Table 3.

FOCUS guidelines

GQ – Should interventions to prevent or delay the progression of frailty, or to reverse frailty, be adopted in prefrail or frail older people?
Recommendation RG	Conditions for the intervention to succeed [14]
We suggest implementing interventions specifically intended to have an impact on frailty in older age, i.e. preventing or delaying the progression of frailty, or reversing frailty (conditional strength of recommendation)	Participant factors • Co-create the details of interventions with intended recipient groups • Consider the level of frailty of participants • Employ best practice health psychology behaviour change strategies • Consider group and fun, rewarding interventions wherever possible • Determine whether the intervention is only appropriate if a specific deficiency is present, e.g. nutritional deficiency • Before implementing an intervention, consider correcting deficiencies that can interact with the intervention’s working mechanisms • Address understanding and attitudes towards malleability of frailty of patients before the intervention • Address self-efficacy in the intervention activity • Consider accessibility of locations to individuals • Employ approaches that are person, family and ‘lifeworld’ centred • Include social and psychological wellbeing factors Organisational factors • Co-create the details of interventions with intended delivery practitioners • Ensure training to emphasise implementation fidelity and standardisation of delivery • Address practitioners’ understanding and attitudes towards the malleability of frailty before the intervention • Consider expectations of older adults’ commitment and ability to participate • Provide some training in health psychology components Country/contextual/cultural factors • Consider the suitability of the intervention for your context (e.g. clinical, community, inpatient, outpatient) • Consider likely cultural preferences, e.g. for expert-led or self-directed interventions • Consider what ‘normal care’ is in your context • Consider the level of existing health literacy in your population
Q1 – Should physical interventions be recommended to prevent or delay the progression of frailty, or to reverse frailty, in prefrail or frail older people?
Recommendation R1	Conditions for the intervention to succeed [14]
We suggest implementing physical interventions, including physical activity/exercise, nutritional interventions, and a combination of exercise and nutritional interventions, to prevent or delay the progression of frailty, or to reverse frailty (conditional strength of recommendation). The recommendation is stronger for group-based supervised exercise programmes, either alone or in association with nutritional supplementation	Among the factors to consider when an intervention on frailty is implemented, those which are particularly relevant in the case of physical interventions are: • Consider implementing those factors that can increase participants’ acceptance of and, as a consequence, compliance to the intervention, i.e. the inclusion of elements favouring or promoting socialisation, fun, accessibility, self-efficacy and commitment. Among those factors, consider the implementation of group-based exercise programmes and supervision by professionals with adequate training; in general, include professionals with adequate skills in health psychology and communication; the inclusion of these elements might affect the adherence to the intervention • Consider the characteristics of the participants to whom the intervention will be directed, for example, the presence of deficits that make the intervention necessary, and the level of expected compliance. The level of frailty particularly may have an important impact, not least because it is likely to be associated with these other characteristics • Even though physical interventions for physical components of frailty are appropriate, considering the person as a whole, including, for example, their psychological wellbeing and functions and their social context, may be beneficial • The opportunity to take into account and include these elements might affect the feasibility and suitability of the interventions in each specific context
Q2 – Should interventions based on tailored care and/or GEM be recommended to prevent or delay the progression of frailty, or to reverse frailty, in prefrail or frail older people?
Recommendation R2	Conditions for the intervention to succeed [14]
We suggest implementing interventions based on tailored care and/or GEM, to prevent or delay the progression of frailty, or to reverse frailty (conditional strength of recommendation). The recommendation is stronger for GEM-based interventions involving a multidisciplinary team, especially in inpatient clinical settings, but still conditional to the confirmation from further studies of good quality	Among the factors to consider when an intervention on frailty is implemented, those of particular relevance to interventions aimed at a more comprehensive concept of frailty: • Consider the context (the clinical setting, usual care, cultural preferences) • Co-create the details of interventions with intended delivery practitioners, provide adequate training to ensure implementation fidelity • Consider the inclusion of professionals with adequate skills or provide training in health psychology and communication • Employ approaches that are person, family and ‘lifeworld’ centred
Q3 – Should other interventions be recommended to prevent or delay the progression of frailty, or to reverse frailty, in prefrail or frail older people?
Recommendation R3	Conditions for the intervention to succeed [14]
We suggest considering interventions to prevent or delay the progression of frailty, or to revert frailty, based on cognitive training, alone or in combination with exercise and nutritional supplementation (conditional strength of recommendation), and on exercise combined with diet consultation, at least in prefrail populations. At the moment, the panel does not suggest adopting interventions based on hormone therapy or on problem-solving therapy with the aim of preventing or delaying the progression of frailty or of reverting frailty (conditional strength of recommendation). Currently, there is no evidence in favour or against other interventions potentially effective on frailty (e.g. other types of psychological interventions, interventions mainly focused on increasing socialisation, other types of hormone therapies and pharmacological interventions).	Many of the factors described for the success of a physical intervention (refer to Q1), or for interventions based on a patient-centred approach and comprehensive care (refer to Q2), are also relevant to alternative interventions described in Q3.

GQ general question; Q question; R recommendation