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The Journal of Frailty & Aging©

Volume 1, Number 1, 2012

FRAILTY AND AGING

M. CESARI1,2,3
1. Institut du Vieillissement, Université de Toulouse, Toulouse, France; 2. Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; 3. INSERM Unit 1027, Toulouse,
France. Address for correspondence: Matteo Cesari, MD, PhD, Institut du Vieillissement, Université de Toulouse; 37 Allées Jules Guesde, 31000 Toulouse, France;
Phone: +33 (0)5 61145628, Fax: +33 (0)5 61145640, email: macesari@gmail.com

As a geriatrician, I have always been taught to look at and mortality (6). Its detection is important because frailty,
medical issues in a different way, from an alternative differently from disability, is described as a reversible
perspective. What is true and well-established in younger adults condition, thus still amenable of interventions.
becomes arguable and doubtful in the complex older patient.
Such uncertainty is largely at the basis of the long-lasting The clinical relevance of frailty is obvious. The idea of
“evidence-based medicine” issue which has necessarily detecting subjects at increased risk of adverse outcomes to
generated an immediate practical sense in geriatrics. With preventively act constitutes one of the cornerstones of
advancing age, even the importance of the clinical and research medicine. At the same time, it should not be ignored the
endpoints characteristic of adulthood tends to become weaker. important role played by frailty in the research setting. Frail
For example, the mortality outcome may lose most of its subjects may represent the ideal candidates to test interventions
significance when evaluating the efficacy of an intervention in aimed at preventing negative events (e.g., onset of disability).
nonagenarians or centenarians. In fact, any (forcely relative) Their higher profile of risk may specifically support the design
extension of survival might easily become misleading if not of trials (by selecting a sample population more likely to
sided by a broader evaluation of the effects on the multifaceted experience the study outcome, thus reducing the length of the
health status (1). In this context, other conditions may appear follow-up) and enhance the intervention efficacy (by excluding
more determinant in driving clinical choices, developing low-risk profile subjects from the study).
guidelines, and directing research interests in geriatrics. Among
all, disability surely deserves a special spot. Unfortunately, although several algorithms have been
developed over the last decade to support clinicians and
The inability to adequately interact with the surrounding researchers in objectively screening older persons for frailty, a
environment does not only represents a major burden for the controversy exists about the optimal instrument to adopt (7).
person, but is also associated with relevant public health The major reason for the difficulties in reaching an agreement
expenditures. Paradigmatical are data published some years ago probably resides in the multidimensional nature of frailty (1).
by Fried and colleagues (2) showing that the 19.6% of Frailty is a syndrome, and its clinical manifestation may greatly
community-dwelling older persons with functional dependence vary. The only way to appropriately measure it is by using
accounted for almost 50% of total health care expenditures in instruments that may comprehensively evaluate the subject’s
the United States. From these figures and taking into account overall health status. It is true that most of the available
the epidemiological trends documenting the progressive aging screening tools share the common concept of a “critical mass”
of our societies, it is natural considering disability as a major of symptoms and signs to determine the frailty status (in
public health issue (3). accordance to the syndromic nature of the condition).
Nevertheless, each tool tends to identify different sets of frail
Since disability is largely considered as an irreversible subjects depending on its conception and design specificities.
condition (4), the most appropriate way to face it is through Thus, for example, the Frailty Index proposed by Fried and
prevention. Thus, it is necessary to implement screening colleagues (8) or by Ensrund and colleagues (9) more closely
programs for the early detection of subjects at increased risk of look at the physical domain of frailty, whereas the measure
experiencing disability in the next future, and to develop designed by Rockwood and colleagues (10) is better focused at
interventions specifically targeting the inner foundations of the estimating the accumulation of deficits. Moreover, some
disabling cascade. We need to promptly act when disability is instruments have been conceived as screening tools to identify
not yet appeared, but the prodromal symptoms and signs start at persons at risk (8, 9, 11), while others are designed to estimate
being manifest. Such pre-disability condition is commonly the clinical reserves of the individual after the completion of
identified with the so-called “frailty syndrome” (5). the comprehensive geriatric assessment (10, 12). Another
limitation of these tools is that they are often felt to be more
Frailty is a state of increased vulnearbility to endogeneous research-oriented than suitable for the clinical setting. The
and exogenous stressors experienced by older persons. It poses physician looks for screening tools able to easily, immediately,
the subject at higher risk of major negative health-related and accurately find support to his/her clinical decisions in the
events, including disability, hospitalization, institutionalization, often crowded and busy environment of a clinic. Long
Received February 14, 2012
Accepted for publication February 21, 2012
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The Journal of Frailty & Aging©

Volume 1, Number 1, 2012

FRAILTY AND AGING

questionnaires, complex scales, or multiple tasks to administer Today, a growing interest is directed towards the study of
are (too) easily considered inadapt for the clinical assessment of age-related conditions, and frailty represents an ideal
the older patient. A possible alternative might be represented by benchmark to start. We are at the very beginning of the study of
the adoption of physical performance tests (13), especially this syndrome, but our knowledge is exponentially growing.
those focused on mobility (a capacity shared by all living After all, we need to take into account that the paper by Fried
beings, from Drosophila to humans (14)). Physical performance and colleagues proposing the most commonly used phenotypic
measures (in particular, gait speed (15, 16)) should not be description of the syndrome is only dated 11 years (8). At the
anymore considered as mere markers of the physical (or lower same time, the relative novelty of the topic imposes a cautious
extremity) function. These tests have shown to indeed predict a approach and flexibility. Too rigid statements and positions at
wide and heterogeneous spectrum of adverse outcomes, even the present time may hamper the proper collection of
those not directly related to the functional domain (e.g., experience precluding the development of clear definitions and
hospitalization, institutionalization, mortality). Moreover, guidelines.
physical performance measures are strongly associated with the
subclinical and clinical factors which are well-established key- The frailty syndrome is an extremely exciting, innovative,
components of frailty (e.g., inflammation (17), oxidative and ambitious topic of research with crucial relevance for
damage (18, 19), body composition modifications (20), medicine of tomorrow (necessarily focused on older persons as
comorbidities (5, 21), poor lifestyle behaviours (22-24)), suggested by the epidemiological trends). It is time to start
implicitly mimicking the peculiar multidimensionality of the openly thinking at frailty as a true clinical entity rooted in the
syndrome (1). Interestingly, for all these reasons, gait speed has complex scenario of the aging process. Thus, in the attempt to
even been proposed as an additional vital sign and a marker of promote and convey research in this increasingly important
biological age (15, 25). From this perspective, it might be field, the International Association of Gerontology and
suggested frailty as a clinically evident threshold in the Geriatrics and the Global Ageing Research Network recently
pathophysiological continuum of the aging process. decided to develop the present new editorial initiative.

The adoption of physical performance tests in the screening The Journal of Frailty & Aging (or JFA) is born to be a peer-
of older persons may represent the first step towards a structural reviewed international journal aimed at presenting scientific
reorganization of the current way to offer health care to older articles in the area of aging and age-related (sub)clinical
patients (26). For example, the preliminary evaluation of the 4- conditions. In particular, it publishes high-quality papers
meter gait speed may easily identify subjects presenting the describing and discussing social, biological, and clinical
poorest health status (or frailty) (16), independently of features underlying the onset and development of frailty in
endogenous and/or exogenous causes. These patients (different older persons. The journal is initially composed of five different
from the “only anagraphically old” ones) should indeed be sections entitled 1) “Biology of frailty and aging” (presenting
those electively forwarded to the geriatrician and in the need of preclinical studies and experiences focused at identifying,
undergoing the comprehensive geriatric assessment (with describing, and understanding the subclinical
subsequent planification of the individualized intervention) pathophysiological mechanisms at the basis of frailty and
(15). aging), 2) “Physical frailty and age-related body composition
modifications” (exploring the physical and functional
Since multiple factors determine and aliment the frailty components of frailty with special attention to sarcopenia and
syndrome (27), intervening only against one of the alterations obesity), 3) “Neurosciences of frailty and aging” (containing
may not be sufficient to restore a solid homeostatic equilibrium reports on cognitive and neurological aspects of frailty and age-
(28). Therefore, it is not surprising that significant results to related conditions), 4) “Frailty and aging in clinics and public
reduce the burden of frailty and prevent disability are more health” (including the description of multidisciplinary
likely to be obtained when adopting interventions acting at experiences facing frailty and aging, e.g., onco-geriatrics,
multiple levels (e.g., physical exercise (29), comprehensive ortho-geriatrics, geriatric cardiology,…), and 5) “Clinical trials
geriatric assessment (30)). Specific research methodologies and therapeutics” (reporting findings from pharmacological and
have also been developed to adequately study the complexity of non-pharmacological interventions aimed at preventing,
geriatric syndromes (including frailty), such as the standardly- delaying, or treating frailty and age-related conditions).
tailored design of clinical trials (in which participants only
receive the intervention components corresponding to the In this first article of the Journal of Frailty & Aging, it is
presented risk factors) (31-33). In other words, appropriate impossible to not warmly thank the Executive Committee of the
modifications to the usual schemes are needed to successfully International Association of Gerontology and Geriatrics for
study and target frailty. trusting and appointing me as Editor-in-Chief. I am honoured
with their choice and committed at doing my best to fully meet
their expectations. Special thanks also go to all the Associate

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Volume 1, Number 1, 2012

THE JOURNAL OF FRAILTY & AGING

Editors and Editorial Board Members for their availability in References

accepting to pursue together this new adventure. I indeed
believe the Journal of Frailty & Aging has a distinguished 1. Cesari M. The multidimentionality of frailty: many faces of one single
panel of high-profile investigators, notable coming from dice. J Nutr Health Aging. 2011;15:663-664.
2. Fried TR, Bradley EH, Williams CS, Tinetti ME. Functional disability and
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Finally, I would like to thank the Authors that made this first 2001;161:2602-2607.
issue possible by submitting their manuscripts to this new 3. Guralnik JM, Fried LP, Salive ME. Disability as a public health outcome
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4. Katz S, Branch LG, Branson MH, Papsidero JA, Beck JC, Greer DS.
This first issue contains two conceptual papers potentially Active life expectancy. N Engl J Med. 1983;309:1218-1224.
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frailty onset. Both these contributions summarize two al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci
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International Association of Gerontology and Geriatrics, the 9. Ensrud KE, Ewing SK, Taylor BC, Fink HA, Cawthon PM, Stone KL et
World Health Organization, and the Société Française de al. Comparison of 2 frailty indexes for prediction of falls, disability,
fractures, and death in older women. Arch Intern Med. 2008;168:382-389.
Gériatrie et Gérontologie. The meeting was held in Athens 10. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell
(Greece) on January 19-20, 2012 and convened worldwide I et al. A global clinical measure of fitness and frailty in elderly people.
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13. Abellan van Kan G, Rolland Y, Bergman H, Morley JE, Kritchevsky SB,
interesting original and methodological articles as well. Waters Vellas B. The I.A.N.A Task Force on frailty assessment of older people in
and colleagues (36) explore the gender-specific differences of clinical practice. J Nutr Health Aging. 2008;12:29-37.
body composition potentially at the basis of the frailty 14. Dickinson MH, Farley CT, Full RJ, Koehl MA, Kram R, Lehman S. How
phenotype. An Italian group of researchers describes the animals move: an integrative view. Science. 2000;288:100-106.
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design, methods, and preliminary results of a large cohort of 2011;305:93-94.
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responsible for dementia (37). Moreover, a valuable Bonnefoy M et al. Gait Speed at Usual Pace as a Predictor of Adverse
contribution confirms the importance of physical performance Outcomes in Community-Dwelling Older People An International
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persons, encouraging its use in the acute care setting (38). Last 17. Walston J, McBurnie MA, Newman A, Tracy RP, Kop WJ, Hirsch CH et
but not least, Yamada and colleagues (39) present the al. Frailty and activation of the inflammation and coagulation systems
promising results of a clinical trial demonstrating the beneficial with and without clinical comorbidities: results from the Cardiovascular
Health Study. Arch Intern Med. 2002;162:2333-2341.
effects of an extremely simple intervention on physical 18. Mulero J, Zafrilla P, Martinez-Cacha A. Oxidative stress, frailty and
function in sedentary older persons. cognitive decline. J Nutr Health Aging. 2011;15:756-760.
19. Serviddio G, Romano AD, Greco A, Rollo T, Bellanti F, Altomare E et al.
We all hope the journal will soon become a primary resource Frailty syndrome is associated with altered circulating redox balance and
increased markers of oxidative stress. Int J Immunopathol Pharmacol.
of information for both clinicians and researchers daily facing 2009;22:819-827.
the complexity of the frailty and aging phenomena. With such 20. Cesari M, Leeuwenburgh C, Lauretani F, Onder G, Bandinelli S, Maraldi
ambitious aim in mind, we invite all the readers to consider C et al. Frailty syndrome and skeletal muscle: results from the Invecchiare
Journal of Frailty & Aging as a potential journal to host their in Chianti study. Am J Clin Nutr. 2006;83:1142-1148.
21. Garcia-Garcia FJ, Gutierrez Avila G, Alfaro-Acha A, Amor Andres MS,
scientific works. Hopefully, we might contribute together in De Los Angeles De La Torre Lanza M, Escribano Aparicio MV et al. The
fighting age-related conditions (in particular, disability), offer prevalence of frailty syndrome in an older population from Spain. The
better services to older persons, and improve quality of life at toledo study for healthy aging. J Nutr Health Aging. 2011;15:852-856.
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23. Hubbard RE, Searle SD, Mitnitski A, Rockwood K. Effect of smoking on

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the accumulation of deficits, frailty and survival in older adults: a and standardly-tailored designs. Clin Trials. 2008;5:121-130.
secondary analysis from the Canadian Study of Health and Aging. J Nutr 32. Allore HG, Tinetti ME, Gill TM, Peduzzi PN. Experimental designs for
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