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Lameirinhas J, Gorostiaga A, Etxeberria I. Definition and assessment of psychological frailty in older adults: A scoping review. Ageing Res Rev 2024; 100:102442. [PMID: 39084321 DOI: 10.1016/j.arr.2024.102442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 07/22/2024] [Accepted: 07/26/2024] [Indexed: 08/02/2024]
Abstract
OBJECTIVES The confusion surrounding psychological frailty and its components prompts the need for a standardized conceptual definition. To address this, we aimed to (1) identify the psychological variables included in multicomponent frailty assessment instruments used with older adults and examine their operationalization; and (2) formulate a thorough conceptualization of psychological frailty based on the variables identified. METHODS This study followed the most recent recommendations for conducting scoping reviews and is reported in accordance with PRISMA-ScR guidelines. We systematically searched the CINAHL, MEDLINE, PsycInfo, Scopus, and Web of Science databases, with additional searches in Google Scholar and reference lists. RESULTS Sixteen instruments were identified. The results suggested that: (1) In multicomponent frailty assessment instruments, psychological variables are poorly represented; (2) A wide variety of psychological variables are included in the instruments, the most frequent being cognitive functioning and affective functioning (e.g., depressive symptoms, emotional loneliness, anxiety symptoms, poor coping, and suicidal ideation); and (3) The way in which variables are referred to and operationalized varies across instruments. CONCLUSIONS Including both cognitive and affective variables in psychological frailty assessments may lead to inaccuracies. We suggest distinguishing between two separate dimensions within psychological frailty: cognitive frailty and affective frailty. A conceptual definition for each dimension is provided. This proposal aims to advance the debate regarding the conceptualization and assessment of psychological frailty, with further research and discussion needed to ensure its practical applicability.
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Affiliation(s)
- Joanes Lameirinhas
- Department of Clinical and Health Psychology and Research Methodology, Faculty of Psychology, University of the Basque Country UPV/EHU, Donostia/San Sebastián, Gipuzkoa, Spain.
| | - Arantxa Gorostiaga
- Department of Clinical and Health Psychology and Research Methodology, Faculty of Psychology, University of the Basque Country UPV/EHU, Donostia/San Sebastián, Gipuzkoa, Spain
| | - Igone Etxeberria
- Department of Clinical and Health Psychology and Research Methodology, Faculty of Psychology, University of the Basque Country UPV/EHU, Donostia/San Sebastián, Gipuzkoa, Spain
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Gobbens RJJ, Uchmanowicz I. Frailty Viewed From a Nursing Perspective. SAGE Open Nurs 2023; 9:23779608221150598. [PMID: 36636626 PMCID: PMC9829991 DOI: 10.1177/23779608221150598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/18/2022] [Accepted: 12/24/2022] [Indexed: 01/09/2023] Open
Abstract
Introduction More and more researchers are convinced that frailty should refer not only to physical limitations but also to psychological and social limitations that older people may have. Such a broad, or multidimensional, definition of frailty fits better with nursing, in which a holistic view of human beings, and thus their total functioning, is the starting point. Purpose In this article, which should be considered a Practice Update, we aim at emphasizing the importance of the inclusion of other domains of human functioning in the definition and measurement of frailty. In addition, we provide a description of how district nurses view frailty in older people. Finally, we present interventions that nurses can perform to prevent or delay frailty or its adverse outcomes. We present, in particular, results from studies in which the Tilburg Frailty Indicator, a multidimensional frailty instrument, was used. Conclusion The importance of a multidimensional assessment of frailty was demonstrated by usually satisfactory results concerning adverse outcomes of mortality, disability, an increase in healthcare utilization, and lower quality of life. Not many studies have been performed on nurses' opinions about frailty. Starting from a multidimensional definition of frailty, encompassing physical, psychological, and social domains, nurses are able to assess and diagnose frailty and conduct a variety of interventions to prevent or reduce frailty and its adverse effects. Because nurses come into frequent contact with frail older people, we recommend future studies on opinions of nurses about frailty (e.g., screening, prevention, and addressing).
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Affiliation(s)
- Robbert J. J. Gobbens
- Faculty of Health, Sports and Social Work, Inholland University of
Applied Sciences, Amsterdam, the Netherlands,Zonnehuisgroep Amstelland, Amstelveen, the Netherlands,Department of Family Medicine and Population Health, Faculty of
Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium,Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg
University, Tilburg, the Netherlands,Robbert J. J. Gobbens, Faculty of Health,
Sports and Social Work, Inholland University of Applied Sciences, De Boelelaan
1109, 1081 HV Amsterdam, the Netherlands.
| | - Izabella Uchmanowicz
- Department of Nursing and Obstetrics, Faculty of Health Sciences,
Wroclaw
Medical University, Wroclaw, Poland,Institute of Heart Diseases, University Hospital, Wroclaw,
Poland
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Voie KS, Blix BH, Helgesen AK, Larsen TA, Maehre KS. Professional home care providers' conceptualisations of frailty in the context of home care: A focus group study. Int J Older People Nurs 2023; 18:e12511. [PMID: 36357358 PMCID: PMC10078232 DOI: 10.1111/opn.12511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 09/13/2022] [Accepted: 10/17/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND In Norway, as in many other countries, more people receive health and care services in their homes than before. Home care professionals provide care and support to people with a range of health and care needs. Older home care service users are sometimes referred to as 'frail', but the terms 'frail' and 'frailty' have different meanings in different contexts, and little is known about the meaning ascribed to the terms in the context of home care services. Home care services are crucial for many older persons who have health challenges, and how home care professionals conceptualise frailty might shape clinical encounters. OBJECTIVES The purpose of this study is to explore how home care professionals conceptualised frailty in the context of home care. METHODS We conducted four focus group discussions with 14 home care professionals who worked in municipal home care in northern Norway and analysed the data using thematic analysis. RESULTS Our analysis resulted in five themes: '"Frail" - a term which is too imprecise to be useful', 'Frailty as a consequence of ageing', 'Frailty as lack of engagement and possibilities for engagement', 'Frailty as a contextual phenomenon' and 'Frailty as potentially affected by care'. The home care professionals conceptualised frailty as an individual trait but also as resulting from the interplay between individual and environmental factors. Moreover, their conceptualisations of frailty represented a continuum between frailty as related to prevention and management ('cure') and frailty as related to ageing as natural decline ('care'). CONCLUSION The home care professionals conceptualised frailty diversely, as moving along a continuum between cure and care. Diverse conceptualisations of frailty might be necessary if nurses are to meet the changing and varying care needs of older persons who live in their own homes and need health and care services.
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Affiliation(s)
- Kristin S Voie
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Bodil H Blix
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Ann Karin Helgesen
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.,Faculty of Health, Welfare and Organisation, Østfold University College, Halden, Norway
| | - Toril Agnete Larsen
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Kjersti Sunde Maehre
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
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Lachonius M, Wallström S, Odell A, Pétursson P, Jeppsson A, Skoglund K, Nielsen SJ. Patients' motivation to undergo transcatheter aortic valve replacement. A phenomenological hermeneutic study. Int J Older People Nurs 2023; 18:e12521. [PMID: 36464490 PMCID: PMC10078399 DOI: 10.1111/opn.12521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/08/2022] [Accepted: 11/17/2022] [Indexed: 12/08/2022]
Abstract
BACKGROUND Aortic stenosis is the most common valvular disease, and its prevalence is increasing due to the ageing population. Transcatheter aortic valve replacement (TAVR) is the recommended method when treating frail, older patients. Knowledge of what motivates older patients to undergo TAVR is important, in order to meet patients' expectations. OBJECTIVE The study aimed to explore the meaning of older patients' motivation to undergo TAVR. DESIGN AND METHODS The design was a qualitative study, analysed using a phenomenological hermeneutic approach. In-depth, semi-structured interviews with open-ended questions were conducted. Participants were selected from a specialist cardiology clinic in Sweden. Eighteen patients, six women and twelve men, aged 66-92, were recruited. RESULTS The analysis showed that patients who had agreed to undergo TAVR were deeply affected by their body's failure. Before the TAVR procedure, the participants were limited in their daily activities and experienced that their life was on hold. They experienced that they were barely existing. They were aware of their life-threatening condition and were forced to confront death. Yet despite an advanced age, they still had considerable zest for life. It was very important to them to remain independent in everyday life, and fear of becoming dependent had a strong impact on their motivations for undergoing TAVR. CONCLUSION Older patients' motivations to undergo TAVR are strongly influenced by their fear of being dependent on others and their zest for life. Health care professionals need to support these patients in setting realistic and personalised goals. IMPLICATION FOR PRACTICE Person-centered care actions could facilitate patients' involvement in the decision about TAVR and strenghten patients' beliefs in their own capabilities, before and after TAVR.
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Affiliation(s)
- Maria Lachonius
- Department of Molecular and Clinical Medicine, Sahlgrenska AcademyGothenburg UniversityGothenburgSweden
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | - Sara Wallström
- Institute of Health and Care SciencesUniversity of GothenburgGothenburgSweden
- Center for Person‐Centered Care (GPCC)University of GothenburgGothenburgSweden
- Department of Forensic PsychiatrySahlgrenska University HospitalGothenburgSweden
| | - Annika Odell
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Institute of Health and Care SciencesUniversity of GothenburgGothenburgSweden
| | - Pétur Pétursson
- Department of Molecular and Clinical Medicine, Sahlgrenska AcademyGothenburg UniversityGothenburgSweden
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Sahlgrenska AcademyGothenburg UniversityGothenburgSweden
- Department of Cardiothoracic SurgerySahlgrenska University HospitalGothenburgSweden
| | - Kristofer Skoglund
- Department of Molecular and Clinical Medicine, Sahlgrenska AcademyGothenburg UniversityGothenburgSweden
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | - Susanne J. Nielsen
- Department of Molecular and Clinical Medicine, Sahlgrenska AcademyGothenburg UniversityGothenburgSweden
- Department of Cardiothoracic SurgerySahlgrenska University HospitalGothenburgSweden
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Canbolat Seyman C, Sara Y. What do orthopaedic nurses think about frailty? A qualitative analysis. Collegian 2022. [DOI: 10.1016/j.colegn.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Gobbens RJ, Vermeiren S, Van Hoof A, van der Ploeg T. Nurses' Opinions on Frailty. Healthcare (Basel) 2022; 10:1632. [PMID: 36141244 PMCID: PMC9498801 DOI: 10.3390/healthcare10091632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 11/26/2022] Open
Abstract
Nurses come into frequent contact with frail older people in all healthcare settings. However, few studies have specifically asked nurses about their views on frailty. The main aim of this study was to explore the opinions of nurses working with older people on the concept of frailty, regardless of the care setting. In addition, the associations between the background characteristics of nurses and their opinions about frailty were examined. In 2021, members of professional association of nurses and nursing assistants in the Netherlands (V&VN) received a digital questionnaire asking their opinions on frailty, and 251 individuals completed the questionnaire (response rate of 32.1%). The questionnaire contained seven topics: keywords of frailty, frailty domains, causes of frailty, consequences of frailty, reversing frailty, the prevention of frailty, and addressing frailty. Regarding frailty, nurses especially thought of physical deterioration and dementia. However, other domains of human functioning, such as the social and psychological domains, were often mentioned, pointing to a holistic approach to frailty. It also appears that nurses can identify many causes and consequences of frailty. They see opportunities to reverse frailty and an important role for themselves in this process.
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Affiliation(s)
- Robbert J. Gobbens
- Faculty of Health, Sports and Social Work, Inholland University of Applied Sciences, 1081 HV Amsterdam, The Netherlands
- Zonnehuisgroep Amstelland, 1186 AA Amstelveen, The Netherlands
- Department Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
| | - Sofie Vermeiren
- Department of Health and Science, AP University of Applied Sciences and Arts Antwerp, BE-2000 Antwerp, Belgium
| | - An Van Hoof
- Department of Health and Science, AP University of Applied Sciences and Arts Antwerp, BE-2000 Antwerp, Belgium
| | - Tjeerd van der Ploeg
- Faculty of Health, Sports and Social Work, Inholland University of Applied Sciences, 1081 HV Amsterdam, The Netherlands
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Low physical activity is the strongest factor associated with frailty phenotype and frailty index: data from baseline phase of Birjand Longitudinal Aging Study (BLAS). BMC Geriatr 2022; 22:498. [PMID: 35689187 PMCID: PMC9188172 DOI: 10.1186/s12877-022-03135-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 05/12/2022] [Indexed: 11/29/2022] Open
Abstract
Background Frailty is the most complicated expression of aging that is related to disability or multi-morbidity. The aim of the present study was to estimate the prevalence of frailty and its associated factors among community-dwelling aged population. Methods A total of 1529 eligible community- dwelling older adults (≥ 60 years) were enrolled in the baseline phase of Birjand Longitudinal Aging Study (BLAS) from 2019 to 2020. Their frailty status was assessed using the Fried’s frailty phenotype and frailty index. Sociodemographic factors, including sex, age, marital status, and education level, were collected. Health status assessment included the history of hypertension, diabetes mellitus, cardiovascular disease, Alzheimer’s diseases and dementia, and other health conditions. Furthermore, functional assessment (ADL, IADL) and anthropometric measurements including height, weight, waist, calf, and mid-arm circumference were made and the body mass index was calculated. The nutrition status and polypharmacy (use 3 or more medication) were also evaluated. Results The prevalence of frailty was 21.69% according to the frailty phenotype and 23.97% according to the frailty index. A multiple logistic regression model showed a strong association between low physical activity and frailty phenotype (OR = 36.31, CI = 16.99–77.56, P < 0.01), and frailty index (OR = 15.46, CI = 5.65–42.34, P < 0.01). Other factors like old age (≥80), female sex, malnutrition, polypharmacy, obesity, and arthritis were also associated with frailty. The Kappa coefficient of the agreement between these two instruments was 0.18. Conclusion It seems that low physical activity is the most important determinant of frailty. Low physical activity and some other factors may be preventable or modifiable and thus serve as clinically relevant targets for intervention. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03135-y.
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Mesquita WDR, Ricci NA. What do Brazilian health professionals know about the frailty syndrome? A cross-sectional study. BMC Geriatr 2022; 22:232. [PMID: 35313805 PMCID: PMC8939059 DOI: 10.1186/s12877-022-02927-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background The growing care demand for frail older adults and those at risk of frailty in primary health care (PHC) requires professionals trained in the subject to promote adequate care. This study aimed to analyze the self-reported, theoretical and practical knowledge of PHC professionals about the frailty syndrome. Methods This is an observational cross-sectional study with a sample of 485 Brazilian health professionals (bachelor’s degree) working in PHC with older adults. An electronic questionnaire was used to collect data on professional characteristics and self-reported, theoretical and practical knowledge concerning frailty phenotype. Agreement analysis between types of knowledge and multivariate logistic regression were performed to show the factors associated with knowledge about frailty. Results Theoretical knowledge showed the worse result, with 87.5% of the professionals describing the syndrome incorrectly. Roughly half the professionals self-reported (52.6%) very little/no knowledge concerning the syndrome and demonstrated low practical knowledge (55.1%) when identifying clinical cases. There were misconceptions about the syndrome, like it is natural from the aging process (83.3%) and is synonymous with disability and comorbidity (51.2%). The majority of the professionals were unaware of instruments for assessing frailty (77.9%) and the phenotype criteria (68.2%). No agreement was observed between the types of knowledge. Professionals specialized in or who had taken training courses in older adult health were 6.1 and 2.7-fold more likely, respectively, to self-reported some knowledge on the frailty syndrome. Conclusions PHC professionals presented little knowledge on the frailty syndrome. Most professionals were unaware of the frailty definition, its assessments for diagnosis and evidence for its treatment. The lack of knowledge on frailty could affect the care provided to older adults in primary care. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-02927-6.
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Affiliation(s)
- Wesley Dos Reis Mesquita
- Master's and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo - UNICID, Rua Cesáreo Galeno, 448 Tatuapé, 03071-000, São Paulo, SP, Brazil
| | - Natalia Aquaroni Ricci
- Master's and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo - UNICID, Rua Cesáreo Galeno, 448 Tatuapé, 03071-000, São Paulo, SP, Brazil.
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The conceptual and practical definitions of frailty in older adults: a systematic review. J Diabetes Metab Disord 2021; 20:1975-2013. [PMID: 34900836 DOI: 10.1007/s40200-021-00897-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
Purpose This study aimed to review and extract all publications containing concepts related to definitions of frailty and categorize them. Methods A total of six electronic databases (PubMed, Ovid web, Web of Science, Scopus, Embase, Cochrane Library, and ProQuest) were searched to identify studies that introduced a definition of frailty up to October 2018. No language restrictions were imposed. Results Totally, 104,370 papers were found in the initial search and finally 68 papers were included. Of these, 21 studies provided a conceptual definition and 50 original articles also 9 review articles provided a practical definition. Moreover, 12 papers had both definitions of frailty. Of them, 62 were published in English, 2 in Portuguese, 1 in Japanese, 2 in Korean, and 1 in German languages. Conclusion Many screening tools have been developed but neither of them can cover a wide range of parameters at the same time, nor do they have simplicity in the execution. It is important to note that although a more or less general consensus on one single definition might be expected, we believe that the elderly population is too heterogeneous to allow a tool to address it as a whole, and such a definition may even be impossible. Therefore, in the absence of a "Gold Standard" definition, it is suggested to seek accurate knowledge of the strengths and weaknesses of each definition and choose the most appropriate definition and the most effective evaluation tool according to the purpose of the research and the characteristics of the older population.
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A cross-sectional study investigating the relationships between self-management abilities, productive patient-professional interactions, and well-being of community-dwelling frail older people. Eur J Ageing 2021; 18:427-437. [PMID: 34483806 PMCID: PMC8377131 DOI: 10.1007/s10433-020-00586-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 12/03/2022] Open
Abstract
Worldwide, the maintenance of well-being in ageing populations with associated frailty has become increasingly important. To maintain well-being during ageing, investment in frail older people’s self-management abilities and the fostering of productive interactions with healthcare professionals may lead to higher levels of well-being. The aim of this study was to investigate the relationships between community-dwelling frail older people’s self-management abilities, productive patient-professional interactions and well-being, while controlling for socio-demographic characteristics. This cross-sectional study included 588 community-dwelling frail older people (aged ≥ 75 years) from 15 general practitioner (GP) practices in the Netherlands. Well-being (Social Production Function Instrument for the Level of well-being short), productivity of interactions with GPs (relational coproduction instrument), and self-management abilities (Self-Management Ability Scale short) were measured during in-home face-to-face interviews by trained interviewers. Data were analysed using descriptive statistics, correlation analyses, and linear mixed-effects models. Significant relationships were detected between self-management abilities and the overall, social, and physical well-being of older people, and between productive interactions with GPs and overall and social well-being, but not physical well-being. In a time of ageing populations with associated frailty, investment in frail older people’s self-management abilities and the productivity of patient-professional interactions may be beneficial for this population’s well-being.
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Abstract
There is growing interest in conceptualizing and diagnosing frailty. Less is understood, however, about older adults' perceptions of the term "frail", and the implications of being classified as "frail". The purpose of this scoping review was to map the breadth of primary studies; and describe the meaning, perceptions, and perceived implications of frailty language amongst community-dwelling older adults. Eight studies were included in the review and three core themes were identified: (1) understanding frailty as inevitable age-related decline in multiple domains, (2) perceiving frailty as a generalizing label, and (3) perceiving impacts of language on health and health care utilization. Clinical practice recommendations for health care professionals working with individuals with frailty include: (1) maintaining a holistic view of frailty that extends beyond physical function to include psychosocial and environmental constructs, (2) using person-first language, and (3) using a strengths-based approach to discuss aspects of frailty.
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Avgerinou C, Kotsani M, Gavana M, Andreou M, Papageorgiou DI, Roka V, Symintiridou D, Manolaki C, Soulis G, Smyrnakis E. Perceptions, attitudes and training needs of primary healthcare professionals in identifying and managing frailty: a qualitative study. Eur Geriatr Med 2021; 12:321-332. [PMID: 33125682 PMCID: PMC7990835 DOI: 10.1007/s41999-020-00420-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/14/2020] [Indexed: 10/28/2022]
Abstract
PURPOSE Although frailty can be delayed or prevented by appropriate interventions, these are often not available in countries lacking formal education and infrastructure in geriatrics. The aim of this study was to: (a) explore ideas, perceptions and attitudes of primary health care (PHC) professionals towards frailty in a country where geriatrics is not recognised as a specialty; (b) explore PHC professionals' training needs in frailty; and (c) define components of a frailty educational programme in PHC. METHODS Qualitative design, using two focus groups with PHC professionals conducted in Thessaloniki, Greece. Focus groups were audio recorded and transcribed. Data were analysed with thematic analysis. RESULTS In total 31 PHC professionals (mean age: 46 years; gender distribution: 27 females, 4 males) participated in the study (physicians n = 17; nurses n = 12; health visitors n = 2). Four main themes were identified: (1) Perceptions and understanding of frailty; (2) Facilitators and barriers to frailty identification and management; (3) Motivation to participate in a frailty training programme; (4) Education and training. The main barriers for the identification and management of frailty were associated with the healthcare system, including duration of appointments, a focus on prescribing, and problems with staffing of allied health professionals, but also a lack of education. Training opportunities were scarce and entirely based on personal incentive. Professionals were receptive to training either face-to-face or online. A focus on learning practical skills was key. CONCLUSION Education and training of professionals and interdisciplinary collaboration are essential and much needed for the delivery of person-centred care for people with frailty living in the community.
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Affiliation(s)
- Christina Avgerinou
- Department of Primary Care and Population Health, University College London, Rowland Hill Street, London, NW3 2PF, UK.
| | - Marina Kotsani
- Université de Lorraine, CHRU-Nancy, Pôle "Maladies du Vieillissement, Gérontologie et Soins Palliatifs", 54000, Nancy, France
| | - Magda Gavana
- Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Dimitra-Iosifina Papageorgiou
- Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Violeta Roka
- Farkadona Health Center, Farkadona, Trikala, Greece
| | | | | | - George Soulis
- Outpatient Geriatric Assessment Unit, Henry Dunant Hospital Center, Athens, Greece
| | - Emmanouil Smyrnakis
- Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Okpechi I, Randhawa G, Hewson D. Knowledge and attitude of healthcare professionals to frailty screening in primary care: a systematic review protocol. BMJ Open 2020; 10:e037523. [PMID: 32616492 PMCID: PMC7333811 DOI: 10.1136/bmjopen-2020-037523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/23/2020] [Accepted: 05/29/2020] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Frailty is an increasingly common condition in which physiological decline as a result of accumulated deficits renders older people more vulnerable to adverse outcomes. An increasing range of frailty screening programmes have been introduced in primary care to identify frail older people in order to deliver appropriate interventions. However, limited information on the knowledge and attitude of healthcare professionals (HCPs) with respect to frailty screening is known. The aim of this systematic review is to provide evidence on the knowledge and attitude of HCP in terms of frailty screening, and potentially identify barriers and facilitators to frailty screening to improve implementation of frailty screening in primary care. METHODS/DESIGN A systematic review of qualitative research will be conducted. Databases searched will be MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Web of Science from January 2001 to August 2019. Methods will be reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Population, interest, context and study design methodology was used to develop inclusion and exclusion criteria with HCPs as population, frailty screening as interest and knowledge or attitude of HCPs to frailty screening as context. Studies with a qualitative methodology or a mixed-method design where the qualitative component is analysed separately will also be included. Quality appraisal will be carried out using the Joanna Briggs Institute appraisal tool for qualitative studies. Data will be extracted from each selected study with thematic framework analysis used to synthesise findings. ETHICS AND DISSEMINATION This systematic review does not require ethical approval as primary data will not be collected. The findings will be disseminated at conferences and in a relevant academic journal. This review will assist HCPs and relevant stakeholders to tackle the challenges of frailty screening in primary care. PROSPERO REGISTRATION NUMBER CRD42019159007.
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Affiliation(s)
- Ijeoma Okpechi
- Institute for Health Research, University of Bedfordshire, Luton, Bedfordshire, UK
| | - Gurch Randhawa
- Institute for Health Research, University of Bedfordshire, Luton, Bedfordshire, UK
| | - David Hewson
- Institute for Health Research, University of Bedfordshire, Luton, Bedfordshire, UK
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Pettersson C, Malmqvist I, Gromark S, Wijk H. Enablers and Barriers in the Physical Environment of Care for Older People in Ordinary Housing: A Scoping Review. JOURNAL OF AGING AND ENVIRONMENT 2020. [DOI: 10.1080/02763893.2019.1683671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Cecilia Pettersson
- Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden
- School of Health Sciences, Örebro University, Örebro, Sweden
| | - Inga Malmqvist
- Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Sten Gromark
- Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Helle Wijk
- Institute of Health & Care Sciences, the Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
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15
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Obbia P, Graham C, Duffy FJR, Gobbens RJJ. Preventing frailty in older people: An exploration of primary care professionals' experiences. Int J Older People Nurs 2019; 15:e12297. [DOI: 10.1111/opn.12297] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 11/15/2019] [Accepted: 11/29/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Paola Obbia
- Piedmont Region Health Service Local Health Agency ASLCN1 Cuneo Italy
- Department of Clinical and Biological Sciences University of Turin Turin Italy
| | - Clair Graham
- School of Health and Life Sciences University of the West of Scotland Lanarkshire Campus UK
| | - F. J. Raymond Duffy
- School of Health and Life Sciences University of the West of Scotland Lanarkshire Campus UK
| | - Robbert J. J. Gobbens
- Faculty of Health, Sports and Social Work Inholland University of Applied Sciences Amsterdam The Netherlands
- Zonnehuisgroep Amstelland Amstelveen The Netherlands
- Department of Primary and Interdisciplinary Care Faculty of Medicine and Health Sciences University of Antwerp Antwerp Belgium
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16
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Gee SB, Cheung G, Bergler U, Jamieson H. "There's More to Frail than That": Older New Zealanders and Health Professionals Talk about Frailty. J Aging Res 2019; 2019:2573239. [PMID: 31915552 PMCID: PMC6930781 DOI: 10.1155/2019/2573239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/15/2019] [Accepted: 10/26/2019] [Indexed: 11/17/2022] Open
Abstract
There is general agreement that frailty is common and important in later life, but there is less agreement about what frailty is. Little is known about the extent to which practicing health professionals and older people hold a mutual understanding of frailty. Focus groups were held to engage older people and health professionals in discussion about what made them think that someone was frail. Eighteen older people took part across three focus groups, and se'venteen health professionals took part across another three focus groups. Both the health professionals and the older people talked about the experience of frailty as an interplay of physical, psychological, and social dimensions. Older people with frailty were seen as needing help and being vulnerable to adverse outcomes, but accepting help was positioned by older people as an adaptive choice. The experience of frailty was described as being mediated by the individual's psychological mindset, highlighting the importance of approaches that recognise strengths and resilience. A broader and more balanced understanding of frailty may help create more rounded and appropriate approaches to assessment and management.
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Affiliation(s)
- Susan B. Gee
- University of Otago, Christchurch New Zealand, Canterbury District Health Board, Christchurch 8083, New Zealand
| | - Gary Cheung
- University of Auckland, Auckland 1023, New Zealand
| | - Ulrich Bergler
- University of Otago, Christchurch New Zealand, Canterbury District Health Board, Christchurch 8083, New Zealand
| | - Hamish Jamieson
- University of Otago, Christchurch New Zealand, Canterbury District Health Board, Christchurch 8083, New Zealand
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17
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Edberg AK, Bolmsjö I. Exploring Existential Loneliness Among Frail Older People as a Basis for an Intervention: Protocol for the Development Phase of the LONE Study. JMIR Res Protoc 2019; 8:e13607. [PMID: 31414663 PMCID: PMC6712957 DOI: 10.2196/13607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/30/2019] [Accepted: 07/07/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND International research concerning end-of-life issues emphasizes the importance of health care professionals (HCPs) being prepared to deal with existential aspects, like loneliness, in order to provide adequate care. The last phase of life is often related to losses of different kinds, which might trigger feelings of isolation in general and existential loneliness (EL) in particular. There is a large body of research concerning loneliness among older people in general, but little is known about the phenomenon and concept of EL in old age. OBJECTIVE This study aims to describe the framing, design, and first results of the exploratory phase of an intervention study focusing on EL among older people: the LONE study. This stage of the study corresponds to the development phase, according to the Medical Research Council framework for designing complex interventions. METHODS The LONE study contains both theoretical and empirical studies concerning: (1) identifying the evidence base; (2) identifying and developing theory through individual and focus group interviews with frail older people, significant others, and HCPs; and (3) modeling process and outcomes for the intervention. This project involves sensitive issues that must be carefully reviewed. The topic in itself concerns a sensitive matter and the study group is vulnerable, therefore, an ethical consciousness will be applied throughout the project. RESULTS The results so far show that EL means being disconnected from life and implies a feeling of being fundamentally separated from others and the world, whether or not one has family, friends, or other close acquaintances. Although significant others highlighted things such as lack of activities, not participating in a social environment, and giving up on life as aspects of EL, the older people themselves highlighted a sense of meaningless waiting, a longing for a deeper connectedness, and restricted freedom as their origins of EL. The views of HCPs on the origin of EL, the place of care, and their own role differed between contexts. CONCLUSIONS The studies focusing on identifying the evidence base and developing theory are published. These results will now be used to identify potential intervention components, barriers, and enablers for the implementation of an intervention aimed at supporting HCPs in encountering EL among older people. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/13607.
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Affiliation(s)
- Anna-Karin Edberg
- The Research Platform for Collaboration for Health, Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
| | - Ingrid Bolmsjö
- Faculty of Health & Society, Malmö University, Malmö, Sweden
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18
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Coker JF, Martin ME, Simpson RM, Lafortune L. Frailty: an in-depth qualitative study exploring the views of community care staff. BMC Geriatr 2019; 19:47. [PMID: 30782120 PMCID: PMC6381739 DOI: 10.1186/s12877-019-1069-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 02/13/2019] [Indexed: 12/13/2022] Open
Abstract
Background Frailty is seen across various health and social care settings. However, little is known about how healthcare professionals, particularly those who provide care for older adults living in the community view frailty. There is also a dearth of information about the extent to which a shared understanding of frailty exists across the various disciplines of care. Such an understanding is crucial across care professionals as it ensures consistent assessment of frailty and facilitates interdisciplinary working/collaboration which is a key component in the management of frailty. This study aimed to explore: (i) how community care staff from various specialties viewed frailty; (ii) whether they had a shared understanding; and (iii) how they assessed frailty in everyday practice. Methods Semi-structured interviews were conducted with a purposive sample of 22 community care staff from seven specialties, namely: healthcare assistants, therapy assistants, psychiatric nurses, general nurses, occupational therapists, physiotherapists and social workers, recruited from four neighbourhood teams across Cambridgeshire, England. Interviews were analysed thematically. Results There was a shared narrative among participants that frailty is an umbrella term that encompasses interacting physical, mental health and psychological, social, environmental, and economic factors. However, various specialities emphasised the role of specific facets of the frailty umbrella. The assessment and management of frailty was said to require a holistic approach facilitated by interdisciplinary working. Participants voiced a need for interdisciplinary training on frailty, and frailty tools that facilitate peer-learning, a shared understanding of frailty, and consistent assessment of frailty within and across specialities. Conclusions These findings underscore the need to: (i) move beyond biomedical descriptions of frailty; (ii) further explore the interacting nature of the various components of the frailty umbrella, particularly the role of modifiable factors such as psychological and socioeconomic resilience; (iii) care for frail older adults using holistic, interdisciplinary approaches; and (iv) promote interdisciplinary training around frailty and frailty tools to facilitate a shared understanding and consistent assessment of frailty within and across specialities. Electronic supplementary material The online version of this article (10.1186/s12877-019-1069-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J F Coker
- Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SR, UK.
| | - M E Martin
- Cambridgeshire and Peterborough NHS Foundation Trust, Elizabeth House, Fulbourn Hospital, Cambridge, CB21 5EF, UK
| | - R M Simpson
- Cambridgeshire and Peterborough NHS Foundation Trust, Elizabeth House, Fulbourn Hospital, Cambridge, CB21 5EF, UK
| | - L Lafortune
- Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SR, UK
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19
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Dury S, Dierckx E, van der Vorst A, Van der Elst M, Fret B, Duppen D, Hoeyberghs L, De Roeck E, Lambotte D, Smetcoren AS, Schols J, Kempen G, Zijlstra GAR, De Lepeleire J, Schoenmakers B, Verté D, De Witte N, Kardol T, De Deyn PP, Engelborghs S, De Donder L. Detecting frail, older adults and identifying their strengths: results of a mixed-methods study. BMC Public Health 2018; 18:191. [PMID: 29378540 PMCID: PMC5789734 DOI: 10.1186/s12889-018-5088-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 01/17/2018] [Indexed: 01/07/2023] Open
Abstract
Background The debate on frailty in later life focuses primarily on deficits and their associations with adverse (health) outcomes. In addition to deficits, it may also be important to consider the abilities and resources of older adults. This study was designed to gain insights into the lived experiences of frailty among older adults to determine which strengths can balance the deficits that affect frailty. Methods Data from 121 potentially frail community-dwelling older adults in Flemish-speaking Region of Belgium and Brussels were collected using a mixed-methods approach. Quantitative data were collected using the Comprehensive Frailty Assessment Instrument (CFAI), Montreal Cognitive Assessment (MoCA), and numeric rating scales (NRS) for quality of life (QoL), care and support, meaning in life, and mastery. Bivariate analyses, paired samples t-tests and means were performed. Qualitative data on experiences of frailty, frailty balance, QoL, care and support, meaning in life, and mastery were collected using semi-structured interviews. Interviews were subjected to thematic content analysis. Results The “no to mild frailty” group had higher QoL, care and support, meaning in life, and mastery scores than the “severe frailty” group. Nevertheless, qualitative results indicate that, despite being classified as frail, many older adults experienced high levels of QoL, care and support, meaning in life, and mastery. Respondents mentioned multiple balancing factors for frailty, comprising individual-level circumstances (e.g., personality traits, coping strategies, resilience), environmental influences (e.g., caregivers, neighborhood, social participation), and macro-level features (e.g., health literacy, adequate financial compensation). Respondents also highlighted that life changes affected their frailty balance, including changes in health, finances, personal relationships, and living situation. Conclusion The findings indicate that frailty among older individuals can be considered as a dynamic state and, regardless of frailty, balancing factors are important in maintaining a good QoL. The study investigated not only the deficits, but also the abilities, and resources of frail, older adults. Public policymakers and healthcare organizations are encouraged to include these abilities, supplementary or even complementary to the usual focus on deficits.
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Affiliation(s)
- Sarah Dury
- Department of Educational Sciences, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium. .,Research Foundation Flanders (FWO), Egmontstraat 5, 1000, Brussels, Belgium.
| | - Eva Dierckx
- Department of Clinical and Lifespan Psychology, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium
| | - Anne van der Vorst
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Duboisdomein 30, 6229, GT, Maastricht, The Netherlands
| | - Michaël Van der Elst
- Department of Public Health and Primary Care University of Leuven, Kapucijnenvoer 33 blok J postbus 7001, 3000, Leuven, Belgium
| | - Bram Fret
- Department of Educational Sciences, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium
| | - Daan Duppen
- Department of Educational Sciences, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium
| | - Lieve Hoeyberghs
- Faculty of Education, Health and Social Work, University College Ghent, Keramiekstraat 80, 9000, Ghent, Belgium
| | - Ellen De Roeck
- Department of Clinical and Lifespan Psychology, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium.,Laboratory of Neurochemistry and Behavior, University of Antwerp, Universiteitsplein 1, DT.652, 2610, Antwerp, Belgium
| | - Deborah Lambotte
- Department of Educational Sciences, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium
| | - An-Sofie Smetcoren
- Department of Educational Sciences, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium
| | - Jos Schols
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands.,Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands
| | - Gertrudis Kempen
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands
| | - G A Rixt Zijlstra
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands
| | - Jan De Lepeleire
- Department of Public Health and Primary Care University of Leuven, Kapucijnenvoer 33 blok J postbus 7001, 3000, Leuven, Belgium
| | - Birgitte Schoenmakers
- Department of Public Health and Primary Care University of Leuven, Kapucijnenvoer 33 blok J postbus 7001, 3000, Leuven, Belgium
| | - Dominique Verté
- Department of Educational Sciences, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium
| | - Nico De Witte
- Department of Educational Sciences, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium.,Faculty of Education, Health and Social Work, University College Ghent, Keramiekstraat 80, 9000, Ghent, Belgium
| | - Tinie Kardol
- Department of Educational Sciences, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium
| | - Peter Paul De Deyn
- Laboratory of Neurochemistry and Behaviour, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Sebastiaan Engelborghs
- Laboratory of Neurochemistry and Behaviour, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Liesbeth De Donder
- Department of Educational Sciences, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium
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20
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D’Avanzo B, Shaw R, Riva S, Apostolo J, Bobrowicz-Campos E, Kurpas D, Bujnowska M, Holland C. Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty: A meta-synthesis of qualitative evidence. PLoS One 2017; 12:e0180127. [PMID: 28723916 PMCID: PMC5516973 DOI: 10.1371/journal.pone.0180127] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Frailty is a common condition in older age and is a public health concern which requires integrated care and involves different stakeholders. This meta-synthesis focuses on experiences, understanding, and attitudes towards screening, care, intervention and prevention for frailty across frail and healthy older persons, caregivers, health and social care practitioners. Studies published since 2001 were identified through search of electronic databases; 81 eligible papers were identified and read in full, and 45 papers were finally included and synthesized. The synthesis was conducted with a meta-ethnographic approach. We identified four key themes: Uncertainty about malleability of frailty; Strategies to prevent or to respond to frailty; Capacity to care and person and family-centred service provision; Power and choice. A bottom-up approach which emphasises and works in synchrony with frail older people's and their families' values, goals, resources and optimisation strategies is necessary. A greater employment of psychological skills, enhancing communication abilities and tools to overcome disempowering attitudes should inform care organisation, resulting in more efficient and satisfactory use of services. Public health communication about prevention and management of frailty should be founded on a paradigm of resilience, balanced acceptance, and coping. Addressing stakeholders’ views about the preventability of frailty was seen as a salient need.
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Affiliation(s)
- Barbara D’Avanzo
- Unit for Quality of Care and Rights Promotion in Mental Health, IRCCS Istituto di Ricerche Farmcologiche Mario Negri, Milan, Italy
- * E-mail:
| | - Rachel Shaw
- Aston Research Centre for Healthy Ageing, Aston University, Birmingham, United Kingdom
| | - Silvia Riva
- Unit for Quality of Care and Rights Promotion in Mental Health, IRCCS Istituto di Ricerche Farmcologiche Mario Negri, Milan, Italy
- Department of Oncology and Hematology, University of Milan, Milan, Italy
| | - Joao Apostolo
- Health Sciences Research Unit: Nursing, Nursing School of Coimbra, The Portugal Centre for Evidence-Based Practice: a Collaborating Centre of the Joanna Briggs Institute, Coimbra, Portugal
| | - Elzbieta Bobrowicz-Campos
- Health Sciences Research Unit: Nursing, Nursing School of Coimbra, The Portugal Centre for Evidence-Based Practice: a Collaborating Centre of the Joanna Briggs Institute, Coimbra, Portugal
| | - Donata Kurpas
- Department of Family Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Maria Bujnowska
- Health Sciences Research Unit: Nursing, Nursing School of Coimbra, The Portugal Centre for Evidence-Based Practice: a Collaborating Centre of the Joanna Briggs Institute, Coimbra, Portugal
| | - Carol Holland
- Aston Research Centre for Healthy Ageing, Aston University, Birmingham, United Kingdom
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