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Frailty is a clinical condition where an older adult becomes more vulnerable to stress due to a decline in physical, psychological, and social reserves. It represents a state between healthy ageing and disability. A frail person may experience slower recovery from illness or injury and is at higher risk of hospitalisation, falls, and mortality. Frailty is not an inevitable part of ageing but a syndrome caused by multiple factors that reduce strength, endurance, and physiological function.
Global trends and statistics
Frailty affects about 10–15% of people aged 65 and above worldwide, with prevalence increasing to over 40% among those aged 80 and above. Asia’s rapidly ageing population, including countries such as Japan and Singapore, faces rising frailty rates due to increased life expectancy and chronic diseases. According to the World Health Organization (WHO), by 2050, one in six people in the world will be over 65 years old, underscoring the urgency to address frailty as a public health concern.
Categories of frailty
Frailty is not limited to physical weakness. It involves several dimensions that interact and worsen each other over time. The main categories are physical, cognitive, and social frailty.
- Physical Frailty
Physical frailty is the most visible form. It involves loss of muscle strength, slow gait, exhaustion, and unintentional weight loss. These changes reduce a person’s ability to perform daily tasks and recover from illness. Common causes include ageing, chronic diseases, hormonal decline, and poor nutrition. People with physical frailty are at higher risk of falls, hospitalisation, and disability. Strength training, adequate protein intake, and early rehabilitation help maintain muscle mass and slow decline. - Cognitive Frailty
Cognitive frailty occurs when both physical weakness and mild cognitive impairment coexist, without dementia. It signals early brain vulnerability and often results from vascular disease, malnutrition, or depression. Affected individuals may have memory problems, slower reactions, or reduced concentration. Cognitive frailty increases the risk of dementia and loss of independence. Combined interventions such as exercise, mental training, and social engagement are key to prevention. - Social Frailty
Social frailty refers to reduced social participation and support. It often arises from retirement, bereavement, financial stress, or mobility issues. Socially frail individuals experience loneliness, lack of help, and lower motivation for self-care, which worsen both physical and mental health. Staying socially connected through community activities or volunteer programs protects against decline.
These categories often overlap. A person who becomes socially isolated may lose physical strength and mental sharpness. Addressing all three areas together provides the best outcomes for older adults.
How frailty is measured?
Measuring frailty helps clinicians predict health outcomes and tailor interventions. The most widely used models are:
Fried Frailty Phenotype (FFP)
This method identifies frailty based on five criteria – unintentional weight loss, weakness (grip strength), slow walking speed, self-reported exhaustion, and low physical activity. Meeting three or more criteria classifies a person as frail, while one or two indicates a pre-frail state.Frailty Index (FI)
Developed by Rockwood and Mitnitski, this model views frailty as the accumulation of health deficits. It considers symptoms, diseases, disabilities, and lab abnormalities to generate a score between 0 and 1. A higher score indicates greater frailty severity.Clinical Frailty Scale (CFS)
A simple visual and descriptive tool rating frailty from 1 (very fit) to 9 (terminally ill). It is often used in hospitals and long-term care to guide treatment intensity and care planning.Edmonton Frail Scale (EFS)
A multidimensional tool assessing cognition, balance, nutrition, medication use, and social support. It provides a quick overview of both physical and psychosocial frailty domains.
These tools allow healthcare teams to identify early signs of decline, initiate rehabilitation, and monitor progression over time.
What leads to frailty?
Frailty develops through a combination of biological, social, and environmental factors. Chronic diseases such as diabetes, cardiovascular disease, chronic kidney disease, and arthritis accelerate muscle loss and inflammation, which weaken the body’s resilience. Poor nutrition, particularly inadequate protein and calorie intake, contributes to sarcopenia and weight loss. A sedentary lifestyle and prolonged bed rest further reduce muscle mass and balance. Hormonal changes, including decreased testosterone and growth hormone, lower muscle regeneration.
Medication-related issues, especially polypharmacy, can worsen frailty through side effects like dizziness, fatigue, or confusion. Psychological stress, depression, and social isolation reduce motivation for self-care and physical activity. Over time, these factors interact to create a cycle of decline, where reduced strength leads to inactivity, which then worsens frailty.
Outcomes of frailty
Frailty leads to multiple adverse outcomes that affect both the individual and the healthcare system. Frail older adults are more prone to falls, fractures, and prolonged hospital stays. Recovery from infections or surgery tends to be slower, and complications are more common. Frailty also increases the likelihood of institutionalisation in nursing homes and contributes to higher healthcare costs.
On a personal level, frailty reduces quality of life, independence, and confidence in performing daily activities. Studies have consistently shown that frailty is a strong predictor of mortality among older adults, even more than age or comorbidities alone. Early identification and management are therefore crucial to improving outcomes.
Conclusion
Frailty is a multidimensional syndrome reflecting the body’s reduced ability to cope with stress. It affects physical, cognitive, and social functions, leading to higher risks of falls, hospitalisation, and dependency. While frailty becomes more common with age, it is not an unavoidable outcome. Early detection through standardised assessment tools allows timely intervention. Addressing contributing factors such as chronic diseases, poor nutrition, and inactivity can help slow progression. Multidisciplinary care involving physicians, physiotherapists, dietitians, and social workers ensures that older adults maintain strength, autonomy, and dignity as they age.