Frailty is a complex condition often seen in older adults, characterised by increased vulnerability to stressors due to a decline in physiological reserves across various bodily systems. While it is frequently associated with advanced age, chronic diseases, and physical inactivity, frailty is not an inevitable part of the ageing process. It signifies a loss of resilience, meaning that even minor stressors, such as infections or changes in the environment, can lead to serious negative outcomes, including falls, disability, and hospitalisation. Research indicates that frailty affects between four and seventeen per cent of adults aged sixty-five and over living in the community, with this figure rising to between twenty-five and fifty per cent among those aged eighty-five and older.
The development of frailty is influenced by a variety of factors, including biological, psychological, and social elements. Physiologically, frailty is linked to sarcopenia, which is the loss of muscle mass and strength, chronic inflammation, hormonal changes, and impaired energy metabolism. These physiological changes can lead to reduced physical function, slower recovery from illness or injury, and an increased risk of complications. Psychologically, frailty is often accompanied by conditions such as depression, anxiety, and cognitive decline, which can further worsen physical limitations. Socially, individuals who are frail may face isolation, limited access to care, and a lack of support, all of which can contribute to deteriorating health outcomes.
Physical inactivity plays a significant role in the progression of frailty, as it accelerates the decline in muscle mass, strength, and overall physical function. Many frail older adults suffer from multiple chronic conditions, have very little strength, and may fear falling, which can create a cycle of inactivity and further physical decline. Additionally, frailty is often associated with malnutrition or sarcopenic obesity, a condition where individuals possess insufficient muscle strength to support their body weight, despite being overweight or obese.
The role of exercise in managing frailty
Exercise is a fundamental aspect of managing frailty, as it has the potential to improve physical function, restore resilience, and enhance quality of life. For frail individuals, the primary aim of exercise is to prevent further decline, maintain independence, and reduce the risk of adverse outcomes such as falls. However, exercise programmes must be carefully tailored to accommodate each participant’s physical limitations, chronic conditions, and tolerance levels.
Regular, safe, and controlled movements, such as mobility exercises, are recommended to help restore function as much as possible. Even small amounts of physical activity can yield significant benefits, and it is essential to avoid prolonged periods of inactivity. For very frail older adults, strength training should often take precedence over aerobic training, as improving muscular strength is essential before they can safely engage in more dynamic activities. Strength exercises should begin with bodyweight movements, such as sit-to-stand exercises, and progress slowly and cautiously. As participants build strength, light resistance can be introduced, but any progression should always be tailored to the individual’s tolerance levels and preferences. It is important to monitor participants closely for signs of fatigue or discomfort and to adjust the programme as necessary.
Flexibility and range of motion exercises are also important components of managing frailty. Regular stretching can enhance joint mobility, reduce stiffness, and contribute to the restoration of functional movement, thereby improving the individual’s ability to perform activities of daily living. However, care must be taken to avoid movements that could increase the risk of injury. For instance, forward spinal flexion and rotation should be avoided, as these movements can heighten the risk of vertebral fractures, particularly in individuals with osteoporosis.
Certain types of exercises and movements should generally be avoided for frail individuals due to their increased risk of injury or adverse effects. High-impact activities, ballistic or bouncing movements, and exercises involving excessive or rapid changes in direction should be excluded from exercise programmes. Heavy isometric (static) strength exercises and sustained tight gripping of equipment should also be avoided, as they can cause sharp increases in blood pressure and place undue strain on the cardiovascular system. Instead, exercises should focus on controlled, low-impact movements that prioritise safety and stability. However, light to moderate isometric contractions is often included in strength programmes for older adults under supervision. So, rather than avoiding isometric holds altogether, it is essential to monitor cardiovascular responses, especially in those with hypertension.
Fear of falling is a common concern among frail older adults and can significantly affect their willingness to engage in physical activity. To address this issue, exercise programmes should incorporate balance and stability training to enhance confidence and reduce the risk of falls. Simple exercises, such as standing on one leg or walking heel-to-toe, can help improve balance and coordination.
Nutritional support is another critical aspect of managing frailty, as malnutrition is a prevalent issue among frail individuals. Adequate protein intake is essential for maintaining and rebuilding muscle mass, while sufficient caloric intake is necessary to meet energy needs. For those with sarcopenic obesity, a combination of resistance training and dietary interventions can help improve body composition by increasing muscle mass and reducing excess fat.
In summary, frailty is a complex condition that affects many older adults, making them more vulnerable to health issues. This increased vulnerability often results from a decline in the body’s natural reserves, which can be worsened by factors like lack of physical activity, chronic illnesses, and social isolation. Understanding frailty is essential for effective care. Management strategies should include personalised exercise programmes that help improve physical function and resilience. Regular exercise is vital as it can prevent further decline, promote independence, and lower the risk of serious health problems.
Links
British Geriatrics Society (2018) Frailty: what’s it all about? Available at: https://www.bgs.org.uk/frailty-what%E2%80%99s-it-all-about [Accessed 29 June 2025].
Dent, E., Daly, R.M., Hoogendijk, E.O. (2023) ‘Exercise to Prevent and Manage Frailty and Fragility Fractures’, Current Osteoporosis Reports, 21, pp. 205–215.
Dent, E., Martin, F.C., Bergman, H., Woo, J., Romero-Ortuno, R. and Walston, J.D. (2019) ‘Management of frailty: opportunities, challenges, and future directions’, The Lancet, 394(10206), pp. 1376–1386.
