1.2 How do people transition into frailty?

While the background decline in the reserve capacity of a person’s various bodily functions is gradual, the onset of the experience of frailty can be sudden, for example, arising from a serious stroke or a crippling heart attack. Most people, however, gradually accumulate chronic conditions and the sum of their effects is what begins to erode the person’s ability to function in daily activities. For example, the person living with emphysema in her 80’s begins to find it difficult to take a bath, at least on bad days. Or a person with mild dementia begins to get lost in the neighborhood. Some people have no particular medical illness, but just gradually slow down, lose weight, become weaker and feel tired.

Events that were once minor annoyances will throw a frail person off course: One bad fall, and the injuries and fear make it impossible for the person to live alone again. With a little more loss of sight, an elderly person cannot drive to get food or to visit friends. The margin between living as we wish and being in serious trouble becomes quite thin. Physiologically, people in their eighties and beyond usually have very little reserve in most organ systems, so a challenge to the heart, or lungs, or kidneys, or any other organ system leads to evident and serious illness.

The fact that most of us have no clear onset of frailty mirrors our maturing from children into adults. While social conventions call for certain attributes of adulthood to be assumed at various ages, from about 16 to 21 years old, actually becoming reasonably mature adults is a gradual process. We don’t yet have the social conventions for marking frailty’s onset, in part because the transitions are usually so gradual and the benefits of noticing have been minimal. Under a MediCaring Community model, a frail elderly person will benefit from having a service delivery system that optimizes his or her well-being, so early work on MediCaring Communities will need to develop some conventions on boundaries and expectations. We propose some candidate criteria in section 1.5.