FN 4360

Frailty Case Study: Florence Brown

By: Bridget Brown
March 14, 2014

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Table of Contents
Introduction..3
Methods...5
Results..6
Discussion..9

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Introduction:
The road to aging is filled with many bumps and turns. One of these
bumps could be frailty. Most people think that when an elderly person is
small and weak that they are automatically frail. That would make a
significant amount of elderly people frail. In actuality, only 3% to 7% of
elderly persons between the ages of 65 to 75 years are frail. The
percentages go up as the age brackets go up, which is to be expected, but it
is not more than 32%

[1]

. This misconception could be due to the fact that

many people do not know the exact criteria used to diagnose a person with
frailty.
Frailty is kind of an umbrella term similar to metabolic syndrome. In
order to have the syndrome, you have to exhibit a certain amount of the
conditions listed. One of the most noted researchers in this field who came
up with the phenotype to diagnose frailty is Linda Fried. There are five parts
to the phenotype and in order to be diagnosed, a patient would have to have
three of the conditions. These conditions include decreased walking time,
decreased grip strength, decreased physical activity, self-reported
exhaustion, and unintentional weight loss

[1][2]

. All of these things sound like

the body slowing down and becoming less functional, which is why frailty is
more common with the elderly than younger generations. As people get
older, their body functions less efficiently making things that were minor
scrapes and bruises in their teens, trips to the hospital in their 80s.

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A study in the Journal of the American Geriatrics Society found that
greater frailty was related to greater risk of falls, fracture, and disability.
Additionally, they stated in their results that frail women were more likely to
have ever been diagnosed with hypertension, heart disease, osteoarthritis,
or stroke or to have had a fracture since age 45 than women who were not
frail

[3]

. This is very significant to elderly people. Due to the fact that the

aging process already makes it harder for the body to work the way it used
to, muscle weakness, less energy and exercise, slower walking speeds, less
physical activity, and if they are not eating enough, weight loss, are very
possible

[1][2]

. If the elderly display those parts of the phenotype for frailty and

start to slip into the more serious aspects such as infections, injuries, falls,
and other health problems, then they are more likely to develop the other
health conditions listed above from the study.
In addition to the health conditions previously mentioned, there is
another scary reality that many elderly people face: falls. A study done by
The Lancet found that Balance and gait impairment are major features of
frailty, and are important risk factors for falls

[4]

With the inability to grip things and weakness in general, getting up from a
fall could be very difficult especially if the patient got injured. Falls can do
major damage to the elderly. With the subject of this case study, for instance,
she specifically stated during the interview whenever I fall, I usually break
things. That can cause her to have to go to the hospital to get things fixed
and due to the vulnerability of frail people, she might not be as healthy as

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others and if she were to get an infection it would be very difficult for her to
fight it off.
Both the fall and the infection mentioned above could be considered
stressors. In a study published by the Journal of the American Medical
Directors Association, they stated that Frailty in its broadest sense identifies
vulnerable persons who when exposed to a stressor are very likely to
develop disability or to die

[5]

. This creates the mold for a vicious cycle. If

Florence, the subject of this case study, can be considered frail due to the
past stressors and falls she has encountered, that means she is vulnerable to
other stressors. That means, the more that happens, the worse the frailty
becomes. Florences balance has gotten to be so bad that she falls frequently
and often hurts herself. Thankfully, it does not always result in breaks and
surgeries.
Some studies have shown that exercise can help with frailty by building
up muscle mass and preventing the weakness that goes along with frailty.
They recommend stretching or any physical activity for 30 to 60 minutes a
day, three times a week

[1]

. It is difficult for elderly to do much exercising,

especially if they are already frail. The best thing they could do to improve
their health would be to increase their current level of activity, whether that
is walking around their house, trying to lift things that are not too heavy for
them, or even dancing if they are physically able. Florence has difficulty with
mobility and strength, so exercising is a struggle for her.

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Due to the symptoms that Florence displays such as slow walking,
increased falls, poor balance, decreased grip strength, decreased physical
activity, and self-reported exhaustion, I hypothesize that she is in the realm
of at least prefrailty.

Methods:
I interviewed my 87-year-old grandmother, Florence. We sat down
together Wednesday March 12, 2014 at her house and talked about how her
health has been lately. I asked her to keep track of what she had eaten so far
that day and write down everything she eats for the rest of the day and the
next two days as well making it a full three-day food record. After the three
days, I went back to her house on the 15th and checked up on her again. In
addition to giving me a three-day food record, she also wrote out a story of
the health problems she has had over the last 15 years and included some of
her most recent surgeries and the medications she takes. After collecting all
of the data from her, I calculated her BMI out to be 19.8, which is on the
lower end of the normal weight category. Additionally, I took the three-day
food record and put it into SuperTracker in order to analyze her nutrient
intake.

Results:
Brief Timeline of Health: Her Written Story

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She really started to notice a difference in her health around her 50s
when it became more difficult for her to turn her neck around to back out of
the driveway. After, she started to be able to predict the rain with her joints
because they would get stiff and ache. She has lost four inches (55 to 51)
and 30 pounds (135 to 105 pounds) over the last 12 years. When she was
about 55 she became borderline diabetic. She controlled it with diet and
exercise until she was about 65 and then started taking oral medication. She
kept that up until she lost all of that weight and she has not needed anything
but a healthy, diabetic diet since.
Her arthritis has caused joint deterioration decreasing her mobility.
Primarily, her hands have taken the biggest hit. She is unable to do any of
her old hobbies like quilting, and she is unable to open jars or do anything
that requires hand strength. That makes exercising nearly impossible so her
muscle mass has gone down considerably. She will occasionally do laps with
her walker around her one story home as exercise, but she cannot do much
for her arms or hands.
Recent Surgeries and Injuries
She has had a large amount of surgeries in the last decade. She had
her right knee replaced in 2003, fusion of her 4th and 5th vertebrae with 4, 3
inch titanium screws and rods, she had hand braces and carpal tunnel
surgery in 2010, a pacemaker installed in 2012, and in 2013 she had her left
hip replaced. In addition to her surgeries she has also fallen quite a bit.
Luckily, she has Life Alert and our family lives close by, but her neighbors

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also check on her periodically and help her if they notice her struggling. The
day of the interview she actually called to push it back a few hours because
she had to go to the doctor for a fall she had the previous week. Her balance
has become very shaky and she always at least has a cane, but if we are
walking a farther distance she will bring her walker or use a wheelchair.
Medications and Conditions
She has osteoarthritis, Type 2 diabetes, arthritis, high blood pressure,
depression, and high cholesterol. Her medications include Actos for diabetes,
Tylenol, Tramadol, and Vicodin for pain from surgeries, a low dose of aspirin,
Coreg for high blood pressure, Pletal for circulation, Claritin for allergies,
Ditropan XL for her bladder, Prilosec to aid in her digestion, Citalopram for
depression, Gabapentin for nerve pain, Simvastatin for cholesterol, Calcium/
Vitamin D supplement for bone health, a daily multivitamin, and Lumigan
and consort glaucoma eye drops.
Diet

Florence's Nutrients Report 04/06/14 - 04/08/14

Your plan is based on a 1600 Calorie allowance.

Nutrients

Target

Average Eaten

St

Total Calories

1600 Calories

1434 Calories

OK

Protein (g)***

46 g

73 g

OK

Protein (% Calories)***

10 - 35% Calories

20% Calories

OK

Carbohydrate (g)***

130 g

172 g

OK

Carbohydrate (% Calories)***

45 - 65% Calories

48% Calories

OK

Dietary Fiber

21 g

12 g

Un

Total Fat

20 - 35% Calories

34% Calories

OK

Saturated Fat

< 10% Calories

13% Calories

Ov

Monounsaturated Fat

No Daily Target or Limit

11% Calories

No

Polyunsaturated Fat

No Daily Target or Limit

6% Calories

No

Linoleic Acid (g)***

11 g

8g

Un

Linoleic Acid (% Calories)***

5 - 10% Calories

5% Calories

OK

-Linolenic Acid (g)***

1.1 g

0.8 g

Un

-Linolenic Acid (% Calories)***

0.6 - 1.2% Calories

0.5% Calories

Un

Omega 3 - EPA

No Daily Target or Limit

10 mg

No

Omega 3 - DHA

No Daily Target or Limit

32 mg

No

Cholesterol

< 300 mg

450 mg

Ov

Minerals

Target

Average Eaten

St

Calcium

1200 mg

982 mg

Un

Potassium

4700 mg

2242 mg

Un

Sodium**

1500 mg

2491 mg

Ov

Copper

900 g

850 g

Un

Iron

8 mg

12 mg

OK

Magnesium

320 mg

199 mg

Un

Phosphorus

700 mg

1227 mg

OK

Selenium

55 g

100 g

OK

Zinc

8 mg

10 mg

OK

Vitamins

Target

Average Eaten

St

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It is also significant to note that Florence takes a multivitamin and a

calcium/Vitamin D supplement in order to meet her required levels.
Furthermore, from personal experience eating with Florence, I have reason to
believe that her actual daily intake is much lower. She tends to eat very
small meals so some of her diet may be misreported.

Discussion:
According to most of the information in the introduction, the main
things to look for when dealing with frailty are decreased walking time,
decreased grip strength, decreased physical activity, self-reported
exhaustion, and unintentional weight loss

[1][2]

. Florence exhibits all of these

signs. Some are more severe than others, but all of them were reported in
one way or another. Her mobility problems are evident from watching her.
Moreover her struggle walking makes it easy to tell that she does not stay
physically active, and she takes frequent naps and often tells guests that she
is very tired.
Most of Florences symptoms were evident before she told me about
them, but when she wrote her story it made them clearer. She has always
been very small and has had difficulty gripping things for as long as I can
remember. Additionally, I do not think I can remember a time when she did
not at least have a cane to help her walk. Her body is very small, but I did
not realize the amount of weight and height she had lost in the last 12 years.
Additionally, I did not know she had osteoarthritis. I assumed she had brittle

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bones because she tends to break things when she falls, but I did not know it
was that bad. Furthermore, after comparing her story with the phenotype for
frailty, the data seems to support my hypothesis that she has at least
prefrailty, if not a more severe case.
As far as her diet is concerned, she eats very little. From my personal
experience in eating with her, I believe she takes in less food than she
reported. Her caloric intake was already under her daily budget of 1600
calories, but I believe it was much less. Additionally, she needs to take in
more dairy and more dietary fiber along with protein. I would recommend
trying to fit more fish into her diet so that she can get more omega 3 fatty
acids. The very last day she reported, I brought her a Frosty from Wendys
because she enjoys them and I knew it would give her more calories and that
may have thrown off some of her numbers. The Frosty could have filled her
up and kept her from eating other healthy foods throughout the day.
There is no specific diet associated with frailty, however I told her
before doing any work with her original diet that a healthy balanced diet full
of nutrient dense foods seems to help a lot of problems across the board. For
her conditions specifically, I recommend that she continue to follow her
diabetic diet but also increase her dairy intake and possibly switch to low fat
dairy rather than 2% reduced fat milk. The added calcium to her diet could
help her bone health. Additionally, I recommend that she take in more food
in general but specifically more whole grains. She likes white bread but she
would be healthier if she switched to wheat bread, at least, if not multigrain

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bread. Additionally, due to her high blood pressure and high cholesterol, she
should take in far less sodium and cholesterol every day. She may not be
very receptive, but if it gets bad enough, a vegetarian diet is great for high
cholesterol. In addition to the diet, I would recommend that she tries to
increase her physical activity level to try to gain some muscle mass. Due to
her severe arthritis and lack of strength in her hands, I would tell her to keep
doing laps around her house with her walker.

References
1. Ahmed N, Mandel R, Fain M. Frailty: an emerging geriatric syndrome.
Am J Med. September 2007; 120(9): 748-753.
2. Fried L, Tangen C, Walston J, Newman A, Hirsch C, Gottdiener J, Seeman
T, Tracy R, Kop W, Burke G, McBurnie M. Frailty in older adults:
evidence for a phenotype. J Gerontol. 2001; 56A(3): 145-156.
3. Tom S, Adachi J, Anderson F, Boonen S, Chapurlat R, Compston J,
Cooper C, Gehlbach S, Greenspan S, Hooven F, Nieves J, Pfeilschifter J,
Roux C, Silverman S, Wyman A, LaCriox A. Frailty and fracture,
disability, and falls. J Am Geriatr Soc. 2013; 61(3): 327-334.
4. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly
people. Lancet. March 2013; 381(9868): 752-762.
5. Morley J. Frailty, falls, and fractures. J Am Med Dir Assoc. March 2013;
14(3): 149-151.

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