Be alert to the possibility of this condition, particularly in those older than 75. Find out what steps clinicians can take to keep these patients safe.
Mrs. H, aged 91 and a widow, lives with her daughter. An aide comes in three times a week to assist with the older woman’s personal care while her daughter is at work. Frequent visits from extended family help keep Mrs. H alert. In the past few years, though, Mrs. H has been hospitalized several times with pneumonia. Her appetite is poor, and her weight has dropped from 114 to 89 lb in a year. Although Mrs. H denies feeling depressed, she is discouraged by her deteriorating health, which requires her to use a walker.
Mrs. H has frailty syndrome, especially common after age 75. Some experts believe frailty is due to undiagnosed CAD; frailty can be secondary to cancer, infection, or other chronic diseases. A major contributor is sarcopenia, the loss of muscle strength due to immobility and inactivity. Frailty syndrome is also characterized by exhaustion and unintended weight loss. Although frailty can progress to death, it can often be halted or even reversed with appropriate intervention.
Help elders stay active
One of the most effective ways to counter frailty is with exercise. Even adults in their 80s and 90s retain the ability to respond to exercise with muscle growth and increasing strength. Physical therapists or trainers can assist in developing and monitoring exercise programs for the elderly, and Medicare will often cover the cost.
I frequently enlist a physical therapist to go to elderly patients’ homes and develop an individualized exercise program. I also encourage seniors to do simple strengthening exercises, such as biceps curls while holding a can of soup for weight and walking up and down stairs while wearing light ankle weights. Indoor or outdoor walking is also a good idea. Seniors can start by walking half a block, then slowly increase their distance and time as strength and stamina improve.
Determine each patient’s stamina and encourage him to improve. An easy way to gauge an elderly patient’s strength and mobility is with a simple gait test. Ask the patient to rise from an armless chair, walk a short distance, turn around, walk back, and sit down. By noting the amount of time it takes and the difficulty the patient has performing this task, then repeating the request on future visits, you can track improvement or deterioration in strength and independent function.
Elderly people often avoid exercise and even ordinary activities because of pain; it’s important to manage pain effectively because inactivity leads to muscle wasting and frailty. Along with encouragement, offer adequate analgesia. I generally start patients on acetaminophen, two 325-mg tablets, four times a day. If more pain control is needed, I switch to a combination of nonsteroidal anti-inflammatory drugs and a proton-pump inhibitor (PPI), such as omeprazole (Prilosec) or lansoprazole (Prevacid), to protect the stomach lining. I try to avoid narcotics because they can be sedating.
Prevent debilitating falls
All frail patients should have a home safety evaluation. Identify those at high risk of falling by asking, “In the past month, have you had any fall, including a slip or a trip, in which you lost your balance and landed on the floor or ground?” Because a clinician order is required for Medicare reimbursement, I arrange for a fall assessment by contacting a home-health agency. The assessment, which takes about an hour, is done by a nurse or other trained personnel, who look for loose rugs and other hazards and suggest ways to correct them.
Monitor medication regimens
Some medications contribute to inactivity and resultant frailty. In addition to sedatives, medications that cause electrolyte imbalances, such as diuretics, can exacerbate weakness. Drugs that slow reaction time can interfere with balance and coordination, as can alcohol. Ask elderly patients how much alcohol they consume, and if they’re having problems with balance, suggest that they stop drinking. Decreasing or discontinuing potentially offending medications may also help.
Conversely, some medications can be used to prevent frailty. Identifying and treating depression can help people become more active as their mood improves. Short-term stimulant medication, such as methylphenidate (Ritalin) 5 or 10 mg daily in the morning for two or three weeks, can often help depressed elderly patients be more active while waiting for longer-term improvement from an antidepressant. Note that methylphenidate is not appropriate in patients with uncontrolled hypertension.
Promote good nutrition
As people become weaker and less mobile, they are less likely to eat a balanced diet with adequate protein. At the same time, illness, both acute and chronic, increases nutritional demands on the body and can further accelerate loss of muscle mass. Even in the absence of specific disease, when it becomes difficult to get to the grocery store and prepare nutritious meals, elderly adults may become more dependent on others for their food or may rely on processed snacks.
Eating well can help patients stave off sarcopenia. Programs such as Meals On Wheels work well for many; find out what options are available in your area so you can keep patients informed. Additionally, some elderly patients, particularly men, may lack a basic understanding of proper nutrition, especially if they’ve always depended on others to plan and prepare their meals. In such cases, referral to a skilled dietitian for a session or two can often be helpful, particularly when patients are consuming ethnic diets unfamiliar to you. Dietitians typically charge $50-$100 per hour; Medicaid may cover the cost of one or more sessions. I also recommend adding Carnation Instant Breakfast and/or a scoop of ice cream to milk to increase nutritional value. Protein supplements, such as Ensure and Boost, can be helpful as well.
Consider hormonal treatment
A patient’s hormonal status can influence the development of frailty. Androgen levels exert important effects on muscle mass, so it’s often helpful to check androgen levels in elderly men at risk of frailty. If hypogonadism is present, I often start patients on a topical androgen supplement, Androgel, which can help enhance appetite and increase muscle mass.