What is frailty? Kate Callahan relates a clear metaphor on today’s podcast. A frail person is like an origami boat: fine in still water, but can’t withstand a breeze, or waves. Fundamentally, frailty is about vulnerability to stress.

In 2021 we talked with Linda Fried about phenotypic frailty. Today we talk with Kate Callahan, Ariela Orkaby, & Dae Kim about deficit accumulation frailty. What is the difference, you ask? George Kushel probably explained it best in graphical terms (in JAGS), using the iconic golden gate bridge as a metaphor (Eric and I get to see the bridge daily driving or biking in to work). Phoenotypic frailty is like the main orange towers and thick orange support cables that run between towers. Damage to those critical functions and the bridge can collapse. Deficit accumulation frailty is like the hundreds of smaller vertical cables that connect the thick orange support cables to the bridge itself. Miss a few and you might be OK. But miss a bunch and things fall apart. Resilience is the ability of the bridge to withstand stress, like bridge traffic, wind, waves, and the occasional earthquake (hey it’s California!).

Frailty research has come a long way. We’re now at a point where frailty can be measured automatically, or electronically, as we put in the title. Kate created an eFrailty tool that measures frailty based on the electronic health record (EHR) data. Ariela created a VA frailty index based on the EHR of veterans. And Dae created an index using Medicare Claims. Today we’re beginning to discuss not just how to measure, but how to use these electronic frailty indexes to improve care of patients.

We should not get too hung up on battles over frailty. As Kate writes in her JAGS editorial, “If geriatricians wage internecine battles over how to measure frailty, we risk squandering the opportunity to elevate frailty to the level of a vital sign. Learning from the past, a lack of consensus on metrics impeded the mainstream adoption of valuable functional assessments, including gait speed.”

To that end, modeled after ePrognosis, Dae and Ariela have launched a new tool for clinicians that includes multiple frailty measures, with guidance on how to use them and in what settings. It’s called eFrailty, check it out now!

Did I cheat and play the guitar part for Sting’s Fragile at ⅔ speed then speed it up? Maybe…but hey, I still only have 2 usable fingers on my left hand, give me a break!

-@AlexSmithMD

Additional Links:

eFrailty website is: efrailty.hsl.harvard.edu (efrailty.org is fine).

Dae’s Frailty indexes
CGA-based frailty index web calculator for clinical use: https://www.bidmc.org/research/research-by-department/medicine/gerontology/calculator

The Medicare claims-based frailty index program for research: https://dataverse.harvard.edu/dataverse/cfi/

Ariela’s VA-FI:
Original VA frailty index: https://academic.oup.com/biomedgerontology/article/74/8/1257/5126804

ICD-10 version
https://academic.oup.com/biomedgerontology/article/76/7/1318/6164923

Link to the code for investigators (included in the appendix):
https://github.com/bostoninformatics/va_frailty_index

As an FYI for those in VA the code is readily available through the Centralized Interactive Phenomics Resource (CIPHER)

Recent validation against clinical measures of frailty:
https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18540

Kate’s eFrailty Index
https://doi.org/10.1093/gerona/glz017 our original eFI paper

https://doi.org/10.1111/jgs.17027 & https://doi.org/10.1001/jamanetworkopen.2023.41915 on eFI and surgery

https://doi.org/10.1111/jgs.17510 editorial in JAGS

Electronic Frailty Indexes: Kate Callahan, Ariela Orkaby, & Dae Kim

GeriPal - A Geriatrics and Palliative Medicine Podcast