Fall 2025

Fall 2025 Issue

Beyond Aging
By Stephanie Dunne, MS, RDN, IFNCP
Today’s Geriatric Medicine
Vol. 18 No. 4 P. 20

How Identifying and Addressing Frailty Can Transform Care

Along with sarcopenia, anorexia of aging, and cognitive impairment, frailty is one of the modern Geriatric Giants—a set of syndromes that increase risk for falls, hip fractures, mood disorders, and delirium.1 Specifically, frailty is a syndrome that leaves an individual more vulnerable to stressors in multiple body systems due to a decline in cognitive, psychosocial, and physical capabilities.2 Frailty and the other Geriatric Giants are also associated with substantially increased health care costs and adverse outcomes, including disability, hospitalization, nursing home admission, and death.1,2

Prevalence estimates vary widely because definitions and diagnostic tools are inconsistent. Overall, 12% to 24% of older adults are estimated to be frail.2 More specifically, about 10% of community-dwelling adults aged 65 and older are frail, with prevalence rising to 25% to 50% of those aged 85 and older. In acute care, nearly one-half of hospitalized seniors are frail, and in nursing homes, about half of residents are frail, while another 40% are prefrail.3

Frailty risk is worsened by comorbidities, physical inactivity, poor nutrition, and other factors.4 Women have higher frailty indices than men at every age, with the gap continuously widening after age 75.5 With the global population aging, the number of frail individuals requiring health care is rapidly rising, creating a serious public health challenge.4

Although frailty progresses at an average rate of 3% to 6% annually, it can sometimes be slowed or even reversed with targeted interventions.5 Most importantly, frailty may be prevented when screening and intervention occur during robust or prefrail states.4

Understanding Frailty

Defining and Diagnosing Frailty
When someone is frail, their ability to recover from even minor stressors—whether an infection, a medication change, or a minor fall—is significantly impaired and prolonged, leaving them more vulnerable to disability and death. As well, the individual may never return to their prestressor level of health, even if independence and alert cognitive function are regained.3,4,6

Frailty involves both physical and psychosocial components and can be assessed through several tools. The most common tools used in research are:

Fried’s Frailty Phenotype, which assigns an individual a frail phenotype when they meet three or more of these five criteria: unintentional weight loss, weakness or poor handgrip strength, self-reported exhaustion, slow walking speed, and low physical activity.

Rockwood’s Frailty Index, which provides a continuous score from one through nine, shows an individual’s accumulation of deficits across more than 60 health-related variables. A person is considered frail with a score of five or higher.3-5

Pathophysiology and Risk Factors
Frailty is best understood as a clinical syndrome rather than a single medical diagnosis, since it can stem from multiple underlying causes and is influenced by both biological and social determinants.6 While sarcopenia, malnutrition, and polypharmacy play central roles, additional risk factors—ranging from lifestyle behaviors to comorbid conditions—further increase vulnerability.4,7 Summarizing these factors in a single framework helps highlight both the complexity and the modifiable opportunities for intervention.

The table below provides an overview of the major risk factors that have been associated with the onset and progression of frailty, including their relative risks where available.4,8 These factors span nutrition, physical activity, medical conditions, and social circumstances, emphasizing that frailty is not an inevitable consequence of aging but a condition shaped by multiple influences.

Interestingly, BMI was not associated with increased risk of frailty, likely because BMI alone is not an accurate predictor of muscle mass. As well, although most frail individuals were older than nonfrail individuals in the studies reviewed, this was not always the case, showing that factors other than age are more closely correlated with the onset of frailty.8

The Central Role of Nutrition in Frailty
As shown above, poor nutritional status is one of the most important contributors to the development of frailty. Because nutrition is a modifiable risk factor, it offers a powerful opportunity to prevent, slow, and even reverse this debilitating condition in older adults. Health care practitioners know that inadequate intake of energy or essential nutrients leads to unintentional weight loss and diminished muscle mass, which ultimately leads to frailty.2 In fact, up to 90% of older adults who are malnourished are also frail.6

That said, frailty is not limited to undernutrition alone. Obesity also elevates risk, particularly when excess weight is accompanied by reduced muscle mass and higher body fat percentage. These patterns highlight the dual role of both insufficient and imbalanced nutrition in driving vulnerability.2 Taken together, the evidence underscores that optimizing nutritional intake is central to maintaining strength, independence, and robustness in aging.

Dietary Patterns
Research correlating diet and frailty is limited, making it difficult to determine whether poor diet quality contributes to frailty or frailty leads to eating behavior changes. Nonetheless, observational and longitudinal studies consistently show that nutrient-dense, anti-inflammatory dietary patterns are protective. Diets rich in vegetables, fruits, and whole grains are strongly associated with lower frailty risk. In fact, one study demonstrated a clear dose-response: individuals consuming zero to one servings of fruits and vegetables daily were almost twice as likely to be frail compared with those consuming five to 10 servings. Similarly, in the Nurses’ Health Study, women aged 60 and older reduced their frailty risk by 10% for each standard deviation increase in their diet quality score, as measured by the Alternative Healthy Eating Index-2010.2

The inflammatory potential of the overall diet also appears to be critical. Adherence to the Mediterranean diet—emphasizing plant-based foods, olive oil, and reduced intake of meat and dairy—has been shown to reduce frailty risk across Mediterranean and US populations.2 As well, higher scores on the Dietary Inflammatory Index are linked to elevated circulating inflammatory markers and a greater likelihood of frailty, even after accounting for age, comorbidities, physical activity, and energy intake. Finally, limiting ultraprocessed foods is important, as these displace nutrient-dense options while contributing to adverse outcomes such as cardiovascular disease, metabolic syndrome, and cancer.2,6

Protein and Muscle Health
Adequate protein intake is central to preventing and slowing frailty, given its direct role in preserving skeletal muscle, mobility, and immune function. While the Institute of Medicine sets the Recommended Dietary Allowance of protein at 0.8 g/kg/day for adults aged 51 and older, research suggests older adults benefit from higher intakes. Most older individuals benefit most from consuming 1.0 to 1.2 g/kg/day and up to 2.0 g/kg/day when frailty, sarcopenia, or illness is present.9–11 As well, because older adults’ muscles are less responsive to low doses of protein intake, consuming 30 to 35 g of protein at each of the three main meals helps older adults achieve protein intake saturation, signaling the brain to promote muscle growth.11,12 Unfortunately, nearly one-half of women and one-third of men aged 71 and over fail to meet the minimum requirement for protein intake, and more than 85% of older adults fail to consume 30 g of protein at two or three of their main meals.13,14

Micronutrients and Polyphenols
Inflammation and oxidative stress are implicated in the etiology of frailty, though research findings are not always conclusive. However, given the likelihood, the mechanism by which a higher intake of fruits and vegetables reduces frailty risk is likely due to their polyphenol content, which provides antioxidant effects.2

Evidence regarding the impact of vitamin B12 and folate is also mixed, with some studies showing an association between deficiencies and frailty, while others do not. Nonetheless, given their essential roles in metabolism, methylation, and immune regulation, adequate intake is critical for supporting overall health. Calcium and vitamin D are also key for bone and muscle health, and supplementation in older adults has been linked to improved gait speed and muscle strength.6

Because micronutrient interactions are complex and synergistic, and research studying one or two micronutrients has been inconclusive, focusing on a single nutrient may not be effective. In one study, combined supplementation with folate, calcium, and vitamins B6, B12, and D improved frailty outcomes in community-dwelling older adults.6 However, this level of supplementation may not be feasible in most care settings or for older individuals living at home.

Ultimately, a nutrient-dense, wholefoods diet remains the most reliable approach to ensuring adequate intake of the micronutrients and polyphenols that can help reduce the risk of frailty development and progression.

Nonnutritional Contributors to Frailty

Physical Inactivity
Loss of muscle mass, mobility, and functional capacity are all risk factors in the development of frailty. As such, the importance of exercise to prevent or slow the progression of frailty cannot be understated.2

Across all life stages and levels of frailty, regular exercise protects against multiple frailty risk factors, including its ability to improve muscle strength, mobility, cognition, and mood. Thus, physical activity is as essential as nutrition in managing frailty.1,4 In fact, research consistently shows that the combination of exercise and nutrition can limit frailty progression and, in some cases, even reverse it.4

Interventions such as resistance training, balance exercises, and aerobic activity have all been shown to improve strength, gait speed, and balance in older adults when appropriately implemented. To achieve the greatest benefit, exercise plans should be tailored to each individual for safety and feasibility, especially in prefrail or frail adults.4

Cognitive and Psychological Factors
Beyond physical health, psychological and cognitive factors play a critical role in the onset and progression of frailty. Loneliness, which becomes more common with age as social interactions diminish, is strongly associated with cognitive decline, depression, dementia, fatigue, physical inactivity, and adverse health outcomes.1 Given these connections, loneliness should be recognized as a significant risk factor for frailty.

Evidence also points to a bidirectional relationship between frailty and cognitive decline. Studies show that an increase in frailty can accelerate cognitive impairment, while declining cognition can, in turn, exacerbate frailty. Shared mechanisms such as oxidative stress and chronic inflammation may help explain this interplay.6

Similarly, depression and frailty appear to influence one another. Older adults with major depression, a family history of depression, or moderate to severe depressive symptoms face a higher likelihood of developing frailty, independent of age, gender, or pain status.15 These findings highlight the need for holistic approaches that address both physical and psychological wellbeing in efforts to prevent or slow frailty progression.

Polypharmacy and Medical Burden
Polypharmacy not only reflects an individual’s comorbidity burden but also can directly contribute to frailty through adverse drug interactions and side effects that diminish functional capacity and quality of life.15 Evidence suggests that polypharmacy may contribute to the development of frailty itself, rather than simply serving as a marker of existing vulnerability.16

Older adults with reduced functional reserve are particularly vulnerable, as multiple medications may increase the risk of weight loss, balance difficulties, malnutrition, and loss of independence.16 Regular medication reviews by qualified health care practitioners are essential to minimize duplication, optimize dosages, and reduce unnecessary prescriptions.15

Slowing Frailty

Early Screening and Identification
Early identification of frailty risk is essential, as once a person becomes frail, their lifespan is significantly reduced. Research suggests that average life expectancy is just 3.4 years for women and 1.2 years for men following the onset of frailty.7 Detecting and intervening with individuals in a prefrail state can therefore be critical for extending both lifespan and quality of life.

Although Fried’s Frailty Phenotype and Rockwood’s Frailty Index are widely used research tools, they are often impractical for routine health care settings. A more feasible alternative is the FRAIL scale, which asks patients to self-assess the following five criteria:

Fatigue: Are you fatigued?
Resistance: Can you walk up one flight of stairs?
Aerobic capacity: Can you walk one block?
Illness: Do you have more than five illnesses or chronic conditions?
Loss of weight: Have you lost more than 5% of your body weight in the last six months?17

For practitioners working in long term care, the FRAIL-NH offers additional specificity, accounting for population-specific conditions, such as altered diets and the need for assistance with dressing.18 Incorporating these screening tools into routine care allows health care professionals to detect frailty risk earlier, opening the door for timely interventions to slow or even prevent progression.

Multimodal Intervention
Frailty is shaped not only by physical health but also by nutritional, medical, psychological, and cognitive factors. Because of this complexity, interventions that address multiple domains simultaneously are more effective than those targeting a single area.

For instance, pairing resistance and aerobic exercise with adequate protein and calorie intake helps preserve muscle mass and functional capacity more effectively than either strategy alone.4 Likewise, careful review of medications reduces the risk of side effects that worsen physical decline.15 Addressing psychological and cognitive health is equally important, as depression, anxiety, and cognitive impairment can reduce motivation, limit participation in activities, and accelerate functional loss.1 By combining physical, nutritional, medical, and psychosocial supports, interventions can reinforce one another and create a stronger foundation for resilience.

This coordinated approach allows practitioners to intervene earlier and more effectively, with the goal of slowing or even reversing frailty. Multimodal strategies maximize the opportunity to maintain independence, protect quality of life, and extend healthy lifespan in older adults.

Coordinated Care Approach
Because frailty is multifactorial, its management requires a coordinated team rather than a single provider. Physicians and nurse practitioners oversee medical treatments and medication adjustments, while dietitians address malnutrition and weight loss through individualized nutrition care. Physical and occupational therapists support mobility, strength, and independence, and mental health professionals help manage depression, anxiety, and cognitive decline—factors that may accelerate frailty. By working together, this team creates a unified plan that addresses the whole person, reduces gaps in care, and provides the best opportunity for older adults to preserve function and quality of life.

Conclusion
Frailty is not an inevitable consequence of aging but a complex, multifactorial condition influenced by physical, nutritional, medical, psychological, and social factors. Early identification of prefrailty, combined with interventions that address strength, nutrition, cognition, and emotional wellbeing, can slow or even reverse its progression. Because no single treatment is sufficient, coordinated, team-based care is essential to support independence and preserve quality of life. For health care practitioners, recognizing frailty as both preventable and manageable shifts the focus from decline to resilience, offering older adults the opportunity to live longer, healthier, and more fulfilling lives.

— Stephanie Dunne, MS, RDN, IFNCP, is an integrative registered dietitian, freelance writer, and owner of Feed Your Intention in St Petersburg, Florida.

References
1. Giné-Garriga M, Jerez-Roig J, Coll-Plana L, et al. Is loneliness a predictor of the modern geriatric giants? Analysis from the survey of health, ageing, and retirement in Europe. Maturitas. 2021;144:93-101.

2. Lochlainn MN, Cox NJ, Wilson T, et al. Nutrition and frailty: opportunities for prevention and treatment. Nutrients. 2021;13(7):2349.

3. Le Pogam MA, Seematter-Bagnoud L, Niemi T, et al. Development and validation of a knowledge-based score to predict Fried's frailty phenotype across multiple settings using one-year hospital discharge data: the electronic frailty score. EClinicalMedicine. 2022;44:101260.

4. Doody P, Lord JM, Greig CA, Whittaker AC. Frailty: pathophysiology, theoretical and operational definition(s), impact, prevalence, management and prevention, in an increasingly economically developed and ageing world. Gerontology. 2023;69(8):927-945.

5. Theou O, Haviva C, Wallace L, Searle SD, Rockwood K. How to construct a frailty index from an existing dataset in 10 steps. Age Ageing. 2023;52(12):afad221.

6. O’Connor D, Molloy AM, Laird E, Kenny RA, O’Halloran AM. Sustaining an ageing population: the role of micronutrients in frailty and cognitive impairment. Proc Nutr Soc. 2023;82(3):315-328.

7. Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16-31.

8. Wang X, Hu J, Wu D. Risk factors for frailty in older adults. Medicine. 2022;101(34):e30169.

9. Coelho-Júnior HJ, Milano-Teixeira L, Rodrigues B, Bacurau R, Marzetti E, Uchida M. Relative protein intake and physical function in older adults: a systematic review and meta-analysis of observational studies. Nutrients. 2018;10(9):1330.

10. Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013;14(8):542-559.

11. Baum JI, Kim IY, Wolfe RR. Protein consumption and the elderly: what is the optimal level of intake? Nutrients. 2016;8(6):359.

12. Coelho-Júnior HJ, Rodrigues B, Uchida M, Marzetti E. Low protein intake is associated with frailty in older adults: a systematic review and meta-analysis of observational studies. Nutrients. 2018;10(9):1334.

13. US Department of Agriculture; Health and Human Services. Dietary Guidelines for Americans, 2020-2025. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf. Published December 2020.

14. Moore DR. Keeping older muscle “young” through dietary protein and physical activity. Adv Nutr. 2014;5(5):599S-607S.

15. Oyon J, Serra-Prat M, Limon E, et al. Depressive symptom severity is a major risk factor for frailty in community-dwelling older adults with depression. A prospective study. Fam Pract. 2022;39(5):875-882.

16. Alqahtani, B. Number of medications and polypharmacy are associated with frailty in older adults: results from the Midlife in the United States study. Front Public Health. 2023;11:1148671.

17. Ruiz JG, Dent E, Morley JE, et al. Screening for and managing the person with frailty in primary care: ICFSR consensus guidelines. J Nutr Health Aging. 2020;24(9):920-927.

18. Kaehr EW, Pape LC, Malmstrom TK, Morley JE. FRAIL-NH predicts outcomes in long term care. J Nutr Health Aging. 2016;20(2):192-198.