Elsevier

Preventive Medicine

Volume 119, February 2019, Pages 63-69
Preventive Medicine

Review Article
Should we screen for frailty in primary care settings? A fresh perspective on the frailty evidence base: A narrative review

https://doi.org/10.1016/j.ypmed.2018.12.020Get rights and content

Highlights

  • Frailty is highly prevalent among older people and has serious consequences.

  • Emerging evidence suggests frailty is reversible but needs early identification.

  • Debate continues over whether the evidence base justifies systematic screening.

  • Practitioners and policy-makers need objective criteria to assess the evidence.

  • The evidence base is currently insufficient to support systematic screening of all older adults.

Abstract

With older adults living longer, health service providers have increasingly turned their attention towards frailty and its significant consequences for health and well-being. Consequently, frailty screening has gained momentum as a possible health policy answer to the question of what can be done to prevent frailty's onset and progression. However, who should be screened for frailty, where and when remains a subject of extensive debate. The purpose of this narrative review is to explore the dimensions of this question with reference to Wilson and Jungner's time-tested and widely accepted principles for acceptable screening within community settings. Although the balance of the emerging evidence to support frailty screening is promising, significant gaps in the evidence base remain. Consequently, when assessed against Wilson and Jungner's principles, extensive population screening does not appear to be supported by the evidence. However, screening for the purpose of case-finding may prove useful among older adults.

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

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