Key Messages for a Frailty Prevention and Management Policy in Europe from the Advantage Joint Action Consortium

Abstract

In the 2015 Ageing Report, the European Commission (EC) and the Economic Policy Committee stated that coping with the challenge posed by an ageing population will require determined policy action in Europe, particularly in reforming pension, health care and long-term care systems. The concern for this situation motivated the EC, the Parliament and many of the Member States (MS) to co-fund, in the 2015 call of the Third European Health Programme of the European Union 2014–2020, the first Joint Action (JA) on the prevention of frailty. ADVANTAGE JA brings together 33 partners from 22 MSs for 3 years. It aims to build a common understanding on frailty to be used in the MSs by policy makers and other stakeholders involved in the management, both at individual and population level, of older people who are frail or at risk for developing frailty throughout the European Union (EU). It is a formidable challenge but also a great opportunity for concerted action resulting in fostering effective and successful policies in frailty prevention and management in the participating MS. The Consortium has 2 years of hard work ahead to contribute to the needed change for frailty related disability free Europe. The first practical step towards this aim was the preparation of a document: the State of the Art on Frailty Report to support an overview of evidence of what works and what does not work on frailty prevention and management. Subsequently, this will be reflected in the advice that the JA will give to policy makers at MS level. Overall, these messages intend to be an instrument of added value to advocate for policy driven decisions on frailty prevention and management in the JA participating MSs and subsequently towards a frailty related disability free older population in Europe. The aim of this paper is to describe ADVANTAGE JA general structure, approach and recommendations towards a European health and social policy which will support frailty prevention in the participating MS.

Introduction

According to the 2015 European Union Ageing Report the age demographic of the European population is projected to change dramatically over the coming decades, with older people accounting for an increasing proportion. The percentage of citizens aged over 65 years is predicted to rise from 18% to 28% by 2060; the percentage of over-80s will increase from 5% to 12% during the same time period (1).

These demographic trends suggest that there will be an increase in age-related disability and dependence, which will ultimately impact not only on the wellbeing of the individuals affected, but also on the sustainability of healthcare systems (2). This scenario implies that there is a need to re-shape healthcare systems in order to better address new public health challenges, particularly the needs of older people, independent of the socioeconomic background.

In this regard changing our mind-set from the current health care conceptual framework, to a new one is mandatory. It should be oriented to function instead of to disease, to prevent instead of to react, to care instead of to cure, and to provide continued and integrated care instead of episodic and fragmented care (3).

This new framework adapts to the natural sequence whereby people loose health as they age, especially after the age of 70–75 years, when the main manifestation is the loss of functional autonomy caused by a number of chronic conditions and comorbidities in a scenario of limited life expectancy and often social isolation. There are a number of key factors to be considered:

• •The ability of the presence of chronic diseases (CD) to predict disability diminishes as age increases due to the aggregation of comorbidity that is frequent in older patients.
• •The interaction between physical and cognitive factors that contribute to functional decline and disability.
• •Once established, disability is hard to reverse.

As a consequence, the models of care should take into account the need to approach older people not just in terms of curing CD but also in terms of care and support to prevent functional decline, frailty and disability. (2) Although they are related, there is not a linear relationship between CD and function, the latter being the main determinant of both the quality and quantity of life for older people.

Despite ongoing controversy over an agreed definition of frailty, it is widely accepted that it is a geriatric syndrome characterized by a diminished physiological reserve of multiple organs, which means increased vulnerability of older people to adverse outcomes such as disability, institutionalization, hospitalization and death (4, 5, 6)

Frailty is common with a global weighted prevalence of approximately 11% in people over 65 years living in the community (7).

Frailty needs to be adequately assessed and managed because it is important to recognise frailty as a distinct condition independent from ageing as well as from CD and disability. There is strong evidence of the usefulness of the concept of frailty as an important predictive factor of undesirable outcomes independent of CD in populations of older adults. The predictive value of frailty for negative outcomes has been confirmed irrespective of assessment instruments, target populations, and settings. The increased risk of negative health-related events includes falls, hospitalizations, incident disability, institutionalization, and mortality (8).

Another issue of interest is how best to identify trajectories that lead from a robust state to frailty and disability, as there are inter-individual variations in this pathway.

Frailty requires a multi-domain and multidisciplinary approach and timely interventions. Several strategies have been recommended, ranging from quite simple screening methods to those diagnostic procedures requiring a multi-step approach complementing frailty detection with a “comprehensive geriatric assessment to identify and treat the underlying causes. (9)

Multiple instruments have been developed to capture frailty and render it objectively measurable. The validation of these instruments has been carried out mainly, if not exclusively, in the community, thus strong evidence is lacking about its performance in clinical settings, particularly acute settings (10).

Why a European concerted action to address frailty prevention and management?

Demographic ageing is one of the most serious challenges that Europe is currently facing. Older people are at greatest risk of becoming frail and developing disability. However, since frailty is not an inevitable consequence of ageing, it can be prevented and treated to foster a longer and healthier life.

In the 2015 Ageing Report, the EC and the Economic Policy Committee stated that coping with the challenge posed by an ageing population will require determined policy action in Europe, particularly in reforming pension, health care and longterm care systems (1).

Therefore, the reduction of disability and dependence in older people through appropriate action on the frailty process should be at the forefront of all policies to tackle the challenge of population aging. Accordingly, scientific societies (10), Ministries of Health (11), the European Commission (12) and the World Health Organization (13) have proposed several and complementary strategies to tackle this challenge from a public health perspective. All of them are advancing strategies and actions to create awareness about the need to support and care for older people and to build consensus across all sectors of society regarding both the philosophy of care and on how this will be delivered in the most cost-efficient way. For example,

• •The European Innovation Partnership on Active and Healthy Ageing (EIPAHA) was launched in 2012 as an EC response to meet Europe´s demographic challenges. Tackling frailty and disability and integrated care are among its priorities and the specific Action Groups on those topics have since contributed significantly to policy debate at the EU and to shape new models for screening, treatment and monitoring as well as sharing good practices (13).
• •In the Adequate social protection for long-term care needs in an ageing society report, jointly prepared by the Social Protection Committee and the EC, they agreed that national policy makers should move to an increasingly proactive policy approach, seeking both to prevent the loss of autonomy and thus reduce care demand, and to boost efficient, cost-effective care provision (14).
• •The WHO is taking the lead in advocating for a comprehensive public health action on population ageing focusing on supporting action around the new concept of functional ability (13).

Despite these initiatives, frailty is not yet at the top of the public health agenda and there is an urgent need to develop evidence based support to make frailty prevention a public health priority.

The concern for this situation motivated the EC, the Parliament and many of the MS to co-fund, in the 2015 call of the Third European Health Programme of the European Union 2014–2020, the first (JA on the prevention of frailty: ADVANTAGE. (15) Following the call for proposals, it took up to 1 year to prepare the project with the MS representatives led by the Coordinator and to negotiate the contract with EC-Chafea. The JA kicked-off in January 2017. The work that ADVANTAGE JA is implementing is particularly relevant in Europe at present as it addresses the demographic change and the associated increasing demands for social and health care from the burden of CD, frailty, disability and older age, which are a central priority for the EU and its MS. s1]|ADVANTAGE JA, a way forward

With a budget of €3,5 M and a Consortium bringing together 33 partners from 22 MSs for 3 years, this JA involves a wide diversity of countries and regions with very different health systems, diverse health and social policies and different cultural, social and economic backgrounds.

This scenario represents a formidable challenge but also a great opportunity for concerted action resulting in fostering effective and successful policies in frailty prevention and management in the participating MS.

ADVANTAGE JA aims to build a common understanding on frailty to be used in the MS by policy makers and other stakeholders involved in the management, both at individual and population level, of older people who are frail or at risk for developing frailty throughout the EU.

It has the following objectives:

• •To identify the core components of frailty and its management and thus promote the required changes in the organization and implementation of care in the health and social systems to provide those models of care that will allow each MS to face this challenge using a common framework tailored to their own context and care system.
• •To contribute to the reduction of disability and dependence and prevent the growing healthcare demands from the increasing burden of CD.
• •To develop improved strategies for diagnosis, care and education for frailty, disability and multi-morbidity.
• •To develop the concept of the “Frailty Prevention Approach (FPA) in health and social care services, by encouraging consensus and developing common frameworks on screening, prevention, assessment and management of frailty throughout the EU.

Why an ADVANTAGE JA State of the Art report on frailty?

The first practical step towards this aim was the preparation of a document: the State of the Art on Frailty Report to support an overview of evidence of what works and what does not work on frailty prevention and management. Evidence on frailty has been researched and discussed by the professionals involved in the ADVANTAGE JA and crystallized in this document.

The purpose is twofold and thus has two different target groups:

• •The Consortium members themselves so as to have a common framework and agreed concepts on which to base the rationale for future actions and deliverables within the ADVANTAGE JA.
• •The stakeholders in general and policy makers in particular from participant MS to provide them with a useful guide so that their own decisions may be informed by the evidence on frailty.

ADVANTAGE JA partners summarized and analyzed the evidence obtained from four sources of information: peerreviewed articles, grey documents, good practices identified at European level and EU funded projects. Only original articles were considered. Letters to the editor, abstract publications, conference proceedings, non-systematic reviews and editorials were excluded. Languages allowed were English and from any of the ADVANTAGE JA MS.

Partners reviewed papers published from 2002 to 2017, the period that has witnessed a dramatic increase in publications dealing with the concept of frailty. Papers published before 2002 were included on a case-by-case basis if deemed relevant.

Sources of information for peer-reviewed articles were databases of references and abstracts on biomedical topics; Medline via PubMed, CINAHL, Cochrane databases, Up to date, Opengrey, Scopus and the Web of Science. A total of 1,291,904 articles were identified by the search and information from 503 was extracted and subsequently analyzed. (Table 1)

Table 1.

Documents reviewed by ADVANTAGE JA for the State of Art Report

Areas of knowledge reviewed	Papers identified	Papers analysed
Definition	494	74
Relation with chronic diseases	2,282	25
Prevalence and incidence	2,948	63
Individual screening and diagnosis	6,611	52
Prevention	391,910	31
Clinical management	67,462	27
Nutrition	39,885	28
Physical activity	620,043	25
Drugs	28,796	25
ICTs	124,634	33
Population screening	1,186	3
Surveillance	751	0
Monitoring	451	0
Trajectories and transitions	862	3
Health care models	1,065	43
Education/Training	1,914	0
Research	610	71
Total	1.291.904	503

The main results are presented in the State of the Art Report and in this article. For further information on these issues specific report are available at the JA website (16) and will be subject of specific publications.

Key messages for a frailty prevention policy in Europe

The key messages reflected in the State of the Art Report are grounded in scientific knowledge, are assertive and avoid controversial statements whenever further research is needed or results are unclear. Furthermore, they acknowledge the heterogeneity of the MS health and social care systems and diverse societies in a scenario of demographic change and economic constraints across the EU.

Overall these messages intend to be an instrument of added value to advocate for policy driven decisions on frailty prevention and management in the JA participating MS and subsequently towards a disability free older population in Europe.

• 1.Frailty is not an inevitable consequence of ageing, it may be prevented and treated to foster a longer and healthier life. In addition, it has a clear negative impact on the costs of health services. In spite of that, frailty is not yet at the top of the public health agenda.
• 2.Despite ongoing controversy over an agreed definition of frailty, it is widely accepted that it is a geriatric syndrome characterized by a progressive age-related decline in physiological systems that results in decreased functional reserves and a low intrinsic capacity, which confers extreme vulnerability to stressors and increases the risk of a range of adverse health outcomes (WHO definition which ADVANTAGE JA supports).
• 3.Frailty is very common, although the prevalence reported varies considerably contingent on factors such as the definition used, the age of the population studied and the frailty assessment instrument/classification used. A prevalence of more than 11% in community-dwellers over 65 years old seems a reasonable estimate of the current situation in the EU.
• 4.Frailty is a potentially reversible condition that may revert spontaneously to a robust (non-frail) state, especially in its early stages, although little is known about how frequently this can happen without intervention.
• 5.Multi-morbidity, disability and frailty are distinct clinical entities that are causally related, often associated and that may overlap. All three occur frequently and have important clinical consequences. What really affects quality of life is function and not disease, and the best predictor of function is frailty.
• 6.To prevent disability in older age and support healthy ageing in the JA participating MS, the first step is to identify the population group at the highest risk that could benefit most from an intervention aimed at delaying or reversing disability and dependence. These are the frail individuals.
• 7.Many instruments have been proposed and are used to identify (screen and diagnose) frail individuals in clinical practice and for public health level frailty detection programs. From all tools available, ADVANTAGE JA proposes those that fulfill certain characteristics. For screening: Clinical Frailty Scale; Edmonton Frailty Scale; Fatigue, Resistance, Illness, Loss of Weight Index (FRAIL Index); Gait Speed; Inter-Frail; Prisma-7; Sherbrooke Postal Questionaire; Short Physical Performance Battery (SPPB) and Study of Osteoporotic Fractures Index (SOF). For diagnosis: Frailty Index of accumulative deficits, Frailty Phenotype and Frailty Trait Scale. (table 2, table 3).
• 8.It is recommended to screen opportunistically for frailty in populations aged over 70 years old, giving the possibility of designing and implementing preventive, population-based interventions targeting identified risk factors.
• 9.Individual interventions, either in the community or in every setting of care, often share a three-step structure: a) frailty screening to identify pre-frail or frail older persons, b) use of diagnostic tools to diagnose frailty, and c) a CGA to assess individual needs and develop multidimensional interventions to match these needs in the frame of individual care plans (Fig. 1).
• 10.Early stages of frailty are the most appropriate target for intervention because they are more likely to be reversible.
• 11.The specific components of frailty interventions (both for prevention and treatment) include adequate physical activity and exercise, adequate nutrition, healthy lifestyles and drugs revision (Fig. 1).
• 12.General practitioners have been identified as the preferred healthcare professional to identify physical health problems and risks and as such to potentially screen and monitor for frailty at population level.
• 13.Models of care should take into account the need to approach older people not just in terms of their diseases but also in terms of physical, cognitive and psychosocial care and support to prevent functional decline, frailty and disability. Key components to address frailty are those that define also integrated care, with the addition of targeting high risk frail individuals, an enablement attitude and a focus on outcomes most relevant to frail individuals and their caregivers. For these purposes, a coordinated system able to provide the most effective care in the different settings (community, primary care, hospitals and institutions) needs to be provided.
• 14.Health and social care professionals across settings and countries need to be trained to address future needs related to ageing, frailty and disability.
• 15.Further research is needed to better understand the nature of frailty and to improve screening and diagnostic tools and test the effectiveness of interventions.

Table 2.

Tools for the screening of frailty recommended by ADVANTAGE JA

Tool name	Original reference	Tool description	Time needed to perform	Number of items	Special equipment needed
Clinical Frailty Scale	Roockwood et al. Can Med Assoc J 2005	Single descriptor of a person’s state of frailty (fitness)	5 min	NA	No
Edmonton Frail Scale	Rolfson et al, Age Ageing. 2006	Timed up and Go Test, Clock draw test, 7 Questions exploring frailty domains	<5 min	9	No
Fatigue, Resistance, Ambulance, Illness, Loss of weight (FRAIL Index)	Morley et al. J Am Med Dir Assoc. 2008	5 items: fatigue, resistance, ambulation, illnesses, loss of weight	< 10 min	5	No
Inter-Frail	Bari et al. J Am Geriatr Soc 2014	1 disability and 10 frailty items (yes-or-no questions)	10 min	11	No
Prisma-7	Raiche et al. Arch Gerontol Geriatr 2007	Self-reported. 7 questions on demographics and performance	5 min	7	No
Sherbrooke Postal Questionnaire	Hebert et al. Age Ageing 1996	Self-reported questionnaire. 6 items: living alone, polypharmacy, mobility, eyesight, hearing, memory.	< 5 min	6	No
Short Physical Performance Battery (SPPB)	Guralnik et al. J Gerontol 1994	3 dimensions: balance, gait and weakness.	<10 min	12	No
Study of Osteoporotic Fractures Index (SOF)	Ensrud et al. Arch Intern Med. 2008	3 items: weight loss, reduced energy level and inability to rise from a chair.	< 5 min	3	No

Table 3.

Tools for the diagnosis of frailty recommended by ADVANTAGE JA

Tool	Original reference	Tool description	Time	Number of items	Special equipment needed
Frailty Index of accumulative deficits	Mitnitski et al. Sci World J. 2001	Number of health deficits present / Number of health deficits measured	20-30 min	>30	No
Frailty phenotype	Fried at al. Gerontol A Biol Sci Med Sci 2001	5 items: weight loss, low physical activity, exhaustion, slowness, weakness	< 10 min	5	Yes (dynamometer)
Frailty Trait Scale (FTS)	García-García et al. J Am Med Dir Assoc. 2014	Seven dimensions: energy balance and nutrition, activity, nervous system, vascular system, weakness, endurance, slowness	20 min	12	Yes (albumin, dynamometer)

Figure 1.

Algorithm for the management of frailty at individual level

Conclusions

ADVANTAGE JA is facilitating the cooperation of the participating MS to identify and define key elements in their own communities to ensure an optimal response of the health and social system to older peoples´ health needs, including frailty and disability.

ADVANTAGE JA will make significant progress on frailty prevention and management across the EU through 6 main areas of action.

a) Overcoming the traditional disease-centered approach to put the focus on one of the main health-related problems in older people (disability) and its main risk factor (frailty).

b) Giving a comprehensive view on the challenge that frailty represents to the European health care and social services.

c) Providing policy-makers, health providers and health managers, among other stakeholders, evidence-based tools to face the challenge that frailty and disability represents to the sustainability of the European welfare state.

d) Promoting relevant changes in EU health and social system model of care, disregarding inefficient practices while adopting useful and more efficient ones.

e) Harnessing the significant collective experience of participating the institutions, many of whom have led, or are currently leading, seminal projects assessing and implementing tools, procedures or strategies developed to face new challenges associated to frailty and disability.

f) Adopting two complementary approaches with a) a perspective on the quality of life and interventions for the individual affected by or at risk of developing frailty, and b) the public health perspective focusing on the societal and systems issues required to build efficient and sustainable systems of care in the short- and mid-term.

The ADVANTAGE Consortium believes that the adoption and application of these recommendations to the health and social policies of the participating MS will contribute to a frailty related disability free Europe.

We have 2 years of hard work before us to progress on the needed change for a frailty related disability free Europe. We are jointly laying the ground to make this happen.

Acknowledgments: ADVANTAGE JA is co-funded by Third European Health Programme of the European Union 2014–2020, under grant number 724099. The European Commission´s support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein.

Conflict of interests: The authors declare that they have no conflict of interest concerning this article.