It is important to understand frailty as it can inform the best treatment plans and help provide the most appropriate goal-directed care for older people. The ageing process is inevitable across all animal species and is accompanied by accumulated molecular and cellular damage, resulting in the decline of physiological systems over one's lifespan. Therefore, frailty can be defined as a state of vulnerability, which develops through a cumulative and age-related decline in physiological functioning, which results in depleting homeostatic reserves, vulnerability and sudden changes in health status, triggered by minor stressor events (Clegg et al, 2013). It is estimated that between a quarter and half of people aged over 85 years are frail, which makes them significantly more at risk of falls, disability and death, and while alive, in need of long-term care (Clegg et al, 2013).
Clegg et al (2013) proposed two models of frailty, namely the phenotype model and the cumulative deficit model. The phenotype model has five symptoms: unintentional weight loss; self-reported exhaustion; low energy expenditure; slow gait speed; and weak grip strength. The cumulative deficit model was derived from a large Canadian prospective cohort study, which developed and tested a frailty index using 92 variables (symptoms, abnormal laboratory values, diseases and disabilities). There is considerable overlap between these models and importantly, they both demonstrate strong predictive validity, although the continuous frailty index shows better discriminant validity regarding people with moderate versus severe frailty. Both models have spurred the development of various assessments/tools of frailty, which enable clinicians to move away from age-based assumptions and organ specific interventions, and adopt a more holistic approach to the routine care of older people, including prophylactic exercise and nutritional interventions. To this end, Dent et al (2019) recommended individually tailored/person-centred interventions to preserve an individual's independence, physical function and cognition once frailty has been identified through assessment, so that it does not become an expression of ageism within the service provision.
‘Older people with multiple and complex health conditions, minimised and reframed their ill health with scant regard to the extent that their health problems impacted on their lives; health problems were normalised and accepted… but they were determined to maintain independence, autonomy and dignity as far as was possible in the face of diminishing control.’
Rasiah et al (2022) reviewed 32 frailty assessment tools for community dwelling older people. Some tools adopted a categorical approach (individual deficits), while others adopted a continuous approach resulting in cumulative scores. In light of the range of assessment tools available, they recommended that tool selection should be based upon the context and best fit with practice, although the National Institute for Health and Care Excellence (NICE) (2016) guidelines relating to multimorbidity recommends the PRISMA-7 questionnaire (Raîche et al, 2005). NICE draws upon the British Geriatric Society's (2014; 2015) Fit for Frailty model—Find, Recognise (frailty in a person), Assess, Intervene, Long Term (care) (FRAIL)—to be considered alongside the relevant NICE guidelines relating to multimorbidity (NICE, 2016) and older people with social care needs and multiple long-term conditions (NICE, 2015).
The World Health Organization (WHO) (2015) proposed healthy ageing as the answer to global demographic trends relating to frailty so that dependency would be minimised and confined to the very end stage of the life course, with most older people able to maintain their functional ability and wellbeing. To this end, they promoted the development of integrated care for older people (WHO, 2017), so that access to preventive services, healthcare and long-term care may be offered in a timely manner in response to functional decline as it arises. The UK and other countries are developing their integrated care offerings, although the UK is challenged by its current weak social care provision and associated strain upon primary and acute health services.
It seems that the UK is not alone in struggling to develop its integrated care offering. Elliott et al (2022) set out the challenges faced by a health system in Ontario, Canada, if the needs and goals of older patients and their families, in addition to access issues, are to be addressed alongside adequate training and education for healthcare professionals.
Chen (2022) has noted how the COVID-19 pandemic has caused major disruption to service development with the widespread adoption of home-based smartphone interventions. Such interventions lack interpersonal connectivity and a social milieu, absence of which may exacerbate loneliness, social isolation and lead to cases of depression remaining unrecognised. However, it is likely that in the next few years, older people will possess better knowledge and skills to handle digital solutions for health and wellbeing with the ubiquity of mobile technologies. Nonetheless, the evidence is consistent that place of residence and personal choices have a major impact upon healthy ageing, which emphasises the importance of age-friendly communities (Chen, 2022).
Although frailty and sarcopenia are related, they are separate conditions relating to muscle disease in old age. Angulo et al (2020) have set out the case for physical activity/exercise as a means of preserving or improving functional status (delaying frailty), especially where the interventions target strength and power, aerobics, balance and flexibility, in combination or separately. Bruyère et al (2022) echoed Angulo et al (2020) and others, asserting that loss of physical function and its consequences can be countered by physical activity, while also advocating healthy lifestyles in the form of a nutritionally sound diet and the avoidance of tobacco and alcohol.
Each older person is an individual who has a unique history with their own preferences and aspirations; it is important to acknowledge this individuality and avoid assumptions associated with age or group membership. Anderson et al's (2022) qualitative interviews with 23 older people aged 97–99 years living in the north of England revealed that they felt largely positive about their lives, even if their world had shrunk, as well as feeling determined to retain their independence and autonomy, sometimes using subversive tactics to outwit the best efforts of carers and family. Perceptions of independence and autonomy were relative with the older people, often comparing themselves to peers who were more dependent, and they were prepared to take risks judiciously to achieve a workaround in light of functional constraints. There was a fine balance between the risk of adverse events, such as falls and the risks of diminished autonomy and ceding control. While changing familial relationships caused tensions and challenges, these relationships remained of central importance and sources of companionship, as well as informal support. Older people with multiple and complex health conditions minimised and reframed their ill health with scant regard to the extent that their health problems impacted on their lives; health problems were normalised and accepted. In consequence, some older people rejected safety and support aids, mainly because they did not view them as necessary and their absence was a source of pride. In summary, older people in this study ‘picked their battles’ and did not openly reject help, but they were determined to maintain independence, autonomy and dignity as far as was possible in the face of diminishing control.
Frailty is increasingly viewed as preventable with its early identification and targeted interventions involving physical activity programmes offering the possibility of improving physical performance (Kwak and Thompson, 2021). But we are social beings, and therefore the scourge of loneliness among older people needs urgent attention, especially in light of the consistent evidence that loneliness is associated with significantly higher risk of worsening frailty (Kojima et al, 2022).