Review ArticleShould we screen for frailty in primary care settings? A fresh perspective on the frailty evidence base: A narrative review
Introduction
Frailty has assumed increasing importance as a public health concern for policy-makers and practitioners worldwide in recent years (Boeckxstaens and De Graaf, 2011; Mur-Veeman et al., 2008; Nicholson et al., 2012; Cesari et al., 2016; Buckinx et al., 2015). Frail older adults currently interact with the health system in a wide variety of settings (Turner and Clegg, 2014), with hospitals, long-term care facilities and specialist geriatric units traditionally assuming responsibility for management. However, treatment within these settings is necessarily focused on acute rather than preventive care. Given increasing pressure on the health care system, screening and management within the community to proactively identify frailty has been advanced as a rational solution (Turner and Clegg, 2014). In particular, general practice is often identified as one of the most appropriate settings for frailty screening within the community (Sutorius et al., 2016), given the relatively frequent presentation of older adults to primary care (Hoogendijk et al., 2012).
Frailty assessment is widely considered to be a useful means of risk stratification within the diverse population of older adults (Chen et al., 2014). Consequently, an expert consensus has called for widespread screening of all older adults for frailty in recent years (Morley et al., 2013). In contrast, some have argued against taking action on screening until the evidence base improves (Sourial et al., 2013). This inconsistency is unfolding against the context of a rapidly ageing population worldwide (United Nations, 2017), leading some to conclude that “we cannot wait” for research to catch up with clinical practice (Vellas et al., 2012). Others have argued for a “screening as case-finding” approach (Turner and Clegg, 2014; Martin-Lesende et al., 2015), believing that frail older people may be falling through the gaps of frailty identification and management. A recent initiative reflecting this kind of approach is the United Kingdom's “GP contract” policy initiative requiring general practitioners (GPs) to identify and manage all older patients (aged 65+ years) who are moderately to severely frail (Chapman and Thomas, 2017). Meanwhile, the volume of frailty research continues to grow rapidly in size and complexity, frustrating attempts to arrive at meaningful consensus over a practical way forward. Now more than ever, health service providers and policy makers need objective criteria to formally assess the appropriateness of frailty screening in primary care settings.
Since the 1960s, the principles identified by Wilson and Jungner (Wilson and Jungner, 1968) (Table 1) have served as the standard for determining the appropriateness of screening (Andermann et al., 2008). However, to our knowledge, frailty screening has not been explicitly assessed against their framework. In part, this may be due to the fact that frailty is commonly characterised as a syndrome (Morley et al., 2013; Byard, 2015; Chen et al., 2016; Ferrucci et al., 2003; D et al., 2017; Ahmed et al., 2007), rather than as a disease per se. Whereas a syndrome can be defined as a group of “symptoms and signs definable without necessarily implying knowledge of etiology, pathology or a clear course of treatment”, a disease usually signifies that the cause is known (Merchant et al., 1995). Although understanding of the etiology of frailty is increasing, much still remains unexplained (Ahmed et al., 2007; Fulop et al., 2010), and so the syndrome characterisation seems appropriate.
A related question arises: is it appropriate then to apply Wilson and Jungner's criteria to a syndrome rather than a disease? Further, given the established link between frailty and increased risk of negative outcomes (Vermeiren et al., 2016), is it appropriate to apply the criteria to a risk factor rather than a disease? In both cases, numerous precedents within public health research indicate that it is. Wilson and Jungner's criteria have previously been applied to assess the appropriateness of screening for syndromes, disorders and risk factors as diverse as Lynch syndrome (Cragun et al., 2015), childhood eye disorders (Jarvis et al., 1990), Coxiella burnetii infection (Munster et al., 2012), congenital cytomegalovirus infection (de Vries et al., 2011) and TP53 mutation (Isabel et al., 2009), among many others. Lastly, the widespread frequency in practice of screening for risk factors and syndromes, rather than just diseases per se, would also seem to justify including frailty. Thus, the aim of this narrative review is threefold: (1) to synthesise and interpret the current frailty evidence against Wilson and Jungner's principles within the context of primary care; (2) to inform policy and practice; (3) and to highlight any evidence gaps.
Section snippets
Frailty definition
Frailty is frequently characterised as a biological syndrome within the clinical literature (Clegg et al., 2013). It features “decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes” (Fried et al., 2001):M146. There are two key approaches to defining frailty. The first is the Frailty Phenotype (FP), a physical frailty model incorporating “involuntary weight loss, exhaustion, slow gait
Results
Arguments for and against frailty screening against each of Wilson and Jungner's principles are summarised in Fig. 1. The pros and cons of screening as presented in the diagram are a descriptive summary against each principle.
Discussion
Frailty is one of the most prevalent and yet relatively unrecognized public health problems associated with population ageing. While screening has the potential to proactively address frailty, many pros and cons surround the practice when compared to Wilson and Jungner's principles for screening. Other questions of why, who, and when to screen also remain. In addition, the principles contain little guidance as to how they should be weighed against each other or how many should be met before
Conclusion
Society's awareness of frailty and frailty screening is at a very early stage; however, the quality of the evidence is improving rapidly. This article has compared existing evidence to Wilson and Jungner's principles for screening. Although emerging evidence is promising, it is currently insufficient to reach a definitive recommendation on screening based on those principles, and readiness for screening is likely to vary greatly by setting. Ultimately, to successfully address frailty,
Conflict of interest
All authors report no conflicts of interest.
Author contributions
The paper concept and design were formulated by RA, JB, RV, ED, SY, and ABM. Preparation of the manuscript was completed by RA. RA, JB, RV, ED, SY, and ABM reviewed and edited the manuscript. All authors have read and approved the final version of the manuscript.
Funding
This research was supported by the National Health and Medical Research Council of Australia via funding provided for the Centre of Research Excellence in Frailty and Healthy Ageing [grant
References (92)
- et al.
Frailty: an emerging geriatric syndrome
Am. J. Med.
(2007) Frailty syndrome - medicolegal considerations
J. Forensic Legal Med.
(2015)- et al.
Frailty: an emerging public health priority
J. Am. Med. Dir. Assoc.
(2016) - et al.
Frailty in elderly people
Lancet
(2013) - et al.
Frailty measurement in research and clinical practice: a review
Eur. J. Intern. Med.
(2016) - et al.
The Asia-Pacific clinical practice guidelines for the management of frailty
J. Am. Med. Dir. Assoc.
(2017) - et al.
Economic evaluation of a multifactorial, interdisciplinary intervention versus usual care to reduce frailty in frail older people
J. Am. Med. Dir. Assoc.
(2015) - et al.
The frailty syndrome: a critical issue in geriatric oncology
Crit. Rev. Oncol. Hematol.
(2003) - et al.
The Tilburg frailty indicator: psychometric properties
J. Am. Med. Dir. Assoc.
(2010) - et al.
Frailty in institutionalized older adults from Albacete. The FINAL study: rationale, design, methodology, prevalence and attributes
Maturitas
(2014)
Transitions in frailty states among community-living older adults and their associated factors
J. Am. Med. Dir. Assoc.
The effectiveness of a comprehensive geriatric assessment intervention program for frailty in community-dwelling older people: a randomized, controlled trial
Arch. Gerontol. Geriatr.
Effects of a home-based and volunteer-administered physical training, nutritional, and social support program on malnutrition and frailty in older persons: a randomized controlled trial
J. Am. Med. Dir. Assoc.
Frail elderly people: detection and management in primary care
Eur. Geriatr. Med.
A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans
J. Nutr. Health Aging
Frailty consensus: a call to action
J. Am. Med. Dir. Assoc.
Comparing integrated care policy in Europe: does policy matter?
Health Policy (New York)
Living on the margin: understanding the experience of living and dying with frailty in old age
Soc. Sci. Med.
PRISMA-7: a case-finding tool to identify older adults with moderate to severe disabilities
Arch. Gerontol. Geriatr.
Research on frailty: continued progress, continued challenges
J. Am. Med. Dir. Assoc.
A multicomponent exercise intervention that reverses frailty and improves cognition, emotion, and social networking in the community-dwelling frail elderly: a randomized clinical trial
J. Am. Med. Dir. Assoc.
Editorial implementing frailty into clinical practice: we cannot wait
J. Nutr. Health Aging
Looking for frailty in community-dwelling older persons: the Gérontopôle Frailty Screening Tool (GFST)
J. Nutr. Health Aging
Frailty and the prediction of negative health outcomes: a meta-analysis
J. Am. Med. Dir. Assoc.
Application of an electronic Frailty Index in Australian primary care: data quality and feasibility assessment
Aging Clin. Exp. Res.
Revisiting Wilson and Jungner in the genomic age: a review of screening criteria over the past 40 years
Bull. World Health Organ.
Predicting risk and outcomes for frail older adults: an umbrella review of frailty screening tools
JBI Database Syst. Rev. Implement. Rep.
Perspectives of frailty and frailty screening: protocol for a collaborative knowledge translation approach and qualitative study of stakeholder understandings and experiences
BMC Geriatr.
Mild cognitive impairment: coping with an uncertain label
Int. J. Geriatr. Psychiatry
Making sense of nonsense: experiences of mild cognitive impairment
Sociol. Health Illn.
Multidimensional structure of the Groningen Frailty Indicator in community-dwelling older people
BMC Geriatr.
Cost-effectiveness of a proactive primary care program for frail older people: a cluster-randomized controlled trial
J. Am. Med. Dir. Assoc.
Associations of frailty with health care costs - results of the ESTHER cohort study
BMC Health Serv. Res.
International exchange primary care and care for older persons: position paper of the European forum for primary care
Qual. Prim. Care
Burden of frailty in the elderly population: perspectives for a public health challenge
Arch. Publ. Health Arch. Belg. Santé Publique
A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial
BMC Med.
Spontaneous reversion of clinical conditions measuring the risk profile of the individual: from frailty to mild cognitive impairment
Front. Med.
The frailty phenotype and the frailty index: different instruments for different purposes
Age Ageing
A physical activity intervention to treat the frailty syndrome in older persons - results from the LIFE-P study
J. Gerontol. Ser. A Biol. Sci. Med. Sci.
Falls and the rise of the GP contract: an EMIS web protocol and template to help identify frail patients
Br. J. Commun. Nurs.
Frailty syndrome: an overview
Clin. Interv. Aging
Frailty is a geriatric syndrome characterized by multiple impairments: a comprehensive approach is needed
J. Frailty Aging
Frailty characteristics and preventive home visits: an audit on elderly patients in Danish general practice
Fam. Pract.
Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review
Age Ageing
Development and validation of an electronic frailty index using routine primary care electronic health record data
Age Ageing
Prevalence of frailty in community-dwelling older persons: a systematic review
J. Am. Geriatr. Soc.
Cited by (55)
Clinical practice guidelines for frailty vary in quality but guide primary health care: a systematic review
2023, Journal of Clinical EpidemiologyFrailty in Patients with Chronic Graft-versus-Host Disease
2023, Transplantation and Cellular TherapyA global perspective on risk factors for frailty in community-dwelling older adults: A systematic review and meta-analysis
2023, Archives of Gerontology and GeriatricsSelf-Reported Frailty Screening Tools: Comparing Construct Validity of the Frailty Phenotype Questionnaire and FRAIL
2022, Journal of the American Medical Directors AssociationCitation Excerpt :The concept of frailty identification in the community is complex, in part because frailty is characterized as a syndrome and the appropriateness of screening for a particular syndrome has not yet been clearly determined, as it does not entirely resemble screening in its traditional sense. Moreover, recommendations for frailty screening in the community are currently inconsistent, with arguments for and against being proposed but with yet no clear consensus.29 Nonetheless, the role of frailty as an increasing health concern in the older population creates a growing imperative to address frailty within the community setting despite challenges in its identification and management.
Frailty in primary care: Diagnosis and multidisciplinary management
2022, Atencion PrimariaFacilitating the planning and evaluation of narrative intervention reviews: Systematic Transparency Assessment in Intervention Reviews (STAIR)
2022, Evaluation and Program PlanningCitation Excerpt :Some reviews provided detailed information into the search methodology used, listing all the databases used and the search terms employed, but did not provide the total number of articles reviewed. One review tantalised with ‘the references of included studies were selectively searched’ (Ambagtsheer et al., 2019) but did not provide total article numbers or references. The communication of both the total number of articles and the references is needed.