, but anorexia independently predicts mortality at a slightly higher hazard ratio than weight loss,” Dr. Morley said.
He recommends the Simplified Nutritional Appetite Questionnaire as a “simple, easy” way to screen for anorexia. Developed by the Council for Nutritional Strategies in Long-Term Care, this tool is a four-item, single-domain questionnaire. Responses are scored by using a 5-point, verbally labeled Likert-type scale, low scores indicating deterioration in appetite (Am. J. Clin. Nutr. 2005;82:1074–81).
The questionnaire “has very good sensitivity and specificity for weight loss, and it can predict weight loss 6 months down the line,” commented Dr. Morley.
Measuring frailty in elderly patients is important because of its direct link topoor nutrition. DR. MORLEY