We are grateful to all those who have responded to our article about the term frailty.(1)
The importance of cultural context is highlighted by Professor Prakash, who helpfully describes how in “India, aging and frailty are often viewed as natural processes”, contrasting this with Western prioritisation of independence. This exemplifies the role of culture in influencing how people make sense of their situation. There is a need for further research into the experience of living with frailty in different cultural contexts, which will be valuable when considering how to improve clinical communication about frailty. Professor Prakash’s account of the different ways in which frailty is conceptualised and managed reminds us of the need to seek consensus about the concept of frailty, not just its name.
Professor Olde Rikkert’s suggestion that frailty should “stimulate older people to grow realistic expectations of dying” draws attention to another important area. Professor Olde Rikkert associates a “frailty identity crisis”(2) with a lack of words and knowledge about dying with frailty. Yet a growing body of evidence shows that many people living with frailty prefer to focus not on their future but on their “current status”, to adopt Dr Honess’ helpful term, and prioritise living well day to day.(3,4) For many such people, death may be less of a concern than fears about developing dementia, becoming a burden or moving to a care home.(5) So while we agree with Professor Olde Rikkert that honest conversations are needed to protect people from a “frailty identity crisis”, we suggest a broader remit than he does for those conversations: we emphasise the need to help people make sense of living with frailty, and advocate looking for ways to support them to maintain their sense of self in the face of the multiple losses frailty may represent. Although there is some research pointing towards approaches that may be helpful – for instance, reflecting on personal memories may help older people maintain a sense of self towards the end of life(6) - we need to work more closely with people living with frailty to develop a greater evidence base about how clinicians can assist in this process.
We agree with Professor Olde Rikkert’s broader point that a central aim of any changes to how clinicians talk about frailty with older people should be to help them, and their families (as Dr Honess reminds us), to make sense of their health status. By working with patients to construct a narrative that they feel ‘fits’, clinicians may help individuals to maintain an identity that they feel comfortable with. The extent to which the potential imminence of death should be a prominent feature of this narrative remains an open question, and one we suggest needs careful discussion with people living with frailty, and those who care for and about them.
References
1. Hopkins SA, Hoare SE, Polak L, Lovick R, Simpson R, Chhetri JK, et al. Does frailty need a new name? BMJ. 2024 Jul 9;386:e076862.
2. Fillit H, Butler RN. The Frailty Identity Crisis. Journal of the American Geriatrics Society. 2009;57(2):348–52.
3. Combes S, Gillett K, Norton C, Nicholson CJ. The importance of living well now and relationships: A qualitative study of the barriers and enablers to engaging frail elders with advance care planning. Palliat Med. 2021 Jun;35(6):1137–47.
4. Mathie E, Goodman C, Crang C, Froggatt K, Iliffe S, Manthorpe J, et al. An uncertain future: The unchanging views of care home residents about living and dying. Palliative Medicine. 2012 Jul;26(5):734–43.
5. Lloyd A, Kendall M, Starr JM, Murray SA. Physical, social, psychological and existential trajectories of loss and adaptation towards the end of life for older people living with frailty: a serial interview study. BMC Geriatr [Internet]. 2016 Oct 20 [cited 2019 Mar 25];16. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5072327/
6. Synnes O. Narratives of nostalgia in the face of death: The importance of lighter stories of the past in palliative care. Journal of Aging Studies. 2015 Aug 1;34:169–76.
Competing interests:
No competing interests
11 September 2024
Sarah A Hopkins
Geriatric medicine registrar
Sarah E Hoare, Louisa Polak, Roberta Lovick, Rhian Simpson, Jagadish K Chhetri, Michael P Kelly, Stephen Barclay, Rowan H Harwood
Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge
Primary Care Unit, East Forvie Building, Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
Rapid Response:
Frailty and honest conversations
Dear Editor,
We are grateful to all those who have responded to our article about the term frailty.(1)
The importance of cultural context is highlighted by Professor Prakash, who helpfully describes how in “India, aging and frailty are often viewed as natural processes”, contrasting this with Western prioritisation of independence. This exemplifies the role of culture in influencing how people make sense of their situation. There is a need for further research into the experience of living with frailty in different cultural contexts, which will be valuable when considering how to improve clinical communication about frailty. Professor Prakash’s account of the different ways in which frailty is conceptualised and managed reminds us of the need to seek consensus about the concept of frailty, not just its name.
Professor Olde Rikkert’s suggestion that frailty should “stimulate older people to grow realistic expectations of dying” draws attention to another important area. Professor Olde Rikkert associates a “frailty identity crisis”(2) with a lack of words and knowledge about dying with frailty. Yet a growing body of evidence shows that many people living with frailty prefer to focus not on their future but on their “current status”, to adopt Dr Honess’ helpful term, and prioritise living well day to day.(3,4) For many such people, death may be less of a concern than fears about developing dementia, becoming a burden or moving to a care home.(5) So while we agree with Professor Olde Rikkert that honest conversations are needed to protect people from a “frailty identity crisis”, we suggest a broader remit than he does for those conversations: we emphasise the need to help people make sense of living with frailty, and advocate looking for ways to support them to maintain their sense of self in the face of the multiple losses frailty may represent. Although there is some research pointing towards approaches that may be helpful – for instance, reflecting on personal memories may help older people maintain a sense of self towards the end of life(6) - we need to work more closely with people living with frailty to develop a greater evidence base about how clinicians can assist in this process.
We agree with Professor Olde Rikkert’s broader point that a central aim of any changes to how clinicians talk about frailty with older people should be to help them, and their families (as Dr Honess reminds us), to make sense of their health status. By working with patients to construct a narrative that they feel ‘fits’, clinicians may help individuals to maintain an identity that they feel comfortable with. The extent to which the potential imminence of death should be a prominent feature of this narrative remains an open question, and one we suggest needs careful discussion with people living with frailty, and those who care for and about them.
References
1. Hopkins SA, Hoare SE, Polak L, Lovick R, Simpson R, Chhetri JK, et al. Does frailty need a new name? BMJ. 2024 Jul 9;386:e076862.
2. Fillit H, Butler RN. The Frailty Identity Crisis. Journal of the American Geriatrics Society. 2009;57(2):348–52.
3. Combes S, Gillett K, Norton C, Nicholson CJ. The importance of living well now and relationships: A qualitative study of the barriers and enablers to engaging frail elders with advance care planning. Palliat Med. 2021 Jun;35(6):1137–47.
4. Mathie E, Goodman C, Crang C, Froggatt K, Iliffe S, Manthorpe J, et al. An uncertain future: The unchanging views of care home residents about living and dying. Palliative Medicine. 2012 Jul;26(5):734–43.
5. Lloyd A, Kendall M, Starr JM, Murray SA. Physical, social, psychological and existential trajectories of loss and adaptation towards the end of life for older people living with frailty: a serial interview study. BMC Geriatr [Internet]. 2016 Oct 20 [cited 2019 Mar 25];16. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5072327/
6. Synnes O. Narratives of nostalgia in the face of death: The importance of lighter stories of the past in palliative care. Journal of Aging Studies. 2015 Aug 1;34:169–76.
Competing interests: No competing interests