One small step in frailty research, a giant leap in evidence based practice

Demographic aging represents one of the greatest challenges in sustainability and efficiency of health and social care systems, requiring a fundamental shift in health policy at national and regional levels. Concerned international agencies, such as the World Health Organization (WHO) and the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA), have developed action plans aimed at supporting the accessibility of the benefits of increased life expectancy to older people. The plans address both person-related and environmental factors, and foster commitments to promote practices involving stakeholders from multiple sectors.^1,2 The maximization of older peoples’ functional ability and preservation of their independence and autonomy for as long as possible are considered priority goals. The strategies proposed have included the strengthening of links between health-related research, practice and policy.

In this context, many researchers and health professionals have directed their attention at frailty, an age-related and transitional state of decreased physiological reserves characterized by an increased risk of poorer health-related outcomes.³ The first step is a series of initiatives to define a set of tools applicable for screening, diagnosis, treatment and monitoring. Unfortunately, research over the last two decades has been based on multiple conceptual frameworks of frailty, leading to different operational definitions of this clinical condition. Although the current scenario reflects the natural evolution of classification, description and validation of a newly identified phenomenon, the lack of a consistent approach in research may have repercussions on decision-making in frailty management.

The results from a recent meta-synthesis of stakeholders’ views and experiences on frailty screening, intervention and care highlight this issue.⁴ One of the salient findings was the uncertainty of frail adults, caregivers and health professionals about the malleability of frailty; this reflects the difficulty of the latter in obtaining adequate tools for frailty screening and treatment. Clarification of whether frailty is a reversible condition is crucial in public health and health-related policy as it is required for appropriate determination of priority health needs and delineation of lines of action (anticipatory and active care versus reactive management of clinical conditions) that are feasible, appropriate, meaningful and effective. Moreover, it will have a significant impact on end-users’ expectations and beliefs, especially those regarding the relationship between frailty and aging (frailty as an inevitable versus an avoidable consequence of aging), and the tangible effects of frailty-focused health and social care (interventions postponing frailty onset/evolution, reversing frailty, or treatment to alleviate discomfort resulting from this clinical condition). Improvements in evidence transfer and utilization are necessary to create synergies between stakeholders who share common objectives, such as realignment of health resources with the needs of older people.

Difficulties with screening are clearly reflected in the study of Buckinx et al.⁵ who assessed the prevalence of frailty among institutionalized older adults based on different operational definitions of this clinical condition. Depending on the tool used in the screening process, the prevalence ratios varied from 1.70% to 76.3%. The consequences of this large variation can be significant, especially from the perspective of health decision-makers. Frailty may be either a minor problem, affecting a reduced number of older adults or a priority issue on the agenda of policy debate, as the high prevalence of this clinical condition can have serious consequences on the sustainability of public health care systems.

Our recent research syntheses,^6,7 developed within the context of the project 664367/FOCUS,⁸ reveal answers that can clarify some of these issues. For example, based on findings from our umbrella review, which summarized the best available evidence on reliability, validity diagnostic accuracy and predictive ability of screening tools for frailty,⁶ frailty indices based on an accumulation of deficits model and gait speed emerged as the most useful tools in routine care and community settings. However, it is still necessary to investigate whether these measures are equally valuable in health settings beyond primary care and whether they are appropriate for community-based intervention programs. There is also a need for tools to assess frailty in emergency departments.

Regarding malleability of the frailty condition, our systematic review on the effectiveness of interventions to prevent progression of pre-frailty and frailty in older adults⁷ showed that interventions based on physical exercise with supplementation, supplementation alone, cognitive training and combined treatment had favourable effects on frailty indicators. This all supports clinical investment of resources in frailty interventions.

However, there is need for further studies to examine whether the severity of frailty can interfere with the benefits of different interventions. Economic evaluations of frailty interventions are also required. Finally, the findings from our realist review⁹ point to the necessity to include the person's family, social and environmental contexts in intervention design, and to consider strategies that enhance the social and psychological aspects of the treatment to improve adherence and compliance.

We intend that our findings will sensitize stakeholders from the diverse sectors involved in health and social care towards the necessity of frailty care and prevention improvement. This should contribute in shaping a new model for frailty screening, treatment and monitoring. We expect that our research will contribute towards policy debates at the international level, allowing for better evidence transfer and utilization. Our qualitative work with European policy makers¹⁰ concluded that interventions for and prevention of frailty need to be “owned” by a greater range of stakeholders than is the case presently, transcending health-professions, including social and community stakeholders, and of course older adults themselves. The interviewed policy makers were clear that there is potential for frailty to be managed in a more integrated and person-centered manner. The range of investigations in the FOCUS project emphasized the need to prioritize education and development of a common understanding of the malleability of frailty, and for more consistency in its measurement.