The meaning of frailty according to Dutch older frail and non-frail persons

Abstract

Frailty is a term often used by researchers and clinicians to describe a state in which older persons are at risk for adverse outcomes such as falls, disability, institutionalization and mortality. However, no study so far examined what frailty means to older persons. Therefore the aim of this study was to describe the meaning that older community-dwelling persons attach to frailty. Twenty-five semi-structured interviews were conducted. The interviews were analyzed using the grounded theory method. Frailty was described as being in poor health, having walking difficulties, feeling down, being anxious, having few social contacts and not being able to do the things one likes to do. Men described in more detail the physical dimension whereas women elaborated in more depth on the psychological and social component. Existing definitions of frailty should be adjusted to better reflect the meaning of frailty for older 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.