The world’s population is projected to grow for another 50 to 60 years, reaching an estimated peak of about 10.3 billion by the mid-2080s. This represents a significant increase from the estimated 8.2 billion in 2024.
Population aging is a universal phenomenon, and this demographic shift will result in a substantial rise in the number of individuals aged 60 years and above. By 2030, it is expected that one in six people worldwide will be 60 or older, amounting to approximately 1.4 billion individuals. By 2050, this number is projected to increase to 2.1 billion, with the population of those aged 80 and above tripling to 426 million.1 As our population ages, we can also anticipate an increased prevalence of geriatric issues, such as frailty.
Frailty is a complex, multi-factorial, and age-associated clinical condition. It is characterized by a combination of various contributing factors that increase the likelihood of adverse health outcomes in older adults.2
As the proportion of older adults continues to rise, frailty is becoming an increasingly important health concern.
Research has shown that frailty is linked to elevated risks of mortality and morbidity. Individuals with severe frailty are generally considered uninsurable due to these elevated risks.
Frailty is caused by cumulative cellular damage from various sources throughout an individual's life. This damage leads to a gradual reduction in the homeostatic reserve of physiological systems. Despite this reduction, many older adults manage to maintain their functional abilities as they age. However, when stress or injury impacts these physiological reserves, it can result in decompensation and increased frailty.3 The evidence suggests that dysregulated stress response systems – including immune, endocrine, and energy response systems – play a crucial role in the development of physical or syndromic frailty.
A key physiologic component of frailty is sarcopenia, the age-related loss of skeletal muscle and muscle strength.4 The decline in skeletal muscle function and mass is often a consequence of age-related hormonal changes and alterations in inflammatory pathways, including an increase in inflammatory cytokines.5
Figure 1: The cycle of frailty6 (recreated)
Psychological factors such as anxiety, depression, and concerns about falling (CaF) have also been identified as possible risk factors.
Frailty can be challenging to identify in primary care settings because it often occurs alongside other age-related conditions and there is no widely recognized clinical definition.10
Frailty is assessed through a comprehensive history and physical examination, focusing on several key elements. Over the years, different theories have shaped our understanding of frailty, leading to the development of various assessment tools. Each tool offers unique insights and has its own strengths, and each country selects a debilitation scale suited to its own needs.11
The most used physical frailty screening tool is the Fried Frailty Tool or Frailty Phenotype. It is defined as meeting three or more of the following five criteria:
Prefrailty is defined as one or two of the above characteristics. It is a multi-dimensional concept that may be evident before the onset of clinically identifiable frailty and is potentially reversible. Interventions, particularly those focusing on nutrition and physical exercise, may prevent onset of frailty in prefrail individuals.12 Those without any of the above characteristics are considered robust.
Clinically, frailty is recognized as a state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiological systems such that the ability to maintain homeostasis is compromised with illness, or even daily stressors. It has been identified as an indicator of increased risk for mortality, falls, fractures, progression of disability, loneliness, delirium, dementia, depression, hospitalization, and care home admission in elderly populations.13
Frail individuals have an elevated risk for suboptimal surgical outcomes, including prolonged hospitalization, greater vulnerability to deconditioning, accelerated functional decline, and increased healthcare costs.14,15
Signs of frailty can be obvious or subtle. The first symptom that usually presents itself is undue exhaustion, where daily activities begin to cause excessive fatigue. This often results in the individual slowing down and becoming less physically active over time, which can lead to a cycle of muscle loss and general weakness.
Common presentations of frailty include:
Frailty is dynamic and at least partly reversible, especially in the prefrail and mildly frail stages. Emerging strategies can be utilized to help mitigate the daily impact of frailty on quality of life and overall health status.16
The development and progression of frailty is a dynamic process. Frailty is a significant prognostic factor that negatively impacts survival and health outcomes across various conditions, especially among older adults. Compared with non-frail adults, a prefrail or frail diagnosis is predictive of a 1.3- to 2.6-fold risk of worsening mobility, decreased activities of daily living, and an overall increased rate of falls, disability, hospitalization, and death.17
Frailty independently predicts complications, slower recovery, institutionalization, and mortality in heart disease, stroke, cancer, and major surgery – beyond age or standard risk scores. In hospital settings, frailty predicts all-cause mortality, longer hospital stays, and adverse events such as major bleeding. Severe frailty confers a high risk of death, with clinical and functional decline serving as warning indicators. Individuals with severe frailty are about five times more likely to die within a year compared to those without frailty. This underscores the importance of identifying frail individuals early on for appropriate palliative and supportive care interventions.18
A personalized assessment by a geriatric team is crucial because the prognosis is influenced by the severity of frailty, underlying illnesses, cognitive status, social support, and response to interventions.
Frailty is a significant and growing concern as the global population ages, increasing vulnerability and healthcare needs in older adults. Early identification and targeted interventions – such as exercise, nutrition, and medication review – can be effective strategies to mitigate progression, improve quality of life, and promote adequate care planning.
For the insurance industry, recognizing signs of frailty is essential for appropriate risk assessment to ensure suitable coverage. Addressing frailty benefits not only individuals but also society at large by promoting healthier aging and reducing the burden on healthcare.
RGA experts are eager to engage with clients to better understand and tackle the industry’s most pressing challenges together. Contact us to learn more about RGA's capabilities, resources, and solutions.
