Frailty as a terminal illness.

Roughly one in two Americans has a chronic disease, and an estimated 1.7 million die each year from chronic illness.1 Most will have a chronic illness for a prolonged time before they die. Until 2005, lung cancer was the most common terminal diagnosis in hospices. Now, however, debility not otherwise specified (NOS) has surpassed lung cancer as the most common diagnosis (Table 1). Debility NOS and failure to thrive (FTT) are often diagnosed in frail older adults who may not have a specific terminal illness, but one or more comorbid chronic illnesses and progressively declining functional status. Frail older adults often have poor appetite, weight loss, increased fatigue, and progressively declining functional status, and may be eligible for services provided by the Medicare hospice benefit if they have other primary terminal diagnoses.2,3 In August 2013, the Centers for Medicare and Medicaid Services issued a rule that debility NOS and adult FTT can no longer be listed as principal hospice diagnoses, but rather, secondary comorbid conditions4 (Table 2). Frailty is a state of increased vulnerability resulting from age-associated decreases in physiologic and functional reserves that limit the body’s ability to cope with increased demands from daily and acute stressors. Its hallmarks are weakness, fatigue, weight loss, poor grip strength, and slow gait. Unlike cancer or heart disease, in which there is a focal point of pathology, frailty is characterized by diffuse and diminishing physiologic reserves and decreased ability to cope with noxious insults. FTT is diagnosed in patients with the triad of physical frailty, disability, and impaired neuropsychiatric function. Other conditions that can present as FTT include undiagnosed and untreated anemia, depression, delirium, and dementia; patients also may present with fatigue, weakness, and impaired physical and cognitive performance. Older adults who are experiencing elder abuse or neglect may have positive results on frailty assessments, but the symptoms may reverse partially when they are removed from the Editorials