Frailty and Medical Nutrition
|By Rachel Sipaul, RD|
When we think of frailty it often conjures an image of a hunched over elderly person, edging along with a walking aid. The reality is that frailty is not always so easily recognisable and as such can take time to diagnose. The relationship with malnutrition is also of interest, malnutrition can play a role in the development of frailty, so it seems logical that as medical nutrition is used in the management of malnutrition, it also has a role in the management of frailty.
Frailty is defined as “a clinically recognised state of increased vulnerability among older adults. It is associated with a decline in an individual’s physical and psychological reserves” (British Geriatrics Society).
Clinically, a feature of physical frailty is loss of skeletal muscle mass and function (sarcopenia), which may or may not also have associated weight loss. Frail people are at a higher risk of adverse outcomes such as falls, delirium, admission to hospital or the need for long term care. In the UK, around 10% of people aged >65 years, increasing to 25-50% of those >85 years have frailty (BGS, 2015). While frailty does increase with age, it is not inevitable that ageing will result in frailty.
“Older people who are living with frailty often say they have fatigue, unintended weight loss, diminished strength and their ability to recover from illness, even minor ones, or injury is greatly reduced. This can have a marked impact on the quality and length of their lives.”
In looking at the above characteristics of frailty, we can see that this has similar effects as malnutrition. Some of the clinical consequences of malnutrition include increased falls risk, impaired recovery from illness and surgery, reduced muscle strength & frailty, and impaired psycho-social function (Malnutrition Pathway, 2017). To look at the similarities in more details, Laur et al (2017) investigated the relationship between the assessment tools used to assess frailty and malnutrition and found that while the tools assess different criteria, overlapping characteristics include; weight loss, functional capacity, weakness and cognitive status. They went on to consider that given there is common ground in the assessment of frailty and malnutrition, could combining interventions such as oral nutritional supplements (ONS) and physical activity be a way forward for simultaneously treating both conditions?
Another approach by Roberts et al (2019) was to look at managing malnutrition in patients that are also frail. They reported a recent meta-analysis (Verlaan, 2017) in which 68% of out-patients who were assessed to be malnourished, were also classified as frail. Weight loss is recognised as a modifiable risk factor for malnutrition, therefore correcting weight loss with an adequate provision of macro- and micro- nutrients may also lessen the risk of frailty. They went on to review different nutrition support options, including ONS stating “ONS in the form of energy- and protein- dense sip feeds can be effective to improve nutritional intake among malnourished older people, including those with frailty”.
Nutritional supplements have also been shown to be beneficial in improving the physical performance in frail and sarcopenic elderly. Veronese et al (2019) completed a systematic review and meta-analysis concluding that in particular multi-nutrient supplementation can improve a number of physical outcomes (handgrip strength, chair-rise time) in older people that are affected by specific medical conditions or by frailty/sarcopenia.
Frailty and malnutrition are related, though the full complexity of the relationship is beyond the scope of this short summary. Recent reviews have highlighted the role of ONS in both the treatment of malnutrition and improvement of physical function in the elderly with frailty, showing that medical nutrition does have a role to play in the management of frailty. This is an area of evolving research and one definitely worth keeping an active watch on.