"A biological syndrome of decreased reserve and resistance to stressors, resulting from cumulative decline across multiple physiologic systems, and causing vulnerability to adverse outcomes." — Fried et al 2001 ^[2]

Why this matters from first principles: The slide's balance graphic places insults/stressors on one side and reserve on the other. A robust person can absorb a stressor and return towards baseline; a person with little reserve may cross a decompensation threshold after the same insult. Reserve is not visible from chronological age alone, so assessment should establish baseline function and vulnerability rather than infer frailty from appearance.

Historical slide statement (2013 consensus): screen all persons over age 70, and adults with multiple chronic illnesses or weight loss ≥5 kg over a year ^[2].

Current consensus is better expressed as opportunistic case identification: offer older adults a brief, validated tool appropriate to the setting, then clinically assess anyone who screens positive for frailty or pre-frailty. ICFSR uses age ≥65 for this recommendation but rates the certainty of evidence as low ^[8]. Do not label a patient frail from age, one slow performance test or an electronic flag alone.

FRAIL Scale — Detailed Scoring (Morley): ^[2]

• Fatigue: "How much of the time during the past 4 weeks did you feel tired?" — responses "All of the time" or "Most of the time" score 1; all others score 0
• Resistance: "By yourself and not using aids, do you have any difficulty walking up 10 steps without resting?" — Yes = 1, No = 0
• Ambulation: "By yourself and not using aids, do you have any difficulty walking several hundred yards?" — Yes = 1, No = 0
• Illnesses: ≥5 out of 11 illnesses (hypertension, diabetes, cancer, chronic lung disease, heart attack, CHF, angina, asthma, arthritis, stroke, kidney disease) = 1; 0–4 = 0
• Loss of weight: Percent change = [(weight 1 year ago − current weight) / weight 1 year ago] × 100; > 5% loss = 1, otherwise 0

The 9-point CFS (Rockwood): ^[2][4]

For dementia: the degree of frailty corresponds to the degree of dementia ^[4]

How to use the visual scale safely: score the person's usual baseline state, not how they look during the acute illness. In acute care, guidance commonly anchors this to approximately two weeks before presentation. The pictograms are prompts; the score requires a clinical history of mobility, function, cognition and dependence, and it must not be used as an automatic triage or treatment-withholding rule ^[9].

Historical 2022 slide statement: an electronic Frailty Index (eFI) had been developed by HAHO and was described as becoming available in HA hospitals ^[2]. Current local availability should be checked rather than inferred from that future-tense slide.

An eFI uses routinely collected clinical data to support population-level risk stratification. It can prompt review but cannot establish the patient's current baseline, goals, cognition or social context; it therefore does not replace clinical assessment or CGA.

COVID-19 has been implicated as a new risk factor for frailty ^[2]. Strict lockdown measures to protect older adults often paradoxically worsen frailty through:

• Social isolation and depression
• Malnutrition from reduced access to food/services
• Reduced access to healthcare
• Physical inactivity

Assessment and prevention of frailty and sarcopenia are of particular importance during pandemics ^[2].

Facilitates treatment plan and disposal:

• Hospitalisation vs. discharge from A&E
• Acute hospital vs. step-down geriatric hospitals
• Discharge with community-based care: CGAT, CVMO, ECEOL, GDH, ICDS (ICM CM or IDSP HST), PSCC, CNS, VMP, MDOST, DSCC ^[2]

Why this matters: Frailty assessment at the hospital "front door" identifies patients likely to need early CGA, collateral history, functional support and careful discharge planning. It contributes to — but must not replace — assessment of acute illness severity, treatment needs, capacity, home circumstances and patient goals. Two people with the same age and diagnosis may therefore need very different support, without frailty automatically meaning admission or discharge.

Key ward-based interventions for frail elderly: ^[2]

• Prevention of delirium
• Pressure sore prevention
• Fall prevention
• Rehabilitation
• Nutrition support
• Avoiding polypharmacy
• Early discharge planning
• Appropriate placement

Why each matters:

• Delirium prevention: Frail patients have minimal cognitive reserve; medications, infections, constipation, or unfamiliar environments easily tip them into delirium. Non-pharmacological multicomponent strategies (orientation, sleep hygiene, hydration, early mobilisation, minimising tethers) are the evidence base.
• Pressure sore prevention: Immobility + malnutrition + thin skin = pressure injury. Turning schedules, pressure-relieving mattresses, nutritional optimisation.
• Fall prevention: Multifactorial assessment (medications, vision, footwear, environment, postural hypotension, balance training).
• Nutrition support: Malnutrition accelerates sarcopenia; dietitian involvement, oral nutritional supplements, protein intake optimisation.
• Avoiding polypharmacy: Every additional medication increases the risk of adverse drug events, drug-drug interactions, and non-adherence. Use STOPP/START criteria ^[5].
• Early DC planning: Prolonged hospitalisation causes deconditioning ("hospital-acquired disability"). Aim for early, safe discharge.
• Appropriate placement: Not everyone can go home — assess need for RCHE, community support services.

Frailty is independently associated with mortality ^[2]

• The more frail → the higher the 3-year mortality
• Worsening frailty status in previous 2 years predicts higher mortality in the next 2 years
• Chinese large-scale study: 3-year mortality 14.4% in least frail → 73% in most frail
• Local HK study in RCHE: advanced dementia cases — mortality 34% in one year (Luk JKH et al, HK Med J 2013)

Why this matters: Longitudinal worsening and repeated incomplete recovery after acute illnesses should prompt realistic prognosis discussions, advance care planning and attention to symptom burden.

Frailty predicts poorer surgical outcomes:

• Surgical complications
• Longer length of stay (LOS)
• Discharge to institution
• Mortality ^[2]

Pre-operative frailty assessment enhances:

• Risk management pre-op: medication review, nutritional augmentation, PT/OT (prehabilitation)
• Post-op management: pressure sore prevention, delirium prevention, attention to hydration/nutrition, early mobilisation ^[2]

Why prehabilitation is considered: Exercise, nutrition and medication optimisation aim to improve modifiable reserve before the surgical stressor. Programme content and timing must be individualised; frailty is a prompt for multidisciplinary risk assessment and shared decision-making, not an automatic contraindication to surgery.

The following guideline recommendations are from the Asia-Pacific consensus (JAMDA 2017) ^[2]:

Strategies Superior to Usual Care [2]

Community setting:

• Prescription of physical activity programmes (resistance-based, aerobic, balance/coordination training)
• Multi-component physical activity programmes and community-based group classes
• Protein/protein-energy and micronutrient supplementation
• Individually tailored management of clinical conditions
• Health behaviour improvement advice
• Practical social support and home environment modification

Hospital setting:

• Comprehensive Geriatric Assessment (CGA) — frail older adults receiving CGA in hospital are more likely to survive, have a better experience of care, and return home rather than be discharged to residential settings
• Treat any acute illness contributing to frailty
• Review medications using implicit criteria; reduce inappropriate polypharmacy
• Place the patient on a frailty-specific care pathway

Historical slide definition (EWGSOP 2010): "A syndrome characterised by progressive and generalised loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life and high mortality" ^[2].

Current diagnostic emphasis: EWGSOP2 treats sarcopenia as a muscle disease in which low muscle strength raises suspicion/probability, low muscle quantity or quality confirms the diagnosis, and poor physical performance indicates severe sarcopenia ^[6]. AWGS 2019 retains an Asia-specific framework: low appendicular muscle mass plus low strength and/or low physical performance establishes sarcopenia, using Asian cut-offs ^[7]. Therefore, low mass alone and normal age-related decline alone are not enough.

Two milestones:

1. 2010: Introduction of muscle function into the concept (previously defined by mass alone)
2. 2016: Recognition as an independent condition with ICD-10 code (M62.84) ^[2]

Approximate historical rates quoted by the lecture (not fixed physiological constants):

Muscle mass:

• After age 30: ↓ ~1%/year
• After age 70: accelerates to ↓ ~1.5%/year

Muscle strength:

• Ages 50–60: ↓ ~1–1.5%/year
• After age 60: ↓ ~3%/year ^[2]

Rates vary by sex, starting health, illness and activity. The teaching point is that strength often falls faster than measured mass because it also depends on neural activation, muscle quality, fat infiltration and coordination.

Three key pathological changes: ^[2]

1. Imbalance between muscle protein anabolism and catabolism → overall loss of skeletal muscle
2. Preferential loss/atrophy of type II (fast-twitch) fibres (the slide also describes a shift towards a type I phenotype)
3. Intramuscular and intermuscular fat infiltration (myosteatosis)

First principles:

• Type II fibres are fast-twitch, responsible for rapid, powerful contractions (e.g. getting up from a chair, catching yourself from a fall). These are preferentially lost in ageing, which is why older adults lose power before endurance.
• Myosteatosis (fatty infiltration) reduces the contractile tissue per unit of muscle cross-section, so even if the limb looks the same size on imaging, the muscle is weaker.

Multiple international workgroups have defined sarcopenia using different combinations of diagnostic domains ^[2]:

This table is a historical comparison of 2010–2014 definitions, not a current synthesis. A major reason prevalence differs across studies is that these frameworks select different people. In particular, EWGSOP2 (2019) now prioritises strength rather than treating muscle mass as the first diagnostic gate ^[6].

Primary sarcopenia: Aging itself is the predominant cause

Secondary sarcopenia: Due to:

• Inactivity (bed rest, sedentary lifestyle, deconditioning, zero-gravity)
• Malnutrition (inadequate dietary intake)
• Disease (advanced organ failure, cancer, inflammatory diseases) ^[2]

Three domains: ^[2]

Handgrip strength measurement shown by the lecture: three trials per hand and record the highest value ^[2]. In practice, follow the validated protocol for the dynamometer and reference cut-off being used; AWGS permits the maximum value from either two or three trials ^[7].

Calf-circumference case-finding threshold (AWGS 2019): < 34 cm in men or < 33 cm in women should prompt further assessment. This is a screening measure, not confirmation of low muscle mass ^[7].

The deck contains both frameworks, and the labels are not interchangeable:

Possible/probable sarcopenia is enough to investigate causes and begin safe lifestyle intervention while confirmation is pursued; it is not a reason to delay exercise until DXA/BIA ^[6][7].

*Other reasons for low muscle strength should always be considered, e.g. depression, stroke, balance disorders, peripheral vascular disorders ^[2].

The 2022 slide advocates case finding rather than population-wide sarcopenia screening: ^[2]

Screen in patients with:

• Falls
• Slowness and weakness
• Decreased walking mobility and walking speed
• Weight loss
• Decreased ADL
• Self-reported muscle wasting
• Admission to hospital / RCHEs

High specificity but low sensitivity ^[2]

The SARC-F questionnaire asks about:

• Strength (difficulty lifting/carrying 10 lbs?)
• Assistance in walking (difficulty walking across a room?)
• Rise from a chair (difficulty transferring from chair/bed?)
• Climb stairs (difficulty climbing 10 stairs?)
• Falls (how many falls in the past year?)

Each item is scored 0–2 (total 0–10); SARC-F ≥4 is a positive case-finding result that warrants objective assessment, not a diagnosis. Its low sensitivity means a negative result does not rule out sarcopenia when there is clinical concern ^[7].

Historical cohort estimates shown by the slide (age > 65): ^[2]

• Australia (EWGSOP): 6.4% men, 9.3% women
• China (AWGS): 26.2% men, 33.6% women
• Hong Kong (EWGSOP): 9%

These figures are not directly comparable because country, sampling and diagnostic criteria differ; the China–Australia contrast in the slide illustrates methodological heterogeneity, not a reliable biological ranking between populations.

Resistance exercise improves: ^[2]

• Muscle strength
• Muscle mass
• Balance

Why resistance matters: Resistance training specifically loads muscle and improves strength; balance and functional training address falls and task performance, while aerobic activity adds cardiorespiratory benefit. Programmes should therefore usually be multicomponent, progressive and individualised to baseline ability, comorbidity and fall risk rather than treating resistance and aerobic exercise as alternatives ^[8][10].

From the NEJM review ^[3]: Exercise is the single most effective intervention for frailty. Multicomponent exercise (resistance + balance + flexibility) is ideal. Even in very frail patients, adapted exercise programs show benefit, though the intensity may need to be reduced.

Better when coupled with resistance exercise (Tieland et al) ESCEO recommends protein intake of 1.0–1.2 g/kg body weight/day ^[2]

Practical interpretation: ESPEN advises at least 1.0 g/kg/day for older adults, with 1.0–1.2 g/kg/day often suggested for healthy older people and higher needs sometimes considered during acute/chronic illness or malnutrition. Targets must be individualised to total energy intake, kidney function, illness severity, goals and tolerance; dietitian input is appropriate when malnutrition or significant renal disease is present ^[11]. Protein-rich food or supplements are an adjunct to, not a replacement for, progressive activity.

β-hydroxy β-methylbutyrate (HMB): the 2022 slide describes possible benefit but explicitly notes that more studies are needed ^[2].

HMB is a leucine metabolite marketed as a supplement. Evidence is not strong enough to make it routine first-line treatment; prioritise adequate food/energy intake and exercise, and consider any supplement within an individual nutritional plan ^[10].

Historical slide recommendation (osteosarcopenia context): ^[2]

• Vitamin D 800 IU/day to maintain 25(OH)D > 50 nmol/L
• Calcium 1000 mg/day
• Regular exercise 3–5 times/week
• The slide presents these together as prevention of osteosarcopenia

Current safety correction: vitamin D or calcium should not be presented as a stand-alone treatment for sarcopenia or prescribed automatically to every frail person. ICFSR found insufficient evidence that vitamin D supplementation alone treats sarcopenia, and physical-frailty guidance recommends it when deficiency is present rather than systematically ^[8][10]. Assess dietary calcium, vitamin D deficiency risk/level when clinically indicated, osteoporosis/fracture risk, kidney function, stones and interacting medicines; treat deficiency and bone disease according to the relevant local guideline.

The following have been tried but LACK sufficient evidence: ^[2] Combined estrogen-progesterone, DHEA, Growth Hormone, GH-releasing hormone, Testosterone, IGF-1, Pioglitazone, Omega-3 PUFA, ACEI

Selective Androgen Receptor Modulators (SARMs): Of particular interest because of tissue selectivity — hoped to achieve gains in muscle without dose-limiting side effects of androgens. Still in clinical development. ^[2]

Current safety correction: there is no established first-line drug therapy for sarcopenia. Hormones and investigational agents should not be prescribed for sarcopenia outside an appropriate specialist indication or trial ^[10]. SARMs sold as bodybuilding products are unapproved drugs; the FDA warns of potentially serious harms and advises against their use ^[12].

CGA is itself an intervention: systematic multidimensional assessment of medical, functional, cognitive, psychological, social and environmental domains, followed by an integrated care plan. In hospital studies, CGA-based care improves the chance of being alive and at home after admission and can reduce institutional placement; do not promise reversal of frailty or a mortality benefit to every patient.

• 2018 EMQ ^[1]: "USE OF ASSESSMENT SCALES IN GERIATRIC MEDICINE" — tested Barthel Index, MoCA, MUST, FRAIL score, handgrip dynamometer. Key learning: Know which tool measures what. Frailty = FRAIL score or CFS. Grip strength = handgrip dynamometer (for sarcopenia). Nutrition = MUST. Cognition = MoCA. Function (ADL) = Barthel. Function (IADL) = Lawton's.
• Frailty definition questions: Expect MCQs asking you to identify the 5 Fried criteria or differentiate frailty from disability/comorbidity.
• Sarcopenia diagnostic cut-offs: Grip strength thresholds (< 28 kg male, < 18 kg female) and AWGS criteria are testable.
• Management priorities: "What is the most important intervention for sarcopenia?" → Resistance exercise.

"List 5 components of the Fried frailty phenotype" — write all 5 with brief description:

1. Unintentional weight loss
2. Self-reported exhaustion
3. Weakness (grip strength)
4. Slow walking speed
5. Low physical activity

"Describe 4 ward-based interventions for a frail elderly patient admitted to hospital" — pick from the 8 listed on the lecture slide and explain WHY each is important.

"Outline the management of sarcopenia" — structure as:

1. Exercise (resistance training — strongest evidence)
2. Nutrition (ensure adequate energy and protein; a common healthy-older-adult range is 1.0–1.2 g/kg/day, individualised and coupled with exercise)
3. Address underlying causes (secondary sarcopenia: inactivity, malnutrition, acute/chronic disease, medication contributors)
4. Correct vitamin D or other nutrient deficiency and treat osteoporosis when indicated — not as universal sarcopenia therapy
5. State that routine pharmacotherapy is not established; HMB evidence is limited and SARMs are investigational/unapproved