Quality of care in frail older people: the fragile balance between receiving and giving

BMJ 2011; 342 doi: (Published 25 March 2011) Cite this as: BMJ 2011;342:d403
  1. Myrra Vernooij-Dassen, research professor1,
  2. Sheila Leatherman, research professor23,
  3. Marcel Olde Rikkert, professor4
  1. 1Scientific Institute for Quality of Healthcare, Department of Primary Care, Kalorama Foundation IQ Healthcare 114, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500HB Nijmegen, Netherlands
  2. 2Gillings School of Global Public Health, University of North Carolina, USA
  3. 3London School of Economics, London, UK
  4. 4Department of Geriatrics, Radboud University Nijmegen Medical Centre
  1. Correspondence to: M Vernooij-Dassen M.Vernooij-Dassen{at}
  • Accepted 27 December 2010

The focus on providing essential medical and social care for frail older people often leaves them feeling unable to contribute. But building in reciprocation could help preserve social inclusion and foster autonomy, dignity, and quality of life, say Myrra Vernooij-Dassen, Sheila Leatherman, and Marcel Olde Rikkert

Average and maximum life expectancy are now higher than ever in most of the developed world and still rising. However, it is not ageing itself, but the sharply increasing age related prevalence of frailty and multimorbidity, that is the major challenge for healthcare. A fundamental problem is that healthcare services are designed for frail elderly patients without really asking them what they need and want. One of the most basic but often neglected human needs is reciprocity—the ability to give something in return for receiving.1 We summarise the emerging evidence that reciprocity is an important means of improving health and wellbeing in frail elderly people and argue that taking it into account in health interventions will help older people feel included in their own care.

Frailty in social relations

Estimates of the prevalence of frailty among people aged 65 or older living in the community vary from 6% to 17%.2 3 Frailty as a concept has been defined as loss of resources in several domains of functioning, including physical, psychological, and social.3 4 5 An important characteristic of frailty is the high risk of decreasing functional performance in the near future. Consequently, frailty threatens dignity and autonomy by reducing a person’s control over his or her life.6 Dignity refers to the importance of not being perceived as a burden to others as well as continuing to be useful.7 Dependency caused by frailty directly challenges the normal balance in life between giving and taking—and thereby social inclusion, a key factor in wellbeing. …

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