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What Are Multimorbidity and Frailty and How Do They Affect the Care of Older Adults?
Acknowledgments
We would like to thank Suzy Goldhirsch, MA, MsEd, for contributions to editing and reviewing the text.
Introduction and Scope of the Problem
Multimorbidity and frailty are two concepts utilized increasingly by clinicians to evaluate the risk profile of older adults in order to guide clinical decisions or treatment interventions. While these two terms are sometimes used interchangeably, their underlying conceptual frameworks and operational definitions are very different. This chapter provides an evidence-based review of our current knowledge about multimorbidity and frailty and suggests how these frameworks can be used to discuss key considerations in the clinical care of older adults.
Definition and Epidemiology of Multimorbidity
Multimorbidity is defined as the coexistence of two or more chronic health conditions; understanding its implications is a core element of high-quality care of older, frail adults. The phrase multiple chronic conditions is used interchangeably as well. More than 50% of older adults have multimorbidity. Older adults with multimorbidity, even those diagnosed with the same list of chronic conditions, are heterogeneous in illness severity, functional status, prognosis, and risk of adverse events. The combinations and severity of these chronic conditions can have varying cumulative effects on each individual. Therefore the approach to caring for older adults with multimorbidity requires thoughtful clinical judgment and significant flexibility.
The prevalence of multimorbidity in the older adult population is high. Nearly 50% of those age 65 to 69 have two or more chronic conditions. This prevalence increases to 75% for those over the age of 85. As the U.S. population continues to age, multimorbidity will undoubtedly increase in the older adult population and will add to the financial burden on the health care system. As an example of the cost implications, a study by the Veterans Health Administration in 2014 reported that older patients with multimorbidity accounted for 67% of total health care costs.
Definition and Epidemiology of Frailty
Frailty syndrome describes a clinical state of increased vulnerability characterized by progressive multisystem decline, reduced physiological reserve and ability to cope with acute stress, and increased adverse health outcomes. Frailty in its earliest stage is often not clinically apparent. In contrast, late clinical manifestations of frailty, such as recurrent falls and injuries, frequent hospitalization, or progressive disability, are readily observable. Although a number of frailty screening tools have been developed and validated in multiple large population studies, no single gold-standard definition of frailty has been established or widely incorporated into clinical practice. The lack of a consensus frailty definition is in part due to differences in the way frailty is conceptualized. While some experts conceive frailty as a physiological condition, or phenotype, associated with age-related multisystem decline, others theorize that frailty is an accumulation of functional deficits, disease states, and cognitive decline.
Because frailty in older adults has been widely examined in clinical investigations, epidemiological data from North America and Europe are now available. In the United States, for instance, the overall prevalence of frailty in community-dwelling adults older than 65 years ranged from 7% to 12%. Frailty prevalence increased with age from 3.9% in 65- to 74-year-olds, to 25% in those older 85 years. Older women (8%) were more likely to be frail than older men (5%). Frailty was less common in White Americans (6%) than Black Americans (13%) but similar to that in Mexican Americans (7.8%). In Europe, the overall prevalence of frailty was 17%, with a geographic variation that showed a higher prevalence in southern Europe (e.g., 27% in Spain, 23% in Italy) than in northern Europe (e.g., 5.8% in Switzerland, 8.6% in Sweden). In these studies, the prevalence of frailty demonstrated similar age trends and gender differences.
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