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Transitions Between Frailty States Among Community-Living Older Persons
Open accessAbstract
BACKGROUND: Little is known about the natural course of frailty. We performed a prospective study to determine the transition rates between frailty states and to evaluate the effect of the preceding frailty state on subsequent frailty transitions. METHODS: We studied 754 community-living persons, aged 70 years or older, who were nondisabled in 4 essential activities of daily living. Frailty, assessed every 18 months for 54 months, was defined on the basis of weight loss, exhaustion, low physical activity, muscle weakness, and slow walking speed. Participants were classified as frail if they met 3 or more of these criteria, as prefrail if they met 1 or 2 of the criteria, and as nonfrail if they met none of the criteria. RESULTS: Of the 754 participants, 434 (57.6%) had at least 1 transition between any 2 of the 3 frailty states during 54 months. The rates were 36.8%, 21.5%, and 9.2% for 1, 2, and 3 transitions, respectively. During the 18-month intervals, transitions to states of greater frailty were more common (rates up to 43.3%) than transitions to states of lesser frailty (rates up to 23.0%), and the probability of transitioning from being frail to nonfrail was very low (rates, 0%-0.9%), even during an extended period. The likelihood of transitioning between frailty states was highly dependent on one's preceding frailty state. CONCLUSIONS: Frailty among older persons is a dynamic process, characterized by frequent transitions between frailty states over time. Our findings suggest ample opportunity for the prevention and remediation of frailty.
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“and moderate/severe frailty (RR 2.60, 95% CI 1.36-4.96) (95).”
From Frailty in elderly people (2013) · cites this paper as [95]
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“Risk of admission to long-term care is also increased in those with mild frailty (adjusted risk ratio (RR) 2.54, 95% CI 1.67-3.86)”
From Frailty in elderly people (2013) · cites this paper as [95]
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“The Yale Precipitating Events Project (PEP) is a cohort study based in New Haven CT that enrolled individuals aged 70 years or older.”
From A standard procedure for creating a frailty index (2008) · cites this paper as [15]
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“Moreover, patients classified as prefrail and frail, excluding those who are totally dependent for personal care [37, 38], have the potential for functional improvement, which is supported by the findings of our study and those of a previous study on GEM unit [16].”
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“However, we believe our sample represents a group particularly important in terms of targeting of preventative interventions given their increased likelihood of experiencing poor outcomes including transitioning to frailty (53).”
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“31,32 Consequently, healthcare policy should prioritize interventions that aim to prevent or slow the progression of frailty, effectively mitigating significant functional decline.”
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Zhabokritsky, A., Klein, M. B., Harris, M., Loutfy, M. R., Guillemi, S. A., Tan, D. H. S., Falutz, J., Andany, N., Guaraldi, G., Lovblom, L. E., et al. (2024) · JAIDS Journal of Acquired Immune Deficiency Syndromes · doi:10.1097/qai.0000000000003485 · Cited by 11
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“Frailty is dynamic [8]; a recent international meta-analysis found that over an average follow-up of 3.”
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“, hypertension, myocardial infarction, congestive heart failure, stroke, diabetes mellitus, arthritis, hip fracture, chronic lung disease, and cancer), physical frailty (Gill et al., 2006), cognitive status (Folstein et al.”
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Somasundar, P. S., Mourey, L., Lozza, L., Maggi, S., & Stepney, R. (2017) · Tumori Journal · doi:10.5301/tj.5000661 · Cited by 11
“Gill et al (31) found that, while more people moved towards an increasingly frail state over 18 months of follow-up, change in the opposite direction was possible: 23% of people moved from being frail to pre-frail, and 12% from pre-frail to robust.”
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Wang, J., Dietrich, M. S., Bell, S. P., Maxwell, C. A., Simmons, S. F., & Kripalani, S. B. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-024766 · Cited by 11
“One is the dynamic nature of physical function related to vulnerability and physical frailty—a phenotype focused on objective physiological changes that is closely intertwined with vulnerability.(11) 32–37 As shown in the groundbreaking study by Gill et al,(11) community-dwelling older adults experienced frequent tran…”
BackgroundDeterioro cognitivo en adultos mayores con VIH/sida y síndrome de fragilidad
Zamudio‐Rodríguez, A., Aguilar-Navarro, S. G., & Ávila‐Funes, J. A. (2017) · Gaceta Médica de México · doi:10.24875/gmm.17002875 · Cited by 11
Assessing operative risk and benefit in elderly patients with heart valve disease
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“to point out that frailty should be distinguished from comorbidity and disability (up to 27% of patients defined as frail have no associated comorbidity or disability).(10) Many physicians often refer to the ‘eyeball test’, when assessing the likelihood that a patient will survive receiving a benefit froma procedure.”
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Frailty and Environmental Attributes in Older Adults: Insight from an Ecological Model
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“Frailty is recognized as a dynamic process that includes a natural progression as well as a remission, and is not a fixed irreversible pathway that leads to disability or mortality 10) .”
BackgroundProgression of frailty and cardiovascular outcomes among Medicare beneficiaries
Gong, Y., Song, Y., Xu, J., Dong, H., Orkaby, A. R., Kramer, D. B., Dodson, J. A., & Strom, J. B. (2024) · Journal of the American Geriatrics Society · doi:10.1111/jgs.19116 · Cited by 10
“22,41 While these strategies are predicated on the possibility of frailty improvement, few studies have quantitatively evaluated whether frailty changes over time, the expected rates of change, and the independent association of these changes with adverse health outcomes.”
Cho, H. J., Jung, H., Won, C. W., & Kim, M. (2024) · Archives of Gerontology and Geriatrics · doi:10.1016/j.archger.2024.105637 · Cited by 12
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“A longitudinal study of 754 community-dwelling older adults without disabilities over 54 months found 57.6% experienced at least one transition between three frailty states [3].”
InfluentialLee, J. L. C., Wong, A. Y. L., Ng, P. H. F., Fu, S. N., Fong, K. N. K., Cheng, A. S. K., Lee, K. N. K., Sun, R., Zhang, H. Y., & Xiao, R. (2025) · JMIR mhealth and uhealth · doi:10.2196/69259 · Cited by 11
“Research has shown that interventions and health strategies can be effectively used to prevent, delay, or even reverse frailty among community-dwelling older adults [6].”
Considerations for assessing frail older adults requesting medical assistance in dying
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“The health-related factors included multimorbidity,(16) based on nine selfreported, physician-diagnosed chronic conditions,(17) and frailty.(18) The functional factors included disability in 1 or more of 13 daily activities, as described below, and cognitive impairment.”
BackgroundSelf-citationTeriö, M., Pérez‐Rodríguez, R., Guevara, T. G., Valdés-Aragonés, M., Kornevs, M., Bjälevik-Chronan, S., Taloyan, M., Meijer, S., & Guidetti, S. G. E. (2022) · Pilot and Feasibility Studies · doi:10.1186/s40814-022-01147-4 · Cited by 10
“These factors have been significantly associated with frailty and pre-frailty status [32, 33].”
BackgroundEvidence-based Prevention of Frailty in Older Adults
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Frailty: a term with many meanings and a growing priority for community nurses
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“An outcome of death was commonly associated with frailty and pre-frailty(3,5-6,9).”
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Shin, J. W., Kim, M., & Choi, J. (2021) · The journal of nutrition health & aging · doi:10.1007/s12603-021-1652-0 · Cited by 10
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“in frailty [20, 21] or mobility research [22].”
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“It is suggested that there were more transitions to greater frailty than to lesser frailty (28).”
Culverhouse, J., Hillsdon, M. M., Metcalf, B. S., Nunns, M., Lear, R., Brailey, G., & Pulsford, R. M. (2023) · BMJ Public Health · doi:10.1136/bmjph-2023-100000 · Cited by 9
“16 However, identifying opportunities to intervene in mid-life relies on the ability to detect impairments in function prior to the point that reduced function results in presentation in medical settings.”
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The impact of frailty syndrome on skeletal muscle histology: preventive effects of exercise
Ji, F., Lee, H. S., Lee, H., & Kim, J. (2025) · FEBS Open Bio · doi:10.1002/2211-5463.70049 · Cited by 10
“This finding underscores the efficacy of endurance exercise as a non-pharmacological intervention to mitigate the effects of frailty syndrome and maintain skeletal muscle health in aging populations.”
Murphy, T. E., Allore, H. G., Han, L., Peduzzi, P. N., Gill, T. M., Xu, X. J., & Lin, H. (2015) · Experimental Aging Research · doi:10.1080/0361073x.2015.1021640 · Cited by 9
Self-citationGuevara, E., Simó-Servat, A., Perea, V., Quirós, C., Puig-Jové, C., Formiga, F., & Barahona, M. J. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13175325 · Cited by 12
The Role of Intervening Illnesses and Injuries in Prolonging the Disabling Process
Gill, T. M., Allore, H. G., Gahbauer, E. A., & Murphy, T. E. (2015) · Journal of the American Geriatrics Society · doi:10.1111/jgs.13319 · Cited by 9
“Based on initial sample size calculations, persons were oversampled if they were physically frail, defined on the basis of slow gait speed.(11) Eligibility was determined during a screening telephone interview and confirmed during an in-home assessment.”
BackgroundSelf-citationStill going strong: perceptions of the body among 85‐year‐old people in Sweden
Fischer, R. S., Altin, E., Ragnarsson, C., & Lundman, B. M. (2008) · International Journal of Older People Nursing · doi:10.1111/j.1748-3743.2007.00104.x · Cited by 9
Nessighaoui, H., Geniaux, H., Dantoine, T., & Laroche, M. (2016) · Therapies · doi:10.1016/j.therap.2016.02.021 · Cited by 9
Anthropometric Measures and Frailty Prediction in the Elderly: An Easy-to-Use Tool
Closs, V. E., Ziegelmann, P. K., Flores, J. H. F., Gomes, I., & Schwanke, C. H. A. (2017) · Current Gerontology and Geriatrics Research · doi:10.1155/2017/8703503 · Cited by 9
Transcatheter Aortic Valve Replacement
Goel, K., & Holmes, D. R. (2017) · Journal of Cardiopulmonary Rehabilitation and Prevention · doi:10.1097/hcr.0000000000000301 · Cited by 9
Association of the CAN score with the FRAIL scale in community dwelling older adults
Ruiz, J. G., Rahaman, Z., Dang, S., Anam, R., Valencia, W. M., & Mintzer, M. J. (2018) · Aging Clinical and Experimental Research · doi:10.1007/s40520-018-0910-4 · Cited by 9
Doody, P., Lord, J. M., & Phillips, A. C. (2019) · Pilot and Feasibility Studies · doi:10.1186/s40814-019-0470-1 · Cited by 9
Wang, Y., Han, H., Yang, W. Y. L., Zhang, H., Zhang, J., Ruan, H., Tang, N., Ren, J., Sun, X., Li, C., et al. (2021) · International Journal of Nursing Sciences · doi:10.1016/j.ijnss.2021.03.008 · Cited by 9
Self-citationThe Validity and Reliability of the Kaigo-Yobo Checklist in Korean Elderly
Hwang, H. S., PhD., P., Yoon, J. L., PhD., P., Park, B., PhD., P., Choi, H. R., PhD., P., Kwon, I. S., PhD., P., et al. (2012) · Journal of the Korean Geriatrics Society · doi:10.4235/jkgs.2012.16.3.121 · Cited by 9
“(2) 활력 감소: “모든 일들에 대해 힘든 느낌이 들었습니까?” 혹은 “도무지 해나갈 수 없다는 느낌이 들었습니까?”라는 질문에 한가지라도 일주일에 3일 이상인 경우를 1점, 그 미만 인 경우는 0점으로 처리하여 평가하였다.”
Shé, É. N., McCarthy, M. A., O’Donnell, D., Collins, O., Hughes, G., Salter, N., Cogan, L., O'Donoghue, C., McGrath, E. E., O'Donovan, J., et al. (2018) · HRB Open Research · doi:10.12688/hrbopenres.12804.1 · Cited by 9
Gómez‐Pavón, J., López, C., Cristofori, G., Aguado, R., & Conde, B. A. (2018) · Medicine - Programa de Formación Médica Continuada Acreditado · doi:10.1016/j.med.2018.09.001 · Cited by 9
Strojnik, V., & Gabrovec, B. (2019) · Slovenian Journal of Public Health · doi:10.2478/sjph-2019-0011 · Cited by 9
“Frailty among older persons is a dynamic process (11).”
BackgroundEpidemiology of Sarcopenia and Frailty
Patel, H. P., Clift, E., Lewis, L., & Cooper, C. C. (2017) · InTech eBooks · doi:10.5772/intechopen.69771 · Cited by 12
“Using the life course approach to conceptualise frailty is worth considering as this broadens the window of opportunity to identify markers and mechanisms contributing to frailty with a view to intervention [56] (Figure 2).”
BackgroundSeo, A.-R., Kim, M.-J., Kim, B., Seo, Y.-M., Lee, G.-Y., Park, K., & Yoo, J. (2021) · Yonsei Medical Journal · doi:10.3349/ymj.2021.62.3.249 · Cited by 8
Wei, Y., & Yu, J. (2024) · Frontiers in Nutrition · doi:10.3389/fnut.2024.1495792 · Cited by 8
Wang, X., Hu, W., & Zhang, J. (2025) · Chinese Medical Journal - Pulmonary and Critical Care Medicine · doi:10.1016/j.pccm.2025.02.002 · Cited by 8
“97 Early assessment, identification, and intervention of frailty is crucial in preventing or slowing down its progression, thereby improving the adverse outcomes for patients with COPD.”
Lorenzo‐López, L., López‐López, R., Maseda, A., Diego‐Díez, C., Gómez‐Caamaño, S., & Millán-Calentí, J. C. (2016) · Journal of the American Geriatrics Society · doi:10.1111/jgs.13908 · Cited by 8
“[2] Because frailty has been associated with risk of multiple adverse outcomes,[3-5] and prefrailty status seems to be partially reversible and an optimal target for interventions,[6-8] it is crucial to identify individuals who are at risk of frailty (prefrailty) to develop early and effective preventive interventions…”
BackgroundWakida, M., Asai, T., Kubota, R., Kuwabara, T., Fukumoto, Y., Sato, H., Nakano, J., Mori, K., Ikezoe, T., & Hase, K. (2022) · Geriatrics and gerontology international/Geriatrics & gerontology international · doi:10.1111/ggi.14346 · Cited by 8
Li, L., Guan, X., Huang, Y., Qu, B., Yao, B., & Ding, H. (2024) · Sports Medicine and Health Science · doi:10.1016/j.smhs.2024.01.005 · Cited by 8
“11,12 Recommendations for the appropriate design of exercise programs for frail individuals are not always clear.”
BackgroundPredictors of Frailty Transitions in Mexican Older Adults
Rivera‐Almaraz, A., Salinas‐Rodríguez, A., Gutiérrez‐Peña, E., & Manrique-Espinoza, B. S. (2024) · The Journals of Gerontology Series A · doi:10.1093/gerona/glae068 · Cited by 8
Creation of a New Frailty Scale in Primary Care: The Zulfiqar Frailty Scale (ZFS)
Zulfiqar, A. (2021) · Medicines · doi:10.3390/medicines8040019 · Cited by 12
“The time is longer for the Fried scale and for the SEGA grid A (from 6 to 10 min) [6], making them more difficult for general practitioners to apply during consultation.”
BackgroundRuangsuriya, J., Wongpoomchai, R., Srichairatanakool, S., Sirikul, W., Buawangpong, N., & Siviroj, P. (2022) · Nutrients · doi:10.3390/nu14061192 · Cited by 8
“From a medical perspective, the crucial feature of frailty is that it is a dynamic process that can be prevented and sometimes reversed to robustness [14,15].”
BackgroundTan, R. S., Goh, E. F., Wang, D., Chan, R. C. L., Zeng, Z., Yeo, A., Pek, K., Kua, J., Wong, W. C., Shen, Z., et al. (2022) · Frontiers in Medicine · doi:10.3389/fmed.2022.955785 · Cited by 9
“Longitudinal studies show that the risk of transitioning to greater states of frailty increases with age (7, 8).”
BackgroundChen, M., Lu, C. X., & Zha, J. (2022) · Journal of Applied Gerontology · doi:10.1177/07334648221147917 · Cited by 8
“It is generally believed that the occurrence and development of frailty is a dynamic process (Crow et al., 2018; Gill et al., 2006) that presents a spiral decline, mainly transitioning from prefrailty to frailty, leading to worse health outcomes and even death.”
BackgroundLi, G., Παπαϊωάννου, Α., Thabane, L., Levine, M., Ioannidis, G., Wong, A. K. O., Lau, A. N., & Adachi, J. D. (2017) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2016.11.015 · Cited by 8
Ó’Caoimh, R., Molloy, D. W., Fitzgerald, C., van Velsen, L., Cabrita, M., Nassabi, M. H., de Vette, F., Weering, M. D.-V., Jansen-Kosterink, S. M., Kenter, W., et al. (2018) · Communications in computer and information science · doi:10.1007/978-3-319-93644-4_4 · Cited by 9
Lewis, F. J., Stewart, H., & Roddam, H. (2019) · European Journal of Physiotherapy · doi:10.1080/21679169.2019.1645882 · Cited by 8
“58 The term pre-frail refers to the state between robust and frail and is associated with an 59 increased risk of becoming frail [5].”
BackgroundMłynarska, A., Młynarski, R., Uchmanowicz, I., Marcisz, C., & Golba, K. S. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17061954 · Cited by 8
Khan, N. H., Hewson, D. J., & Randhawa, G. (2020) · BMJ Open · doi:10.1136/bmjopen-2020-038437 · Cited by 8
Metadata
- Authors
- Gill, T. M., Gahbauer, E. A., Allore, H. G., & Han, L.
- Affiliations
- Yale University (US)
- Venue
- Archives of Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2006-02-27
- Volume
- 166
- Issue
- 4
- Pages
- 418
- ISSN
- 0003-9926 (ISSN-L)
- OpenAlex
- W2022181538
- Cited by
- 1,141
- References
- 44
- Citations by year
- 2026: 76 · 2025: 67 · 2024: 84 · 2023: 56 · 2022: 91 · 2021: 85 · 2020: 82 · 2019: 82 · 2018: 81 · 2017: 73 · 2016: 66 · 2015: 53 · 2014: 43 · 2013: 39 · 2012: 37
- FWCI
- 10.04
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Archives of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Patrick and Catherine Weldon Donaghue Medical Research Foundation
- Yale University (P30AG21342)
- National Institute on Aging (R01AG022993, R37AG017560, K24AG021507, R37AG17560, P30 AG21342, P30AG021342)
- Topics
- Health Sciences › Medicine › Geriatrics and Gerontology › Frailty in Older Adults
- Health Sciences › Medicine › Physiology (medical) › Nutrition and Health in Aging
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Keywords
- frailty, pre-frailty, frailty transitions, community-dwelling older adults, frailty prevention, activities of daily living, weight loss, muscle weakness, physical activity, walking speed, exhaustion
- MeSH terms
- Aged, Aged, 80 and over, Female, Geriatrics, Humans, Male, Prospective Studies, Severity of Illness Index, Time Factors, Frail Elderly
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