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Interviewer
In the light of your political experience in the field of frailty in older people, how would you define frailty considering its multidimensional nature (for example, health, social, economic, ethical, legal )?

Interviewee
If it could be summed up in one word, it would be vulnerability.

I believe that frailty or a frail person is a person who has decreased physiological reserves and has the greatest risk of decline. Therefore, the individual is more vulnerable to the environment, to the outside world and is more likely to experience adverse incidents, such as hospitalisation, falls and a loss of function that would generate a disability or dependency, which is precisely what we never want to happen to a frail patient.

Interviewer
From your point of view, what are the needs related to frailty? Are they changing over time?

Interviewee
Frailty-related needs are adequate detection, assessment and treatment in line with scientific evidence. This means that it may be necessary to make a paradigm shift and make a change of approach within our health and socio-health system.
Another important factor is the level of coordination. We need to coordinate and collaborate in all the areas or services in which we work to deal with elderly people.
With regard to the second question, I would say yes, but not much. We still talk about performing interventions to maintain or reverse functionality, which is the cornerstone of what would somehow improve or reduce the number of frail patients, and we are still focusing on the disease, or on chronic care. Currently, there are many health programmes that focus on pluripathological patients, when we know that the greatest impact is functional capacity. So, if I am optimistic, I think we'll tackle it but we're still at an early stage.

Interviewer
How does frailty affect and is affected by many different aspects of a person's life? (including the person´s physical health, immobility, mental health, loneliness, cognitive function and their social and family environment)

Interviewee
If we were to ask an elderly person what he or she would not like to lose, the person would probably tell us that he or she would not like to lose functional capacity, he or she would not tell us: ‘I want to have a good glucose level’ or "I want to have good blood pressure’. Functional capacity is so closely linked to frailty that it impacts on everything, on the loss of independence, on health, on immobility; it is like a chain. Even in a social setting, an independent person who suffers a fall, an adverse incident or hospitalisation and loses all function, and from being independent ends up as a frail person. Therefore, it would affect all areas.

Interviewer
How does the extent of a person's frailty change over time and how can it be influenced by lifestyle or other factors?

Interviewee
It is clear that the degree of frailty may change over time. Ageing is a process that gradually impairs functional capacity, intrinsic and extrinsic function. Frailty is influenced by lifestyle. Nutrition and physical exercise are two fundamental pillars for maintaining functional capacity, and polypharmacy, which is not a lifestyle itself. With a correct lifestyle, frail people can even reverse frailty. So, it is very important to focus on promoting healthy lifestyles.

Interviewer
What national policies, strategies and initiatives are put in place for addressing the needs of older people who live with frailty? How are current policies suggesting the multidimensional nature of old–age frailty?

Interviewee
Our health plan states that ageing must be addressed in a certain way. As such, healthcare systems must assess people over 70 years of age. Osakidetza [Basque Health care provider] strategies also include an approach to ageing. On the basis of this framework, it was decided to address the situation of the elderly by establishing a care plan, which we have called the Plan de Atención al Mayor or PAM [Care Plan for the Elderly]. This plan involves carrying out a functional assessment, a multidimensional assessment, and on the basis of the results of the assessments a series of interventions are proposed.
At a regional level, the Provincial Council of Gipuzkoa promotes healthy ageing through the Adinberri programme. Euskadi Lagunkoia [Age-Friendly Basque Country] aims to encourage the participation of elderly people and general public in order to improve neighbourhoods and surroundings in municipalities. The research units of Osakidetza are also doing basic research on issues related to ageing and frailty.

Interviewer
On 13th December 2018, in Madrid, the ADVANTAGE JA coordinator presented the ‘Frailty Prevention Approach’, which is a common approach to frailty to be used in Europe to overcome differences between countries. In 2019 the Frailty Prevention Approach document will be widely disseminated, and member states will be contacted to understand, at a governmental and regional level how they plan to implement this document in practice. In this context, are there any policies, strategies, experts´ groups, national and international initiatives, that you consider valid and that we should consider and take as best practices?

Interviewee
Yes, at national level the document of 2Frailty prevention and falls,” published by the Ministry of Health, provides a good framework or at least a starting point to address this issue. Advantage, will also be able to provide us with lines of action and ensure that health systems are geared towards addressing the issue of frailty.

Interviewer
Do you think frailty should be addressed through the synergy and joint work of policy makers and stakeholders? If yes, what would you say, is the situation in your country regarding this issue?

Interviewee
There is no other way. If we do not approach it through collaborative work, it is very difficult to address frailty in an integral way. In terms of the situation in our country, we are progressing bit by bit. I think it's a long-distance race. We have to agree on how we are going to approach it and we have to make a paradigm shift, because it is the only way to approach this issue with some guarantee of success.

Interviewer
From your experience, what are the barriers encountered in health and social care settings for managing frailty in older people? What are the possible effective solutions to overcome such barriers?

Interviewee
Coordination and a paradigm shift are some of the barriers. The health system should change from an essentially curative or disease-centred model to one focused on older people and the detection of frailty. This will help us to have a healthy older or less deteriorated person.

Interviewer
In your opinion, what new services or strategies are needed for meeting the multidimensional needs of an ageing population? Shall the role of the healthcare system change or evolve in this respect?

Interviewee
I believe that new services are not necessary, it would be necessary to focus on other health services. It is important to try not to lose functionality from the moment of admission, not to go to primary care and with a significant loss of functionality.
At community level, we would need to approach ageing in a different way than the one we are dealing with. If we want patients to stay at home, if we want to make progress in maintaining patient autonomy, we obviously need a network, a much broader network at a social and health level. An attempt is being made to establish a plan of care for the elderly, focused on physical activity to provide appropriate intervention for the elderly and coordinated, in nutrition.

Interviewer
In your country, where can advice, support and information be obtained for people with frailty, families and carers?

Interviewee
From all systems that work with the elderly. Support service, information and advice setting can be found in health centres. Work is also ongoing on this in the Social Services departments of town councils and provincial councils. We must try to work together so that the response will be quicker, more effective and coordinated.