The Frail Brain

Abstract

FRAILTY “How slight a thing will disturb the equanimity of our frail minds.” wCharles Dickens, Oliver Twist Recently in the Journal of the American Medical Directors Association, an expert panel strongly advocated screening for physical frailty, using a simple screening test, such as the FRAIL.1e5 Physical frailty and comorbidity have been shown to be strongly associated with a variety of poor functional outcomes, hospitalization, and mortality.6e14 Simple treatment strategies for many of the components of frailty have been identified.15e18 In this issue of the Journal, Shimada et al19 show that although frailty and cognitive impairment can overlap, in most cases of persons with either frailty or early cognitive impairment, there is no overlap. This raises the question of whether or not brain or psychosocial frailty can equally lead to poor outcomes. A number of studies have suggested that frailty when associated with mild cognitive impairment or dementia has very poor outcomes.20e25 Stressors, such as earthquakes26 or even the threat of returning Hong Kong to China,27 have been shown to increase mortality in older persons. Psychological distress correlates with frailty and functional decline.28e32 Cigolle et al33 found that although a “burden model” of frailty had substantial overlap with biological and functional models of frailty, almost 40% of persons shown to be frail with this model were not frail using other models. Similarly, the “Kihon Checklist” identified cognition as a key separate component of frailty.34 A number of social factors, such as socioeconomic status and life space constriction, are associated with adverse outcomes in older persons.35e37 In nursing homes, changes in routine and environment increase the risk of hospitalization.38 Social engagement has a protective effect on functional dependence.39 Cognitive impairment can lead to a number of factors that increase fall risk and frailty.40e45 Dual tasking, the inability to think and walk at the same time, is a major problem as older persons lose executive function.46 Persons with vascular dementia tend to have high-level gait disorder, which leads to high-stepping, variability, and postural instability.47 Persons with Lewy body dementia can have freezing of gait, leading to inability to generate appropriate stepping. Persons with cognitive problems lack attention and have poor rescue and protective arms reaction when they fall. Finally, they have an