© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
EDITORIAL
Ageing and frailty
Ben YF Fong, MPH (Syd), FHKAM (Community Medicine)
Division of Science, Engineering and Health Studies, College of Professional and Continuing Education, The Hong Kong Polytechnic University, Hong Kong
Corresponding author: Dr Ben YF Fong (ben.fong@cpce-polyu.edu.hk)
Ageing and healthcare services
The consequences of population ageing are major
concerns for most governments, particularly in
economically developed countries and regions. This
has been exacerbated by the ongoing coronavirus
disease 2019 (COVID-19) pandemic. In Hong Kong,
government officials, professionals, academics,
community leaders, parents, family members,
carers, teachers and frontline workers have been
facing unpredictable and changeable situations
arising from measures introduced to limit the
number of COVID-19 cases and associated deaths.
There has also been excess mortality among the
older population, mostly residents of elderly homes,
during the fifth wave of the outbreak in early 2022.1
In this issue of Hong Kong Medical Journal, Luk
and Chan2 highlight that the measures intended
to protect the elderly population may have had the
unintended adverse effect of worsening frailty and
sarcopenia. Policymakers and healthcare providers
are often caught off guard no matter how much time,
effort, and resources have been invested in planning
and preparing for public health crises.
Ageing populations aggravate the demand
on social and health services, and Hong Kong’s
population—with one of the world’s longest life
expectancies of 85.2 years—is no exception.
Longevity naturally results in more age-related
problems such as declining functional and intrinsic
capacities, including frailty, that require care and
attention by family members, carers, and healthcare
providers.3 The Hong Kong population aged ≥65
years is predicted to increase from 16% in 2017
to 34% in 2066.4 Many older adults need regular
and long-term care; most of them have at least
one common chronic condition resulting from
ageing. Older adults also consume 6 times more in-patient
services than do younger patients, and this
represents a continuing burden to the healthcare
system, affecting its sustainability.5 6 The traditional
model of public financing and delivery of acute-centric
hospital-oriented care leads to significant
and negative effects on accessibility, equity, and
sustainability. In contrast, primary care effectively
and efficiently provides better and more appropriate
care to the residents in the best interests of the
community.7
Geriatric syndromes
Complex health states commonly called geriatric
syndromes are unavoidable in ageing and caused
by a number of potentially concurrent bodily
conditions like frailty, urinary incontinence,
recurrent falls, mental impairment and pressure
ulcers. Frailty is an emerging global health burden
coming from the ageing populations. It is a
syndrome arising from continuing changes and
decline across multiple physiological systems of the
immune, musculoskeletal and endocrine systems,
often considered as minor and associated with
fatigue, decreased muscle strength, and increase
in dependence, falls, hospitalisation, mortality, and
vulnerability to stressors as well as health costs. The
affected older adults look shrinking, feel weak and
exhausted, move slowly, resulting in low level of
activity, cognitive impairment, slow gait, and poor
balance. Thus, frailty is an important predictor and
health indicator for the older adults. The prevalence
increases with age and is found to be lower in the
rural ageing population. Risk factors include multi-morbidity,
polypharmacy, female gender, low socio-economic
status and educational background, poor
diet, and physical inactivity.8 9 About 10% of older
adults are affected by frailty but they may maintain
almost full daily life capacity. However, there is
potential of severe long-term effects on the wellbeing
of individuals.10 The affected older adults are less
ready or able to recover from illnesses or injuries.
This can have an obvious impact on the quality of
daily living and life expectancy.11
Frailty and sarcopenia
As noted by Luk and Chan,2 frailty and sarcopenia
are closely related syndromes in geriatrics. Ageing
entails the catabolism of muscles resulting in
sarcopenia and frailty, and these often overlap in
clinical presentation. The loss of muscle mass and
function in sarcopenia is usually related to ageing
but can also be induced by starvation, malnutrition,
or inactivity. In contrast, frailty is age-related multi-system
impairment and loss of weight and energy,
but is not limited specifically to the muscles. Gait
speed and hand grip strength are employed as
diagnostic measures for both frailty and sarcopenia.
Treatments for both of these two conditions also overlap, including adequate protein and vitamin
D supplementation, plus resistance exercise
programmes, which may not be feasible for the old
and frail.12 13
Detection and management of frailty
Lifestyle risk factors are potentially modifiable by
specific interventions and preventive actions. The
concept of frailty is increasingly being discussed
in public health, and primary, acute and specialist
care.9 However, frailty may be missed or ignored as
a process of normal ageing.14 It is thus imperative to
identify frailty routinely, as part of the comprehensive
geriatric assessments in older adults, using validated
simple-to-use screening tools.
In this issue of Hong Kong Medical Journal,
Umehara et al15 developed prediction models for the
prognosis of pre-frailty and frailty in older patients
with heart failure, and evaluated their accuracy. They
found that the patient’s condition at admission was
predictive of pre-frailty and frailty, and that cardiac
rehabilitation may help to improve frailty after
cardiac intervention. These findings are consistent
with a recent review by Ijaz et al,16 who found that
tailored cardiac rehabilitation in patients with
cardiac failure was associated with positive results on
frailty. Those authors therefore proposed that active
screening should be incorporated into a patient-centred
model of cardiovascular practice in order
to identify frail older adults who would benefit from
frailty intervention, particularly after cardiovascular
interventions.16 Such practices should be adopted
in Hong Kong where cardiovascular diseases are
prevalent and detection of early or pre-frailty will be
beneficial to the older adults at higher risk.
Management of co-morbid conditions is
essential when caring for frailty. Walking and simple
body movements are considered useful in improving
strength, thereby alleviating weakness, even for
the very old.17 The author started learning sitting
tai chi a year before and had found it very effective
for relaxation, co-ordination and positive feeling.
Treatment plans must be individualised to address
the age, goals of care and expectations of the patient
and their family. When indicated, palliative care and
symptom control can be considered for frailer older
people.14
Ageing with frailty and dignity
Frailty is drawing more attention worldwide because
of the increasing ageing populations. It is being
better defined through consensus conferences,
and research in ageing and the associated intrinsic
capacity. Frailty is considered as partly preventable
and thus early detection with screening tools is a
critical step in routine geriatric assessment. Targeted interventions and management plans can then be
initiated to allow the older adults to live a quality life
with dignity, as part of the holistic and humanistic
approaches in elderly care and services.18 19
Author contributions
The author contributed to the concept or design, drafting of
the manuscript, and critical revision for important intellectual
content. The author had full access to the data, contributed to
the study, approved the final version for publication, and takes
responsibility for its accuracy and integrity.
Conflicts of interest
The author has disclosed no conflicts of interest.
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