3.1 Introduction

To provide optimum care following fragility fracture, all members of the disciplinary team need an awareness of frailty and its relationship with the outcomes of fractures.

Ageing, frailty, sarcopenia, falls, and fragility fractures are strongly linked [1]. They are all predictors of hospitalisation and negative health outcomes for older people, including functional decline, deteriorating physical and mental health, and death [2]. Falls and associated injuries in older people are connected with multicomponent impairments, particularly of muscle function, balance, and cognition, so are best understood as resulting from complex system failure, as part of the frailty syndrome in the presence of sarcopenia [3]. Falls and fall prevention are considered in more detail in Chap. 4, but it is important to bear them in mind here as a significant feature of frailty.

All older people who have fallen and/or sustained an injury/fracture should receive an assessment for the existence of frailty and sarcopenia and an interdisciplinary plan of interventions devised to prevent, slow, or reverse frailty [4]. Such interventions have become a fundamental element of care for older people with fragility fractures [5] in all health, social care, and community settings.

This chapter aims to outline the role of health professionals in (a) identifying frailty and sarcopenia and (b) preventing decline and improving health in older people with fragility fractures who live with frailty. It will review the concepts of frailty and sarcopenia and their assessment. It will also outline the interventions that can be implemented by nurses and other healthcare professionals, which have the potential to positively affect health and functional status and may promote independent functioning of older people with frailty, sarcopenia, and fragility fractures.

3.2 Learning Outcomes

At the end of the chapter, and following further study, the practitioner will be able to

  • Explain the causes and impact of frailty and sarcopenia on recovery and outcomes following fragility fractures.

  • Identify individuals with frailty, sarcopenia, and associated reduced function.

  • Promote health and well-being and prevent health deterioration in older people with frailty and sarcopenia.

  • Educate older people about frailty and sarcopenia and their relationship with falls and fractures.

  • Promote optimum nutrition and physical exercise in older people living with frailty and sarcopenia.

3.3 Frailty

Ageing is a universal experience with physical, sociocultural, and psychological implications. The physiological aspects of ageing can have a significant bearing on fragility fracture care. As Watson (2021 p. 23) [6] says:

… ageing itself is not a disease process, but for some people the combined effect of ageing on several systems can take a toll, and this can range from frailty—a general lowering of resilience to adversity and decreasing ability to carry out activities of daily living—to multipathology—where several pathological conditions co-exist in one individual

The importance of physical, functional, psychological, and social factors in realising a successful old age is recognised by older people and their families, healthcare professionals, policy advisors, and decision-makers [7]. Frailty is a complex health issue that impacts the ageing global population and has significant implications for patients, their families, healthcare services, and society as a whole [8]. It is an important aspect of clinical assessment and intervention in patients with fragility fractures.

As the number of older people grows globally, their needs have become an increasingly important public health issue. Reduction in physical function can lead to loss of independence and need for hospital admission and long-term nursing home care as well as premature death. Frailty is a syndrome which has been of interest to geriatricians and physicians for some time and has more recently been drawn to the attention of other health professionals such as nurses and physiotherapists in fragility fracture care settings. Recognising its elements and effects and intervening appropriately have the potential to significantly improve fragility fracture care and outcomes, especially if the whole multidisciplinary team are involved.

There is no universally accepted definition of frailty, but it is widely considered to be:

… a progressive age-related decline in physiological systems that results in decreased reserves, which confers extreme vulnerability to stressors and increases the risk of a range of adverse health outcomes (Martin and Ranhoff 2021 p. 53) [4]

Such physiological vulnerability results in a recognisable and identifiable clinical syndrome that typically involves a depleted ability to resist physiological stress during health events, along with increased risk of further health deterioration, functional impairment, and poor outcomes of healthcare [9, 10]. It reflects the complexity of older individuals’ responses to ill health and injury. An event such as an accidental fall, injury, or infection can lead to additional physiological stresses, which worsen a person’s health status, increase functional decline, and can lead to death. Box 3.1 captures the main elements of frailty from commonly cited definitions. Frailty, however, is not simply a physical/physiological phenomenon, but also a psychological, cognitive, and social experience as each of these aspects of a person’s well-being is both positively and negatively linked.

There are two common models used to explain frailty

  1. 1.

    As a syndrome where sarcopenia (loss of muscle with ageing) is the main underlying concept [11] and individuals experience at least three of a list of features including unintentional weight loss, exhaustion, weakness, slowness, and reduced physical activity

  2. 2.

    As the sum of an individual’s deficits and non-specific disorders [12] that prevent them from launching an effective response to health stressors, leading to adverse health outcomes [9, 13]

Epidemiological studies indicate that frailty is common among older people [14] and have estimated the prevalence of frailty at between 4 and 59%, depending on the population being studied [15], gender (frailty is more common in women than men), and age (increasing age brings a higher prevalence of frailty) [16, 17].

Frailty is a term commonly used, although not necessarily based on a clear understanding of the concept, to describe an older person who lacks robustness; who is thin, weak, and unsteady; and who seems to be failing to function. It is also a state that may not be immediately apparent even though it is threatening the health and well-being of someone who is recovering from acute ill health, injury, surgery, and other physiological challenges. Healthcare professionals often develop their own ‘sense’ of what frailty looks like in an individual, but clinicians may not all be using the same parameters when they describe someone as frail. A nurse and a physiotherapist (or a nurse and a physician, for example) may see frailty differently through the lens of their different clinical experiences. Older people, their families and carers, society, and policymakers may also hold different views of what frailty is [18].

We must be careful not to view frailty as simply a medical diagnosis and something which labels older people as ‘failing’ or dying. McKay [19] describes a more positive way to view the needs of older people as ‘rest-of-life’ care, and this applies as much to frailty as any other health or social care issue. It is also important, therefore, to view frailty as a multiple, complex, health and well-being challenge with health and social care solutions.

Box 3.1 Elements of Frailty Definitions Discussed in the Literature

  • A clinical syndrome

  • A state of increased vulnerability

  • Diminished resistance to stressors—both physical and psychological

  • Can lead to functional impairment—with social impacts

  • Increases risk of adverse health outcomes

  • Physical and/or psychological

Although research exploring many aspects of frailty and its management has grown significantly and clinical knowledge of the syndrome is increasing all the time, the individual older person’s experience of being frail, and their own views of its impact and meaning, has not been studied in detail [18, 20]. As largely a condition of later life, frailty has traditionally been seen as central to geriatric medicine and care but has only more recently become an important topic in other areas of practice such as general surgery, orthopaedics, and trauma. It is also a relatively new concept for nurses working in these areas.

Box 3.2 Provides some examples of quotations from older people about their individual experience of being frail in their own words. These highlight for the practitioner that frailty is not simply a medical concept but a phenomenon which older people experience in different ways and that this personal experience must be considered when assessing individuals and providing individualised care.

Box 3.2 Examples of Individuals’ Experiences of Frailty from Qualitative Research Studies

“… they get a bit old age in the joints maybe a knee gets a bit sore then that’s I mean pain is a big, big a cause of frailty isn’t it? You begin to wonder whether you can actually walk anymore … and you think I can’t do it and you get depressed and you become frail and it’s a kind of on-going cycle of decline” [21].

“Well, I’ll be sitting a lot inside. At home. I cannot even get around doing any work outside” [22].

“So I have, stopped the work outside. There is very little to do after I got problems with my hands and was no longer able to work. After that I got problems with my stomach and trouble with constipation. This caused some irregularities with sleep, and the medication was not so easy to dose. So I have to make sure I am near the toilet” [22].

“I do feel frail sometimes. There have been times when I have been walking with my stick and I’ve felt as though I’m going to trip you know. I’m frightened of tripping” [23].

“I try and make myself a cup of tea, if I can walk in the kitchen … but this morning I couldn’t manage to go in the kitchen as me feet were right swollen. And you know when I’m walking I count a lot, to keep me going, I thought if I count I might keep going me-self, but I couldn’t this morning I was just too tired after getting downstairs” [23].

3.4 Assessment and Recognition of Frailty

Early recognition of those with fragility fractures who are frail and whose presentation is complex is the first step in planning effective interdisciplinary care. Undertaking an assessment of frailty will also identify those individuals who are at increased risk of adverse outcomes following their fragility fracture so that care can be optimised to meet their needs through ‘frailty-aware’ care [24] and help identify resource requirements and care priorities. Recognising frailty also plays an important role in preventing fractures in older adults [25] as it highlights factors that lead to fracture risk. While this assessment process is the responsibility of the entire healthcare team, much of the data is likely to be gathered and recorded by those who spend the most time with patients, usually the nursing team supported by other team members.

All people over 70 years of age and anyone with unintentional and significant weight loss should be assessed for frailty [9]. While this chapter focuses on frailty and its assessment, it is important to note that, in the orthogeriatric setting, frailty assessment and comprehensive geriatric assessment (CGA) form an integrated ongoing assessment. A more detailed discussion of the principles and conduct of CGA in providing comprehensive information about an older individuals’ health, cognitive, psychological, social, physical, and functional domains is provided in Chap. 6. It is essential that both CGA and frailty assessment data are shared and discussed within the interdisciplinary team so that the clinical lead (preferably a geriatrician where one is available) can make sense of the data and plan multidisciplinary interventions to combat frailty, facilitate recovery, and improve outcomes.

Assessing frailty and its elements is an integral aspect of the admission and ongoing assessment process with several tools available for this. The selection of an instrument to assess frailty in a specific clinical setting should be based on its purpose, theoretical approach, clinical validity of the items used, and its feasibility in the clinical context [26] as well as its sensitivity to local language and culture.

A 2021 review [27] identified 15 unique frailty instruments used in older hospitalised orthopaedic patients, all reported as having acceptable reliability and validity. It is not within the scope of this chapter to undertake a detailed review of all frailty scales appropriate for assessing patients with fragility fractures. There is such a review in the first edition of this chapter [28], and, as yet, there is no formal study that has identified the best instrument for use in either community-dwelling older people at risk of fracture or hospitalised older people with a fragility fracture. The choice of an instrument is, therefore, best made by individual teams working together to identify a tool that will best serve the fundamental purpose of identifying patient need. However, instruments which have not been specifically developed for this patient population and the relevant setting may require local modifications to meet specific needs [27].

For the purposes of this chapter, three examples of tools which might be considered for those with fragility fractures both in community/home and hospital settings will be discussed to provide illustrations so that practitioners can understand how a frailty instrument works and then investigate within their teams what local needs might be and how such tools might be implemented and used.

3.4.1 The Clinical Frailty Scale (Rockwood et al. 2005)

The Clinical Frailty Scale (CFS) was initially developed to enable clinicians to summarise the overall level of fitness or frailty of an older person [29]. It has since been widely used as a clinical tool and has been revised and assessed for reliability and validity. The CFS uses pictographs and descriptors to categorise individuals as (1) very fit, (2) fit, (3) managing well, (4) living with very mild frailty, (5) living with mild frailty, (6) living with moderate frailty, (7) living with severe frailty, (8) living with very severe frailty, and (9) terminally ill. The assessment involves assessing an individual’s self-reported (with no need for face-to-face examination) comorbidities and needs for assistance with activities of daily living [29, 30]. This tool is widely used in a variety of clinical settings to make judgements about an individual’s degree of fitness and frailty. For further information about CFS and its use, see Box 3.3.

The CFS has been studied in the orthogeriatric setting, particularly following fragility hip fracture. In one study [31], the validity of undertaking retrospective non-orthogeriatrician-assigned CFS scoring for hip fracture patients was assessed. CFS scores assigned by non-orthogeriatricians were shown to be a valid means of assessing frailty status in hip fracture patients.

Box 3.3 The Clinical Frailty Scale (CFS)

Full information about the CFS [32] can be found at a specific website devoted to the tool and other associated information. The scale is available in several languages. The authors of the tool make it freely available along with a variety of other resources but simply ask all potential users to complete a Permission for Use Agreement. Agreement requests for non-commercial educational, clinical, and research use, as well as for reprint, do not usually require a license agreement.

Clinical Frailty Scale https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.html

CFS guidance and training https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale/cfs-guidance.html

Further Reading:

Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–495.

Pulok MH, Theou O, van der Valk AM, Rockwood K. The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine. Age Ageing. 2020;49(6):1071–1079.

Rockwood K, Theou O. Using the Clinical Frailty Scale in Allocating Scarce Health Care Resources. Can Geriatr J. 2020:23(3):210–215.

3.4.2 FRAIL Scale

The FRAIL scale is composed of five questions with ‘FRAIL’ as an acronym: F = fatigue, R = resistance, A = ambulation, I = illnesses, and L = loss of weight [33, 34]; three or more positive answerers indicate frailty, and one or two positive answers indicate pre-frailty.

3.4.3 The Study of Osteoporotic Fractures (SOF)

The Study of Osteoporotic Fractures (SOF) frailty tool assesses frailty according to three characteristics: (1) loss of 5% of body weight in the last year, (2) inability to stand up from a chair five times without the use of arms, and (3) replies ‘No’ to the question, ‘Do you feel full of energy?’. Two positive answers to the first and second items and/or a negative to the last one classifies the person as frail [35].

Box 3.4 provides a case study that offers an example of how frailty may present clinically in the fragility fracture setting.

Box 3.4 Frailty Case Study

Mrs. Garcia is a former schoolteacher who lives alone in a small second-floor apartment in a suburb of a large city. Her three daughters and one son and their children live in the same locality. They provide most of her social support, and she receives visits from various members of her family daily, particularly to bring shopping and prepare meals.

Mrs. Garcia is 88 years old and was widowed 10 years previously. Prior to her husband’s death, she was very active for her age but, since then, she has become more isolated and now rarely leaves her apartment. Like many older people, this situation has worsened since the Covid-19 pandemic. She can mobilise around her apartment but tends to use the furniture to help to steady herself.

Eight years ago, Mrs. Garcia had a myocardial infarction followed by coronary angioplasty. She takes medication for primary hypertension [angiotensin-converting enzyme (ACE) inhibitor: ramipril] as well as a beta blocker (atenolol) and a statin (atorvastatin) and aspirin. She has osteoarthritis in her hands and a very evident thoracic spine curve which has happened gradually over the last few years and seems to throw her body weight forwards meaning that she often feels like she might fall. She also reports that she has episodes of dizziness and breathlessness.

Mrs. Garcia has been admitted to the orthopaedic trauma unit via the emergency department following a fall at home. X-rays reveal an intertrochanteric fracture of her right hip—identified as a fragility fracture—as well as multiple previous vertebral fractures likely to be due to previously undiagnosed osteoporosis. On admission to the orthopaedic trauma ward, Mrs. Garcia is assessed by the nurse. This includes an assessment of frailty.

Some questions:

What more might you want to know about Mrs. Garcia to help you understand her degree of frailty and the factors that contribute to this?

How could you best assess her frailty given her current acute health state?

What impact might her degree of frailty have on her following surgery for her intertrochanteric fracture?

3.5 Interventions for Frailty

Once frailty has been identified through assessment, there must be a focus on those interventions which are most likely to benefit patients. Although progress is likely to be slow, there are some healthcare interventions that can improve the degree of frailty over time [9]. Evidence identifies four easily accessible interventions most likely to improve frailty status in those at risk of, or following, fragility fractures (Box 3.3): (1) exercise (aerobic and resistance), (2) calorie and protein supplementation, (3) vitamin D supplementation, and (4) reduction of polypharmacy [9, 17, 34] (Box 3.5).

  • Planned exercise can develop muscle strength and improve physical performance and functionality [36] as well as decrease depression and fear of falling [9]. A mix of specifically prescribed aerobic and resistance exercises improves frailty and is effective in preventing its adverse outcomes [37, 38]. One systematic review found that an exercise programme, continued three times a week for 30–45 min per session for approximately 5 months, had positive impact [39].

  • In frail older people with significant weight loss, it is essential to identify the cause (Chap. 8). Dietary calorific supplementation has been shown to be successful in achieving weight gain and reducing complications in malnourished individuals [40]. Protein supplementation of 15 g of protein twice a day over 24 weeks improves muscle strength and physical performance [41], while oral nutritional supplements provide additional protein and calories.

  • Vitamin D supplementation can play a role in preventing or treating frailty by enhancing balance and maintaining muscle strength [42] but, while this is likely to be beneficial for frail older people, there have been no large-scale studies that have confirmed this to be the case on its own [9].

  • Undertaking a medication review and considering side effects, interactions, and consequences for frailty are essential. Medication review and reduction of polypharmacy have also been advocated as an option for improving outcomes, especially in reducing mortality, hospital admissions, and falls [43].

These four interventions should be considered following frailty assessment so that they can be individually tailored to target specific identified problems and needs through an interdisciplinary approach [44].

As well as these interventions, it is essential that the clinical team work collaboratively with the patient and their family to understand their degree of frailty and how it has contributed to their current health status. It is equally important for the patient to understand that frailty is reversible and that working towards a greater degree of well-being is likely to both improve the outcomes from the current health event as well as help to prevent further fractures. Patients also need to be able to believe in their own influence over their future health, and the health-promoting role of the clinical team is essential in achieving this. It is vital that these messages are relayed to the patient and their family from the beginning of their hospital stay and throughout the pathway to rehabilitation and beyond.

Box 3.5 Interventions for frailty

  • Exercise (aerobic and resistance)

  • Caloric and protein supplementation

  • Vitamin D supplementation

  • Reduction of polypharmacy

3.6 Sarcopenia

Frailty and sarcopenia are linked, while frailty is a geriatric syndrome, sarcopenia is a disease. Sarcopenia contributes to the development of physical frailty and physical decline so is an important consideration in the care and management of patients with fragility fractures. Sarcopenia is a muscle disease rooted in adverse muscle changes that accrue across a lifetime, which can be viewed as ‘muscle failure’. With the continued increase in the older global population, sarcopenia has become a serious international public health problem. It can occur at any age but is most common among older adults.

Sarcopenia is characterised by low levels of muscle strength, muscle quantity/quality, and physical performance. It is a ‘progressive and generalised skeletal muscle disorder that is associated with increased likelihood of adverse outcomes including falls, fractures, physical disability and mortality’ ([45] p. 18).

The overall prevalence of sarcopenia is reported to be 10% [46], but it is more common in women than men [4] (Martin and Ranhoff 2021). Changes in body composition occur with normal physiological ageing [47]. Body weight usually increases during adulthood and peaks at the age of 65 years in women and 54 years in men [48]. In later life, muscle mass is lost at a rate of approximately 8% per decade between the ages of 50 and 70 years. After the age of 70 years, weight loss is coupled with an accelerated loss of muscle mass, reaching a rate of 15% in each decade [48]. In addition to this age-related decline in muscle mass, important factors in progression of loss include [4]:

  1. 1.

    Declining physical activity

  2. 2.

    Reduced food intake

  3. 3.

    Chronic health conditions and acute illness

The presence of these factors provides important indicators for the management and prevention of sarcopenia.

Sarcopenia is a powerful predictor of disability that is associated with age-related loss of muscle mass and strength which, in turn, affects balance, gait, and overall ability to perform tasks of daily living [49, 50]. The risk of disability is 1.5–4.6 times higher in older people with sarcopenia than in those with normal muscle. These common age-related changes in skeletal muscle are major causes of impaired physical function in older adults, contributing to impaired mobility, falls, and hospitalisation.

The causes of sarcopenia are multifactorial and can include muscle disuse, changing endocrine function, chronic diseases, inflammation, insulin resistance, and nutritional deficiencies [51]. Reductions in testosterone and oestrogen that accompany ageing appear to accelerate its development [52]. It has also become apparent that the Covid-19 pandemic has led to an increase in the incidence of sarcopenia because of both the physiological impact of the virus itself and the impact on social activity in older people whose physical and social activity, particularly outside of the home, has been limited by lockdown restrictions and fear, leading to deconditioning [51, 52].

3.6.1 Screening and Assessment for Sarcopenia

Since sarcopenia, frailty, osteoporosis, and fragility fracture are linked [4], identifying sarcopenia in those with or at risk of fragility fracture is central in both fracture prevention and recovery/rehabilitation following fractures. An interdisciplinary approach to management of sarcopenia begins with diagnosis so that the team can plan care accordingly.

Sarcopenia, like many other health conditions, is asymptomatic in its initial stages, when interventions can best prevent the adverse health outcomes [53]. Screening tends not to be a routine aspect of clinical practice, partly because of the lack of appropriate screening strategies [54].

Several expert groups have convened with the goal of establishing a consensus about diagnostic criteria for sarcopenia [45, 55,56,57,58]. In 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) published a sarcopenia definition [44, 56] that aimed to foster advances in identifying and caring for people with sarcopenia. The group met again (EWGSOP2) in 2019 to update the original definition to reflect progress over the previous decade [45], identifying three criteria for the diagnosis of sarcopenia. Common tests used in the diagnosis of sarcopenia are outlined in Box 3.6.

Box 3.6 Common tests for the diagnosis of sarcopenia [45, 56]

  1. 1.

    Low muscle strength is the primary parameter of sarcopenia and the most reliable measure of muscle function.

    • Measuring grip strength is simple and inexpensive using a calibrated handheld dynamometer.

    • The chair stand test (or chair rise test) can be used to assess the strength of leg muscles (quadriceps muscle group). This measures the amount of time needed for a person to rise five times from a seated position without using their arms.

  2. 2.

    Low muscle quantity or quality confirms the presence of sarcopenia.

  3. 3.

    Low physical performance

    • Physical performance can be measured by gait speed and the timed-up and go test (TUG), among other tests.

  • Probable sarcopenia is identified by criterion 1

  • Diagnosis is confirmed by criterion 2

  • If all three criteria are met, sarcopenia is considered to be severe.

The screening tests outlined above are important aspects of fracture prevention and are central to CGA as well as frailty assessment. In orthogeriatric care settings, screening and assessment are best done through an interdisciplinary approach, with specific collaboration needed among physiotherapists, geriatricians/physicians, and the nursing team. An important consideration in assessing muscle strength, quality, quantity, and physical performance is that the person with a significant new fragility fracture affecting physical function will be unable to perform the test. Hence, taking a history of their functional abilities prior to the fracture will be important instead. Physical performance measures may also be affected by issues such as memory loss, or gait and/or balance problems.

3.6.2 The Clinical Consequences of Sarcopenia

Osteoporosis predicts the future risk of fracture, and sarcopenia is a powerful predictor of future disability [47] alongside frailty. Reduced muscle mass and strength are also associated with lower bone mineral density [59, 60], consistent with the ‘mechanostat’ theory of bone loss due to reduced forces of muscle on bone [61]. Sarcopenia also contributes to falls and, consequently, increases fracture risk [62, 63]. There is significant evidence that low muscle mass and strength are associated with fractures [63]. Several studies have confirmed associations between low muscle mass, future functional decline, and physical disability [2]. Physical inactivity or decreased physical activity is part of the underlying mechanisms of sarcopenia, so physical activity is important in reversing or modifying it, especially given the impact of the Covid-19 pandemic on outdoor activity in older people in many communities.

Several interventions have been proposed for the treatment of loss of muscle and strength, but exercise is central. Sarcopenia has also been linked to higher hospitalisation rates, increased morbidity, and mortality [64, 65]. Sarcopenia may also be associated with metabolic and cardiovascular diseases such as diabetes, dyslipidaemia, and hypertension.

3.6.3 Interventions to Prevent Sarcopenia

It is better to prevent progressive loss of skeletal muscle mass, strength, and function rather than try to restore it later, so preventive strategies should be initiated early, before loss of skeletal muscle mass and strength occurs. These are particularly important considerations in primary and secondary fragility fracture prevention services (see Chap. 5).

Since important causes of depleted muscle mass are declining activity, depleted nutrition, and acute and chronic health conditions, these are central factors in preventing and managing sarcopenia. These issues are frequently discussed throughout this book and are central to both frailty management and orthogeriatric care. Interventions for this are discussed earlier in this chapter in relation to frailty. Exercise is considered in more detail in Chap. 8 and nutrition in Chap. 11. A brief overview of these main interventions for sarcopenia will be provided here, however, for the sake of completeness.

Exercise interventions have the most significant potential to improve sarcopenia. The benefits of physical activity in older people include lower mortality and better functional independence (Chap. 6). There are four specific categories of recommended exercise: (1) aerobic exercise, (2) progressive resistance exercise, (3) flexibility exercise, and (4) balance training [3]. See Chap. 8.

Nutrition is also important in preventing and reversing sarcopenia. Increasing age is associated with reduced appetite and early satiety, resulting in many older people failing to meet the recommended daily dietary allowance (RDA) for protein, which has important implications for skeletal muscles [66]. Older adults will require higher dietary protein (up to 1.2 g/kg/day) to counteract age-related changes in protein metabolism and higher catabolic state associated with chronic or acute diseases [67]. See Chap. 11.

It is the combination of exercise and nutrition interventions that are key to preventing, treating, and slowing down the progression of sarcopenia [66]. Pharmaceutical agents are under investigation but with no current proven benefit with inadequate evidence to support their use. Low serum vitamin D levels are associated with reduced muscle strength, and it has also been demonstrated that a dose-response relationship exists between serum levels and muscle health. If serum levels are low, vitamin D should be replaced with replenishment dosages ranging from 700 to 1000 IU/day [68].

Implementing interventions for frailty and sarcopenia has several challenges and barriers. One systematic review demonstrated that older people believe that exercise is unnecessary or, even, potentially harmful [69]. Others recognise the benefits of exercise but report a range of barriers to participation in exercise interventions. Raising awareness is important to enhance exercise participation among older people and to prevent sarcopenia.

Another barrier that needs to be considered in planning long-term strategies to prevent and treat sarcopenia in older people is the financial ability to attend exercise programmes [44]. Factors such as access to food, finances, and social isolation may all impact an older person’s ability to obtain optimal food intake.

3.7 Conclusion

Both frailty and sarcopenia are linked with falls and fragility fractures, although they are concepts relatively new to nurses and other health professionals working in clinical settings outside of dedicated geriatric/elder care units. Being able to identify frailty and sarcopenia and plan and implement interventions for their modification are important skills for all members of the interdisciplinary team. Managing these conditions and their associated effects will be central to improving recovery and outcomes following fragility fracture.

3.8 Suggested Further Study

  • Review reading materials, information, and online programmes relating to the impact of ageing on older people and consider how frailty and sarcopenia are part of this picture. See for example:


Aging in Motion https://www.aginginmotion.org/


Martin FC, Ranhoff AH. Frailty and Sarcopenia (2021) In: Falaschi P, Marsh D, editors. Orthogeriatrics: The Management of Older Patients with Fragility Fractures 2nd edition. Springer; Chapter 4. doi: 10.1007/978-3-030-48126-1_4 Available from: https://www.ncbi.nlm.nih.gov/books/NBK565582/

McSherry, W. Rykkje, L. Thornton, S. (Eds) (2021) Understanding Ageing for Nurses and Therapists. Springer Nature Switzerland AG. https://doi.org/10.1007/978-3-030-40075-0

Journal articles:

Cruz-Jentoft AJ, et al. Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. (2019) Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 48(1):16–31. doi: 10.1093/ageing/afy169. 06. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6322506/pdf/afy169.pdf

  • Talk with patients, carers, and other staff about the things they feel that lead to and prevent frailty and sarcopenia. Reflect on what these conversations suggest about how practice might be developed to improve mobility outcomes by involving patients.

3.9 How to Self-Assess Learning

  • Discuss what you have learned about frailty and sarcopenia with other team members.

  • Consider a patient you recently provided care for who you recognise as being frail or having sarcopenia or both. Make some notes about how your understanding of these issues has improved since reading this chapter. Discuss with your clinical colleagues how the care of the patient could have been improved in light of this learning.