Frailty in Older Women

Original Editor - Winrose Windsor

Top Contributors - Winrose Windsor, Lucinda hampton, Vidya Acharya, Khloud Shreif, Kim Jackson and Peace Samuel

Introduction

Frailty affects 9-15% of community-dwelling older women and over 50% of nursing home residents. Women face higher frailty risk than men despite longer life expectancy, with unique risk factors including early childbearing and premature menopause.

• A recent systematic review and meta-analysis, across 62 countries worldwide (including 240 studies) found the prevalence of frailty was higher among women (15%) than men (11%) .
• Although frailty prevalence is higher in females than males, the mortality rate is found to be lower in women , termed the “sex-frailty paradox”.
• Sex-specific differences in frailty are greatly influenced by various biological, psychosocial, and behavioural factors .

Prevention

For physiotherapists, frailty represents a modifiable condition requiring early intervention. The Clinical Frailty Scale can identify at-risk patients. Physiotherapists are well-positioned to screen for frailty and implement preventive strategies, particularly strength training combined with holistic approaches addressing multiple risk factors.

Evidence shows physiotherapy interventions can delay frailty onset and reduce adverse outcomes, preventing hospital admissions and improving quality of life. Early identification and intervention are crucial, with physiotherapists playing a vital role in promoting healthy aging among older women.

Frailty and Sex-specific pathophysiological characteristics in Older Women

Sex-specific frailty differences may stem from a combined effect of several biological, psychosocial, and behavioural factors, as proposed in various hypotheses. In older women, physical frailty (weakness, wasting, slowness) is more pronounced due to a greater risk of osteoporosis, sarcopenia, and obesity, contributed to by inflammatory, hormonal, immunosenescence, and obstetric history.

Examples are given below:

• Post-menopausal estrogen decline increases osteoporosis risk in women, who are four times more likely than men to develop the condition, leading to greater fracture susceptibility in older age.

• Women experience a greater reduction in muscle mass (sarcopenia) and strength.
• The impact of a woman's obstetric history during the reproductive years, which is inclusive of pregnancy, childbirth, postpartum, and lactation, may contribute to more frailty in her later years of life, as an older woman.
• Elderly women have an increased risk of falls compared with their male counterparts due to increased variation in their gait patterns.
• Psychological frailty (highly associated with physical frailty) is notably higher in women compared to older men due to post-menopausal mood changes, increased anxiety and depression.
• Nutritional frailty in older women is found to be associated with altered hormonal changes, reduced anabolic response to protein synthesis and chronic low-grade inflammation, which is higher in older women than men.
• The key determinants contributing to social frailty in older women are gender roles. social assets and deficits, widowhood and social isolation.

Physiotherapy

Physiotherapists can play a role in screening for frailty using tools like the Clinical Frailty Scale. Interventions for frail older adults often focus on:

• Maintaining muscle strength, soft tissue length, and joint range of motion
• Improving posture, balance, and coordination
• Maximising independence
• Reducing fall risk

Sex-specific Intervention Strategies in Older Women

Key Points:

• Evidence suggests that it would be more advantageous for older women to focus more on weight-bearing activities, and balance exercises, as these measures can be beneficial for addressing the effects of osteoporosis and minimizing its related negative consequences.
• In addition to that, an individualised physical activity regimen incorporating targeted, progressive resistance training can be highly advantageous in addressing muscle weakness and wasting, which is more pronounced in older women.
• It is also recommended that physical activity should be encouraged during the prefrail and frail stage, unless contraindicated.
• Research reveals that older women preferred group training sessions with indoor options and were less likely to engage in vigorous, competitive activities outdoors .
• Psychological factors, that are attributed to post-menopausal and age-related changes, were found to be managed by cognitive therapy along with physical activity, rather than cognitive therapy alone. Furthermore, older women have an increased morbidity rate
• Older adults face increased undernutrition risk due to age-related physiological changes affecting appetite and food intake. Protein intake is particularly important for older people, especially women at higher frailty risk, supporting healing, immunity, and recovery. While standard protein recommendations are 0.8g/kg body weight, emerging evidence suggests this may be insufficient for elderly people. Adequate protein intake helps prevent sarcopenia and maintains muscle mass - crucial considerations for physiotherapists working with older adults to preserve function and reduce fall risk. Physiotherapists should recognize signs of malnutrition and understand how protein deficiency impacts rehabilitation outcomes and muscle strength preservation.
• It is crucial to customise exercise prescriptions for each individual, taking into account their specific needs and characteristics. This includes understanding the distinct pathophysiological differences between males and females, as well as recognising the unique motivational factors and exercise preferences that may vary based on sex. By considering these factors, rehabilitation professionals can develop tailored exercise programs and implement effective patient education strategies to better benefit older women.