Elsevier

The Lancet

Volume 394, Issue 10206, 12–18 October 2019, Pages 1376-1386
The Lancet

Series
Management of frailty: opportunities, challenges, and future directions

https://doi.org/10.1016/S0140-6736(19)31785-4Get rights and content

Summary

Frailty is a complex age-related clinical condition characterised by a decline in physiological capacity across several organ systems, with a resultant increased susceptibility to stressors. Because of the heterogeneity of frailty in clinical presentation, it is important to have effective strategies for the delivery of care that range across the continuum of frailty severity. In clinical practice, we should do what works, starting with frailty screening, case identification, and management of frailty. This process is unarguably difficult given the absence of an adequate evidence base for individual and health-system interventions to manage frailty. We advocate change towards individually tailored interventions that preserve an individual's independence, physical function, and cognition. This change can be addressed by promoting the recognition of frailty, furthering advancements in evidence-based treatment options, and identifying cost-effective care delivery strategies.

Introduction

Frailty is without question one of the most serious global public health challenges we will face this coming century. The rapid expansion of the ageing population has brought a concomitant rise in the number of older adults with frailty,1, 2 which in turn places an increased pressure on health-care systems worldwide.3 Unfortunately, older people with frailty have an increased likelihood of unmet care needs, falls and fractures, hospitalisations, lowered quality of life, iatrogenic complications, and early mortality.4, 5, 6, 7, 8, 9 This increased risk of adverse outcomes can occur even without the presence of comorbidities.4 Therefore, effective strategies that target the prevention and management of frailty in an ageing population will probably reduce the condition's burden at the level of both the individual and the health system.

In reflection of increased research interest, the term frailty was introduced as a PubMed Medline Search Heading (MeSH) in January, 2018. Frailty is recognised as an age-related clinical condition10, 11, 12 that is typically observed by a deterioration in the physiological capacity of several organ systems,4, 8, 12, 13 and that causes an increased susceptibility to stressors.4, 7, 8, 10, 11, 12 When stressor events (such as acute illness) occur, a person with frailty rapidly deteriorates in functional capacity. Thus, interventions to prevent or slow the progression of frailty before it leads to substantial functional decline are key concerns for health-care policy and provision.

In general, frailty is recognised as the physical state that exists before occurrence of disability,7, 8 although it is possible for frailty and disability to coexist.14 Frailty is also a dynamic entity that exists on a continuum from fit to frail,4, 13, 15 wherein an individual's level of frailty is able to change in either direction over time.7 Correspondingly, frailty is potentially reversible7, 8 and its associated functional decline is also a potentially preventable disability.16 In many cases, frailty onset starts before age 65 years, although not all adults develop frailty, even at advanced ages.4 Notably, the use of frailty measurements for the purposes of prognosis has recently emerged from geriatric medicine and into the medical specialties.9, 17, 18, 19 What this means is that recognition of an individual's frailty status can inform treatment decisions, goals of care, and recovery expectations.20

Key messages

  • Although presence of frailty might seem like an ideal way to identify people who need additional support services, there is a shortage of substantial research evidence to support this strategy and to identify the most effective instruments to detect frailty

  • In clinical practice, the management of an older adult with frailty is complex because of the inadequate evidence base for individual and health-system interventions to manage the condition

  • We need to accrue more knowledge about which intervention strategies are effective for frailty, and to determine whether they are feasible and cost-effective

  • High quality clinical trials are needed that take into account the perspectives and needs of health-care providers, older people with frailty, and their carers

  • In the absence of a firm evidence base for interventions, strategies to manage frailty in daily practice can be based on existing consensus guideline recommendations

  • It is important that frailty does not become a new aspect of ageism that prevents access to interventions that could be appropriate

Over the past two decades, strategies to manage frailty have progressed substantially. However, to progress from traditional, episodic-based care to more proactive, person-centred care, we need to do much more. In this Series paper, we provide a critical review of the evidence base behind both individual and health-care system interventions targeting individuals with frailty. With a noticeable lack of high-quality research evidence regarding how best to identify and treat people with frailty, we provide a research-informed viewpoint of what strategies appear to work best. We acknowledge that although frailty can occur in people of all ages (particularly if comorbidities are present), the majority of intervention trials involve older populations. Hence, the focus of our review is on older adults, although findings might also be applicable to younger people with frailty. This paper is the second in this Series on frailty, with the first paper overviewing the concept of frailty, as well as its global burden, life-course perspective, and potential targets for prevention. An outline of terminology used in this Series is shown in panel 1. For this review, we consider frailty as distinct from advanced age, functional ability, and multimorbidity, even though it is related to these concepts.

Section snippets

The natural history of frailty

There is much heterogeneity in the course of physical frailty in the absence of treatment, with different initial manifestations often leading to different trajectories of frailty progression.12 Nevertheless, epidemiological studies have reported commonalities with regards to the first components of frailty to develop. For instance, on the basis of two large-scale cohort studies (the Longitudinal Aging Study Amsterdam with 15-year follow-up, and the InCHIANTI study with 9-year follow-up), the

Identification of frailty

Frailty instruments are prognostic across a broad range of medical interventions, including chemotherapy doses,31 cardiology procedures,17, 20 and abdominal surgery.18 In long-term care facilities, these instruments can be used to grade severity of frailty, thereby identifying individuals who might benefit most from a palliative approach and advanced care planning.32 Relatedly, in the acute care setting, frailty instruments can be used to assign triage categories to patients for the purposes of

Evidence from clinical trials targeting the individual

Table 2 outlines several individual strategies used for the management of people living with frailty, all of which have been shown to be superior to usual care in recent systematic and structured reviews. We excluded systematic reviews that did not use a validated frailty instrument to identify frailty. Also excluded were reviews that combined results of studies on both treatment and prevention, noting that older adults with frailty might respond differently to interventions than those without.

Potential goals and strategies of care

The management of frailty is not limited to physical and psychosocial domains.73 The objectives of clinical care for people with frailty are to maintain functional independence and quality of life, while avoiding unnecessary admissions to hospital or long-term care facilities.73, 74 Major evidence gaps in treatment strategies can be filled with existing consensus guideline recommendations. For example, NICE guidelines for multimorbidity encompass recommendations for the clinical management of

Interventions focusing on health-system targets

To manage the complexity of frailty and its array of associated factors, it seems logical to offer multi-component intervention packages at the public health and system levels (table 2). Theoretically, these packages will achieve their desired outcomes if their component strategies are implemented effectively. However, in practice, success rates of such packages have been underwhelming,86, 87, 88 which could perhaps reflect good usual care (including primary care services) in countries where

Implementing frailty identification in clinical practice

Health practitioners need to be aware of the great responsibility faced by caregivers of older adults with frailty.97 Recent work has also highlighted the importance of identifying the social support networks, resilience, and coping skills of older adults with frailty;98, 99, 100 these health assets can be used to ameliorate the challenges that frailty presents. The implementation of frailty identification in clinical practice should also take into consideration the potential burden of

Closing gaps between evidence and practice

Possible strategies to close gaps between evidence and practice in the field of frailty are outlined in panel 3. Examples of the most urgently required strategies are: high quality clinical trials with a broadened focus on health system targets and strategies; robust evidence on how to best manage frailty (including cost-effectiveness and the effectiveness of specialty care); and efficient care delivery strategies. We also need to derive precise biomarkers of frailty that will facilitate the

Conclusion

In response to population ageing, recent years have seen a rapid expansion in the recognition and knowledge of the phenomenon of frailty. At this point in time, many interventions for the clinical management of frailty are available, including physical activity, protein-calorie supplementation, and de-prescription of unnecessary medications. However, the effectiveness of these interventions is not supported by a firm evidence base. We need to accrue more evidence-based knowledge regarding which

Search strategy and selection criteria

We searched PubMed and the Cochrane Central Register of Controlled Trials for relevant publications using combinations of several search terms: “frailty”, “frailty/therapy*”, “patient care planning/standards”, “diet therapy”, “physical therapy modalities”, “drug therapy”, “therapy”, “aged”, “frailty/complications”, “frailty/diagnosis”, “geriatric assessment”, “frailty/metabolism”, “frailty/rehabilitation”, “micronutrients/administration and dosage” and “clinical trials”. Searches were limited

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