The meaning of frailty according to Dutch older frail and non-frail persons
Introduction
Frailty is a fast growing research area in gerontology and geriatric medicine, addressing its causes, risk factors and adverse outcomes. The term frailty was not often used before the 1990's (Hogan et al., 2003, Hamerman, 1999, Rockwood et al., 1994, Swinne et al., 1998). Since then, the concept of frailty has been used as a reservoir for different health problems that accompany aging.
Historically, frailty is a term used with a variety of definitions and most of those early definitions included adverse health outcomes of frailty rather than a definition of frailty itself. For example, Woodhouse et al. (1988) described frail elderly as “individuals, aged 65 and over, dependent on others for activities of daily living and suffering from several diseases” whereas Gillick (1989) described frail older persons as “old debilitated individuals who cannot survive without the help from others”.
In the more recent definitions, some sort of impaired physiological functioning is included and the adverse outcomes are excluded. Buchner and Wagner (1992) defined frailty as “the state of reduced physiologic reserve associated with increased susceptibility to disability”. Currently the most frequently used definition in research is the one by Fried et al. who defined frailty as “frailty represents a state of age-related physiologic vulnerability resulting from impaired homeostatic reserve and a reduced capacity to withstand stress” (Walston & Fried, 1999) and operationally defined frailty when three or more of the following criteria were present: unintentional weight loss, muscle weakness, poor endurance and energy, slowness and low physical activity Fried et al. (2001).
Although there is no consensus yet about the definition, the term frailty is often used by health care professionals and researchers (Bergman et al., 2007, Hogan et al., 2003, Rockwood, 2005). Recently on the JAMA patient page, it was described which impact frailty can have on the lives of older patients and what the older patient can do to prevent frailty (Torpy, Lynm, & Glass, 2006). Geriatricians in the USA were asked what they considered to be components of frailty. More than half of the respondents mentioned the following characteristics: undernutrition, functional dependence, prolonged bed rest, pressure sores, gait disorders, generalized weakness, aged > 90 years, weight loss, anorexia, fear of falling, dementia, hip fracture, delirium, confusion, going outdoors infrequently and polypharmacy (Fried et al., 2004).
While there is no consensus on the definition yet, there is agreement on the impact of frailty on the older person, their family, and the caregivers as well as on society as a whole (Bergman et al., 2004, Rockwood, 2005). Several studies provide evidence that frailty is a predictor of adverse outcomes such as falls disability, institutionalization and mortality (Chin A Paw et al., 2003, Fried et al., 2001, Puts et al., 2005, Woods et al., 2005, Rockwood et al., 1999, Mitnitski et al., 2002). As the number of older persons increases, the prevalence of frailty in the population will increase. Frailty will be a major health problem and will lead to an increase in the use of health care by older persons.
Kaufman (1994) explored the construction of frailty in vulnerable elderly and found that frailty is ascribed by others to older persons with health problems. To date there is little research on what the term frailty means to older persons. A better understanding of what frailty encompasses according to older persons can be useful to health care providers to help older adults age successfully. Furthermore, a better understanding of the meaning of the term frailty may help future research to establish a valid definition that is meaningful to researchers, clinicians and older persons. Qualitative research may give insight into older adults' perceptions. The aim of this study is to describe the meaning of frailty to older persons.
Section snippets
Study sample
For this study the data were collected in the context of the Longitudinal Aging Study Amsterdam (LASA). LASA is an ongoing multidisciplinary study on predictors and consequences of changes in physical, cognitive, emotional and social functioning in older people in the Netherlands. A random sample of people aged 55 to 85 was drawn from population registers of eleven municipalities in three geographical areas in the Netherlands in 1992. The details of the LASA study have been described elsewhere (
Results
Fourteen non-frail and eleven frail respondents participated (see Table 1), including fourteen men and eleven women; the mean age was 78.7 years (range 67–90). Most respondents had one or more chronic diseases. Physical and mental health was lower for the frail persons. The mean SF-12 Physical Component Score for the non-frail respondents was 45.6 (range 17.0–56.3) and for the frail respondents 38.2 (28.0–54.2) (P = 0.10). The mean SF-12 Mental Component Score for non-frail respondents was 55.2
Respondent 10 (non-frail)
R: well indeed an older person is frail when you suffer from certain ailment that makes you vulnerable. For example an operation that resulted in complications, which leads to another surgery, this person is vulnerable because he/she needs to be very careful to prevent other negative consequences, so that person is frail. For example, this person has to watch out when walking on the street, because a fall could be lethal for this person. So frail in the sense that is person is at high risk for
Respondent 7 (non-frail)
Well a person is frail when he cannot cope with everyday life.
Respondent 6 (non-frail)
R: Well, then I would have to tell you about my youngest sister. She is quite frail. She lives in fear. Well, I don't know if she is as fearful as my wife, but she is afraid of dogs, she is afraid of flying, she does not dare go shopping alone, she is, well…
I: Would you say that if somebody is living in constant fear that makes you frail?
R: Yes. That definitely makes you frail because that makes you dependent on whether somebody wants to hold your hand and go with you, go with you when you go
Respondent 20 (frail)
R: A person is frail when he/she is, well not even that much physically but mentally traumatized.
I: Traumatized in what sense?
R: Well, when other persons yell at you, aggressive behavior of other persons, it did not happen to me but pickpockets often select older persons to rob, well that person must feel very frail.
These citations show that frailty also had a more psychological/cognitive functioning dimension according to the respondents. Not feeling well, not being optimistic, not being
Respondent 3 (non frail)
Well my mother-in-law, she lived for a while in the Poort (nursing home) and then you come there and you see those people, all people who functioned well in society, and I noticed that occasionally when I was working with the fire brigade, you come there (the nursing home) and then you see people around you pee-ing in the corner and another one has a diaper, I find that terrible, really. Then I find you are very frail, yes…. And also a friend of mine has Alzheimer's disease, which is a
Respondent 17 (frail)
R: Well look at my sister. Physically her health is declining terribly. She used to be a beautiful women and she can no longer take part in things. She lived at the park and she worked with young people as a volunteer for 30 years. Now she can't do that any more. My other sister and her husband will be 65 years old and there will be a brunch but she can't go because of her stoma and I think that's so sad.
I: Is that the reason you say your sister is frail?
R: Yes. Yes, definitely, because she
Respondent 23 (frail)
R: Well there is a man in this building. He used to be a teacher and nowadays he walks with a walking-cane, he trembles when he walks. The way his health is declining, I find that awful for him. Last time he went away with a bus trip and he was so worn out, the next day he could not do anything. He did not go on the next bus trip and he stayed home. Well his wife was able to go and she went. But I mean I find it pitiful that he was all alone at home that day.
These quotes clearly show that an
Differences in frailty between men and women
We have examined whether there were differences between men and women and the descriptions of frailty. Both men and women mention all three aspects, reduced health, psychological well-being and social contacts. However, men stress more the presence of chronic diseases, functional limitations and dependence in activities of daily living. Most men name multiple diseases such as cancer, arthritis, stroke and heart infarcts and the impact of those diseases on a person's ability to remain living
Respondent 10 (non-frail)
R: I am not frail! My wife however is frail, but I am not. I am not defeated quickly; I do not give up easily!
I: does not giving up prevent frailty?
R: YES!
The non-frail respondents described the meaning of frailty in a more distant manner, they often gave an explanation why they are not frail in that regard; they contrasted their own abilities with those considered frail. Frail persons, when describing a frailty characteristic, were less likely to use contrasting examples but more often use
Respondent 22 (frail)
R: I am frail, due to all my health problems.
Respondent 16 (frail)
R: Well I am frail in the sense that I am afraid that something will happen to me. If I would fall off my bike I am very afraid to break something.
As shown in these citations, frail respondents used themselves and sometimes others to describe what frailty meant to them and why they themselves felt frail.
There were eight persons for whom our classification did not match with their own classification: two non-frail and six frail. From the 2 non-frail persons who classified themselves as partially
Prevention of frailty
As a last topic, participants were asked their opinion on whether or not frailty was something that could be prevented and were probed for their reasons for their answer. In case they felt frailty could be prevented, it was asked how they thought it could be prevented and subsequently it was asked what they themselves were doing to prevent frailty. The non-frail respondents mentioned more often spontaneously the importance of preventive actions, while the frail respondents more often described
Respondent 4 (non-frail)
R: You have to watch your diet and try to eat healthy, that will help prevent frailty. So that is what we do.
Respondent 5 (non-frail)
I: Is there something that you do to prevent becoming frail?
R: Well you have to eat healthy, right. I am not that meticulous but lots of vegetables and lots of fruits. And milk and yoghurt, and oil and occasionally butter.
I: So according to you frailty can be prevented by eating healthy?
R: Yes and staying active! You have to stay physically active. And you don't need to go to the gym but you have to stay active!
As shown in the citations above, the non-frail persons reported that frailty is
Respondent 20 (frail)
I: Is there something that you do to prevent becoming frail?
R: Frailty is not something that you can prevent, you cannot do anything, it just happens when you get older.
Respondent 25 (frail)
I: Is there something that you do to prevent becoming frail?
R: You cannot avoid getting frail, nothing can be done to prevent it. Only if you stay healthy everything is much easier when you get older.
These two frail persons reported that frailty was something that happened to a person with aging, and that a person could not influence this very much; they felt it all depended on whether one's health remained good. This was mentioned by several other frail respondents. Frail persons stated also
Discussion
This study explored the meaning of frailty to older frail and non-frail respondents living in the community, which no study has done so far. Frailty appeared to consist of three dimensions: physical functioning, psychological/cognitive functioning and social functioning.
The concept of frailty was described as a state of multiple health problems combined with other problems such as anxiety and isolation. The non-frail persons often contrasted their own abilities to those of persons they
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2019, International Journal of Nursing StudiesCitation Excerpt :Another study investigating older adults’ perspective of frailty concluded that frailty was associated with physical appearance (the body, size, strength and power) and emotional experiences (helplessness and irresponsibility) (Grenier, 2007). Puts et al. (2009) stated that “frailty is viewed as a state that is characterized by reduced health together with psychological and social limitations that leads to a situation in which a person is not able to do what he/she enjoys”. Frailty was described as a clinically identifiable geriatric syndrome with multiple dimensions, deficits and weakness, across a continuum (Abellan van Kan et al., 2008a; Calvani et al., 2015; Rodriguez-Manas et al., 2013; Siriwardhana et al., 2018; Walston et al., 2006).
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2019, Geriatric NursingCitation Excerpt :Subjects in both studies described frailty holistically with physical, psychological and social elements,26,29 which is similar to how successful aging values are typically classified by participants. Participants in both studies also spoke about the value of health behaviors, particularly physical activity, for frailty prevention, and frail participants also discussed the inevitability of frailty, similar to the discussions of acceptance in the aging literature.26,29 One notable difference between participants' discussions of frailty vs. aging is that frail participants often optimistically do not identify as frail, whereas aging is more difficult to deny.26,29
- 1
Centre for Clinical Epidemiology and Community Studies, Solidage Research group, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, 3755 Côte Ste-Catherine, Montréal, Québec, Canada H3T 1E2.