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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2017  |  Volume : 28  |  Issue : 4  |  Page : 716-724
Assessment of frailty in elderly pre-dialysis population using simple tools

Department of Renal Medicine, Heart of England Teaching Hospitals NHS Foundation Trust, Birmingham, United Kingdom

Click here for correspondence address and email

Date of Web Publication21-Jul-2017


Prevalence of chronic kidney disease (CKD) is increasing worldwide principally among the elderly population many of whom will eventually need renal replacement therapy. The relationship between frailty and CKD in the elderly population has been recognized. However, studies concentrating on frailty in pre-dialysis patients are limited. CKD predisposes to frailty through many potential mechanisms; anemia, bone mineral disease, oxidative stress, and malnutrition which in turn lead to progression of CKD culminating in a vicious cycle. Identifying potential causes of frailty in elderly pre-dialysis patients and recognizing individuals at risk should be an area of focus to nephrologists and researchers. Modalities that may improve frailty in elderly pre-dialysis patients such as treatment of anemia and bone mineral disease may improve outcome. However, this has not been established and further research is needed. The aim of this review is to address the importance of recognizing frailty in elderly pre-dialysis patients using simple tools and describing its implications on clinical outcome.

How to cite this article:
Ali H, Abdelaal F, Baharani J. Assessment of frailty in elderly pre-dialysis population using simple tools. Saudi J Kidney Dis Transpl 2017;28:716-24

How to cite this URL:
Ali H, Abdelaal F, Baharani J. Assessment of frailty in elderly pre-dialysis population using simple tools. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2020 May 31];28:716-24. Available from: http://www.sjkdt.org/text.asp?2017/28/4/716/211361

   Introduction Top

Prevalence of chronic kidney disease (CKD) is increasing worldwide, especially among the elderly population. Approximately 25% of the dialysis population is over the age of 80 years. [1] CKD is associated with detrimental clinical outcomes; worsening disability, increased risk of infections, cardiovascular diseases, and frailty .[2],[3],[4] In addition, this population has a higher risk of suffering from cognitive dysfunction, urinary incontinence, gait disorders, falls, immobility, and weakness. They more often opt to discontinue long-term dialysis or refuse its initiation .[1],[5]

Frailty is a peculiar health condition associated with the aging process, in which multiple body organs constantly lose their inbuilt reserves. Almost 10% of people aged over 65 years are frail; quarter to half of them are aged above 85 years. [6] Fragility leads to reduced activity and low response to stressors and this, in turn, leads to loss of lean body mass (sarcopenia), weakness, and increasing risk of death. [7] This is usually provoked by social isolation and depression that fortifies behaviors causing more inactivity and loss of function. [8] Several studies showed that frailty is associated with death and hospitalization in elderly patients, and this association is non- aligned with other comorbid conditions.[9]

The relationship between frailty and CKD in elderly population has been recognized; how- ever studies on frailty in pre-dialysis patients are limited,[10],[11] and this is a compelling gap knowing that CKD is associated with aging, by that having akin demographic-like frailty. [7] CKD leads to many physiological alterations; mineral bone diseases, chronic inflammation, and atherosclerosis which can end up with sarcopenia and weakness that are main realms of the frailty. [10] Contrarily, frailty can negatively influence adjustments to the various health conditions that CKD patients endure with time. Therefore, patients with coexisting CKD and frailty can have a collusive risk of facing detrimental clinical outcomes. Knowing that frailty can be managed using some interventions, the research of frailty in the CKD patients implies distinct advantages. [11]

Incidence of progression of CKD to end stage renal failure increases specifically among the elderly population (more than 10 times) and they will eventually end up in dialysis. [12]

The aim of this review is to address the importance of recognizing frailty in elderly pre-dialysis patients using simple tools and its implications on clinical outcome.

   Frailty Top

Definition of frailty

Frailty is a discrete health condition, in which different body organs steadily lose their reserves with aging. [6] The specific definition of frailty is not clear due to the complicated comorbidities and health conditions associated with it. In 2001, Ferrucci et al defined frailty as age-related changes in pathophysiology of different body systems that cause weakness, loss of reserve of multiple organs, and limited ability to respond to internal and external stressors and this leads to adverse medical and functional results. [13] Fried et al described frailty as an accumulative drop in multiple body systems that leads to a decrease in body reserves and causes vulnerability and poor clinical outcomes. [14] Some researchers found that elderly people develop ways to cope with frailty and that they do not like considering themselves as frail people although they accept that they are old. [15]

Models of frailty

There are two main models for frailty; the phenotype model and the deficit model. The phenotype model focuses on a band of patient's features that can anticipate adverse outcomes. [16] It also allows for the definition of pre-frailty in case of presence of fewer patient features. The deficit model concludes aggregation of deficits that can happen with aging. [17] Combination of these deficits forms the frailty index which can predict poorer outcomes. Comparison of the two models is illustrated in [Table 1].
Table 1. Comparison of phenotype model and frailty

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The frailty index does not use the precise definition for frailty and depends on mainly extended and flexible items for measurements and identifies frailty along a gradient from non-frail to severely frail individuals and this can be advantageous in longitudinal research and studies. [18] However, there is no definite cutoff point to identify outcomes, and it cannot be generalized in daily clinical practice due to its complex analytical characteristics, and moreover, it cannot be used as a model of recognition frailty except after a formal clinical assessment as it was designed to assess frailty after a full clinical review. [16]

The phenotype model identifies frailty by the presence of a significant impairment in any three of its items. Recently, cognitive impairment has been included in the phenotype model. [19] This model has more precise definition of frailty than the frailty index; how- ever, there are questions about the sensitivity of this model as it identifies individuals into frail or non-frail, thus missing a group of people with mild frailty by identifying them as non-frail. Despite the high prevalence of frailty among the elderly population being around 38%, the phenotype model only identifies 3% of the general population as frail. [20],[21]

A UK study in 2010 showed that using phenotype model, the prevalence of frailty is 8.5% in women and 4.1% in men aged more than 65 years. [17] Some studies showed that fragility index can potentially identify risk of mortality among the elderly population more than the phenotype odel. [22],[23],[24]

Relationship between frailty and chronic kidney disease

Frailty is a progressive syndrome that can result from long-standing inflammation and biochemical changes that lead to depletion of body reserves that makes frail individuals unable to cope with different internal and environmental stressors and decrease their survivals. [25] The main domains of phenotype frailty model include sarcopenia, exhaustion, and fatigue and these could be affected by presence of several comorbid diseases that can trigger a lot of age-related changes in nutrition and body composition, increase oxidative stress, and release of free radicals which leads to long-standing inflammation and release of cytokines and inflammatory markers ending up in sarcopenia and frailty. [26] Frailty, in turn, leads to worsening of these comorbid conditions with a resultant vicious circle.[10] These bio- chemical changes and stressors are shown in [Figure 1].
Figure 1. Biochemical changes and physiological stressors in Frailty.46

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CKD is one of the chronic diseases that can induce chronic inflammation and biochemical changes in addition to being a physiological stressor, and it has been shown that it is one of the causes of weakness and poor aging. [27] Some studies showed that combination of aging and CKD leads to higher physiological stress ending up in frailty. [28]

Many studies showed the strong relationship between frailty and chronic hemodialysis pa- tients. [29],[30] In a retrospective study in the United States Renal Data System (USRDS) Wave 2, risk of death for patients who started hemodialysis was 2.24-fold higher in those with physiologic deterioration.9 Furthermore, in the USRDS comprehensive dialysis retrospective study, physiologic decline was linked with a 1.26-fold higher risk of hospital admission. [31] Recent prospective studies showed that prevalence of frailty among hemodialysis patients is huge, irrespective of their age and that frailty is a strong independent factor of death and hospital admissions. [32]

Relation between frailty and pre-dialysis patients has become an area of concern by many nephrologists. A recent cross-sectional study in Korea on 168 CKD stage II-IV patients above the age of 20 years showed that frailty influenced quality of life in predialysis patients, and these results were consistent with another previous study done in Brazil on 61 CKD stage III-V patients with a mean age of 60.5 years [33],[34] and few studies proved that frailty is prevalent and worsens among pre-dialysis patients who are older and have lower kidney functions. [19],[28],[34],[35] Furthermore, few studies proved that risk of death and progression to dialysis increase significantly in CKD patients who are frail. [19],[36],[37] This was again noted in systemic review on frailty in CKD patients that found worsening of phy- sical performance among older patients with worsening kidney functions. [38] These conclusions suggest that metabolic abnormalities associated with worsening kidney function might affect degree of frailty and that there is obvious overlap between pathophysiological alterations in CKD patients and factors and mechanisms that lead to frailty.

How to recognize frailty?

Early identification of frailty is a vital target- first, due to its high prevalence, that is expected to increase more in the future, [39] second, due to its prognostic importance, kno- wing that frail population has higher risk of having detrimental health problems, [40],[41] and also, because there are potential managements which may retard or oppose frailty in its early presentation, ahead of the start of unreversible impairment. [42],[43] Frailty should be taken into account when taking decisions about further management plans for patients in addition to their comorbidities. [39]

Nonetheless, recognition of frailty using the phenotype and deficit models in routine prac- tice has some impediments because the cutoff points for some elements could not constantly be figured and anticipated in peculiar populations; [44],[45],[46] furthermore, it is planted on a compound of at least five investigations that need instruments and take more than 15 min to execute. Therefore, a test which is applicable in daily routine practice and is highly accurate to frailty is of great importance.

Frailty can present with several symptoms and signs and has been recognized by British Geriatric Society as a syndrome that could present with falls, immobility, delirium, incon- tinence, and susceptibility to side effects of medications. [47] To recognize and identify frailty in routine conditions, there are seven plain ways identified by British Geriatric Society that can be used: [48]

  1. The PRISMA questionnaire: It consists of seven points that identify frailty when a score of more than 3 is recorded as shown in [Figure 2]
  2. Gait speed: walking speed over a 4 m distance
  3. Timed up and go test (TUGT): time needed to get up and walk for a distance of 3 m
  4. Self-reported health: By asking the patient: How can you rate your health on a scale of 0-10 A score of less than six was used to identify frailty
  5. General practitioner assessment: where the practitioner identifies frail patients based on clinical review
  6. Polypharmacy: An individual is considered frail if five or more drugs are used.
  7. The Groningen Frailty Indicator question-naire: A questionnaire of 15 points that identifies frailty in case a score of more than 4 is recorded.
Figure 2. PRISMA questionnaire used for identifying frailty.9

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Few studies used simple tools in assessing frailty in different populations. In 2013, Castell et al tried to assess gait speed over a 4 m distance, and its relation to frailty using a variety of cutoff points in a study involved 1327 individuals in Spain. They identified frailty using Fried criteria and found that frailty was prevalent in 10.5% of the selected population. They concluded that frailty can be excluded in individuals with walking speed more than 0.8 meters/second and that prevalence of frailty increases with age. [46]

An Irish study on 1814 individuals was done to assess relationship between TUGT and frailty as defined using Fried criteria. They found that TUGT is a sensitive (66%) and specific (77%) tool to assess frailty and can be used in measurement of frailty where application of Fried criteria is not practical. [49]

In the Netherlands, a study on 102 individuals older than 65 years was done to assess accuracy of several instruments for assessment of frailty against Fried Criteria as a standard reference tool to assess frailty. Instruments included were PRISMA questionnaire, Poly- pharmacy, The Groningen frailty indicator questionnaire, general practitioner assessment, and self-reported health. They concluded that PRISMA questionnaire with a cutoff of three or more positive questions has the highest sensitivity (86%) and specificity (83%) when compared to other instruments. [50]

In a systemic review done in University of Leeds-UK, they found very few studies that focused on this area. They included the three previously mentioned studies and tried to assess accuracy of these tests to diagnose frailty. They concluded that PRISMA questionnaire, TUGT, and gait speed tests have high sensitivity and moderate specificity to recognize frailty. A summary of their results is listed in [Table 2]. [51]
Table 2. Accuracy of different simple tests to identify frailty

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Gait speed could also be used as an estimate of survival in elderly population which is of great importance in taking decisions about management plans in this population. Few studies showed that gait speed is affiliated with survival and functional performance. [52] Studenski et al analyzed data from nine cohort studies involving 34,485 individuals with a mean age of 73 years old and concluded that gait speed was significantly affiliated with survival in elderly population as shown in [Figure 3]. [25] These studies show a vicious circle involving gait speed, survival, and frailty.
Figure 3. Gait speed and survival in elderly

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The British Geriatric Society has identified Gait speed, PRISMA questionnaire, and the TUGT test as tests with good sensitivity and moderate specificity and recommends the use of two methods to increase accuracy of identifying frailty. [47] Further studies about accuracy of simple tools to assess frailty in daily routine practice should be area of focus by researchers and nephrologists.

Management of frailty

The main domain for management of frailty in the elderly population is comprehensive geriatric assessment (CGA) which is a package of care that includes holistic and multidimensional assessment of the patient to determine the individual's medical, psychological, and functional abilities, so an integrated plan of management and long-term follow-up could be performed and this correlated with positive outcomes in many settings. [53] Based on the CGA, individuals will be referred to specialists that will aid them in further management as specialist nurses, dietitians, and psychiatrists as shown in [Figure 4]. [47]
Figure 4. Cognitive geriatric assessment.42

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Modalities that may improve frailty in elderly pre-dialysis patients such as treatment of potential factors as anemia and bone mineral disease may improve outcome; however, this has not been sufficiently proved, and more research and studies are needed in this field.

   Conclusion Top

Frailty is prevalent in elderly population who suffer from CKD and this prevalence increases with progression of the disease which increases the risk of adverse outcomes and they will eventually need dialysis. Early recog- nition of frailty in a clinical setting in this population will help identify individuals at risk. CKD predisposes to frailty through many potential mechanisms; anemia, bone mineral disease, oxidative stress, and malnutrition and this, in turn, leads to progression of CKD ending up in a vicious circle. Identifying potential causes of frailty in elderly pre- dialysis patients and recognizing individuals at risk should be area of focus by nephrologists and researchers. Current standard tests for frailty are complex and not applicable in routine daily basis. Therefore, identifying simple tools which is applicable in daily routine practice and is highly accurate to frailty is of great importance.

Conflict of interest: None declared.

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Correspondence Address:
Jyoti Baharani
Department of Renal Medicine, Heart of England Teaching Hospitals NHS Foundation Trust, Birmingham
United Kingdom
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PMID: 28748872

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