JAMDA 14 (2013) 392e397

JAMDA
journal homepage: www.jamda.com

Special Article

Frailty Consensus: A Call to Action

John E. Morley MB, BCh a, *, Bruno Vellas MD b, c, G. Abellan van Kan MD b, c, Stefan D. Anker MD, PhD d, e,
Juergen M. Bauer MD, PhD f, Roberto Bernabei MD g, Matteo Cesari MD, PhD b, c, W.C. Chumlea PhD h,
Wolfram Doehner MD, PhD d, i, Jonathan Evans MD j, Linda P. Fried MD, MPH k, Jack M. Guralnik MD, PhD l,
Paul R. Katz MD, CMD m, Theodore K. Malmstrom PhD a, n, Roger J. McCarter PhD o,
Luis M. Gutierrez Robledo MD, PhD p, Ken Rockwood MD q, Stephan von Haehling MD, PhD r,
Maurits F. Vandewoude MD, PhD s, Jeremy Walston MD t
a
Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO
b
INSERM UMR 1027, Univerisité de Toulouse III Paul Sabatier, Toulouse, France
c
Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
d
Applied Cachexia Research, Department of Cardiology, Charité Medical School, Berlin, Germany
e
Center for Clinical and Basic Research, IRCCS san Rafaette, Rome, Italy
f
Geriatrics Centre, Carl von Ossietzky University, Oldenberg, Germany; Institute for Biomedicine of Ageing, Friedrich-Alexander University, Erlangen-Nuremberg, Germany
g
Department of Geriatrics, Neurosciences and Orthopaedics, Catholic University of Sacred Heart, Rome, Italy
h
Department of Community Health, Lifespan Health Research Center, Wright State University, Boonshoft School of Medicine, Dayton, OH
i
Centre for Stroke Research, Berlin, Charité-Universitätsmedizin, Berlin, Germany
j
President, American Medical Directors Association (AMDA)
k
Joseph L. Mailman School of Public Health and College of Physicians and Surgeons, Columbia University, New York, NY
l
Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, MD
m
Baycrest Health Science Center and University of Toronto, Toronto, Ontario, Canada
n
Department of Neurology and Psychiatry, Saint Louis University School of Medicine, St. Louis, MO
o
Biobehavioral Health, The Pennsylvania State University, University Park, PA
p
Instituto Nacional de Geriatria, Institutos Nacionales de Salud de Mexico, Mexico City, Mexico
q
Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
r
Applied Cachexia Research, Department of Cardiology, Charité-Universitätsmedizin, Berlin, Germany
s
Department of Geriatrics, ZNA St. Elizabeth Hospital, University of Antwerp, Antwerp, Belgium
t
Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, MD

a b s t r a c t

Keywords: Frailty is a clinical state in which there is an increase in an individual’s vulnerability for developing
Frailty increased dependency and/or mortality when exposed to a stressor. Frailty can occur as the result of
physical frailty a range of diseases and medical conditions. A consensus group consisting of delegates from 6 major
rapid screening tests
international, European, and US societies created 4 major consensus points on a specific form of frailty:
weight loss
physical frailty.
comorbidities
1. Physical frailty is an important medical syndrome. The group defined physical frailty as “a medical
syndrome with multiple causes and contributors that is characterized by diminished strength,
endurance, and reduced physiologic function that increases an individual’s vulnerability for devel-
oping increased dependency and/or death.”
2. Physical frailty can potentially be prevented or treated with specific modalities, such as
exercise, protein-calorie supplementation, vitamin D, and reduction of polypharmacy.
3. Simple, rapid screening tests have been developed and validated, such as the simple FRAIL
scale, to allow physicians to objectively recognize frail persons.

The authors declare no conflicts of interest.

* Address correspondence to John E. Morley, MB, BCh, Division of Geriatric
Medicine, Saint Louis University School of Medicine, 1402 S. Grand Boulevard,
M238, St. Louis, MO 63104.
E-mail address: morley@slu.edu (J.E. Morley).

1525-8610/$ - see front matter Copyright Ó 2013 - American Medical Directors Association, Inc.
http://dx.doi.org/10.1016/j.jamda.2013.03.022
 J.E. Morley et al. / JAMDA 14 (2013) 392e397 393

4. For the purposes of optimally managing individuals with physical frailty, all persons older
than 70 years and all individuals with significant weight loss (
5%) due to chronic disease
should be screened for frailty.

Copyright Ó 2013 - American Medical Directors Association, Inc.

Frailty is a condition in which the individual is in a vulnerable Table 1

state at increased risk of adverse health outcomes and/or dying when Examples of Well-Validated Frailty Models

exposed to a stressor.1 The European Union has placed specific Cardiovascular Health Study10,11
importance on defining frailty, as frail persons are high users of Study of Osteoporotic Fractures12,13
community resources, hospitalization, and nursing homes. It is Deficit Model14,15
FRAIL e International Academy of Nutrition and Aging16,17
assumed that early intervention with frail persons will improve
SHARE-FI18,19
quality of life and reduce costs of care.2,3 Vulnerable Elder Survey-1320e22
Frailty is either physical or psychological or a combination of the 2 Tilburg Frailty Index23,24
components, and is a dynamic condition that can improve or worsen Groningen Frailty Indicator25,26
over time. Two approaches to defining physical frailty have become
popular. The deficit model consists of adding together an individual’s for frailty, a consensus conference was convened in Orlando, Florida,
number of impairments and conditions to create a Frailty Index.4 The on December 7, 2012. The conference was based on the International
second model originally defined a specific physical phenotype con- Association of Gerontology and Geriatrics and World Health Organi-
sisting of a constellation of 5 possible components (weight loss, zation white paper, recognizing the need to improve the “ability of
exhaustion, weakness, slowness, and reduced physical activity), older persons to age in place” rather than to be institutionalized.19 The
which marked an underlying physiologic state of multisystem and aim of this consensus conference was to define an operational defi-
energy dysregulation.5 Both of these definitions are currently used to nition of frailty and to frame aspects for screening and treatment and
define a frail and a prefrail state, a condition between frail and identify an appropriate population to screen. A major finding of this
nonfrail. Frailty domains appear to belong to a common construct, group was a recognition and agreement on the distinction between
with physical strength being one of the discriminating characteris- the broader definition of frailty, which is a general state or condition of
tics.6 Numerous other frailty definitions have been developed, for the an individual, and a more specific medical syndrome: physical frailty.
most part based on one or the other of these 2 basic approaches. This communication provides the consensus opinions of experts
A recent systematic review incorporating 31 studies of frailty in involved in the Frailty Consensus Conference.
persons 65 years or older found a prevalence of from 4.0% to 17.0%
(mean 9.9%) of physical frailty, with a higher prevalence when Methods
psychosocial frailty was also included.7 Women (9.6%) were almost
twice as likely as men (5.2%) to be frail. The prevalence of frailty is Six major international (International Association of Gerontology
markedly increased in persons older than 80. and Geriatrics; Society on Sarcopenia, Cachexia, and Wasting
A previous consensus conference on frailty agreed “on the Diseases; and the International Academy of Nutrition and Aging),
usefulness of defining frailty in clinical settings” and that there was European (European Union Geriatric Medicine Society), and US
a need for a clear conceptual framework.8 Other areas in which they societies (American Medical Directors Association and American
had more than 80% agreement included that frailty is Federation for Aging Research) provided delegates to attend this
consensus meeting. In addition, 7 other experts in the area of frailty
 A clinical syndrome were invited by the conveners (Bruno Vellas and John Morley) to
 Not disability enrich the content knowledge base. Separate areas were discussed
 Increased vulnerability in which minimal stress can cause and a broad consensus was reached on a variety of recommendations.
functional impairment During the discussion, it became apparent that a major reason that
 Might be reversible or attenuated by interventions prior attempts at a consensus around frailty were not successful is
 Mandatory for health workers to detect as soon as possible that they did not resolve distinctions between broad definitions of
 Useful in primary and community care frailty and more specific subsets. In this meeting, a full consensus was
developed and agreement attained around physical frailty being
However, the conference failed to recommend a clear course a specific medical syndrome within the broader context of frailty.
forward because of an inability to agree on a “single operational Based on this consensus, a preliminary manuscript was developed
definition of frailty that can satisfy all experts.” The heterogeneity of and a modified Delphi process was used in which the manuscript was
that consensus group may have contributed to the inability to come circulated to all the delegates until agreement was obtained on the
to a firm conclusion. content, leading to the development of this consensus report.27
Rockwood9 previously suggested criteria for a successful defini-
tion of frailty. These are content validity (ie, is dynamic, includes Recommendations
multiple determinants, and is useful in different situations), construct
validity (ie, more common in women and advancing age and related 1. Physical Frailty Is an Important Medical Syndrome
to disability), and criterion validity (ie, predicts adverse outcomes
including mortality). Numerous models are available that meet most The group defined frailty as
of these criteria (Table 1).10e26 “A medical syndrome with multiple causes and contributors that
Because of the uncertainty created by the previous consensus is characterized by diminished strength, endurance, and reduced
conference on frailty and a need to determine whether there is physiologic function that increases an individual’s vulnerability for
sufficient information available to advocate screening by all physicians developing increased dependency and/or death.”
394 J.E. Morley et al. / JAMDA 14 (2013) 392e397

In addition to the definition, the group made 4 key points: Table 3

Cardiovascular Health Study Frailty Screening Scale10,48

1. Although recognizing that frail individuals could be disabled Prefrail, 1 or 2; Frail,
3

and that not all disabled persons are frail, the group agreed that 1. Weight Loss e Loss of 10 pounds unintentionally in past year or weight at
examination 10% of age 60 weight.
the emphasis on case finding should target the pre-disabled
2. Exhaustion e Self-report of fatigue or felt unusually tired or weak in the
not the dependent (defined here as persons with 1 or more past month
deficits in basic activities of daily living). Targeting those who 3. Low Activity e Frequency and duration of physical activities (walking,
are frail and pre-disabled in this manner, case finding becomes doing strenuous household chores, doing strenuous outdoor chores,
of major importance, as it allows interventions that could dancing, bowling, exercise).
4. Slowness e Walking 4 m
7 s if height 159 cm or
6 s if height
159 cm.*
prevent dependency.
5. Weakness e Grip strength (kg) for body mass index (kg/m2).
2. Although sarcopenia may be a component of frailty, it was
*Data for older women (lowest 20th percentile).
agreed that frailty is more multifaceted than sarcopenia
alone.27e31
3. The group agreed that a number of well-validated models of
intervention development. However, they agreed that at this time at
frailty existed and that the definitive diagnosis of frailty should
least some evidence supported 4 possible treatments that appeared
be done by a geriatrician using the basic criteria of these well-
to have some efficacy in the treatment of frailty.
defined models. It is accepted that these models predict
increased vulnerability to adverse health outcomes and
 Exercise (resistance and aerobic)
mortality.32e39
 Caloric and protein support
4. As conceived in this document, physical frailty differs from
 Vitamin D
multimorbidity. Both are common, but multimorbidity is more
 Reduction of polypharmacy
pervasive, being present in 3 of 4 persons older than 65 years
and 1 of 4 in those younger than 65.40 Physical frailty focuses
Singh et al49 demonstrated that a year of resistance exercise in
on specific areas for which a general treatment approach can be
frail persons following hip fracture decreased hospitalizations and
developed, whereas multimorbidity moves the focus to the
nursing home placement. Yamada et al, 50 in a community-based
management of each condition separately, although both
exercise program involving 610 frail persons, found that exercise
require multidimensional assessment and management. A
was cost effective in preventing frailty progression and disability.
larger construct of frailty, as proposed by Rockwood et al,41 as
Theou et al,51 in a systematic review, found that 45 to 60 minutes of
a state of increased vulnerability due to impairments in many
exercise 3 times a week seemed to have positive effects on frail older
systems that may give rise to diminished ability to respond to
adults and may be used for the management of frailty. Exercise in frail
even mild stresses, incorporates multimorbidity and central
individuals increases functional performance, walking speed, chair
nervous system impairments that can be recognized in relation
stand, stair climbing, and balance, and decreased depression and fear
to cognitive and affective disorders.
of falling. Group and home-based exercise programs reduce falls.52
Weight loss is a major component of the frailty syndrome.53e55
2. Simple Screening Tests Are Available to Be Used by Physicians to Calorie supplement enhanced weight gain and reduced mortality in
Recognize Frail Persons and Identify Persons With Physical Frailty or undernourished older individuals and reduced complications ac-
at Risk of Frailty cording to the Cochrane Collaboration.56 Protein-calorie supplemen-
tation improved outcomes in persons with chronic obstructive
The Royal College of Physicians and the French Society of Geriat- pulmonary disease.57 Nutritional supplementation is effective in the
rics and Gerontology advocated screening for frailty in older treatment of weight loss.58,59 Protein supplementation increases
persons.42,43 Simple rapid screening tests have been developed and muscle mass,60e65 reduces complications,66 improves grip strength,66
validated to allow physicians to rapidly recognize frail persons. produces weight gain,66 and may act synergistically with resistance
Examples of some commonly used and validated frailty tools include exercise in older persons.62,63 Frailty can also be seen in persons who
the FRAIL (Table 2),44e47 the Cardiovascular Health Study Frailty are morbidly obese.67
Screening Measure (Table 3),10,11 the Clinical Frailty Scale (Figure 1),41 In older persons who are 25(OH) vitamin D deficient, there is
and the Gérontopôle Frailty Screening Tool (Table 4).48 The group evidence that vitamin D supplementation will reduce falls,68 hip
agreed that such instruments can be used to identify persons with the fractures,69 and mortality.70 It may also improve muscle function.71
physical frailty syndrome who are in need of a more in-depth Although there are no large-scale clinical trials that show that
assessment. All persons aged 70 years and older, as well as any frailty can be prevented or treated by vitamin D alone, there is
person with significant weight loss (
5% over the past year) due to sufficient evidence of efficacy in frailty-appearing populations to
chronic illnesses should be screened for frailty. suggest that vitamin D in frail persons who are vitamin D deficient
would be useful.
3. Physical Frailty Is a Manageable Condition It was agreed that interventions against sarcopenia could be
clinically beneficial in cases of frailty.72,73 Polypharmacy is recognized
The committee recognized there are numerous potential causes of as a possible major contributor to the pathogenesis of frailty.74e78
physical frailty, and many of these could be targeted in future Hence, reduction in inappropriate medicines can clearly decrease
Table 2
costs79 and medication side effects in frail populations.80e83 The
The Simple “FRAIL” Questionnaire Screening Tool Beers criteria84 and STOPP and START criteria85,86 can be helpful
guidelines to reduce inappropriate medicine use in this population.
3 or greater ¼ frailty; 1 or 2 ¼ prefrail
Fatigue: Are you fatigued?
Other potential causes for frailty can be found in some specific
Resistance: Cannot walk up 1 flight of stairs? individuals. These include depression, visual and hearing problems,
Aerobic: Cannot walk 1 block? diabetes mellitus, congestive heart failure, and cognitive decline, as
Illnesses: Do you have more than 5 illnesses? examples. The intervention plan in frail older adults must include the
Loss of weight: Have you lost more than 5% of your weight in the past 6 months?
management of reversible diseases.
 J.E. Morley et al. / JAMDA 14 (2013) 392e397 395

Fig. 1. Clinical Frailty Scale. Scoring is based on clinical judgment. Reprinted with permission from Rockwood et al.41

with heart failure,93 cancer,94 renal failure,95 HIV,96 or diabetes,97 as

4. All Persons Older Than 70 Years Should Be Screened for Frailty
well as those undergoing surgery,98 are more likely to be frail and
have more adverse outcomes than those who are not frail. Hence,
It was agreed that sufficient evidence exists for the implementa-
a focus on the treatment of frail persons in this group may improve
tion of frailty screening by health care providers in persons 70 years
overall outcomes. The frailty diagnosis can be implemented to judge
and older. Although finite evidence is not yet available, there are
the appropriateness of a number of invasive management strategies,
compelling reasons to screen, as it is noninvasive and may uncover
such as radiotherapy, chemotherapy, surgery, and cardiology
remedial conditions. Based on available data, screening tests for
procedures.
frailty meet the major criteria for screening, viz. they are sensitive.
To successfully combat frailty, our medical practice must be tar-
Effective treatments are available for components of the syndrome
geted, strong, and sustained. With the aging of our population, we
and simple screening tests produce more beneficial than harmful
cannot wait and must implement the screening and management of
outcomes.87 In the presence of a positive screen, the physician can
frailty into clinical practice worldwide.
institute management for frailty or refer the patient to a geriatri-
cian.88 A similar approach has been successfully instituted by the
Gérontopôle in Toulouse.48,89 A screening approach is being carried Acknowledgments
out widely in Japan, with interventions as suggested by the consensus
group proving successful.90e92 Both primary care physicians and Supported by unrestricted educational grants from Sanofi and
specialists need to screen for frailty. Evidence suggests that persons Nutricia Advanced Medical Nutrition (group Danone).

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