Frailty is a significant health problem in the elderly, including in Asia, where the number of elderly people is increasing rapidly. Therefore, physicians need to be actively assessing elderly for the presence and severity of frailty in order to provide the best possible care for them. The physiological development of frailty and sarcopenia is a continuum, highlighting the importance of identifying ways to prevent the development of frailty, and the transition from prefrailty to frailty among elderly people.

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Southeast Asia is undergoing rapid demographic transition, with a reduction in fertility, an ageing population and rural-to-urban migration. These trends have a significant impact on health in the region, with a shift from primarily infectious diseases to non-communicable chronic diseases (including hypertension, diabetes, cardiovascular/cerebrovascular disease, cancer, osteoporosis, dementia). (1)

An important aspect of this transition is the growing proportion of the population in Asia aged ≥65 years. In fact, across Asia, the number of elderly people is expected to treble by the year 2050, and there will be a marked increase in the number of people in the oldest age groups (75 years and above).(2)

Elderly people have unique health and social needs associated with declining functional capacity and increasing dependency. Because of declines in fertility, the elderly in Asia will have fewer adult children to support them in coming years, and the changing social and economic environment means that fewer elderly Asian people will live with extended family (2). Therefore, in addition to increasing physical health needs, many older Asian people must care for themselves in relative social isolation, and any physical health concerns can be exacerbated by psychological, economic and nutritional deprivations.

A key determinant of health outcomes in elderly people is frailty. Frail elderly people are more vulnerable to stresses, such that a small event has a disproportionately large effect on their physical and mental status. (3)

What is frailty?

Frailty is a result of physiological decline in multiple body systems (3):

  • Neurocognitive
  • Endocrine
  • Immune
  • Musculoskeletal
  • Respiratory
  • Cardiovascular
  • Renal
  • Haematological

These systems are intricately linked, ie, decline in one area can trigger worsening in another, and the cumulative effect of dysfunction in multiple physiological systems results in frailty. For example, because of the link between the brain and the endocrine system, physiological changes in the ageing brain affect the endocrine control of metabolism and energy use. One theory suggests that the accumulation of deficits within a number of systems determines the onset of frailty. (3) What is known is that frail people often have multiple impairments, including low bodyweight, cognitive impairment, fatigue, impaired mobility and problems with balance (4).

Five key clinical manifestations predict poor outcomes (Table 1) (5). These five clinical indicators, known as the Fried criteria, are commonly used to define frailty and prefrailty states in research on the impact of frailty, although other criteria exist. For example, the Frailty Risk Index (FRI) is a validated tool developed by Singapore researchers from the Singapore Longitudinal Ageing Studies, and it includes both risk factors and manifestations of frailty. (6).

TABLE 1 Fried criteria for defining frailty

Clinical manifestations:

  • Weakness (measured by hand grip strength)
  • Unintended weight loss (≥4.5 kg in the last year)
  • Low walking speed
  • Fatigue (self-reported; at least 3 times per week)
  • Low levels of activity
Not frail = 0 clinical manifestations
Pre-frail = 1 or 2 clinical manifestations
Frail = 3+ clinical manifestations

Source: Fried et al (2001)

Frailty is a dynamic process – individuals can transition between non-frail, pre-frail and frail states. However, it is much more common for them to progress to worse states than to transition to a less impaired state. (7)

Elderly people can be frail without having additional chronic disease, but chronic illness and frailty frequently overlap. This highlights the importance of carefully assessing frail elderly for early signs of comorbidity in order to implement preventive strategies. (3)

What causes frailty?

Frailty develops as a result of multiple physiological processes (Figure 1) (4). A common hypothesis is that the lifelong accumulation of molecular and cellular damage causes organ dysfunction (3). The organ dysfunction disrupts physiological homeostasis, and once the impairment exceeds the body’s capacity to compensate, the person begins to show signs and symptoms of frailty.

FIGURE 1 Hypothesized molecular, physiological and clinical pathway to frailty (4)

Source: Walston et al (2006).

Sarcopenia (loss of muscle mass) is an important contributor to frailty, and this is related to both anorexia (reduced food intake) and increased muscle protein breakdown. (8,9). Weight loss contributes to muscle wasting, and exacerbates some of the physiological changes associated with ageing, such as increased oxidative stress and worsening tissue damage (8). This perpetuates the cycle of physical decline by contributing to low energy and fatigue, reducing exercise capacity and the inherent effects of exercise on muscle building.

In addition to maintaining exercise, adequate nutrition is an important component of delaying or reversing the changes associated with frailty. Elderly people need to ensure that their caloric intake, and the essential nutrient content of their food, is adequate to maintain their declining systems. Poor nutrition is a key risk factor for frailty development. (6).

How common is frailty?

In Caucasian populations, the prevalence of frailty and prefrailty (as defined by the criteria in Table 1) is about 13.6% and 33.5%, respectively, in community-dwelling people aged ≥65 years (10).

In Asia, the prevalence of frailty (using Fried criteria), varies widely from 2% in Chinese adults in Singapore to 17.4% in a rural area of South Korea (Table 2) (11-18). However, it should be noted that these prevalence data are not all based on comparable populations (some were aged <65 years, and there was a mix of rural and urban dwelling people). The lowest rates of frailty are seen in studies from Taiwan or Singapore where the studied populations included individuals aged ≥50 or 55 years, respectively (13-14,18). In Asian populations aged ≥65 years, the prevalence varies between 7.4% and 17.4% (11-12,15-17),similar to the rates reported in Western populations (10).

TABLE 2 The prevalence of frailty and prefrailty in Asian studies using the Fried criteria

Source N Prevalence (of studied population)
Frailty Prefrailty
Makizako et al. 201511 4341 3.9% 49.6%
Shimada et al. 201312 5104 11.3%
Feng et al. 2016 (SLAS)13 2804 2.6% 33.3%
Feng et al. 2016 (SLAS)14 1575 2% 32%
South Korea
Jung et al. 201615 382 17.4% 52.6%
Jung et al. 2014 (KLoSHA)16 693 13.2% 59.4%
Kim et al. 201417 486 7.4% 50.2%
Liu et al. 2015 (I-Lan Longitudinal Aging Study)18 1839 3.6% 39.2%

*Study participants were aged ≥55 years; †Study participants were aged ≥50 year

Source: Fried et al (2001)

Why is frailty important?

Frail people can have a disproportionate and dramatic decline in their health status in response to apparently small insults (e.g. minor infection or minor surgery) (3). The impact of frailty is not just physical – frail elderly often become socially isolated and more susceptible to stressors as a result of their physical impairments (4).

Frailty significantly increases the risk of a number of adverse health outcomes in elderly people, including (3):

  • Falls
  • Worsening disability
  • Hospitalisation
  • Care home admission
  • Death

Since frailty is at least partially reversible, interventions to reduce the severity or prevalence of frailty can have important benefits, not only for elderly, but for their families and society. This is especially true early in the course of frailty, when interventions are more likely to produce improvements in functional abilities. (3)


Frailty is significant health problem in the elderly, including in Asia, where the number of elderly people is increasing rapidly. Since a mild insult can have dramatic health consequences in a frail person, the presence of frailty can shift the risk:benefit balance of some interventions, such as surgery. Therefore, physicians need to be actively assessing elderly for the presence and severity of frailty in order to provide the best possible care for them. The physiological development of frailty and sarcopenia is a continuum, highlighting the importance of identifying ways to prevent the development of frailty, and the transition from prefrailty to frailty among elderly people.


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