specialist in cardiology and internal medicine - Research leader, lecturer, The Research and Development Unit, NU Hospital, and the Department of Health Sciences, University West, Trollhättan-Uddevalla, Sweden 

Q. In the light of your clinical and research experience in the field of frailty and old-age frailty, how would you define old-age “frailty”, considering its multidimensional nature (e.g., health, social, economic, ethics, legal)?

A. There are different models and instruments, which can be used in order to define and describe frailty. Basically, frailty can be defined as a biological syndrome implying vulnerability to stressors and reduced physiological reserves.

Most researchers agree that there are two types of frailty; physical and psychological, where the occurrence of sarcopenia and diminished muscle strength is one important discriminatory characteristic. Fried's definition of physical frailty includes the following components: muscle weakness, unintended weight loss, slow gait speed, self-reported exhaustion and reduced physical activity (Fried 2001). Another commonly used definition is The accumulation of deficits model, which adds together a person’s different diseases and disabilities to produce an index (Rockwood 2005). Furthermore, a holistic, integrated model of frailty, which also addresses social and psychological domains in the assessment, is evolving, i.e. is under development.

Frail elderly individuals are characterised by high health care resource-use. From an ethical and legal aspect, i.e. according to the Swedish legislation, the assessment of the needs of these individuals should be given high priority. Whether this is true in practice can be discussed.

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

A. Frailty denotes a dynamic syndrome with negative health outcomes, which can improve and worsen over time. Thus, the health care needs of a frail individual are changing over time.

For the individual patient, frailty predicts a high risk of being institutionalised and dying within a short period of time. Furthermore, frailty is strongly associated with functional decline, activity limitations, and prolonged recovery.

Consequently, frail elderly patients are characterised by high health care resource-use. For frail individuals, critical illness requiring hospitalization and prolonged bed rest are associated with physical deterioration and functional impairment persisting for a long time after hospital discharge.

Q. What national policies, strategies and initiatives are put in place for addressing the needs of older people with frailty? Are current policies addressing the multidimensional nature of old-age frailty?

A. Up until now, to my knowledge, relatively few comprehensive initiatives and strategies have been put in place in order to address the needs of frail elderly individuals in Sweden. There are, however, some exceptions. Hopefully, the ADVANTAGE action will improve the situation.

  • In 2013, an expert group within the Swedish Council on Health Technology Assessment (SBU) carried out a systematic review, which addressed frailty and Comprehensive geriatric assessment (CGA): Comprehensive geriatric assessment and care of frail elderly. Stockholm: 2013. SBU report no 221.
  • In 2013, the Swedish National Board of Health and Welfare published a report, which emphasised that the evaluation of frailty is crucial when elderly patients with organ-specific diagnoses, e.g. acute coronary syndromes, are treated: Frail elderly patients and national guidelines. How the guidelines can be adjusted to meet the needs of frail elderly patients. Report for the National Board of Health and Welfare. Stockholm, Sweden: National Board of Health and Welfare, 2013. (in Swedish).
  • For some years, some hospitals in the Västra Götaland Region of Sweden run elderly care units, which are characterised by a structured, systematic interdisciplinary CGA and care performed on the ward, including an early rehabilitation strategy. Similar initiatives have been taken in Region Skåne and the Östergötland Region.
  • Recently a network of health care professionals addressing clinical and research issues on frailty was formed in Sweden. One of the aims is to coordinate the efforts within this area.
  • Since November 2017, the Clinical Frailty Scale as developed by Professor Kenneth Rockwood is used in a pilot study in order to assess frailty in myocardial infarction patients who have been included in the SWEDEHEART register. It is assumed that the CFS constitutes an appropriate and clinically relevant instrument in the context of cardiovascular patients with complex needs. There is an intention to study the association between frailty and clinical outcomes for these patients.
  • In Gothenburg, the FRESH (FRail Elderly Support research group) instrument is used in order to make a primary screening for frailty among elderly individuals. Similar initiatives have been taken in other health care areas in Sweden.