Photo Credit: iStock.com/andreswd

Frailty is common in rheumatic diseases and linked to worse outcomes. Early screening and targeted prevention can improve quality of life and prognosis.

A recent review published in Joint Bone Spine highlights the importance of identifying and addressing frailty in clinical practice, especially for patients with inflammatory rheumatic diseases.

“Currently, there is no consensus on frailty criteria, and its assessment in clinical practice remains challenging,” wrote Anne Tournadre, MD, PhD. “However, its impact on morbidity, mortality, quality of life, and implementation for preventive measures, make it of interest in rheumatologic conditions. This is especially true for age-related diseases like polymyalgia rheumatica and giant cell arteritis, as well as more broadly within elderly rheumatic conditions, whose prevalence rises with an aging population.”

Frailty’s Link to Rheumatic Diseases

Physiological reserves decline, and individuals become more susceptible to stressors as they age. At the cellular level, this includes shortened telomeres, oxidative stress, hormonal dysregulation, and chronic low-grade inflammation. These changes can impact multiple systems—musculoskeletal, cardiovascular, respiratory, renal, and immune—and contribute to frailty.

In patients with inflammatory rheumatic diseases, frailty is not only a marker of biological age but also an indicator of disease burden, multimorbidity, and potential treatment complications.

The prevalence of frailty is high in those with rheumatic diseases, particularly in older adults. For example, frailty affects one in three patients of any age with rheumatoid arthritis (RA), but an estimated two in three older patients.

In a recent study of 42 patients with recent polymyalgia rheumatica, 17% had frailty and 59% had pre-frailty, despite low disease activity. Reduced handgrip strength and exhaustion were the most frequent features of frailty, which was associated with elevated C-reactive protein at diagnosis.

In giant cell arteritis, frailty has been linked to a higher infection risk. A study of patients with Medicare found that 27% of those with giant cell arteritis had frailty, and frailty—alongside age—was independently associated with severe infections. Another cohort study reported that older age and comorbidities significantly influenced mortality, particularly when vascular complications or infections occurred.

Screening & Management Strategies

According to the review, the Fried criteria—weight loss, exhaustion, weakness, slow walking speed, and low physical activity—remain a widely used screening tool.

“However, it requires measuring walking speed, handgrip strength, and physical activity levels. Moreover, in the case of frailty, these criteria offer limited guidance on underlying causes and interventions, and multidimensional geriatric assessment may be needed for predictive and preventive care,” Dr. Tournadre wrote.

The Frailty Index can also be used but requires a thorough geriatric assessment to account for an array of domains including cognition, mood, motivation, mobility, balance, activities of daily living, nutrition, social conditions, and comorbidities.

“Frailty is a dynamic, reversible condition, with possible transitions over time between non-frail (robust), pre-frail, and frail states,” Dr. Tournadre wrote. “Factors indicating a poor prognosis for transitions include advanced age, weight loss, low muscle strength, low physical activity, osteoarthritis, cognitive impairment, diabetes, a history of cancer or stroke, albumin levels, and IL6 levels. This dynamic state therefore justifies early screening at the pre-frail stage to implement preventive measures.”

Citing a lack of guidelines for managing frailty and pre-frailty, Dr. Tournadre wrote that clinicians can use general recommendations to support patients and curb comorbidities like sarcopenia. Strategies may include muscle-strengthening exercises, physical activity, and nutritional support.

Given frailty’s link to multimorbidity and poorer outcomes, Dr. Tournadre also emphasized screening, prevention, and management of comorbidities in patients with rheumatic diseases—especially comorbidities that impact infection risk, bone health, and cardiovascular health.