Background
Frailty and its impact
The FOCUS project
FOCUS project deliverablesa | Evidence type | EtD criteria for which the evidence was considered relevant |
---|---|---|
Systematic review of the effectiveness of interventions on frailty (D4.1.2) [11] | Quantitative: A systematic review of randomised studies on interventions on frailty in older people, including health economy studies | Benefits, harms, resource use, cost-effectiveness, equity |
Review of qualitative studies on frailty interventions with stakeholders (D4.1.3) [12] | Qualitative: A meta-synthesis of qualitative studies on stakeholders’ views and experiences of care and interventions in the context of frailty | Outcome importance, value, equity, acceptability, feasibility |
Thematic summary of focus groups with stakeholders in three different EU states (D4.1.4) [13] | Qualitative: An inductive thematic analysis of semi-structured focus groups and individual interviews in three European countries (Italy, Poland, UK) with five groups of stakeholders, including frail and non-frail older adults, family caregivers, and health and social care professionals | Outcome importance, value, equity, acceptability, feasibility |
Thematic summary of joint focus groups with EU policy-makers (D4.1.5) [14] | Qualitative: An inductive thematic analysis of semi-structured interviews with seven healthcare policy-makers across Europe | Outcome importance, value, equity, acceptability, feasibility |
Structured survey of partners within the EIP-AHA (D4.1.7) [15] | Mixed: A structured survey seeking the opinions of EIP-AHA partners | Outcome importance, value, equity, acceptability, feasibility |
Realist review (D4.1.8) [16] | Mixed: A realist review combining findings from the different components to examine what works, for whom and in what circumstances | Outcome importance, value, equity, acceptability, feasibility |
Comprehensive report of the results of the comparative analyses and modelling (FOCUS internal deliverable D5.2.1–5) | Quantitative: Comparative analyses of EIP-AHA commitments upon structure, process and outcome indicators; modelling analyses of significant predictors of outcome, health and social care needs and use in the frame of frailty, with projected impact of changes in frailty as a result of interventions | Resource use and feasibility (additional considerations) |
The need for clinical guidelines
Main text
Definition of the clinical questions: frailty as an outcome
GQ – Should interventions to prevent or delay the progression of frailty, or to reverse frailty, be adopted in prefrail or frail older people? | |
Q1 – Should physical interventions be recommended to prevent or delay the progression of frailty, or to reverse frailty, in prefrail or frail older people? | |
Q2 – Should interventions based on tailored care and/or GEM be recommended to prevent or delay the progression of frailty, or to reverse frailty, in prefrail or frail older people? | |
Q3 – Should other interventions be recommended to prevent or delay the progression of frailty, or to reverse frailty, in prefrail or frail older people? | |
Patients: People aged 65 years or older, defined as prefrail or frail according to a pre-specified scale, index or criteria, not at the end-of-life phase or selected because of an index disease Interventions: GQ: Any intervention explicitly defined as an intervention for frailty (regardless of the definition of frailty used) Q1: Physical interventions • Interventions based on exercise/physical activity • Nutritional interventions (e.g. diet change, supplementation) • Exercise/physical activity combined with nutritional interventions Q2: Interventions based on tailored care and/or GEM • Uni-professional interventions based on tailored care/GEM • Multidisciplinary interventions based on tailored care/GEM Q3: Other interventionsa • Cognitive training • A composite of exercise + nutritional supplementation + cognitive training • Exercise + nutritional consultation • Problem-solving therapy • Hormone therapy • Others Reference intervention: No intervention or placebo or usual care Outcomes: • Frailty – defined according to a composite index, or based on physical performance tests commonly related to the ‘frailty’ definition (SPPB, TUG, gait speed, handgrip strength) • Other relevant patient important outcomes – cognitive performance, functional performance, other measures of physical performance, quality of life, depression, self-perceived health, social engagement, caregiver burden, falls and fractures, mortality, hospitalisation, institutionalisation, comorbidity burden, drug prescription Setting: Any (community, primary care, nursing homes, hospitals) Perspective: Population |
Selection of a framework: GRADE and Evidence-to-Decision
FOCUS evidence base
Consensus process
FOCUS guidelines and their justification
GQ – Should interventions to prevent or delay the progression of frailty, or to reverse frailty, be adopted in prefrail or frail older people?
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Recommendation RG
| Conditions for the intervention to succeed [14] |
We suggest implementing interventions specifically intended to have an impact on frailty in older age, i.e. preventing or delaying the progression of frailty, or reversing frailty (conditional strength of recommendation) |
Participant factors
• Co-create the details of interventions with intended recipient groups • Consider the level of frailty of participants • Employ best practice health psychology behaviour change strategies • Consider group and fun, rewarding interventions wherever possible • Determine whether the intervention is only appropriate if a specific deficiency is present, e.g. nutritional deficiency • Before implementing an intervention, consider correcting deficiencies that can interact with the intervention’s working mechanisms • Address understanding and attitudes towards malleability of frailty of patients before the intervention • Address self-efficacy in the intervention activity • Consider accessibility of locations to individuals • Employ approaches that are person, family and ‘lifeworld’ centred • Include social and psychological wellbeing factors
Organisational factors
• Co-create the details of interventions with intended delivery practitioners • Ensure training to emphasise implementation fidelity and standardisation of delivery • Address practitioners’ understanding and attitudes towards the malleability of frailty before the intervention • Consider expectations of older adults’ commitment and ability to participate • Provide some training in health psychology components
Country/contextual/cultural factors
• Consider the suitability of the intervention for your context (e.g. clinical, community, inpatient, outpatient) • Consider likely cultural preferences, e.g. for expert-led or self-directed interventions • Consider what ‘normal care’ is in your context • Consider the level of existing health literacy in your population |
Q1 – Should physical interventions be recommended to prevent or delay the progression of frailty, or to reverse frailty, in prefrail or frail older people?
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Recommendation R1
| Conditions for the intervention to succeed [14] |
We suggest implementing physical interventions, including physical activity/exercise, nutritional interventions, and a combination of exercise and nutritional interventions, to prevent or delay the progression of frailty, or to reverse frailty (conditional strength of recommendation). The recommendation is stronger for group-based supervised exercise programmes, either alone or in association with nutritional supplementation | Among the factors to consider when an intervention on frailty is implemented, those which are particularly relevant in the case of physical interventions are: • Consider implementing those factors that can increase participants’ acceptance of and, as a consequence, compliance to the intervention, i.e. the inclusion of elements favouring or promoting socialisation, fun, accessibility, self-efficacy and commitment. Among those factors, consider the implementation of group-based exercise programmes and supervision by professionals with adequate training; in general, include professionals with adequate skills in health psychology and communication; the inclusion of these elements might affect the adherence to the intervention • Consider the characteristics of the participants to whom the intervention will be directed, for example, the presence of deficits that make the intervention necessary, and the level of expected compliance. The level of frailty particularly may have an important impact, not least because it is likely to be associated with these other characteristics • Even though physical interventions for physical components of frailty are appropriate, considering the person as a whole, including, for example, their psychological wellbeing and functions and their social context, may be beneficial • The opportunity to take into account and include these elements might affect the feasibility and suitability of the interventions in each specific context |
Q2 – Should interventions based on tailored care and/or GEM be recommended to prevent or delay the progression of frailty, or to reverse frailty, in prefrail or frail older people?
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Recommendation R2
| Conditions for the intervention to succeed [14] |
We suggest implementing interventions based on tailored care and/or GEM, to prevent or delay the progression of frailty, or to reverse frailty (conditional strength of recommendation). The recommendation is stronger for GEM-based interventions involving a multidisciplinary team, especially in inpatient clinical settings, but still conditional to the confirmation from further studies of good quality | Among the factors to consider when an intervention on frailty is implemented, those of particular relevance to interventions aimed at a more comprehensive concept of frailty: • Consider the context (the clinical setting, usual care, cultural preferences) • Co-create the details of interventions with intended delivery practitioners, provide adequate training to ensure implementation fidelity • Consider the inclusion of professionals with adequate skills or provide training in health psychology and communication • Employ approaches that are person, family and ‘lifeworld’ centred |
Q3 – Should other interventions be recommended to prevent or delay the progression of frailty, or to reverse frailty, in prefrail or frail older people?
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Recommendation R3
| Conditions for the intervention to succeed [14] |
We suggest considering interventions to prevent or delay the progression of frailty, or to revert frailty, based on cognitive training, alone or in combination with exercise and nutritional supplementation (conditional strength of recommendation), and on exercise combined with diet consultation, at least in prefrail populations. At the moment, the panel does not suggest adopting interventions based on hormone therapy or on problem-solving therapy with the aim of preventing or delaying the progression of frailty or of reverting frailty (conditional strength of recommendation). Currently, there is no evidence in favour or against other interventions potentially effective on frailty (e.g. other types of psychological interventions, interventions mainly focused on increasing socialisation, other types of hormone therapies and pharmacological interventions). | Many of the factors described for the success of a physical intervention (refer to Q1), or for interventions based on a patient-centred approach and comprehensive care (refer to Q2), are also relevant to alternative interventions described in Q3. |