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Frailty and the future of old age
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Prof. Cees M Hertogh, MD,PhD
Geriatric Ethics
EMGO Institute for Health and Care Research
Topics
Analysis of the concept of ‘frailty’
Against the theoretical
background of ‘healthy ageing’
and its presuppositions
Seneca on old age
Ad Lucilium epistolae
morales
Seneca on old age
• I shall not abandon old
age, if old age preserves
me intact for myself, and
intact as regards the better
part of myself; but if old
age begins to shatter my
mind, and to pull its
various faculties to pieces,
if it leaves me, not like, but
only the breath of life, I
shall rush out of a house
that is crumbling and
tottering
Ad Lucilium epistolae morales
The transformation of health and illness
• Three era’s since 1900:
– Infectious disease
– Chronic disease
– ‘Senescence-process’
Compression of morbidity paradigm:
“A new syllogism for aging”
•1. natural life span is relatively fixed
•2. the age of first appearance of aging
manifestations and and chronic symptoms can
increase more rapidly than life expectancy
•3. therefore the duration of morbidity and disability
will decrease
• (James F. Fries, 1980)
Explanations and policy implications
• Early detection and ‘medicalization’ of chronic
disease
• Patient education and life style approaches
• Investment in ‘plasticity’ of ageing
• (Function-enhancing medical interventions)
• (improvements in built environment)
‘rectangularization’ of the survival curve
Grimley Evans on healthy old age:
• By delaying the onset of
disabling diseases to later
ages when intrinsic aging has
raised fatality by reducing
adaptability, the average
duration of disability before
death will be shortened.
• In brief: we shall spend a
longer time living and a
shorter time dying
Grimley Evans on healthy old age:
• By delaying the onset of
disabling diseases to later
ages when intrinsic aging
has raised fatality by
reducing adaptability, the
average duration of disability
before death will be
shortened.
• In brief: we shall spend a
longer time living and a
shorter time dying
Intrinsic ageing
• ‘homoeostenosis’ :
• The progressive narrowing
of the capacity to adapt
through loss of reserve
power
• ‘natural death’ :
• quality of host resistance >
nature of insult to
equilibrium
The future of old age from the point of view of
compression theory
Frailty: a controversial concept
• Multiple conceptualizations!
• Dictionary and daily life:
• Health care:
Frailty: a controversial concept
• Multiple conceptualizations!
• Dictionary and daily life:
– Liability to break or to be broken, weakness
– Moral weakness, instability of mind
– (susceptibility to be wounded)
• Health care:
Frailty: a controversial concept
• Multiple conceptualizations!
• Dictionary and daily life:
• Health care:
– Transition from service-directed concept (70’s)
– To ‘interventionist’ concept (90’s)
• ‘narrow’ biomedical concept (Fried)
• ‘broad’ epidemiological concept (Deeg, SCP, TFI)
Federal council on aging (USA):
• Persons, usually but not always over the age of
75, who because of an accumulation of various
continuing problems often require one or several
supportive services in order to cope with daily life
• (FCA, 1978)
• Frailty = Chronic disease = Disability
‘Frailty’ as a clinical syndrome:
• A biologic syndrome of decreased reserves in
multiple systems that result from dysregulation
that can occur with aging, disease, and/or lack of
activity or inadequate nutritional intake
• Primary and secondary frailty
• Progressive or temporary frailty
• (Fried et al, 2001)
The cycle of frailty (Dayhoff et al, 1998):
Phenotype of frailty
• Weight loss
• Low grip strength
• Low levels of physical activity
• Subjective exhaustion
• Slow walking speed
• (Fried et al, 2001)
Frailty according to the SCP:
• A heuristic term to identify risk groups
• A process involving the accumulation of physical,
psychological and/or social deficits in functioning
which increase the risk of adverse health
outcomes (functional impairments, admision to an
institution, death)
SCP, februari 2011:
• 2010:
– 700.000 frail persons (> 65 jr)
– 550.000 living independently
– 150.000 in care home or nursing home
• 2010 – 2030:
– > 1.000.000 frail persons
– = 300.000 increase, but 100.000 fewer than
expected
Recommendations and policy implications
• Early, preventive interventions
• Monitoring older persons with measurement
instruments (self administered)
• Responsibility for older person herself, as well as
for GP, home care and municipal officer
• Focus of interventions on life style approaches,
care network and resilience
• Fits in with present accent on self management
and personal responsibility for functional
autonomy and participation
Comments
• No evidence
• Antonym of ‘successful’ ageing
• Denies the patient perspective
• Potentially stigmatizing
• Unilateral focus on prevention denies the meaning
of frailty as a transitional state
Recent news from gerontology…
• The good news: the third age (young old)
• Increase in life expectancy: more people live longer
• Substantial latent potential for better fittness in old age
• Succesive cohorts show gains in physical and mental fitness
• Evidence of cognitive-emotional reserves of the aging mind
• More and more people age succesfully
• High levels of emotional and personal well-being (selfplasticity)
• Effective strategies to master the gains and losses of late life
Recent news from gerontology…
• The not-so-good or bad news: the fourth age (oldest
old)
• Sizeable losses in cognitive potential and ability to learn
• Increase in chronic stress syndrome
• Sizeable prevalence of dementia (about 50% in 90-yearolds)
• High levels of frailty, dysfunctionality and multimorbidity
• Dying at older ages: with human dignity?
•  prospects for the 21st century: the era of chronic
incompleteness of mind and body?
• (Baltes & Smith, BASE)