Intended for healthcare professionals

Analysis

Does frailty need a new name?

BMJ 2024; 386 doi: https://doi.org/10.1136/bmj-2023-076862 (Published 09 July 2024) Cite this as: BMJ 2024;386:e076862
  1. Sarah A Hopkins, geriatric medicine registrar1,
  2. Sarah E Hoare, medical sociologist1,
  3. Louisa Polak, retired GP1,
  4. Roberta Lovick, patient and carer representative2,
  5. Rhian Simpson, community geriatrics consultant3,
  6. Jagadish K Chhetri, geriatric medicine consultant4,
  7. Michael P Kelly, professor of public health1,
  8. Stephen Barclay, professor of palliative care1,
  9. Rowan H Harwood, professor of palliative and end of life care5
  1. 1Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  2. 2Patient representative, Great Yarmouth, UK
  3. 3Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
  4. 4National Clinical Research Center for Geriatric Diseases, Xuanwu Hospital of Capital Medical University, Beijing, China
  5. 5Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
  1. Correspondence to: S A Hopkins saah2{at}medschl.cam.ac.uk

Sarah Hopkins and colleagues argue that labelling patients as frail can be problematic and call for greater inclusion of older people in deciding how best to talk about the condition

The biomedical concept of frailty has been an important advance in how we approach the care of older people: it is central to better evidenced medicine and policy.1 In high income countries, around 40% of older patients with unplanned hospital admissions are living with moderate or severe frailty.2 Identifying frailty can help clinicians provide best care for such patients, keeping people living at home,3 helping avoid iatrogenic harm,4 and potentially reversing some aspects of frailty.5

Reflecting the importance of detecting and acting on frailty, NHS England included assessment targets for acute hospitals in its 2023 Commissioning for Quality and Innovation (CQUIN) guidance, which is linked to performance related financial incentives.6 Globally, national guidelines recommend using frailty to guide patient care and service design.7

Research into the nature, underlying mechanisms, measurement, and reversibility of frailty is ongoing.1589 However, here we focus on the term itself, which many older people find pejorative. We consider the pros and cons of renaming frailty and, aligning with the UN’s plan of action for a decade of healthy ageing, recommend greater collaboration with older people to develop improved ways of talking about the condition.10

Differences between clinical and lay understandings of frailty

Research on public perceptions of frailty shows that older people commonly understand frailty to be a state of physical, psychological, and social decline linked to dependency, loss of identity, social exclusion, and stigma.1112 It is associated with negative age related stereotypes. “Frail” is thus often understood as a pejorative term and can have connotations of a weak incapable person who is “failing” (box 1).1114

Box 1

Oxford dictionary definitions of frailty13

  • The quality of being physically weak or fragile, or vulnerable to damage. In later use chiefly with reference to physical weakness or infirmity as a result of old age

  • Weakness in an abstract or immaterial sense; the state of being transient, subject to change, or vulnerable to harm

  • A moral failing; a particular weakness or character flaw

  • • Moral weakness; sinfulness; propensity to give in to temptation, especially of a sexual nature

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By contrast, geriatricians and researchers use frailty to describe a reduction in biological reserves across multiple body systems that reduces the body’s capacity to respond to stressors, resulting in increased vulnerability to adverse health outcomes associated with the ageing process (table 1).11516 Frailty explains why an apparently small insult (eg, a new drug, minor infection, or minor surgery) results in a disproportionately large change in health state, such as from independent to dependent, or lucid to delirious.16

Table 1

Differences in biomedical and lay understandings of frailty

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Although there have been no large scale surveys of older people’s views, studies in Europe, North America, and Australia have all found similar conceptual differences between lay and biomedical understandings of frailty.1112172021222324 Research from non-English speaking countries is limited, but similar findings have been reported among Dutch and French older adults.2224 We are not aware of any research in low or middle income countries, despite the high prevalence of frailty.25

Concepts of frailty also differ among clinicians. Studies in English primary, secondary, and emergency care have found a range of views, with some healthcare professionals who are not geriatricians sharing the lay understanding of frailty as an irreversible, end-of-life state, although this view may be changing.172627 This has implications for how these clinicians care for people identified as frail.2627

Many older people resist identifying as frail

Given the lay meaning of frailty, it is unsurprising that older people have an aversion to the term.1112 Older people often do not self-identify as frail despite meeting the biomedical criteria for frailty.11122023

The effects on older people of a frailty label are hard to measure, but growing qualitative evidence suggests detrimental consequences. Research shows that older people emphasise the potential negative effects of frailty language, with some believing that identifying as frail leads to reduced self-esteem, disengagement, and exclusion.1112 Some saw being labelled frail as “damaging to health” because it may lead to feeling and acting frail, reducing healthy behaviours.111920 Although further research is needed, a small US study suggested that some people (classed as non-frail and “pre-frail”) may stop consulting healthcare professionals who discuss frailty.28

By using the term frailty, with its connotations of personal weakness, the medical profession may inadvertently contribute to negative societal perceptions of ageing and focus responsibility for poor health on to individuals rather than structural inequalities.29 At an individual level, negative perceptions of ageing have been linked to lower quality of life and poor health outcomes, including disability, hospital admissions, and frailty itself.3031

Addressing the problems associated with the term frailty

Various strategies have been proposed to address the problems associated with the term frailty (table 2).1112141728 These are based on research into older people’s views on the label frailty but, to our knowledge, older people themselves have had limited involvement in producing the recommendations.33 Older people should be directly involved when developing approaches to talking about frailty, including discussing whether a new term would be helpful.

Table 2

Strategies to reduce the problems associated with the biomedical term “frailty”

View this table:

Arguments for a new term

By clearly positioning “biomedical frailty” as a separate concept, a new term could lose many of the pejorative connotations that frailty carries. It is likely to remain an unwelcome diagnosis, but renaming frailty would mean it is no longer conflated with personal weakness. A new, less stigmatising term could help people with the condition make sense of their situation and discuss it with their clinicians.

Helping people make sense of their situation is an important goal in itself. People living with biomedical frailty often struggle to make sense of what is happening to them, feeling that old age does not offer an adequate explanation and there is no clear medical illness to blame.34 This struggle is associated with reduced wellbeing.35 People living with frailty note that “who they are” does not fit with “how they are,” a distressing mismatch that undermines their sense of self and their meaning and purpose in life.35 For such people, a biomedical explanation for their situation may help. Although this is something clinicians already try to do, their efforts are hampered by the term frailty, which is liable to be misconstrued and resisted. However, avoiding naming frailty loses out on an important benefit; having a name for your condition provides an explanation both for yourself and for others.36 A new, widely acceptable name could therefore be beneficial.

The suggestion that clinicians avoid using the term frailty with patients is problematic unless clinicians also avoid using the term among themselves. In a study of non-specialist clinicians from 2015, participants believed that they should not describe patients in language they would not use with the patient themselves.17 In another study clinicians describe finding it “hard to negotiate the tension between the clinical use of the term frailty and the translation of this to the patient” and believe a different term would help.27 This is supported by research in other conditions: although real world effects are difficult to evaluate, terminology can influence perceived disease severity, management preferences, and anxiety.3738 Recently, monkeypox was renamed mpox because of concerns about stigma and its effect on people’s willingness to present for diagnosis and treatment.39

Potential difficulties with new term

One argument against renaming biomedical frailty is the clinical usefulness of a widely accepted term: a new term risks confusion in the transition period. However, confusion about frailty is already widespread among patients, and there is some evidence of misunderstanding among non-specialist clinicians.1726 This existing confusion reflects the differing lay and biomedical meanings of frailty and is a key reason to look for a new term.

Frailty has a robust evidence base, which gives the term validity, and measuring frailty is important for both research and clinical practice. Some believe that debating alternative names for frailty will divert attention away from more important clinical, policy, and research work,40 but this seems a false dichotomy. Moreover, such a debate may bolster public and professional awareness.

Changing terms is not easy. A new term would require not just wide acceptance of the term itself but also development and validation of measurement instruments, and assessment of its clinical and research utility. Although this is a big task, there is presently no consensus on how to measure frailty. Over 50 different instruments are available, partly reflecting debate over the nature of the condition.89

A final consideration is that any term that replaces frailty might itself become stigmatising, potentially reflecting societal ageism. Although this is possible, the biomedical label frailty is stigmatising partly because of the pre-existing pejorative lay meaning. Renaming biomedical frailty would help position it as a separate concept from the lay definition.

How to choose a new term

If we change the term for frailty, how should we decide what to replace it with? Consideration of the word “neurodiversity,” which has been described as “a term that changed the world for the better,”41 can provide some guidance. Neurodiversity is the idea that people experience and interact with the world in a range of ways and that these differences are not necessarily pathological.42 Several factors contributed to the success of this term (box 2).

Box 2

Attributes of a helpful term

  • Selected with input from the population to whom it applies

  • Acceptable to all parties who will use it

  • Does not already have an existing meaning, especially one with negative connotations

  • Refers to a spectrum rather than a binary state

  • Does not over-pathologise

  • Possesses biomedical gravitas

  • Refers to something modifiable that can improve or deteriorate

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First, neurodiversity originated within the community it describes.42 Second, it refers to a spectrum—recognising that we all lie somewhere on this spectrum is less othering than, for example, “special needs,” which can be a binary distinction between pathological and normal.42 By referring to a spectrum, neurodiversity does not automatically pathologise difference.42 Third, it does not have a pre-existing lay meaning, and certainly not a pejorative one. Finally, it imparts a sense of biomedical gravitas that helps with providing an explanation to self and others.

There are, however, concerns about the term, especially that it calls for acceptance of things that some people would want treated.43 Like neurodiversity, a new term for frailty must steer a tricky course that minimises negative connotations but still denotes a condition that may be both challenging and amenable to medical help.

Drawing on these attributes, the most important consideration is that diverse older people, including those living with biomedical frailty, are involved in the process of finding the new term. In addition, the new term should highlight that there is a range of biological reserve across the whole population. We suggest avoiding words that already have negative connotations, such as vulnerability, and constructs that imply personal responsibility as this can engender shame and impede access to healthcare.44 The new term should have biomedical gravitas, as this is likely to give it greater explanatory power, helping individuals make sense of their circumstances. Finally, the selected term should recognise that what an individual can do (their functional ability) is a combination of personal and environmental factors.15

The World Health Organization advocates using the overlapping constructs of intrinsic capacity and functional ability (box 3) instead of frailty. The term intrinsic capacity possesses several of the attributes we have highlighted as important: it has biomedical gravitas and refers to a spectrum across the whole population. It takes a lifecourse, assets based approach that has positive implications for societal perceptions of ageing. This framework also emphasises the importance of environment on an individual’s capabilities.

Box 3

WHO definitions of intrinsic capacity and functional ability15

  • Intrinsic capacity—The composite of all the physical and mental capacities that an individual can draw on

  • Functional ability—Health related attributes that enable people to be and do what they have reason to value. It is made up of the intrinsic capacity of the individual, relevant environmental characteristics, and the interactions between the individual and these characteristics

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As these terms are not yet much used in clinical practice (partly because there is less evidence supporting them),45 this is a good time to explore public perceptions—for example, asking people how it would feel to be given a label of low intrinsic capacity. In addition, we should seek views on the constructs themselves: unlike biomedical frailty, intrinsic capacity encompasses all attributes of an individual, including aspects such as “sociality,” not just biological reserve.45 This breadth highlights that someone may use psychological strength to compensate for reduced physical capacity. Conversely, however, it means that “low intrinsic capacity” risks implying psychological weakness.

Looking to the future

The UN and WHO have made “changing how we think, feel and act towards age and ageing” a key area for action in plans for their joint Decade of Healthy Ageing .1046 Reconsidering how we think and talk about frailty aligns closely with this broader aim. Working collaboratively with older people, we should aim to develop ways of talking about frailty that help biomedically frail people to make sense of their experiences and maintain their wellbeing, and that are not a barrier to accessing care.

Key messages

  • Frailty is a useful construct but clinical and lay understandings of the term differ widely

  • Some older people may resist the label frailty, which makes it a potential barrier to accessing medical care

  • A new term could lose many of the pejorative connotations that frailty carries, helping people make better sense of their situation and maintain their wellbeing

  • Greater collaboration with older people is needed to develop ways of talking about frailty and any possible new term

Acknowledgments

We thank Tom Gentry, Age UK senior lead for health and care policy, for his insights and comments. We acknowledge funding from Dunhill Medical Trust, British Geriatrics Society, Alzheimer’s Society, and the National Institute for Health and Care Research. The views expressed are those of the authors and not necessarily those of the​ funding bodies, the NIHR, or the Department of Health and Social Care.

Footnotes

  • Contributors and sources: SAH is undertaking a joint Dunhill Medical Trust and British Geriatrics Society doctoral fellowship. SEH is a medical sociologist. LP is a retired general practitioner and a medical sociologist. RL is an older person and has experience of caring for older relatives. RS is geriatrician. JKC is a geriatrician who researches healthy ageing. MPK is a previous director of public health for NICE. SB is a general practitioner as well as researching palliative and end of life care. RHH is a geriatrician and researches palliative and end of life care. SAH, SEH, LP, and MPK devised the idea for this article and refined it with input from RL, RS, SB, and RHH. SAH, SEH, LP, RL, RS, MPK, SB, and RHH contributed to developing the first draft and all authors contributed to editing and writing of subsequent versions. SAH is the guarantor.

  • Public and patient involvement: The concept for this article built on discussions with patient representatives and older members of the public about use of the term frailty. RL, who identifies as an older person, was involved in planning and writing this article.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare no competing interests.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References