Frailty – Knowledge

1. Why this article?

Two people, both 82 years old, both in hospital with pneumonia. One is home after two weeks and carries on as before. The other also goes home – but no longer gets out of the armchair unaided, no longer does the shopping, and six months later needs help with everyday life.

Same illness, same treatment, a completely different outcome. The difference rarely lies in the pneumonia. It lies in how much reserve each person had before falling ill. That reserve – and its absence – is exactly what the term frailty describes.

Frailty is not a niche topic. In the medicine of ageing it is one of the few concepts that explains why people with the same diagnoses cope so differently [1]. And it has an unusually good property: in a substantial share of cases it can be influenced – provided it is noticed early enough.

This article explains what frailty is, how common it is, how you can assess it in yourself or in a relative, and what is proven to help. It also says where the limits are – that belongs in the picture. Every statement is referenced; the numbers in square brackets point to the reference list at the end.

2. What frailty means

Frailty describes a state of reduced reserves across several body systems. Muscles, circulation, immune system, metabolism, nervous system – each of them perhaps still just within range, but together without a buffer.

The most widely cited definition puts it like this: a clinical state in which a person's vulnerability to becoming dependent, or to dying, is increased when they are exposed to a stressor [3]. The decisive word is stressor. This does not mean a major accident, but the everyday: influenza, a urinary tract infection, a planned operation, a new medication, a heatwave.

2.1 The image that fits best

Picture two bank accounts. One holds 10,000 francs, the other 200. An unexpected bill for 300 francs is an annoyance for the first account. For the second it is a crisis.

Frailty is the second account. The literature likes to show this as a curve: after a small stressor, function drops – and in a person with good reserves it climbs back to the old level afterwards. In a person with frailty it stays lower [4]. Not because the illness was worse, but because there was nothing left to absorb it.

This is why frailty is more than the sum of the diagnoses. You cannot list all of someone's conditions and calculate their resilience from them. Frailty is a quantity in its own right – and in studies it predicts falls, hospital admissions, dependency and mortality independently of the individual diagnoses [2], [1].

2.2 A note on the word

In German the obvious translation would be «Gebrechlichkeit». Specialists in German-speaking countries increasingly avoid that word, for two good reasons – and both apply to «frail» in English too.

First, it sounds like a verdict rather than a finding. «Frail» describes a person; frailty describes a state that can change. That is not word play – it helps decide whether someone starts an exercise programme at all.

Second, the everyday word is firmly tied to advanced age. Frailty is not. It also occurs in middle age, particularly alongside chronic conditions – more on that shortly.

So the term needs one caveat: frailty does not mean that someone is close to the end of life. It means the buffers have become thin – and that they can be worked on.

2.3 The five signs (Fried phenotype)

The most widely used approach comes from a large American study published in 2001 [5]. It describes five measurable signs:

• Unintentional weight loss – more than about 4.5 kg in the past year, without dieting and without a change in training.
• Exhaustion – the feeling that everything is an effort and that you cannot get going, on several days per week.
• Low physical activity – measured with a questionnaire about activities in recent weeks.
• Slow walking – a walking speed below about 0.8 metres per second serves as a guide value.
• Weak grip strength – measured with a calibrated dynamometer, with cut-offs by sex and body build.

Scoring is simple: no criterion met means robust, one or two criteria mean pre-frail (an intermediate stage), three or more mean frail [5].

Remember the middle stage above all. Pre-frailty is not a statistical in-between category – it is the actual window in which most can be changed. See section 6.

2.4 The second approach: counting deficits

Alongside the phenotype there is a second, quite differently built approach: the frailty index [6]. Instead of five fixed signs it adds up as many health problems as possible – diseases, symptoms, limitations, laboratory values – and divides them by the number of items checked. Someone with 10 out of 40 items has an index of 0.25.

The index is finer and picks up small changes better; the phenotype is quicker and easier to carry out in practice. A European analysis of more than 311,000 survey records applied both methods in parallel and concludes that they are complementary, not interchangeable [8].

For you as a reader this means: if two professionals quote different numbers, that is not a contradiction but often just a different measuring instrument.

3. How common is frailty?

The broadest analysis to date pools studies from 62 countries covering roughly 1.76 million people [7]. As expected, the figures rise with age:

• Frailty: 11 to 16 per cent among 50- to 69-year-olds, 20 to 51 per cent from age 70.
• Pre-frailty: 41 to 45 per cent among 50- to 69-year-olds, 49 to 56 per cent from age 70.

The ranges are wide, and for an honest reason: prevalence figures depend on three things – age, the measuring instrument used, and the setting. In acute hospitals, in nursing homes and in poorer countries the values are considerably higher than in the general population [1]. A European analysis also shows a strong link with prosperity: in the 65–79 age group, frailty is two to three times more common in countries with a low gross domestic product per head than in high-income countries [8]. Women are more often affected than men in practically every age band [8].

Pre-frailty is not a harmless intermediate state. An analysis of 26 studies with more than 222,000 people aged 65 and over found a roughly 38 per cent higher risk of death for pre-frailty [9]. That is not a figure to be alarmed by, but one to act on: the state in which most is possible is also the most common one.

3.1 Frailty starts earlier than expected

The largest study in middle age comes from the British UK Biobank: among 493,737 participants aged 37 to 73, 3 per cent were frail and 38 per cent pre-frail [10]. Frailty there was closely linked to multiple conditions, socio-economic disadvantage, smoking and obesity – and it predicted mortality in practically all age groups.

That clears up a common misunderstanding: frailty is not a nursing-home topic. It often begins two or three decades earlier, at a stage of life when people still consider themselves healthy.

3.2 Figures from Switzerland and from physiotherapy

There is no large nationwide survey for Switzerland, but two useful excerpts exist.

In the canton of Geneva, in a population study of 2,930 people, 22.2 per cent of those aged 50 to 65 showed one frailty indicator, and a further 2.7 per cent two or more [11]. In Ticino, among 660 older adults, frailty prevalence was 10.3 per cent and pre-frailty prevalence 48.2 per cent [12].

Particularly instructive is a study from an outpatient physiotherapy practice in Germany – the setting we work in too. Of 258 patients (mean age 74 years, three quarters referred with an orthopaedic diagnosis), 17.8 per cent were frail and 43.4 per cent pre-frail by the Fried phenotype [13]. The three most frequent findings were slow walking, reduced grip strength and exhaustion.

Put differently: in an ordinary waiting room, mostly shoulders, knees and backs, fewer than one in four people over 65 is fully robust. Someone who comes because of the knee often brings frailty along unnoticed.

4. Frailty, sarcopenia, multimorbidity – which is which?

Three terms that are constantly confused, although they mean different things.

Sarcopenia is a muscle disease: too little muscle strength, too little muscle mass. Specialist societies now classify it as a treatable disease, not as a normal sign of ageing [14]. It is usually the physical core of frailty – but not the whole of it. If you want the detail, we have a separate article on it: Muscle weakness in older age.

Frailty is broader. Alongside the muscles come exhaustion, unintentional weight loss, reduced activity – and, in many models, cognitive and social aspects too. Frailty describes the resilience of the whole system, not of a single tissue.

Multimorbidity simply means several diseases at the same time. That is something other than frailty, even though the two often occur together. An analysis of nine studies with 14,704 people shows the direction of this relationship clearly: the majority of people with frailty are also multimorbid, but only a smaller share of multimorbid people are frail [15].

Why the distinction matters: it determines where to start. Where sarcopenia leads, strength training is central. With frailty, several building blocks are added. With multimorbidity, coordinating the treatments and the medications with one another comes on top.

5. How frailty develops: two cycles

Frailty develops along two routes at once – a slow one and an abrupt one. Knowing both is useful, because they call for different countermeasures.

5.1 The slow cycle

The first cycle turns over months and years and has muscle loss at its centre:

Less appetite and less protein in the diet → less muscle mass and strength → less movement, because everything becomes more effortful → lower energy expenditure and even less appetite → even less muscle. Added to this are a persistent, low-grade inflammatory activity and hormonal changes that further favour muscle breakdown.

The insidious part: every single step is small and reasonable in itself. You eat less because you are less hungry. You walk less because it is tiring. Only over years does this become a downward spiral.

The good news is the same as with any cycle: it can be broken at any point. And the two most effective points are well studied – strength training and protein (section 8).

5.2 The abrupt cycle

The second route looks quite different. Here nothing happens for a long time – and then an event comes along: pneumonia, a fall, an operation, a hospital stay.

The underlying illness is treated correctly and resolves. But function does not return completely. Each such episode establishes a new, lower baseline – and increases vulnerability to the next crisis [17]. The course is not a gentle slope but a staircase going down.

The main reason for this is mundane, and all the more important for it: inactivity. A few days of bed rest cost a disproportionate amount of muscle in older age, and rebuilding is markedly slower than the loss [16].

In hospital the phenomenon has its own name: hospital-associated disability – the loss of an everyday ability during a hospital stay, even though the illness was treated successfully. Frailty is the strongest known risk factor for it, and it is common enough to take seriously [18]. We have devoted a separate article to this: Leaving hospital weaker.

6. The key finding: frailty is not a one-way street

If you keep only one section from this article, keep this one.

A synthesis of 16 studies with 42,775 community-dwelling older people followed how frailty status changed over an average of just under four years – without any targeted treatment [19]:

• 56.5 per cent stayed in the same category.
• 29.1 per cent got worse.
• 13.7 per cent got better.

So almost one in seven improved on their own. Frailty is therefore not a diagnosis that only knows one direction.

6.1 The window

It becomes more informative still when broken down by starting point [19]:

• Of those who were robust, 54.0 per cent stayed robust; 40.6 per cent became pre-frail, only 4.5 per cent frail.
• Of those who were pre-frail, 23.1 per cent became robust again; 58.2 per cent stayed pre-frail, 18.2 per cent became frail.
• Of those who were frail, only 3.3 per cent became robust again; 40.3 per cent improved to pre-frail, 54.5 per cent stayed frail.

These figures are asymmetrical, and that is precisely the message. At the intermediate stage almost one in four people returns to robustness entirely on their own – with targeted training that share is higher. Once frailty is established, the chance of a full return drops to around 3 per cent.

That does not mean training is pointless in established frailty – on the contrary, strength, walking and independence improve measurably there too (section 8). It means: the earlier, the more is possible.

6.2 Three trajectories – and why they change the message

Two people with the same frailty score can face completely different courses – depending on what drives the frailty. A recent paper therefore proposes three subtypes [17]:

Remediable frailty. Something treatable lies behind it – an untreated aortic valve stenosis, severe hip osteoarthritis, anaemia, an underactive thyroid, a pneumonia that has been got through. Treat the cause and the state genuinely reverses.

Steady-state frailty. The underlying condition is no longer reversible, but it is not progressing either – after a stroke, for example. Here it is about maintenance: strength, function, suitable aids, an adapted home.

Progressive frailty. A progressive condition drives the course – advanced dementia, end-stage organ failure. In earlier stages, measures can slow the course; in late stages they no longer work and can even be a burden. The goal then shifts to comfort, honest communication and support for relatives.

Why we spell this out at length: the sentence «frailty can be reversed» is correct and motivating for the first two types. For the third it is wrong – and raises expectations that help no one [17]. A good professional works out the type before choosing the message.

7. How to assess it yourself

An international expert group recommends screening for frailty from age 70 – and in addition in anyone who has lost more than 5 per cent of their body weight over the past year [3]. There are short questionnaires for this that you can also complete yourself.

7.1 The FRAIL scale

The FRAIL scale consists of five questions; each counts one point [20]:

1. Fatigue – Were you tired most or all of the time over the past month?
2. Resistance – Do you find it difficult to climb ten steps without resting and without aids?
3. Ambulation – Do you find it difficult to walk several hundred metres at a stretch?
4. Illnesses – Have you been told you have more than five chronic conditions?
5. Loss of weight – Have you unintentionally lost more than 5 per cent of your body weight in the past year? (At 70 kg that would be 3.5 kg.)

Scoring: 0 points = robust. 1 to 2 points = intermediate stage (pre-frail). 3 or more points = suggestive of frailty [20].

The middle category is the important one. One or two points are not a reason for reassurance but the best moment to act – see the transition figures in section 6.1.

7.2 And now the honest appraisal

Short questionnaires are convenient – and imprecise. A network meta-analysis compared the common screening instruments (FRAIL scale, PRISMA-7, Groningen and Tilburg indicators) head to head and concludes that none of them is good enough to carry a diagnosis on its own [21].

In concrete terms:

• An unremarkable result does not rule frailty out.
• A positive result does not prove it.

There is a further point that often gets lost: how informative a test result is depends on how common frailty is in the group the tested person comes from. The same positive value means something quite different on a geriatric ward than in a 68-year-old who has come in for hiking advice.

The self-test is therefore a door-opener for a conversation, not a finding. Use it exactly that way.

7.3 What is measured in physiotherapy

Beyond the questionnaire, physiotherapy uses short, standardised movement tests. Together they take about ten minutes:

• Walking speed over four metres at your usual pace.
• Standing up from a chair five times without using the arms, timed.
• Balance stands – feet together, semi-tandem, tandem, ten seconds each.
• Grip strength with a calibrated dynamometer.
• Timed Up and Go – stand up from a chair, walk three metres, turn, walk back, sit down.

The first three together make up the Short Physical Performance Battery, with a maximum of 12 points. These tests are not an end in themselves: a meta-analysis of 40 reports with 85,515 community-dwelling older people shows that they predict the later loss of everyday abilities. For the Timed Up and Go the authors rated the certainty of the evidence as high – for the other tests it was lower [22].

One test deserves a special mention. From the chair-rise test, sit-to-stand power can be calculated – that is, not only whether you can stand up but how quickly you generate force doing so. In a European study of 9,320 people the risk of mobility limitation was clearly increased below 2.1 watts per kilogram in women and below 2.6 watts per kilogram in men [23]. The calculation takes a minute and needs only body weight, height, chair height and a stopwatch.

Important: only do the chair-rise test at home if you feel safe, and place the chair against a wall.

8. What really helps

Here the evidence is gratifyingly clear. An overview of 23 systematic reviews with 18,768 participants sums it up: physical activity with a strength-training component, at least twice a week, is the most effective single measure against frailty [24]. A nutritional component strengthens the effect further.

The strongest single estimate comes from a meta-analysis of 18 randomised trials with 3,457 older adults: multicomponent training reduced the risk of frailty by about 55 per cent [25]. Effect sizes like that are rare in the medicine of ageing.

8.1 Strength training is the foundation

Which form of exercise works best? A network meta-analysis of 69 randomised trials compared the training modes directly against one another [26]. The ranking:

1. Strength training – first place
2. Mind–body approaches such as tai chi or qigong – just behind
3. Mixed physiotherapy
4. Multicomponent training
5. Endurance training alone

Two things are notable. First, strength training comes top – which is why it belongs in every frailty programme. Second, tai chi is almost level with it. For people who cannot get on with dumbbells and machines, that is not a fallback but an evidence-based alternative.

The classic study on the topic is now over thirty years old and still the finest illustration: one hundred nursing-home residents – mean age 87 years, the oldest 98 – trained for ten weeks with progressive strength training at 80 per cent of their maximum. Strength and function improved markedly. A nutritional supplement on its own, without training, did not [27].

The same core message is in today's international guidelines: a multicomponent exercise programme with a strength-training component is the first-line treatment for frailty [29], [28]. Both documents reject drugs as sole therapy.

8.2 How often, how heavy, how long

For people who are already pre-frail or frail there is a dedicated dose–response analysis. It shows that strength training clearly improves standing up and general physical performance, and that three sessions per week were the optimum. A very high training volume per session, by contrast, produced no better results [30].

That is a reassuring message: it is not about training for a long time, but regularly and demandingly enough.

How heavy? Studies usually give the load as a percentage of maximum strength – useless in everyday life, since nobody does a maximum test at home. The practical route runs via repetitions:

Choose a resistance with which you manage 8 to 12 clean repetitions. At the end of the set you should feel: two to four more would have been possible – no more than that. If you suddenly manage 15 with ease, the load has become too light and is increased.

This step-by-step progression is the active ingredient. Two years with the same resistance band is no longer strength training – it is a habit.

A common mistake is stopping too early. Most people initially underestimate by a wide margin how many repetitions they still had in them. That self-assessment can be trained – best in the first sessions, together with a professional.

How long? Most studies find positive effects from two to three sessions per week over at least twelve weeks. Shorter programmes – eight weeks, say – were not enough in several studies to reverse frailty [24]. So plan for a quarter of a year from the outset, not for a month.

8.3 Train power as well

Strength is not just strength. Maximum strength is how much you can move. Power is how fast you can move it. And power is lost earlier and faster with age.

This is not a subtlety for athletes. Almost all critical moments in everyday life are power moments: a trip gives no warning. The bus does not go slower. The step does not arrive later.

The evidence is positive but nuanced. An early meta-analysis from our own circle compared power training with conventional strength training in people over 60 and found a small advantage for power training in everyday function [31]. A newer analysis of 20 studies with 566 people confirms this: a slight advantage for physical function, a clear advantage for muscle power – but no difference for maximum strength, muscle mass and walking speed. The certainty of that conclusion is rated low to moderate [32].

Honestly: the difference between the two forms of training is smaller than the difference between «training» and «not training».

In practice, power training is simpler than it sounds – and it does not mean waving light weights about. What counts is the intention to accelerate briskly: the upward movement as fast as possible, the downward movement controlled and slow. Standing up from a chair, that means: briskly up, slowly down. Anyone below the guide values of 2.1 or 2.6 watts per kilogram in the chair-rise test [23] is a clear candidate for it.

8.4 Ready-made programmes: Vivifrail and Otago

You do not have to reinvent the wheel. Two programmes were developed and tested for exactly this situation.

Vivifrail combines strength, balance, flexibility and endurance and is adapted to functional status in four levels. The usual pattern is a supervised phase of about four weeks, followed by a structured home programme. The World Health Organization lists the programme in its recommendations on integrated care for older people. A multicentre randomised trial tested it in community-dwelling people with frailty and mild cognitive impairment or mild dementia: after just one month, physical function and walking speed improved; after three months, cognition, muscle function and mood improved as well – and it was well tolerated [33]. That is notable, because this is precisely the group most often excluded from exercise offerings.

The Otago programme is known in Switzerland from falls prevention: 17 strength and balance exercises plus a walking programme, with a clear progression scheme. A meta-analysis of ten studies shows that it also works in frailty and pre-frailty – frailty status, mobility, balance and grip strength all improved [34]. One important caveat: these effects on frailty appeared only after about twelve weeks. A short Otago sequence is enough for falls prevention, but not to reverse frailty.

Both programmes are introduced in physiotherapy and then continued independently. The supervised part is there to set the dose correctly – not to tie you to appointments indefinitely.

8.5 Protein: important, but no substitute

Muscles need building material, and older muscles respond more weakly to the stimulus of protein than young ones. That is why the recommendations are higher than they used to be.

The European society for clinical nutrition recommends at least 1.0 to 1.2 grams of protein per kilogram of body weight per day for healthy older people; during illness or recovery after a hospital stay the requirement is higher, around 1.2 to 1.5 grams [35]. For a person weighing 70 kg that is roughly 70 to 85 grams a day – about a pot of quark, a portion of fish or meat, an egg and a portion of pulses, spread across the day.

Spread the protein across the day. Many people eat almost none in the morning and a great deal in the evening. Spread out, you use the building stimulus several times instead of once.

But: protein without training achieves little. The 1994 study already showed this [27], and current reviews confirm it: nutritional measures without an exercise component remain inconclusive [24]. The building material is only useful once there is a stimulus that starts the building.

Different rules apply in kidney disease – discuss the protein amount with your doctor in that case. And if weight is being lost unintentionally, dietary counselling belongs in the plan; a general recommendation is no substitute for an individual one.

8.6 What is not enough on its own

For completeness, because it saves a lot of time and money:

• Walking alone. Valuable for heart, circulation and mood – but too weak a stimulus for building muscle. Muscle needs a load clearly above everyday demand.
• Supplements alone. Without training the effect remains unclear [24].
• Apps and online programmes alone. Telehealth offerings on their own work only when combined with sufficiently intense physical activity [24].
• Medication. There is no drug for frailty as such; the guidelines reject drug monotherapy [29].

Conversely, a meta-analysis from primary care shows what does work: strength training plus protein supplementation, strength training plus dietary counselling, and strength training alone each clearly reduced the risk of frailty; comprehensive geriatric assessment did too, though somewhat less strongly [36].

9. Being able to get up from the floor

This ability is almost never discussed – until it is missing. Yet it is needed constantly: gardening, picking up something that has fallen, playing with grandchildren, exercising on a mat.

And it is a safety factor of the first order. In a British study that recorded every fall of 110 people aged 90 and over for a year, 80 per cent were unable to get up unaided after at least one fall; 30 per cent lay on the floor for at least an hour [37]. Such a long lie was associated with serious injuries, with hospital admissions and with subsequent admission to a care home.

The most sobering finding of that study: 97 per cent of those who had a long lie had an alarm system – and did not use it [37]. Some were not wearing the pendant, some were determined to manage alone, some feared being admitted to hospital.

It does not follow that alarm systems are unnecessary. It follows that they do not replace training the ability to get up.

How to train it. The best-studied method is called backward chaining. Instead of practising from lying down, the movement is built up from the end: you start standing, step back into half-kneeling, then to four-point kneeling, then to side-sitting, and finally to lying on your back. Each stage is made secure on its own before the next is added. The advantage: no experience of helplessness on the floor, and confidence grows with every step mastered.

A systematic review of seven studies with 446 people (mean age 82.4 years) shows that the method improves the ability to get up, increases mobility, reduces the number of falls and can lessen fear of falling [38]. The authors also note that it is used surprisingly rarely in practice.

In therapy, five to ten minutes per session over three to six weeks is enough, alongside the rest of the programme. Do not practise it alone at home without instruction if you feel unsure.

10. Falls and fear of falling

Frailty and falls reinforce one another. A meta-analysis confirms frailty as an independent risk factor for falls [39] – and any fall can lead back into frailty via injury, protective behaviour and fear.

Since 2022 there have been global guidelines on falls prevention that set out a clear sequence: assess the risk, investigate in a targeted way, then act at several points at once – exercise, medication review, vision, blood pressure, home environment [40]. We cover this in detail in our article Fall prevention.

One point deserves highlighting here because it matters particularly in frailty: fear of falling.

It is not simply the consequence of a fall – it can arise without any fall, and it is an independent driver of what follows. The sequence is always the same: someone who is afraid of falling avoids activities. Someone who avoids activities loses strength and balance. Someone who loses strength and balance is more likely to fall. The fear fulfils itself.

The good news: exercise programmes work against the fear as well. A meta-analysis of 30 randomised trials found a small to moderate effect [41]. Three ingredients are best documented: mind–body approaches with a breathing and mindfulness component (tai chi above all), multicomponent programmes with strength and balance – and individually progressed programmes.

Where fear of falling is pronounced, exercise therapy alone reaches its limits. A psychological approach that works on the catastrophising thoughts then helps in addition («if I fall, I'll break my hip and end up in a home»). Raise it – it is not a sign of weakness but the more effective route.

11. The critical weeks: illness, surgery, hospital

Because inactivity is the strongest accelerator [16], it pays to be deliberate about exactly those phases in which you least feel like moving.

With flu or a cold. Rest is right while there is a fever. After that every day counts. Get up regularly, do a few sit-to-stand movements from a chair several times a day.

Before planned surgery. The weeks beforehand are valuable. Going into an operation with more strength means more reserve for afterwards. Ask actively about a preparation programme – with frailty that is not an extravagance but time well invested.

In hospital. Ask whether you are allowed to get up, and ask about physiotherapy. Sitting in a chair is better than lying; walking in the corridor is better than sitting. Clarify the safety questions with the staff – but do not let the topic drop. This is exactly where the loss of function arises that has to be laboriously recovered later [18].

After the hospital stay. This is the decisive phase. Part of the lost strength does not come back on its own without targeted training. And at the same time this is the situation with the greatest potential: frailty that has arisen through an illness now overcome belongs to the remediable type [17].

With a broken arm or leg. The cast affects one body part, not the whole body. The healthy side and the trunk can and should carry on training.

12. What else counts: sleep, contacts, medication

Frailty is more than muscle. Four areas are well documented and often skipped in practice.

Sleep. A meta-analysis shows a U-shape for sleep duration: both less than six and more than eight hours were associated with a higher risk of frailty compared with six to eight hours [42]. Poor sleep quality and sleep apnoea belong here too. If you snore and are tired during the day, that is a subject for your family doctor.

Loneliness and social isolation. A large British longitudinal study shows that both – the subjective feeling of loneliness as well as objective isolation – increase the risk of becoming frail [43]. This is not a soft side issue: in the data it stands alongside the physical risk factors.

A pleasing counterpoint: dancing showed a favourable effect on frailty in an analysis of several studies [44]. Movement, music, balance, people – four active ingredients in one activity.

Medication. The more long-term medications, the higher the risk of frailty and falls. From about five long-term medications onwards, a structured review by a doctor or pharmacist is worthwhile. Never stop anything on your own – with sleeping tablets and sedatives in particular, abrupt withdrawal can be more dangerous than the drug.

Mood and memory. Depression and cognitive impairment are closely interwoven with frailty, in both directions. They deserve assessment – not least because untreated depression stalls any exercise programme.

Where several of these areas come together, a comprehensive geriatric assessment makes sense. A Cochrane review of 29 studies with 13,766 patients shows that those who receive such an assessment in hospital are more likely to be living at home three to twelve months later [45]. The effect is not huge – but it concerns exactly the outcome that matters most to most people.

13. Exhaustion – and how to pace your energy

Exhaustion is one of the five frailty criteria and at the same time one of the strongest engines of the cycle: it lowers activity, activity lowers strength, and the missing strength makes everything more effortful.

The most important – and for many surprising – point: the most effective remedy against exhaustion is movement. This is well studied, best of all in cancer rehabilitation, and the mechanisms carry over: better muscle function, dampened inflammation, better sleep, better mood.

Progression in small steps is essential. In the first one to two weeks, exhaustion may increase as a result of the activation. That is normal – those who do not know it stop at exactly that moment.

In addition, pacing helps – deliberately dividing up your energy:

• Prioritise. The evening before, note three to four main points for the next day. Everything else is a bonus.
• Plan. Put demanding tasks in your highest-energy part of the day – for most people the morning. Split large tasks (the laundry in two goes rather than one).
• Break before, not after. Schedule breaks before exhaustion arrives, not after it.

A simple energy diary over one to two weeks makes the pattern visible: three lines per day (morning, afternoon, evening), each with your energy on a scale of 1 to 10. After that you know when your good hours are – and can put the shopping there.

One distinction matters: pacing is not the same as taking it easy. It is the method by which you can do as much as possible and as evenly as possible – not as little as possible.

And not every kind of exhaustion belongs to ageing. Newly arisen, unexplained exhaustion lasting more than four weeks, along with breathlessness on exertion, dizziness, sensitivity to cold or persistent low mood – that needs medical assessment. Anaemia, thyroid problems and depression are common and treatable.

14. Six common misunderstandings

«Frailty is just age.»
No. Frailty is a state in its own right that predicts events independently of age and of the individual diagnoses [2]. There are robust 90-year-olds and 60-year-olds who have become frail.

«Frailty only affects the very old.»
In the UK Biobank study, among 493,737 people aged 37 to 73, 3 per cent were frail and 38 per cent pre-frail [10]. The topic starts in middle age.

«Once you are frail, it only goes downhill.»
Without any treatment, 13.7 per cent improved over four years, and 23.1 per cent returned from the intermediate stage to robustness [19]. With training, more is possible.

«Strength training is too dangerous at this age.»
Progressive strength training was carried out in nursing-home residents with a mean age of 87 [27] and is recommended by international guidelines as first-line treatment [29]. More dangerous than the training is the loss of strength that leads to falls.

«I move enough – I go for a walk every day.»
Walking is valuable, but too weak a stimulus for building muscle. In the direct comparison of training modes, endurance training alone comes at the bottom of the ranking and strength training at the top [26]. Both are needed – but they do not replace each other.

«A protein powder solves the problem.»
Nutritional measures without an exercise component remain inconclusive [24]. Protein supports training – it does not replace it.

15. When to involve a professional

Raise the subject if one or more of these statements apply:

• The FRAIL scale gives 1 point or more.
• Standing up from a chair five times takes longer than 15 seconds.
• You have fallen in the past year – or you are afraid of falling.
• You were unable to get up unaided after a fall.
• You have unintentionally lost weight.
• You do not feel «like before» after an illness, an operation or a hospital stay.
• You are exhausted all the time.
• You avoid activities that used to be a matter of course.

What to expect in physiotherapy: the tests from section 7.3, and from them an exercise programme with clear progression steps – and, this is the decisive part, a home programme you carry out yourself between appointments. After four to six weeks everything is measured again. If nothing improves although you have trained regularly, that belongs back with your family doctor: the cause then often lies beyond the reach of physiotherapy – anaemia, thyroid, a new illness, the medication list.

What needs medical assessment: unintentional weight loss, newly arisen severe exhaustion, suspected malnutrition, falls with no recognisable cause, memory problems, suspected depression – and a medication list that has grown long over the years.

And what relatives can contribute: often more than they think. Coming along to training. Watching out for protein when shopping. Asking whether the week still contains social appointments. The three most frequent early signs – slower walking, less strength, more exhaustion – are usually noticed first by those around the person.

16. In summary

Frailty is the state in which the reserves have become thin. It explains why the same pneumonia costs one person two weeks and another their independence.

It is common – at the intermediate stage it affects around half of people over 70 [7] – and it starts earlier than most people think [10]. At the same time it is one of the few states in old age for which recovery is documented and treatment is effective [19], [24].

What you need for that is manageable: two to three demanding strength sessions a week over at least three months, balance exercises as close to daily as possible, enough protein spread across the day, attention for the weeks of illness or rest, a watchful eye on sleep, mood, contacts and the medication list – and the willingness to stop accepting «that's just age» as an explanation.

The body is still adaptable at 85. More slowly than at 40 – but it answers.

References

Every Digital Object Identifier (DOI) was checked individually against the Crossref register. The links in the reference list lead via the DOI service to the publishers' pages. Some of these are located outside Switzerland and the EU. When you click them, your IP address is transmitted to the respective provider – this does not happen on our own site.

[1] Kim DH, Rockwood K. Frailty in Older Adults. New England Journal of Medicine. 2024;391(6):538–548. https://doi.org/10.1056/NEJMra2301292

[2] Hoogendijk EO, Afilalo J, Ensrud KE, et al. Frailty: implications for clinical practice and public health. The Lancet. 2019;394(10206):1365–1375. https://doi.org/10.1016/S0140-6736(19)31786-6

[3] Morley JE, Vellas B, Abellan van Kan G, et al. Frailty Consensus: A Call to Action. Journal of the American Medical Directors Association. 2013;14(6):392–397. https://doi.org/10.1016/j.jamda.2013.03.022

[4] Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. The Lancet. 2013;381(9868):752–762. https://doi.org/10.1016/S0140-6736(12)62167-9

[5] Fried LP, Tangen CM, Walston J, et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of Gerontology Series A. 2001;56(3):M146–M157. https://doi.org/10.1093/gerona/56.3.M146

[6] Rockwood K, Mitnitski A. Frailty in Relation to the Accumulation of Deficits. The Journals of Gerontology Series A. 2007;62(7):722–727. https://doi.org/10.1093/gerona/62.7.722

[7] O'Caoimh R, Sezgin D, O'Donovan MR, et al. Prevalence of frailty in 62 countries across the world: a systematic review and meta-analysis of population-level studies. Age and Ageing. 2021;50(1):96–104. https://doi.org/10.1093/ageing/afaa219

[8] Pitter JG, Zemplényi A, Babarczy B, Németh B, Kaló Z, Vokó Z. Frailty prevalence in 42 European countries by age and gender: development of the SHARE Frailty Atlas for Europe. GeroScience. 2024;46(2):1807–1824. https://doi.org/10.1007/s11357-023-00975-3

[9] Yu L, Tang X, Gong D, Man C, Fan Y. Prefrailty prevalence and all-cause mortality risk in older adults from the general population: A meta-analysis of prospective cohort studies. Geriatrics & Gerontology International. 2025;25(9):1167–1177. https://doi.org/10.1111/ggi.70133

[10] Hanlon P, Nicholl BI, Jani BD, Lee D, McQueenie R, Mair FS. Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants. The Lancet Public Health. 2018;3(7):e323–e332. https://doi.org/10.1016/S2468-2667(18)30091-4

[11] Guessous I, Luthi JC, Bowling CB, et al. Prevalence of Frailty Indicators and Association with Socioeconomic Status in Middle-Aged and Older Adults in a Swiss Region with Universal Health Insurance Coverage: A Population-Based Cross-Sectional Study. Journal of Aging Research. 2014;2014:198603. https://doi.org/10.1155/2014/198603

[12] Jiang M, Corna L, Amati R, et al. Prevalence and association of frailty with SARS-CoV-2 infection in older adults in Southern Switzerland – Findings from the Corona Immunitas Ticino Study. BMC Geriatrics. 2023;23(1):18. https://doi.org/10.1186/s12877-023-03730-7

[13] Braun T, Thiel C, Ziller C, et al. Prevalence of frailty in older adults in outpatient physiotherapy in an urban region in the western part of Germany: a cross-sectional study. BMJ Open. 2019;9(6):e027768. https://doi.org/10.1136/bmjopen-2018-027768

[14] Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age and Ageing. 2019;48(1):16–31. https://doi.org/10.1093/ageing/afy169

[15] Vetrano DL, Palmer K, Marengoni A, et al. Frailty and Multimorbidity: A Systematic Review and Meta-analysis. The Journals of Gerontology: Series A. 2019;74(5):659–666. https://doi.org/10.1093/gerona/gly110

[16] Nunes EA, Stokes T, McKendry J, Currier BS, Phillips SM. Disuse-induced skeletal muscle atrophy in disease and nondisease states in humans: mechanisms, prevention, and recovery strategies. American Journal of Physiology – Cell Physiology. 2022;322(6):C1068–C1084. https://doi.org/10.1152/ajpcell.00425.2021

[17] Mallery L, Shetty N. Redefining Frailty: Planning Care Through the Frailty Trajectory Model. Journal of the American Geriatrics Society. 2026;74(1):297–301. https://doi.org/10.1111/jgs.70090

[18] Giacomino K, Hilfiker R, Beckwée D, Taeymans J, Sattelmayer KM. Assessment tools and incidence of hospital-associated disability in older adults: a rapid systematic review. PeerJ. 2023;11:e16036. https://doi.org/10.7717/peerj.16036

[19] Kojima G, Taniguchi Y, Iliffe S, Jivraj S, Walters K. Transitions between frailty states among community-dwelling older people: A systematic review and meta-analysis. Ageing Research Reviews. 2019;50:81–88. https://doi.org/10.1016/j.arr.2019.01.010

[20] Braun T, Grüneberg C, Thiel C. German translation, cross-cultural adaptation and diagnostic test accuracy of three frailty screening tools: PRISMA-7, FRAIL scale and Groningen Frailty Indicator. Zeitschrift für Gerontologie und Geriatrie. 2018;51(3):282–292. https://doi.org/10.1007/s00391-017-1295-2

[21] Vo NT, Tu YK, Lin KC, Chiu HY, Huang HC. Diagnostic Accuracy of the FRAIL Scale, Groningen Frailty Indicator, Tilburg Frailty Indicator, and PRISMA-7 for Frailty Screening Among Older Adults in Community Settings: A Systematic Review and Network Meta-Analysis. The Gerontologist. 2024;64(6):gnae008. https://doi.org/10.1093/geront/gnae008

[22] Braun T, Thiel C, Peter RS, et al. Association of clinical outcome assessments of mobility capacity and incident disability in community-dwelling older adults – a systematic review and meta-analysis. Ageing Research Reviews. 2022;81:101704. https://doi.org/10.1016/j.arr.2022.101704

[23] Alcazar J, Alegre LM, Van Roie E, et al. Relative sit-to-stand power: aging trajectories, functionally relevant cut-off points, and normative data in a large European cohort. Journal of Cachexia, Sarcopenia and Muscle. 2021;12(4):921–932. https://doi.org/10.1002/jcsm.12737

[24] Money A, MacKenzie A, Parchment A, et al. Evidence on non-pharmacological interventions for preventing or reversing physical frailty in community-dwelling older adults aged over 50 years: overview of systematic reviews. BMC Geriatrics. 2025;25(1):183. https://doi.org/10.1186/s12877-025-05768-1

[25] Sirikul W, Buawangpong N, Pinyopornpanish K, Siviroj P. Impact of multicomponent exercise and nutritional supplement interventions for improving physical frailty in community-dwelling older adults: a systematic review and meta-analysis. BMC Geriatrics. 2024;24(1):958. https://doi.org/10.1186/s12877-024-05551-8

[26] Sun X, Liu W, Gao Y, et al. Comparative effectiveness of non-pharmacological interventions for frailty: a systematic review and network meta-analysis. Age and Ageing. 2023;52(2):afad004. https://doi.org/10.1093/ageing/afad004

[27] Fiatarone MA, O'Neill EF, Ryan ND, et al. Exercise Training and Nutritional Supplementation for Physical Frailty in Very Elderly People. New England Journal of Medicine. 1994;330(25):1769–1775. https://doi.org/10.1056/NEJM199406233302501

[28] Izquierdo M, de Souto Barreto P, Arai H, et al. Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR). The Journal of Nutrition, Health and Aging. 2025;29(1):100401. https://doi.org/10.1016/j.jnha.2024.100401

[29] Dent E, Morley JE, Cruz-Jentoft AJ, et al. Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management. The Journal of Nutrition, Health and Aging. 2019;23(9):771–787. https://doi.org/10.1007/s12603-019-1273-z

[30] Nagata CA, Garcia PA, Hamu TCDS, et al. Are dose-response relationships of resistance training reliable to improve functional performance in frail and pre-frail older adults? A systematic review with meta-analysis and meta-regression of randomized controlled trials. Ageing Research Reviews. 2023;91:102079. https://doi.org/10.1016/j.arr.2023.102079

[31] Tschopp M, Sattelmayer MK, Hilfiker R. Is power training or conventional resistance training better for function in elderly persons? A meta-analysis. Age and Ageing. 2011;40(5):549–556. https://doi.org/10.1093/ageing/afr005

[32] Balachandran AT, Steele J, Angielczyk D, et al. Comparison of Power Training vs Traditional Strength Training on Physical Function in Older Adults: A Systematic Review and Meta-analysis. JAMA Network Open. 2022;5(5):e2211623. https://doi.org/10.1001/jamanetworkopen.2022.11623

[33] Casas-Herrero Á, Sáez de Asteasu ML, Antón-Rodrigo I, et al. Effects of Vivifrail multicomponent intervention on functional capacity: a multicentre, randomized controlled trial. Journal of Cachexia, Sarcopenia and Muscle. 2022;13(2):884–893. https://doi.org/10.1002/jcsm.12925

[34] Yi M, Zhang W, Zhang X, Zhou J, Wang Z. The effectiveness of Otago exercise program in older adults with frailty or pre-frailty: A systematic review and meta-analysis. Archives of Gerontology and Geriatrics. 2023;114:105083. https://doi.org/10.1016/j.archger.2023.105083

[35] Volkert D, Beck AM, Cederholm T, et al. ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clinical Nutrition. 2022;41(4):958–989. https://doi.org/10.1016/j.clnu.2022.01.024

[36] Macdonald SHF, Travers J, Shé ÉN, et al. Primary care interventions to address physical frailty among community-dwelling adults aged 60 years or older: A meta-analysis. PLOS ONE. 2020;15(2):e0228821. https://doi.org/10.1371/journal.pone.0228821

[37] Fleming J, Brayne C. Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90. BMJ. 2008;337:a2227. https://doi.org/10.1136/bmj.a2227

[38] Leonhardt R, Becker C, Gross M, Mikolaizak AS. Impact of the backward chaining method on physical and psychological outcome measures in older adults at risk of falling: a systematic review. Aging Clinical and Experimental Research. 2020;32(6):985–997. https://doi.org/10.1007/s40520-019-01459-1

[39] Yang ZC, Lin H, Jiang GH, et al. Frailty Is a Risk Factor for Falls in the Older Adults: A Systematic Review and Meta-Analysis. The Journal of Nutrition, Health and Aging. 2023;27(6):487–495. https://doi.org/10.1007/s12603-023-1935-8

[40] Montero-Odasso M, van der Velde N, Martin FC, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age and Ageing. 2022;51(9):afac205. https://doi.org/10.1093/ageing/afac205

[41] Feng C, Adebero T, DePaul VG, Vafaei A, Norman KE, Auais M. A Systematic Review and Meta-Analysis of Exercise Interventions and Use of Exercise Principles to Reduce Fear of Falling in Community-Dwelling Older Adults. Physical Therapy. 2022;102(1):pzab236. https://doi.org/10.1093/ptj/pzab236

[42] Pourmotabbed A, Boozari B, Babaei A, et al. Sleep and frailty risk: a systematic review and meta-analysis. Sleep and Breathing. 2020;24(3):1187–1197. https://doi.org/10.1007/s11325-020-02061-w

[43] Davies K, Maharani A, Chandola T, Todd C, Pendleton N. The longitudinal relationship between loneliness, social isolation, and frailty in older adults in England: a prospective analysis. The Lancet Healthy Longevity. 2021;2(2):e70–e77. https://doi.org/10.1016/S2666-7568(20)30038-6

[44] Meng X, Li G, Zhang G, et al. Effects of dance intervention on frailty among older adults. Archives of Gerontology and Geriatrics. 2020;88:104001. https://doi.org/10.1016/j.archger.2019.104001

[45] Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews. 2017;(9):CD006211. https://doi.org/10.1002/14651858.CD006211.pub3