Frailty: A growing health concern in Asian population/Identification and management of frailty in elderly

Fried et al.1 defined frailty as a geriatric clinical syndrome characterized by ≥3 of the following conditions, which consist of either weakness (grip strength), exhaustion (self-reported), weight loss (unintentional), slow walking speed or low physical activity.

Frailty is a condition of increased vulnerability associated with various adverse health outcomes including falls, fractures, hospitalizations, disability, mortality, cognitive decline, depression, loneliness, worsening mobility, decreased quality of life and admission to long-term care2.
Since approximately 60% of the world population resides in Asia, which also harbors the fastest aging population (aged >65 years)3, it is apparent that the greatest impact and the global burden of frailty would fall upon elderly Asians.

However, studies related to frailty are sparse in Asian countries (both in high-income and low-middle-income countries), some studies illuminate the prevalence of frailty in this region of the world.

The Singapore Longitudinal Ageing Study with a cohort of 5414 elders aged ≥55 years depicted an overall prevalence of pre-frailty/frailty and cognitive pre-frailty/frailty of 43.5% and 7.1%, respectively in the study population. Furthermore, the overall prevalence of at-risk/malnutrition (calculated by the Mini Nutritional Assessment) in the pre-frail/frail and cognitive pre-frail/frail population was 42% and 63%, respectively4.

In another cross-sectional study among five Japanese residential areas with a cohort of 9182 people, the frailty prevalence for men and women ranged from 14.2-30.6% and 11.5-21.4%, respectively; the nutritional status and social activity was lowest in areas with higher frailty5.

In another study of community-dwelling 780 elders (mean age: 69.4 years) with knee osteoarthritis in Thailand, the overall prevalence of pre-frailty/frailty and cognitive frailty was 78.5% and 2.44%, respectively. The study also determined a strong association of aging, malnutrition, severe knee osteoarthritis symptoms and functional dependence with frailty6.

The high prevalence of pre-frailty/frailty mandates early identification and intervention to prevent its progression. However, this cannot be achieved without the identification of the onset and progression of risk factors.

The risk factors of frailty can be categorized into social and demographic factors such as advancing age, female sex, low socioeconomic status, ethnic minority, low education, loneliness and living alone; clinical factors involving multimorbidity and chronic diseases, malnutrition, obesity, cognitive impairment, depression and polypharmacy; lifestyle factors such as physical inactivity, low protein intake, alcohol abuse and smoking; and biologic factors including inflammation (elevated CRP or cytokines), endocrine factors (androgen deficiency) and deficiency of micronutrients (vitamin B6, D and E and low carotenoids)2.

Some of the above risk factors (malnutrition, obesity, physical inactivity) are modifiable and the progression of frailty can be prevented to an extent with guided intervention2.
A scoping review found that exercise, nutrition, prehabilitation (physical therapy, exercise and home modification), cognitive training and geriatric assessment and management are effective interventions in the prevention and reduction of frailty, of which, physical exercise interventions (all types and in combination with other interventions) were found to be most effective in preventing frailty7.

Systemic review in Asian region also corroborated with the above scoping review in determining exercise intervention as the most effective intervention for fall prevention (number of fallers: Odds Ratio 0.43 [0.34,0.53]; number of falls: 0.35 [0.21,0.57]; and number of fallers injured: 0.50 [0.35, 0.71]8.
Nutritional deficiency, particularly protein and vitamin D deficiency, has been closely linked to increased risk of frailty. Numerous studies have cited the protective role of proteins in the prevention of frailty; however, there is still a lack of quality intervention in this domain9. Frailty can be best managed with a multidomain approach including both physical activity and optimal nutrition10.

Frailty is a major threat to our aging society; therefore, it is important to identify it at an early stage and incorporate appropriate exercise intervention to prevent and deter its progression along with maintenance of optimum nutritional intake.


1. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2001;56(3):M146-156.
2. Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. Frailty: Implications for clinical practice and public health. The Lancet. 2019;394(10206):1365-1375).
3. 2019 World Population Data Sheet – Population Reference Bureau [Internet]. 2019 [cited 29 November 2019]. Available from:
4. Chye L, Wei K, Nyunt MSZ, Gao Q, Wee SL, Ng TP. Strong Relationship between Malnutrition and Cognitive Frailty in the Singapore Longitudinal Ageing Studies (SLAS-1 and SLAS-2). The Journal of Prevention of Alzheimer’s Disease. 2018;5(2):142-148.
5. Abe T, Kitamura A, Seino S, Yokoyama Y, Amano H, Taniguchi Y, Nishi M, Narita M, Ikeuchi T, Tomine Y, Fujiwara Y, Shinkai S. Differences in the Prevalence of and Factors Associated with Frailty in Five Japanese Residential Areas. International Journal of Environmental Research and Public Health. 2019;16(20):3974.
6. Wanaratna K, Muangpaisan W, Kuptniratsaikul V, Chalermsri C, Nuttamonwarakul A. Prevalence and Factors Associated with Frailty and Cognitive Frailty Among Community-Dwelling Elderly with Knee Osteoarthritis. Journal of Community Health. 2019;44(3):587-595.
7. Puts MTE, Toubasi S, Andrew MK, Ashe MC, Ploeg J, Atkinson E, Ayala AP, Roy A, Rodríguez Monforte M, Bergman H, McGilton K. Interventions to prevent or reduce the level of frailty in community-dwelling older adults: a scoping review of the literature and international policies. Age Ageing. 2017;46(3):383-392.
8. Hill KD, Suttanon P, Lin SI, Tsang WWN, Ashari A, Hamid TAA, Farrier K, Burton E. What works in falls prevention in Asia: a systematic review and meta-analysis of randomized controlled trials. BMC Geriatrics. 2018;18(1):3.
9. Hernández Morante JJ, Gómez Martínez C, Morillas-Ruiz JM. Dietary Factors Associated with Frailty in Old Adults: A Review of Nutritional Interventions to Prevent Frailty Development. Nutrients. 2019;11(1):102.
10. Cruz-Jentoft AJ, Woo J. Nutritional interventions to prevent and treat frailty. Current Opinion in Clinical Nutrition and Metabolic Care. 2019;22(3):191-195.