*Frailty in the Elderly - Understanding and Managing Complexity*


#### **Table 3.**

*Summary of the included studies.*

From this background, two models were proposed in order to identify the concept of frailty in elderly patients.

Rockwood and colleagues have defined frailty as an accumulation of deficits. One such example is the risk to develop dementia which increases in relation to

problems with hypertension or diabetes in older adults [6].

#### *The Complexity of Frailty: Psychological Mechanism and Therapeutic Interventions in Old… DOI: http://dx.doi.org/10.5772/intechopen.92630*

It is becoming clear that a range of subclinical and clinical age-related deficits, which are themselves not recognized as disease-specific risks, are associated with a greater chance of common age-related illness in older adults [7].

On the other hand, the phenotype model suggests that five factors (weight loss, self-reported exhaustion, low-energy expenditure, slow gait speed, and weak grip strength) are associated with frailty [8].

What does it means being frail? And what characteristic defines a frail person? Aging is arguably the most familiar yet least well-understood aspect of human

biology, and it can be present in different stages of severity: From mild to severe [9]\*. It is characterized by a progressive impairment of functions, difficulties in environmental challenges, and a growing risk of death.

Clinicians suggest that frailty is a state of vulnerability in front of a stressful situation, and the consequences are a decline in health status [10].

Therefore, the risk of developing other negative life events including falls, delirium (a temporary condition characterized by the rapid onset of fluctuating confusion and impaired awareness) and disability could increase.

To date, the concept of frailty is well analyzed in the clinical setting, where it is considered as a potential negative factor of the patient's clinical condition.

J. Hewitt and colleagues suggested that frail patients are likely to stay in the hospital longer than those that are not frail.

In fact, there is a linear relationship between the increase of clinical frailty index at admission and increase odds of day 90 mortality [11]\*.

Frailty in old people becomes also evident in many complex physiological systems including cognitive functions.

Aging is characterized by structural and physiological changes in the brain.

The loss of individual neurons in most cortical regions is low, but neurons with high metabolic demands, such as the hippocampal pyramidal neurons, could be affected disproportionally by changes in synaptic function.

The hippocampus has been identified as an important mediator in the pathophysiology of cognitive decline and Alzheimer's disease, and it is a key component of the stress response.

The aging brain is also characterized by structural and functional changes to microglial cells, which have an important role in the pathophysiology of delirium [12].

Accumulated evidence supports an association between frailty, cognitive impairment, dementia and Alzheimer's disease [13]\* [14].

In a prospective, observational cohort study, Boyle et al. show the hypothesis that physical frailty is associated with an increased risk of mild cognitive decline in aging [15].

In this study, more than 700 older people without mild cognitive impairment were involved.

Physical frailty, based on four components (grip strength, timed walk, body composition and fatigue) was assessed at baseline and cognitive function was assessed annually.

Proportional hazard models were used to examine the association of physical frailty with the risk of incident MCI, and mixed effect models were used to examine the association of frailty with the rate of change in cognition.

During up to 12 years of annual follow-up, 305 of 761 persons developed MCI. Moreover, a higher level of physical frailty was associated with an increased rate of decline in global cognition and five systems (episodic memory, semantic memory, working memory, perceptual speed and visual spatial abilities).

In addition, Jennifer and colleagues have evaluated the use of multicomponent frailty assessment tools in assessing frailty also in elderly patients with psychiatric

## *Frailty in the Elderly - Understanding and Managing Complexity*

disorders, comparing the items of each frailty assessment tool with the *Diagnostic and Statistical Manual of Mental Disorder 5th Edition* (DSM-5) criteria to assess the overlap.

The results suggested that there is a significant overlap between the indicators of frailty as conceptualized in frailty assessment tools and DSM-5 diagnostic criteria for a common psychiatric disorder including major depression episode and generalized anxiety disorder that has the potential to confound frailty assessment results [16]\*.

#### *3.1.1 Evaluation tool*

In order to establish frailty, reliable models should be assessed for their success in predicting therapeutic interventions [17]\*.

As we previously described above, there are two main geriatric models: The phenotype model [8] and the cumulative deficit model, which form the basis of the Canadian study of health and aging (CSHA) frailty index [18].

This chapter aims to go deep under the knowledge of these models and explore how do these models are used in the clinical practice.

A frailty phenotype was established with five variables: Unintentional weight loss, self-reported exhaustion, low-energy expenditure, slow gait speed and weak grip strength.

The Fried frailty criteria could help healthcare professionals to identify and efficiently treat frail older people in an efficient way and also contribute to provide indications for other related problems (social, psychological and physical functioning).

In a study of 5210 men and women aged 65 years and older, Fried and colleagues conducted a famous study that is known as the milestone study of the phenotype model [19]\*.

A frailty phenotype was established with the five variables: Unintentional weight loss, self-reported exhaustion, low-energy expenditure, slow gait speed and weak grip strength.

People with Parkinson's disease, previous stroke, cognitive impairment or depression were excluded.

Those with three or more of the five factors were judged to be frail, those with one or two factors as pre-frail and those with no factors as not frail.

This work is important because it suggests that a frailty phenotype can be defined and might be a basis for detection of frailty in routine care.

However, how the variables can be reliably translated into clinical practice is not clear.

Furthermore, other important factors such as cognitive impairment, a prevalent condition associated with functional decline, were not included as part of this model.

Despite the criticism, the general approach of clusters of variables to define frailty phenotype has been independently validated.

The frailty index was developed as part of the CSHA study [18].

10,263 people were involved, and it was designed to investigate the epidemiology and burden of dementia in elderly people in Canada.

92 baseline variables of symptoms (e.g. low mood), signs (e.g. tremor), disabilities and abnormal laboratory values (referred to as deficits) were used to define frailty.

The frailty index was a simple calculation of the presence or absence of each variable.

The frailty condition is defined as the cumulative effect of individual deficits. Additionally, the cumulative deficit model expresses the theory of a gradation of frailty with progressive accumulation of deficits.

This model is clinically attractive because it presents frailty as gradable, rather than present or absent.

*The Complexity of Frailty: Psychological Mechanism and Therapeutic Interventions in Old… DOI: http://dx.doi.org/10.5772/intechopen.92630*

### **3.2 Comprehensive geriatric assessment**

Clinicians and researchers need valid and accurate methods to assess and identify frailty.

Comprehensive geriatric assessment (CGA) [20] (see **Table 1**) has become an internationally established method to assess elderly people in clinical practice.

This method is the goal standard to assess frailty.

It is a process that specializes the elderly care delivered by a multidisciplinary team (psychologists, nurses, occupational therapists, and geriatricians) to establish functional psychological functions and a plan of treatment [21]\*.

Besides, as aging is a process that leads to conditions of vulnerability to mortality and severe stress, also for the caregiver's multidisciplinary approach, programs of prevention should be proposed.

How do clinicians identify frailty in the clinical practice?

More specifically, many types of test are used to evaluate the state of frailty in elderly people.

Among them, the timed up and go test (TUG) and the Edmonton Frail Scale are commonly used for screening the evaluation of frailty.

The TUG test is a simple and specific method to test functional mobility.

This test is easily included as part of the routine medical examination.

This test assesses many dimensions of frailty and requires no specific equipment or training.

Each singular patient is observed and timed, while he/she rises from an armchair, walks 3 m, turns, walks back, and sits down again.

The results indicate that the "up and go" test is a valid test to quantify frailty [22].

Moreover, the Edmonton Scale is a multidimensional scale assessment instrument that includes the timed up and go test and many other tests in order to evaluate cognitive impairment (see **Table 1**).

The test lasts less than 5 minutes and is a valid instrument.

To underlie the negative effects of frailty and the use of Edmonton Frail scale as a multidimensional assessment, an original study was conducted.

Beecher MS and colleagues conducted a retrospective analysis based on 435 elderly patients.

This study aimed to evaluate the probability of early readmission and length of hospital stay, using the Edmonton Scale and the age-adjusted Charlson comorbidity index.

The results suggest that the Edmonton Scale was a significant instrument to predict hospital readmission and length of stay [23]\*.

#### **4. Emotion and frailty**

Social isolation or being socially lonely could have a severe impact on the psychological health of the elderly.

Therefore, it is necessary to support the elderly in order to prevent them from mood disorders.

Importantly, depression merits special attention because it can have negative consequences, including increased burden of physical illness, cognitive impairment and risk of suicide [24]\*.

Living alone, not having a friend to confide in and not spending time with others could have a severe impact on psychological well-being.

Being both active and socially involved are very important for frail patients; therefore, emotions (see **Table 1**) and affective recognitions may play a crucial role during aging.

Moreover, neuropsychological functions are strictly connected with perceptions of satisfaction of life and emotion recognition.

To date, existing literature suggests that age affects emotion recognition.

Does aging affect emotion detection during their life span?

Being socially involved in a relationship, cooperating with others, understanding and reacting appropriately to the social signals sent out by other people determine social perception abilities.

Being able to decode emotional expressions is an important and essential skill to navigate through the social world and to guide appropriate behavior.

Meyer and colleagues propose that social perception is a powerful dimension of emotional intelligence as mental ability including personal and social intelligence [25].

Prosocial behavior is involved in being able to establish a social relationship [26]. However, old people respond differently to emotional stimuli in everyday life.

Little is still known about the emotion recognition of the elderly and how these are linked with the changes in social life during the life span of people.

Ruffman and colleagues examined 60 young and 61 older adults' recognition of emotions in facial, vocal, bodily expression and when matching faces and bodies to voices.

Older adults were worse than young adults, reporting difficulties in recognizing both positive and negative vocal and bodily expression.

In addition, they found that older adult's difficulty in matching emotions was explained by an additional problem of integration [27].

Social perception is a key factor to understand and react at the social signal sent out by other people.

Also, as people grow older, they prioritize close social relationships and focus more on achieving emotional well-being; therefore, the elderly became more selective in what and in where they invest their emotional resources.

It should be noted that most emotions that are decoded from people are not static but dynamic.

Dynamic facial cues improved recognition of facial emotions for both younger and older adults.

In addition, these results could also explain why many elderly have difficulties to recognize emotion which appear stable [28].

Neuroscientists suggest that also gender differences could be involved in emotional regulation and recognition of emotions.

More specifically, the amygdala is essential for enhanced long-term memory associated with emotional events.

There is a strong relationship between men and women in the activity of the right hemispheric of the amygdala and memory functions regarding emotional material [29].

#### **4.1 Cognitive compensatory strategies in ageing**

During aging, the old people could be affected by cognitive impairment and dementia disease.

This means that many cognitive domains like attention, memory and also mood state could be affected [30]\*.

The relationship between depression and frailty remains one of the common problems of the elderly [31]\*.

Besides, many changes in the health of elderly result from both intrinsic and extrinsic factors, such as social vulnerability [32]\*.

However, cognitive declines take place over a long time, and during this lapse of time, the elderly can adopt to many cognitive strategies to manage stressful

#### *The Complexity of Frailty: Psychological Mechanism and Therapeutic Interventions in Old… DOI: http://dx.doi.org/10.5772/intechopen.92630*

situations (e.g. cooking, providing self-care, etc.), while fragility and risk of fall are two negative predictors of well-being [33]\*.

Many researchers from France conducted an innovative study on this topic, comparing the drivers' performances on a driving simulator between 12 elderly (between 65- and 78-year-olds) and 18 younger people (between 21- and 35-yearolds) [34].

They compared their self-assessment of driving as well as their visual and cognitive strategies.

Finally, they assessed their driving competencies and self-regulation practice using a simulator.

This research sheds some additional point on the ability to self-regulate the behaviors of the elderly, which could reduce the risk of being injured and to prevent from social isolation, for example, increasing the safety distance from the vehicle in front when reflexes decrease.

Previous research on this matter found that elderly drivers self-regulate by engaging less frequently in secondary tasks (singing or talking) when the driving task is more difficult.

In this way, they reduce the cognitive cost of sharing attention between two tasks [35].

More specifically, in older people, cognitive strategies are used to solve problems of daily life living.

Being able to self-regulate our mood state and cognitive functions is essential to make sense and meaning of life.

Furthermore, the ability to reflect on how important it is to live these silver years in terms of happiness and quality of life could have a great impact on the subject of well-being.

Therefore, understanding and enhancing these cognitive strategies could be crucial to support people in developing many coping methods.

In addition, a positive technology approach could be useful to identify and solicit cognitive competencies.
