Frailty syndrome: implications and challenges for health care policy
Received 23 September 2018
Accepted for publication 24 January 2019
Published 14 February 2019 Volume 2019:12 Pages 23—30
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 3
Editor who approved publication: Dr Kent Rondeau
Gotaro Kojima,1 Ann EM Liljas,2 Steve Iliffe1
1Department of Primary Care and Population Health, University College London, London, UK; 2Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
Abstract: Older adults are a highly heterogeneous group with variable health and functional life courses. Frailty has received increasing scientific attention as a potential explanation of the health diversity of older adults. The frailty phenotype and the Frailty Index are the most frequently used frailty definitions, but recently new frailty definitions that are more practical have been advocated. Prevalence of frailty among the community-dwelling population aged 65 years and older is ~10% but varies depending on which frailty definitions are used. The mean prevalence of frailty gradually increases with age, but the individual’s frailty level can be improved. Older adults, especially frail older adults, form the main users of medical and social care services. However, current health care systems are not well prepared to deal with the chronic and complex medical needs of frail older patients. In this context, frailty is potentially a perfect fit as a risk stratification paradigm. The evidence from frailty studies has not yet been fully translated into clinical practice and health care policy making. Successful implementation would improve quality of care and promote healthy aging as well as diminish the impact of aging on health care systems and strengthen their sustainability. At present, however, there is no effective treatment for frailty and the most effective intervention is not yet known. Based on currently available evidence, multi-domain intervention trials, including exercise component, especially multicomponent exercise, which includes resistance training, seem to be promising. The current challenges in frailty research include the lack of an international standard definition of frailty, further understanding of interventions to reverse frailty, the best timing for intervention, and education/training of health care professionals. The hazards of stigmatization should also be considered. If these concerns are properly addressed, widespread application of public health approaches will be possible, including screening, identification, and treatment of frailty, resulting in better care and healthier aging for older people.
Keywords: frailty, health care policy, geriatrics
Life expectancy has markedly increased worldwide during the past 100 years, mainly due to public health improvements.1 This demographic transformation of the population has resulted in growing numbers of older adults in both developing and developed countries.2 Between 2000 and 2050, the proportion of people aged 60 years or older in the world is projected to double from about 11% to 22%, an increase from 605 million to 2 billion adults aged ≥60 years.1 The number of older adults aged over 80 years is expected to quadruple to 395 million during the same period.1 In general, we tend to develop more health problems and become frailer as we age. The increase in life expectancy allows chronic diseases to develop while physical and cognitive functions decline, which predisposes older people to disability or dependency.
Older adults are a highly heterogeneous group. Their life courses of health and functional status vary substantially, depending on their genetic, biological, and environmental backgrounds as well as other physical, psychological, and social factors. Therefore, individuals with the same chronological age can have different biological ages.3 Frailty has received increasing scientific attention as a way of understanding health diversity among older adults.4 In the past, the term frailty was used almost interchangeably with aging, disability, or comorbidity, partly because of the similarity and high coexistence rate of these descriptive states.5 However, there are clear differences between frailty, aging, disability, and comorbidity. First, advanced age on its own does not necessarily mean vulnerability to negative health outcomes so typical of frailty.6 Frailty is at least partly programmed in early life and is also associated with lower socio-economic status in adulthood.7 Second, frailty is conceptualized as a state of decreased physiological reserve and compromised capacity to maintain homeostasis as a consequence of age-related, multiple, accumulated deficits.4 Frail older people are highly vulnerable to adverse health outcomes when exposed to an internal or external stressor.4 Third, whereas frailty refers to instability and risk of loss of function, disability indicates loss of function and often assessed based on difficulty or dependency in performing activities necessary to live independently, such as activities of daily living (ADL), eg, bathing, dressing, eating, toileting, continence, and transferring8 and instrumental activities of daily living (IADL), eg, shopping, telephone use, meal preparation, housekeeping, laundry, transportation, medication, and finances.9 Finally, comorbidity is defined as having two or more medically diagnosed diseases.5 Thus, frailty is clearly different and distinguishable from advanced age, disability, and comorbidity.
Definition of frailty
A number of definitions have been proposed to conceptualize and operationalize frailty.10,11 Despite the long-lasting and extensive debates on how best to define frailty, international consensus has yet to be reached and a gold standard definition of frailty is still lacking.4 Nonetheless, most conceptual frailty definitions have some factors in common, such as decreased reserves/capacity to tolerate minor stressors, increased vulnerability to adverse health outcomes, and impairment in multiple physiological systems.10 After the inclusion of these factors, frailty is conceptually defined as “a clinically recognizable state in which the ability of older people to cope with everyday or acute stressors is compromised by an increased vulnerability brought by age-associated declines in physiological reserve and function across multiple organ systems”.12 This definition by the WHO has been widely accepted4,13 and adopted in the Joint Action ADVANTAGE, a recently launched European Union (EU) initiative.14
Among various frailty definitions, the most commonly used is the frailty phenotype,15 developed by Fried et al using the Cardiovascular Health Study cohort in 2001.16 The Fried frailty phenotype consists of five physical components to define frailty: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, and low physical activity.16 Individuals are considered to be frail when they meet three or more criteria, and they are considered to be robust when they have none.16 Individuals who have one or two criteria are defined as prefrail, a state between robust and frail.16
The Frailty Index is another popular approach,15 based on a cumulative deficit model advocated by Mitnitski et al using the Canadian Study on Health and Aging.17 In contrast to the frailty phenotype, this cumulative deficit approach describes frailty as a state caused by the accumulation of health deficits during the life course, and the more deficits individuals have, the more likely they are to be frail.15 The Frailty Index, a continuous score ranging from 0 (no deficit) to 1 (all deficits present), is calculated as the ratio of the number of deficits present in the individual to the number of total deficits considered.18 For the Frailty Index, at least 30–40 deficits, associated with age and adverse health outcomes that are prevalent in 1% or more of the population, should be considered, with fewer than 5% of missing values, and it can include symptoms, signs, diseases, disabilities, abnormalities of laboratory, radiographic, and electrocardiographic findings, and social characteristics.18
There has been some debate regarding the practical application of these two most commonly used frailty definitions.19 The frailty phenotype requires special equipment to measure the handgrip strength and space for measuring gait speed. The population-based lowest 20% of the handgrip strength, gait speed, and physical activity need to be calculated based on the population distributions. Calculation of the Frailty Index requires the recording of various types of deficits (typically more than 30–40) and dividing the number of deficits present by the number of deficits considered, which may take ~20–30 minutes,19 except when data are extracted and calculated automatically from electronic medical records.20
Feasible frailty instruments in a clinical setting
According to the International Association of Nutrition and Aging (IANA) Task Force, a frailty tool should be quick, inexpensive, reliable, and easy to use in clinical settings because the identification of frail older people at risk is an important initial step potentially leading to appropriate preventive and/or treatment interventions and ultimately to higher quality care for this vulnerable population.21 From this perspective, the frailty phenotype and the Frailty Index may be rather impractical and unfeasible especially in a busy clinical setting. Based on a systematic review of the literature as well as input from a panel of geriatric experts, the IANA’s working group advocated a new frailty tool.21 The FRAIL scale is a simple tool consisting of five yes/no questions: Fatigue, Resistance (inability to climb stairs), Ambulation (inability to walk a certain distance), Illnesses (more than five of comorbidities), and Loss of weight (more than 5%),21 and has been shown to be able to predict mortality and incident ADL and IADL disabilities among community-dwelling older people in recent meta-analysis studies.22,23 The FRAIL scale is also recommended as one of the tools to detect frailty by the Joint Action ADVANTAGE, a EU co-funded initiative launched in 2017 involving 22 member states and over 40 organizations.14 The main goal of ADVANTAGE is to establish a common European framework for addressing the problems of frailty, including: 1) improvements in screening, diagnosis, prevention, and treatment for frailty, 2) health care system reforms adapted to population aging, and 3) facilitation of research and education on frailty.14 ADVANTAGE has proposed that tools used for frailty screening should be quick to administrate (no more than 10 minutes to complete); require no special equipment; validated; and be meant for screening. Existing frailty instruments meeting these four criteria are Clinical Frailty Scale, Edmonton Frail Scale, FRAIL scale, INTER-FRAIL, Prisma-7, Sherbrooke Postal Questionnaire, Short Physical Performance Battery, and Study of Osteoporotic Fractures Index.14 The Kihon Checklist, a self-reported comprehensive questionnaire consisting of 25 simple yes/no questions covering multiple domains, is another relatively new frailty tool.24,25 This tool was originally developed by the Japanese Ministry of Health, Labour and Welfare in 2005–2006 as a screening tool to identify vulnerable older adults who are at high risk of dependency and more recently has been recognized as a useful frailty assessment tool.26,27 This is another brief, simple, quick, and cost-effective instrument which does not need special equipment and takes <10 minutes to complete,19 and therefore may be appropriate for screening. These frailty instruments can easily be incorporated into comprehensive geriatric assessment or primary care in a clinical setting for screening frail older adults. Some of them consist of short lists of simple questions and can be administered by not only physicians or other health care professionals but also care givers and non-professionals, in person as well as by phone, mail, or email.
Prevalence and natural course of frailty
The mean prevalence of frailty among the community-dwelling population aged 65 years and older is ~10% but can range widely from 4.0% to 59.1% depending on the frailty criteria used.28 Advanced age is a significant risk factor for frailty and a quarter of those aged 80 years or older are frail.28 A higher prevalence of frailty is also observed in selected populations with specific diseases or conditions, such as patients with cancer (42%),29 end-stage renal disease (37%),30 heart failure (45%),31 Alzheimer disease (32%),32 and nursing home residents (52%).33
Although the mean prevalence of frailty gradually increases with age,28,34–37 the individual course of frailty varies and the level of frailty can be reduced even in old age.4,38 Several longitudinal population-based studies have showed that 8.3%–17.9% of older adults actually improved their frailty status39–44 and that some of them made frequent and dynamic transitions over time.45
Impacts of frailty on health care systems
Frail older adults are at increased risk of premature death20,22,27,46 and various negative health outcomes, including falls,47 fractures,48 disability,23,49 and dementia,50 all of which could result in poor quality of life51 and increased cost52 and use of health care resources,53 such as emergency department visits,54 hospitalization,55 and institutionalization.56 Multiple studies using cohorts of community-dwelling older adults have showed that the health care costs of frail individuals are sometimes several-fold higher than those of non-frail counterparts.57–61
Older adults form the main users of medical and social care services,62 and the majority of health care costs are incurred by them. In the context of ongoing population aging, with an unprecedented growing number and proportion of older adults, this epidemiological and demographic population shift is starting to have a major impact on health care systems. Current health care systems are mostly designed to address organ-specific and disease-specific problems one at a time and are not well prepared to deal with the chronic and complex medical needs of frail older patients and to provide seamless care for them in the long term.63,64 Therefore, older patients often receive suboptimal care due to the fragmented delivery of appropriate treatments and services.65
Interventions for frailty
There is no standard treatment of choice specifically for frailty, but there is a need for high quality cost-effective health care strategies to counter frailty.66 Although various types of frailty intervention models have been developed and investigated, there is a considerable degree of heterogeneity in terms of optimal intervention type, sample size, population characteristic, setting, baseline frailty status, frailty definition, and outcomes, and most findings are inconclusive.67–74 At present, it is therefore not possible to conclude what intervention is the most effective and appropriate. Overall, multi-domain intervention trials, which have been frequently conducted,75,76 and many of which included an exercise component, seemed to have some favorable effects (although not in all trials) compared with mono-domain interventions or the control.73,77 Among the various outcome measures, functional ability, disability, and falls have been commonly examined while only a limited number of trials investigated changes in frailty status as an outcome.78 Although it is still not clear which frailty intervention is the most effective, exercise programs, especially multicomponent exercise including resistance training, have been consistently successful and seem likely to play a pivotal role in frailty interventions.79–84
Implications and challenges for health care policy
One of the plausible implementations of frailty into clinical practice is to identify frail patients using electronic health record data.85–87 In a UK study, Clegg et al developed the electronic Frailty Index (eFI) from 36 deficits,88 based on the Frailty Index of cumulative deficit model.17 The eFI was automatically populated from routinely collected data stored in the existing primary care electronic health record where general practitioners (GPs) list all patient diagnoses.88 The authors showed eFI was able to stratify patients according to the degree of frailty and had robust predictive validity for mortality, hospitalization, and nursing home admission.88 In 2017, NHS England started to require GPs to identify patients aged 65 years or older with moderate and severe frailty using validated frailty instruments including eFI, which is now freely available at most of GP practices.89 Following clinical assessment, patients with severe frailty are monitored using an annual medication review and other clinically relevant interventions if appropriate.89 This is probably the first attempt of nation-wide population-based frailty risk stratification and health utilization predictions in health care systems.90
Population-based screening for frailty could be expensive and resource intensive, and currently there is no clear evidence for potential benefit, cost-effectiveness, or improved outcomes.91 Nonetheless, at the Frailty Consensus Conference in 2012, it was concluded that screening for frailty should be recommended for people with specific conditions or in certain settings.92 One of the four consensus points was that those aged 70 years or older and those with significant weight loss (≥5%) due to chronic disease should be screened for frailty.92 This recommendation is supported by the ADVANTAGE initiative, which advocates opportunistic frailty screening of people aged over 70 years receiving health care at any level of the system.14 The French Society of Geriatrics and Gerontology suggests that people aged over 75 years who do not have difficulty with simple ADL but with early IADL would be good candidates for screening.93 The UK practice guidelines for frailty published from the British Geriatrics Society, Age UK, and Royal College of General Practitioners in 2014 recommend conducting a frailty assessment using all the encounters between health and social care staff and older people in community and outpatient settings.94 Research and development efforts aimed at establishing and disseminating best practice in frailty should not lack policy attention to older people with early (pre-) frailty that misses an opportunity to address some demands on health and social care services.95
Among the current challenges in the field of frailty research, one of the most important issues is the lack of an international standard definition of frailty.92,96 Despite accumulated research evidence on frailty, the variability in frailty definitions used in existing studies influences interpretation of the evidence, comparison with other studies, generalization of findings, and its implementation in the health care policy. In order to further advance and improve the health care services for frail older adults, it is imperative to come to an agreement in terms of frailty definition.97 Ideally, the definition should be not only reliable but also feasible and easy to apply.98 Based on the currently available evidence on frailty intervention, there is strong evidence that exercise is central and possibly the optimal treatment of frailty. This needs to be explored further through multi-domain interventions that include exercise. The best timing for frailty intervention is not known but could range from intervening proactively to decrease risk of developing frailty or targeting those who are found to be prefrail or frail at the time of screening. If these concerns are properly addressed, widespread application of public health approaches will be possible, including screening, identification, and treatment of frailty, resulting in better care and healthier aging for older people. Involving frail older people in exploration of responses to frailty is likely to be fruitful; a Swedish study showed that financial situation, self-rated health, and social networks were determinants of life satisfaction. Actions that benefit life satisfaction – social and financial support – should be promoted.99
Another important area of frailty research is education and training. In order to deliver high quality care and services effectively and efficiently to frail older adults, health care professionals including physicians, nurses, and other medical workers need to understand basic principles of care for frail older adults and to be able to detect frailty and provide treatment/interventions. Different understandings of frailty may impede communication between disciplines and need to be addressed. However, the evidence on education or training for frailty management is lacking. A recent systematic review that involved searches until May 2017 found no relevant article on education and/or training interventions for health care professionals in the field of frailty.100 There are currently ongoing frailty projects including educational components targeting health care professionals, patients, and caregivers, and new findings from these projects are expected to contribute to the field of frailty.14,100
There is an increasing interest in frailty in other medical fields than the geriatrics.101,102 One example is that frailty has recently been pursued as a potential risk assessment measure for older surgical patients and has shown to be promising in predicting post-operative complications, such as mortality or length of hospital stay.103 However, the lack of knowledge about frailty is a major barrier to the preoperative frailty assessment by surgeons, which may be addressed by education and training.104 A US educational interventional study involving cardiothoracic surgery residents showed that online short courses on frailty significantly improved residents’ knowledge of frailty and influenced surgical risk estimates.105
Finally, frailty research may have evolved without taking into account the patient perspective. Frailty can be considered as a highly negative term and being labeled as frail may affect negatively the most vulnerable individuals in various ways. Those who were labeled as “old and frail” by others were more likely to be associated with a loss of interest in social and physical activities, poor physical health, and increased stigmatization.106 The future research and development efforts need to acknowledge the risks of labeling older people in stigmatizing ways, and avoid frailty from becoming the new cloak of ageism and a tool for discrimination.107
There is an urgent need to identify and implement effective long-term care schemes to meet the complex demands of older adults. Frailty is potentially a perfect fit as a risk stratification paradigm and has therefore been recognized as an emerging public health priority.13Although a growing number of frailty studies have been conducted over the last two decades, their findings have not yet been fully translated into clinical practice108 and the implementation of evidence on frailty in health care policy-making is further underrepresented.95 Successful implementation has the potential to improve quality of care for frail older adults and promote healthy aging as well as diminish the impact of frailty on health care systems and strengthen their sustainability. Such actions further demonstrate the substantial public health importance of frailty. Given the multidimensional and heterogeneous nature of frailty and the complex care needs of frail older adults, a multidisciplinary collaborative approach is needed between researchers, clinicians, policy makers, and older people themselves to improve the health and well-being of this subgroup of older adults.109,110 The field of frailty is still evolving and expanding and will need much more time and effort for further progress to occur.96 Better outcomes for older people are likely to come with a time lag, and addressing frailty may require a massive cultural (perhaps generational) shift in the organization of health and care systems.90
The authors report no conflicts of interest in this work.
World Health Organization. World Health Day 2012. Are you ready? What you need to know about ageing; 2012. Available from: http://www.who.int/world-health-day/2012/toolkit/background/en/. Accessed March 2, 2016.
United Nations. World Population Ageing 2017. Available from: http://www.un.org/en/development/desa/population/theme/ageing/WPA2017.shtml. Accessed February 9, 2019
Mitnitski AB, Graham JE, Mogilner AJ, Rockwood K. Frailty, fitness and late-life mortality in relation to chronological and biological age. BMC Geriatr. 2002;2(1):1.
Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752–762.
Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004;59(3):M255–M263.
Schuurmans H, Steverink N, Lindenberg S, Frieswijk N, Slaets JP. Old or frail: what tells us more? J Gerontol A Biol Sci Med Sci. 2004;59(9): M962–M965.
Haapanen MJ, Perälä MM, Salonen MK, et al. Early life determinants of frailty in old age: the Helsinki Birth Cohort Study. Age Ageing. 2018:569–575.
Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist. 1970;10(1):20–30.
Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179–186.
Gobbens RJ, Luijkx KG, Wijnen-Sponselee MT, Schols JM. Toward a conceptual definition of frail community dwelling older people. Nurs Outlook. 2010;58(2):76–86.
Sternberg SA, Schwartz AW, Karunananthan S, Bergman H, Mark Clarfield A. The identification of frailty: a systematic literature review. J Am Geriatr Soc. 2011;59(11):2129–2138.
World Health Organization. WHO Clinical Consortium on Healthy Ageing: Topic Focus: Frailty and Intrinsic Capacity: Report of Consortium Meeting, 1–2 December 2016 in Geneva, Switzerland. Geneva, Switzerland: World Health Organization; 2017.
Cesari M, Prince M, Thiyagarajan JA, et al. Frailty: an emerging public health priority. J Am Med Dir Assoc. 2016;17(3):188–192.
Rodríguez-Laso Á, Mora MAC, Sánchez IG, et al. State of the Art Report on the Prevention and Management of Frailty. 2018. Available from: http://www.advantageja.eu/images/SoAR-AdvantageJA_Fulltext.pdf. Accessed February 12, 2019.
Buta BJ, Walston JD, Godino JG, et al. Frailty assessment instruments: systematic characterization of the uses and contexts of highly-cited instruments. Ageing Res Rev. 2016;26:53–61.
Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–M157.
Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. Sci World J. 2001;1:323–336.
Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr. 2008;8(1):24.
Dent E, Kowal P, Hoogendijk EO. Frailty measurement in research and clinical practice: a review. Eur J Intern Med. 2016;31:3–10.
Stow D, Matthews FE, Barclay S, et al. Evaluating frailty scores to predict mortality in older adults using data from population based electronic health records: case control study. Age Ageing. 2018;47(4):564–569.
Abellan van Kan G, Rolland Y, Bergman H, Morley JE, Kritchevsky SB, Vellas B. The I.A.N.A. Task Force on frailty assessment of older people in clinical practice. J Nutr Health Aging. 2008;12(1):29–37.
Kojima G. Frailty defined by FRAIL scale as a predictor of mortality: a systematic review and meta-analysis. J Am Med Dir Assoc. 2018;19(6):480–483.
Kojima G. Quick and simple FRAIL scale predicts incident activities of daily living (ADL) and instrumental ADL (IADL) disabilities: a systematic review and meta-analysis. J Am Med Dir Assoc. 2018;19(12):1063–1068.
Sewo Sampaio PY, Sampaio RA, Yamada M, Arai H. Systematic review of the Kihon Checklist: is it a reliable assessment of frailty? Geriatr Gerontol Int. 2016;16(8):893–902.
Kojima G, Iliffe S, Taniguchi Y, Shimada H, Rakugi H, Walters K. Prevalence of frailty in Japan: a systematic review and meta-analysis. J Epidemiol. 2017;27(8):347–353.
Satake S, Senda K, Hong YJ, et al. Validity of the Kihon Checklist for assessing frailty status. Geriatr Gerontol Int. 2016;16(6):709–715.
Kojima G, Taniguchi Y, Kitamura A, Shinkai S. Are the Kihon Checklist and the Kaigo-Yobo checklist compatible with the frailty index? J Am Med Dir Assoc. 2018;19(9):797–800.
Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):1487–1492.
Handforth C, Clegg A, Young C, et al. The prevalence and outcomes of frailty in older cancer patients: a systematic review. Ann Oncol. 2015;26(6):1091–1101.
Kojima G. Prevalence of frailty in end-stage renal disease: a systematic review and meta-analysis. Int Urol Nephrol. 2017;49(11):1989–1997.
Denfeld QE, Winters-Stone K, Mudd JO, Gelow JM, Kurdi S, Lee CS. The prevalence of frailty in heart failure: a systematic review and meta-analysis. Int J Cardiol. 2017;236:283–289.
Kojima G, Liljas A, Iliffe S, Walters K. Prevalence of frailty in mild to moderate Alzheimer’s disease: a systematic review and meta-analysis. Curr Alzheimer Res. 2017;14(12):1256–1263.
Kojima G. Prevalence of frailty in nursing homes: a systematic review and meta-analysis. J Am Med Dir Assoc. 2015;16(11):940–945.
Ma L, Tang Z, Zhang L, Sun F, Li Y, Chan P. Prevalence of frailty and associated factors in the community-dwelling population of China. J Am Geriatr Soc. 2018;66(3):559–564.
Kehler DS, Ferguson T, Stammers AN, et al. Prevalence of frailty in Canadians 18–79 years old in the Canadian Health Measures Survey. BMC Geriatr. 2017;17(1):28.
Payne CF, Wade A, Kabudula CW, et al. Prevalence and correlates of frailty in an older rural African population: findings from the HAALSI cohort study. BMC Geriatr. 2017;17(1):293.
Lewis EG, Coles S, Howorth K, et al. The prevalence and characteristics of frailty by frailty phenotype in rural Tanzania. BMC Geriatr. 2018;18(1):283.
Kojima G, Taniguchi Y, Iliffe S, Jivraj S, Walters K. Transitions between frailty states among community-dwelling older people: a systematic review and meta-analysis. Ageing Res Rev. 2019;50:81–88.
Espinoza SE, Jung I, Hazuda H. Frailty transitions in the San Antonio longitudinal study of aging. J Am Geriatr Soc. 2012;60(4):652–660.
Lanziotti Azevedo da Silva S, Campos Cavalcanti Maciel Á, de Sousa Máximo Pereira L, Domingues Dias JM, Guimarães de Assis M, Corrêa Dias R. Transition patterns of frailty syndrome in community-dwelling elderly individuals: a longitudinal study. J Frailty Aging. 2015;4(2):50–55.
Lee JS, Auyeung TW, Leung J, Kwok T, Woo J. Transitions in frailty states among community-living older adults and their associated factors. J Am Med Dir Assoc. 2014;15(4):281–286.
Liu ZY, Wei YZ, Wei LQ, et al. Frailty transitions and types of death in Chinese older adults: a population-based cohort study. Clin Interv Aging. 2018;13:947–956.
Pollack LR, Litwack-Harrison S, Cawthon PM, et al. Patterns and predictors of frailty transitions in older men: the osteoporotic fractures in men study. J Am Geriatr Soc. 2017;65(11):2473–2479.
Trevisan C, Veronese N, Maggi S, et al. Factors influencing transitions between frailty states in elderly adults: the Progetto Veneto Anziani longitudinal study. J Am Geriatr Soc. 2017;65(1):179–184.
Gill TM, Gahbauer EA, Allore HG, Han L. Transitions between frailty states among community-living older persons. Arch Intern Med. 2006;166(4):418–423.
Kojima G, Iliffe S, Walters K. Frailty index as a predictor of mortality: a systematic review and meta-analysis. Age Ageing. 2018;47(2):193–200.
Kojima G. Frailty as a predictor of future falls among community-dwelling older people: a systematic review and meta-analysis. J Am Med Dir Assoc. 2015;16(12):1027–1033.
Kojima G. Frailty as a predictor of fractures among community-dwelling older people: a systematic review and meta-analysis. Bone. 2016;90:116–122.
Kojima G. Frailty as a predictor of disabilities among community-dwelling older people: a systematic review and meta-analysis. Disabil Rehabil. 2017;39(19):1897–1908.
Kojima G, Taniguchi Y, Iliffe S, Walters K. Frailty as a predictor of Alzheimer disease, vascular dementia, and all dementia among community-dwelling older people: a systematic review and meta-analysis. J Am Med Dir Assoc. 2016;17(10):881–888.
Kojima G, Iliffe S, Jivraj S, Walters K. Association between frailty and quality of life among community-dwelling older people: a systematic review and meta-analysis. J Epidemiol Community Health. 2016;70(7):716–721.
García-Nogueras I, Aranda-Reneo I, Peña-Longobardo LM, Oliva-Moreno J, Abizanda P. Use of health resources and healthcare costs associated with frailty: the FRADEA study. J Nutr Health Aging. 2017;21(2):207–214.
Roe L, Normand C, Wren MA, Browne J, O’Halloran AM. The impact of frailty on healthcare utilisation in Ireland: evidence from the Irish longitudinal study on ageing. BMC Geriatr. 2017;17(1):203.
Kojima G. Frailty as a predictor of emergency department utilization among community-dwelling older people: a systematic review and meta-analysis. J Am Med Dir Assoc. 2019;20(1):103–105.
Kojima G. Frailty as a predictor of hospitalisation among community-dwelling older people: a systematic review and meta-analysis. J Epidemiol Community Health. 2016;70(7):722–729.
Kojima G. Frailty as a predictor of nursing home placement among community-dwelling older adults: a systematic review and meta-analysis. J Geriatr Phys Ther. 2018;41(1):42–48.
Bock JO, König HH, Brenner H, et al. Associations of frailty with health care costs – results of the ESTHER cohort study. BMC Health Serv Res. 2016;16(1):128.
Ensrud KE, Kats AM, Schousboe JT, et al. Frailty phenotype and healthcare costs and utilization in older women. J Am Geriatr Soc. 2018;66(7):1276–1283.
Simpson KN, Seamon BA, Hand BN, et al. Effect of frailty on resource use and cost for Medicare patients. J Comp Eff Res. 2018;7(8).
Hajek A, Bock JO, Saum KU, et al. Frailty and healthcare costs-longitudinal results of a prospective cohort study. Age Ageing. 2018;47(2):233–241.
Salinas-Rodriguez A, Manrique-Espinoza B, Heredia-Pi I, Rivera-Almaraz A, Ávila-Funes JA. Healthcare costs of frailty: implications for long-term care. J Am Med Dir Assoc. 2019;20(1):102–103.e2.
Rockwood K, Hubbard R. Frailty and the geriatrician. Age Ageing. 2004;33(5):429–430.
De Lepeleire J, Iliffe S, Mann E, Degryse JM. Frailty: an emerging concept for general practice. Br J Gen Pract. 2009;59(562):e177–e182.
Tinetti ME, Fried T. The end of the disease era. Am J Med. 2004;116(3):179–185.
Clarfield AM, Bergman H, Kane R. Fragmentation of care for frail older people – an international problem. Experience from three countries: Israel, Canada, and the United States. J Am Geriatr Soc. 2001;49(12):1714–1721.
Walston J. Frailty research moves beyond risk assessment. J Gerontol A Biol Sci Med Sci. 2017;72(7):915–916.
Clegg A, Barber S, Young J, Iliffe S, Forster A. The home-based older people’s exercise (HOPE) trial: a pilot randomised controlled trial of a home-based exercise intervention for older people with frailty. Age Ageing. 2014;43(5):687–695.
Gardner B, Jovicic A, Belk C, et al. Specifying the content of home-based health behaviour change interventions for older people with frailty or at risk of frailty: an exploratory systematic review. BMJ Open. 2017;7(2):e014127.
Frost R, Belk C, Jovicic A, et al. Health promotion interventions for community-dwelling older people with mild or pre-frailty: a systematic review and meta-analysis. BMC Geriatr. 2017;17(1):157.
Frost R, Kharicha K, Jovicic A, et al. Identifying acceptable components for home-based health promotion services for older people with mild frailty: a qualitative study. Health Soc Care Community. 2018;26(3):393–403.
Walters K, Frost R, Kharicha K, et al. Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT. Health Technol Assess. 2017;21(73):1–128.
Daniels R, van Rossum E, de Witte L, Kempen GI, van den Heuvel W. Interventions to prevent disability in frail community-dwelling elderly: a systematic review. BMC Health Serv Res. 2008;8(1):278.
Dedeyne L, Deschodt M, Verschueren S, Tournoy J, Gielen E. Effects of multi-domain interventions in (pre)frail elderly on frailty, functional, and cognitive status: a systematic review. Clin Interv Aging. 2017;12:873–896.
Looman WM, Huijsman R, Fabbricotti IN. The (cost-)effectiveness of preventive, integrated care for community-dwelling frail older people: a systematic review. Health Soc Care Community. 2019;27(1):1–30.
Bibas L, Levi M, Bendayan M, Mullie L, Forman DE, Afilalo J. Therapeutic interventions for frail elderly patients: part I. Published randomized trials. Prog Cardiovasc Dis. 2014;57(2):134–143.
Bendayan M, Bibas L, Levi M, Mullie L, Forman DE, Afilalo J. Therapeutic interventions for frail elderly patients: part II. Ongoing and unpublished randomized trials. Prog Cardiovasc Dis. 2014;57(2):144–151.
Eklund K, Wilhelmson K. Outcomes of coordinated and integrated interventions targeting frail elderly people: a systematic review of randomised controlled trials. Health Soc Care Community. 2009;17(5):447–458.
Puts MTE, Toubasi S, Andrew MK, et al. Interventions to prevent or reduce the level of frailty in community-dwelling older adults: a scoping review of the literature and international policies. Age Ageing. 2017;46(3):383–392.
Cadore EL, Rodríguez-Mañas L, Sinclair A, Izquierdo M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation Res. 2013;16(2):105–114.
Chin A Paw MJ, van Uffelen JG, Riphagen I, van Mechelen W. The functional effects of physical exercise training in frail older people: a systematic review. Sports Med. 2008;38(9):781–793.
de Labra C, Guimaraes-Pinheiro C, Maseda A, Lorenzo T, Millán-Calenti JC. Effects of physical exercise interventions in frail older adults: a systematic review of randomized controlled trials. BMC Geriatr. 2015;15(1):154.
Freiberger E, Kemmler W, Siegrist M, Sieber C. Frailty and exercise interventions: evidence and barriers for exercise programs. Z Gerontol Geriatr. 2016;49(7):606–611.
Theou O, Stathokostas L, Roland KP, et al. The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res. 2011;2011(3):1–19.
Dent E, Lien C, Lim WS, et al. The Asia-Pacific clinical practice guidelines for the management of frailty. J Am Med Dir Assoc. 2017;18(7):564–575.
Kan HJ, Kharrazi H, Leff B, et al. Defining and assessing geriatric risk factors and associated health care utilization among older adults using claims and electronic health records. Med Care. 2018;56(3):233–239.
Kharrazi H, Anzaldi LJ, Hernandez L, et al. The value of unstructured electronic health record data in geriatric syndrome case identification. J Am Geriatr Soc. 2018;66(8):1499–1507.
Anzaldi LJ, Davison A, Boyd CM, Leff B, Kharrazi H. Comparing clinician descriptions of frailty and geriatric syndromes using electronic health records: a retrospective cohort study. BMC Geriatr. 2017;17(1):248.
Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing. 2016;45(3):353–360.
Updated guidance on supporting routine frailty identification and frailty care through the GP contract 2017/2018, NHS England; 2017. Available from: https://www.england.nhs.uk/wp-content/uploads/2017/04/supporting-guidance-on-frailty-update-sept-2017.pdf. Accessed November 13, 2018.
Reeves D, Pye S, Ashcroft DM, et al. The challenge of ageing populations and patient frailty: can primary care adapt? BMJ. 2018;362: k3349.
Fit for frailty Part 1. Consensus best practice guidance for the care of older people living in community and outpatient settings. A report by the British Geriatrics Society in association with the Royal College of General Practitioners and Age UK; 2014. Available from: https://www.bgs.org.uk/sites/default/files/content/resources/files/2018-05-23/fff_full.pdf. Accessed November 12, 2018.
Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392–397.
Rolland Y, Benetos A, Gentric A, et al. [Frailty in older population: a brief position paper from the French society of geriatrics and gerontology]. Geriatr Psychol Neuropsychiatr Vieil. 2011;9(4):387–390. French
Turner G, Clegg A; British Geriatrics Society; Age UK; Royal College of General Practioners. Best practice guidelines for the management of frailty: a British geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing. 2014;43(6):744–747.
Drennan V, Walters K, Avgerinou C, et al. Moving upstream in health promoting policies for older people with early frailty in England? A policy analysis. J Health Serv Res Policy. 2018;23(3):168–175.
Sloane PD, Cesari M. Research on frailty: continued progress, continued challenges. J Am Med Dir Assoc. 2018;19(4):279–281.
Poltawski L, Goodman C, Iliffe S, et al. Frailty scales – their potential in interprofessional working with older people: a discussion paper. J Interprof Care. 2011;25(4):280–286.
De Lepeleire J, Degryse J, Illiffe S, Mann E, Buntinx F. Family physicians need easy instruments for frailty. Age Ageing. 2008;37(4):384.
Berglund H, Hasson H, Wilhelmson K, Dunér A, Dahlin-Ivanoff S. The impact of socioeconomic conditions, social networks, and health on frail older people’s life satisfaction: a cross-sectional study. Health Psychol Res. 2016;4(1):5578.
Windhaber T, Koula ML, Ntzani E, et al. Educational strategies to train health care professionals across the education continuum on the process of frailty prevention and frailty management: a systematic review. Aging Clin Exp Res. 2018;30(12):1409–1415.
Ethun CG, Bilen MA, Jani AB, Maithel SK, Ogan K, Master VA. Frailty and cancer: implications for oncology surgery, medical oncology, and radiation oncology. CA Cancer J Clin. 2017;67(5):362–377.
Walston J, Robinson TN, Zieman S, et al. Integrating frailty research into the medical specialties – report from a U13 conference. J Am Geriatr Soc. 2017;65(10):2134–2139.
Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr. 2016;16(1):157.
Eamer G, Gibson JA, Gillis C, et al. Surgical frailty assessment: a missed opportunity. BMC Anesthesiol. 2017;17(1):99.
Ferguson MK, Thompson K, Huisingh-Scheetz M, et al. The impact of a frailty education module on surgical resident estimates of lobectomy risk. Ann Thorac Surg. 2015;100(1):235–241.
Warmoth K, Lang IA, Phoenix C, et al. ‘Thinking you’re old and frail’: a qualitative study of frailty in older adults. Ageing Soc. 2016;36(07):1483–1500.
Mudge AM, Hubbard RE. Frailty: mind the gap. Age Ageing. 2018;47(4):508–511.
Vellas B, Cestac P, Morley JE. Implementing frailty into clinical practice: we cannot wait. J Nutr Health Aging. 2012;16(7):599–600.
Holroyd-Leduc J, Resin J, Ashley L, et al. Giving voice to older adults living with frailty and their family caregivers: engagement of older adults living with frailty in research, health care decision making, and in health policy. Res Involv Engagem. 2016;2:23.
Ferrucci L, Guralnik JM, Studenski S, et al. Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. J Am Geriatr Soc. 2004;52(4):625–634.
© 2019 The Author(s). This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.