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A. M. Mudge and R. E. Hubbard 19. Mukete BN, Ferdinand KC. Polypharmacy in older adults with hypertension: a comprehensive review. J Clin Hypertens 2016; 18: 10–8. 20. Wilson M, Mair A, Dreischulte T, Witham MD. Prescribing to fit the needs of older people—the NHS Scotland Polypharmacy Guidance, 2nd edition. J R Coll Physicians Edinb 2015; 45: 108–13. doi:10.4997/JRCPE.2015.204. 21. Clegg A, Relton C, Young J, Witham M. Improving recruitment of older people to clinical trials: use of the cohort multiple randomised controlled trial design. Age Ageing 2015; 44: 547–50. doi:10.1093/ageing/afv044.

22. McCormack J. Blood Pressure Medicines for Five Years to Prevent Death, Heart Attacks, and Strokes. The NNT. 2014 [cited 2015 11 December]. http://www.thennt.com/nnt/antihypertensives-to-prevent-death-heart-attacks-and-strokes/ 23. Kostis JB, Davis BR, Cutler J et al. Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group. J Am Med Assoc 1997; 278: 212–6. Received 4 December 2017; editorial decision 7 March 2018

Age and Ageing 2018; 47: 508–511 © The Author(s) 2017. Published by Oxford University Press on behalf of the British Geriatrics Society. doi: 10.1093/ageing/afx193 All rights reserved. For permissions, please email: [email protected] Published electronically 29 December 2017

Frailty: mind the gap ALISON M. MUDGE1, RUTH E. HUBBARD2 1

Department of Internal Medicine and Aged Care, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia Centre for Research in Geriatric Medicine, School of Clinical Medicine, The University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia 2

Address correspondence to: Ruth E. Hubbard. Tel: +0061 7 3176 5330; Fax: +0061 7 3176 6945. Email: [email protected]

Abstract Frailty has become the focus of considerable research interest and media attention over the past 15 years. While it has much to offer geriatric medicine, potential pitfalls also need to be acknowledged. The conceptualisation of frailty in very different ways—as a syndrome or a risk state—has created semantic dissonance: the frailest patients by one definition may have early sarcopenia, by another be bedbound and in institutional care. Caution is required in transferring findings between studies enroling these different populations. Furthermore, a yawning gap has emerged between the number of studies reporting the associations of frailty and those investigating interventions such that the empirical benefits of identifying and treating frailty currently remain unclear. Perhaps most importantly, frailty research has evolved with little account of the perspectives and preferences of patients themselves. The label of ‘frail’, being linked to mental or moral weakness, has pejorative implications and care should be taken to avoid the adverse functional effects of negative priming. Here, we suggest pathways for future studies to provide a stronger evidence base to apply this important concept. This research is essential to avoid frailty becoming the new cloak of ageism, a tool for discrimination and disempowerment applied to the most vulnerable. Keywords: older people, frailty, ageism, stereotyping

Frailty has become the focus of considerable research interest over the past 15 years (Figure 1). With development of simple validated measurement tools, there is growing pressure in healthcare organisations to incorporate measurement of frailty into routine screening [1]. Screening however must lead to evidence-based actions and there seems to be philosophical and empirical debate about

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what these actions might be. Is frailty a disease to be battled or even reversed, like heart failure or cancer? Or is it a marker of futility that offers hope for ‘rational rationing’ of stretched health services, packaged as patient-centred care? Acknowledging and discussing some of the reasons behind this debate may help us to work toward solutions.

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Figure 1. Published Papers on Frailty.

The semantic dissonance of frailty Frailty has been conceptualised, and is therefore being quantified, in very different ways. Frailty syndromes are measured by a set of defined symptoms or signs. The core pathophysiological feature of the frailty phenotype [2] is sarcopenia, caused mainly by age-related changes in hormones, and hence it can be largely measured by performance-based tests. If patients become dependent, they are no longer considered frail but disabled. The frailty syndrome is a ‘pre-disability phase’ [3]. The frailty index approach, on the other hand, conceptualises frailty as a state of increased risk of adverse health outcomes which can occur due to a variety of accumulated health deficits [4]; it classifies older people across the health spectrum from the most robust, with no deficits at all, to those who are completely dependent in all activities of daily living. Hence the most frail patients by one definition are those living in the community and having some problems with muscle wasting yet by another definition might be bedbound and in institutional care. Both definitions are associated with a relative increase in mortality, but life expectancy may be very different in ‘frail’ patients classified using different definitions, and caution is required in transferring findings between studies enroling these different populations. Other definitions of frailty continue to emerge, such as the John Hopkins Adjusted Clinical Groups which includes poverty and barriers to medical care as frailty-defining indicators [5]. Socio-economic domains such as wealth are more traditionally considered to be assets. Their inclusion may improve the predictive validity of risk measures, yet teasing out the effects of age-associated decline from mitigating and moderating factors may be an important distinction to design effective management strategies.

The empirical benefits of identifying and treating frailty remain unclear Physical activity and multicomponent interventions can reduce measures of frailty in community-living older people [6]. However, this effect is driven by relatively small changes in physical performance measures, without meaningful changes in daily activities, disability, quality of life, hospitalisations or mortality. It is unclear whether this improvement is unique to frail individuals (i.e. is a treatment effect on frailty per se) or is a universal consequence of physical activity participation. This is critical in understanding whether we should be specifically targeting frail or pre-frail individuals, or continuing a broad public health approach to the many benefits of physical activity participation. In hospitals, frailty predisposes to development of geriatric syndromes such as delirium and functional decline, which mediate poor hospital outcomes such as long hospitalisation, need for continuing care and mortality [7]. Frailty is thus a potential method for identifying patients for multicomponent delirium prevention and functional recovery programs. However, recent findings that the mortality impact of delirium may be greatest in non-frail individuals [8] highlight the complexity of the relationships between frailty, geriatric syndromes and outcomes, and empiric evidence about impact in different frailty subgroups is still required to inform decision making about prioritisation. Delayed recovery from illness and hospitalisation is another hallmark of frailty [4] and manifests as persisting functional, cognitive and nutritional deficits—the ‘post-hospital syndrome’ [9]. The impact of integrated post-hospital programs to enhance functional recovery remains under-researched [10]. Frailty is a strong predictor of 1-year and 5-year mortality and therefore may play a role in advance care planning and


A. M. Mudge and R. E. Hubbard decision making. It could be applied at points of major treatment decision such as major surgery or toxic oncology treatment regimes, which carry substantial burden but may offer little benefit in those with limited life expectancy. There has been reported application in surgical decision making, but the process and nature of these decision has not been well described, and reports have omitted reporting outcomes for conservatively managed participants [11] which may bias results. There is limited published experience in oncology. It also remains unclear the extent to which frailty is responsive to treatment of underlying disease and indicates the need for prioritising treatment, and how much is not treatment responsive and might lead to recommending a conservative approach. Better empiric research in this area is required in order to apply these tools to support appropriate treatment decisions but avoid unjustified rationing.

Frail people have not been central to the discussion Perhaps most importantly, frailty research has evolved with little account of the consumer perspective. Do older people need—or want—to be told that their slow walking speed puts them one foot closer to the grave? There is growing evidence that frailty is a highly negative term for older people themselves. The Oxford English Dictionary defines frailty as ‘the condition of being weak and delicate… weakness in character or morals’ [12]. In discussions with families and, particularly, patients themselves we must be clear that attribution of the term is not suggesting a fading of personhood. A negatively perceived label may do more than hurt feelings. Priming older adults with detrimental age stereotypes has strong adverse effects on behavioural outcomes, including memory and physical performance [13]. In one qualitative study, older people with varying degrees of frailty identified a distinction between feeling frail (which was strongly linked to engagement in social and physical activity) and being labelled as frail (which they felt would contribute to stigmatisation and the development of a frailty identity) [14]. Thus frailty connotes a sense of nihilism and is used as a term of separation, used about others but not about oneself. In an era of ‘healthy ageing’ messages designed to counter prevailing ageism, frailty may represent a personal failure. Frail people and their caregivers also appear to have had limited involvement in design and delivery of frailty interventions. Many community interventions have involved intensive supervised physical activity interventions, which are challenging to translate into practice in patients with high needs for transport and mobility assistance. Participants have often been highly selected, and people with co-existing cognitive impairment usually excluded.

• Rigorous studies understanding the meaning and implications of frailty from the perspective of consumers, caregivers, health providers and decision makers. • Well-designed observational studies of outcomes in frail and non-frail participants who choose to undergo and decline aggressive therapies; and qualitative or mixed methods studies to understand the information needs and decision making of frail consumers making serious treatment decisions. • Empiric studies of multicomponent in-hospital and posthospital interventions targeting prevention of geriatric syndromes, and functional/ cognitive/ nutritional recovery. These studies must be adequately powered for important patientcentred outcomes like functional status, life-space mobility, support needs, social participation and quality of life. • Large pragmatic implementation trials, co-designed by consumers and inclusive of caregivers, of practical and acceptable community interventions to reduce frailty and its impact. These should applicable at scale, include longer term clinically meaningful outcomes and thorough cost– benefit analyses. The concept of frailty has become invaluable in explaining differential outcomes in older people and people with chronic disease, especially mid-term mortality and hospital complications. But without clearer understanding of the preferences and choices of frail people, the impact of interventions on meaningful outcomes, and the relative benefits of interventions in different strata of frailty, frailty may become a new tool for discrimination and disempowerment applied to the most vulnerable. Like all screening tools, we must be confident that the target population is defined, that screening objectives are clear, that risks are minimised, that autonomy and choice are respected, that there is scientific evidence of effectiveness of screening and that benefits outweigh harms [15]. We propose caution in widespread use of frailty screening until the evidence allows us to confidently address these criteria.

Key points • The concept of frailty has much to offer geriatric medicine but potential pitfalls need to be acknowledged. • The measurement of frailty in different ways has created semantic dissonance. • The empirical benefits of identifying and treating frailty currently remain unclear. • Frailty research has evolved with little account of the perspectives and preferences of patients themselves. • A stronger evidence base is needed to avoid frailty becoming the new cloak of ageism.

Ways to bridge the gap How can we provide the empiric evidence base needed to apply this important clinical concept in practice? We suggest that the need for four principal areas of research:


Conflict of interest None declared.

Frailty: mind the gap

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