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M. Puts, N. Shekary, G. Widdershoven, J. Heldens, D. Deeg (2009)
The meaning of frailty according to Dutch older frail and non-frail personsJournal of Aging Studies, 23
(2006)
e distinction between being and feeling frail: exploring emotional experiences in health and social care
J. Morley, B. Vellas, G. Kan, S. Anker, J. Bauer, R. Bernabei, M. Cesari, W. Chumlea, W. Doehner, Jonathan Evans, L. Fried, J. Guralnik, P. Katz, T. Malmstrom, R. McCARTER, L. Robledo, K. Rockwood, S. Haehling, M. Vandewoude, J. Walston (2013)
Frailty consensus: a call to action.Journal of the American Medical Directors Association, 14 6
L. Lafortune, Steven Martin, Sarah Kelly, I. Kuhn, O. Remes, A. Cowan, C. Brayne (2016)
Behavioural Risk Factors in Mid-Life Associated with Successful Ageing, Disability, Dementia and Frailty in Later Life: A Rapid Systematic ReviewPLoS ONE, 11
M. Cesari, R. Calvani, E. Marzetti (2017)
Frailty in Older Persons.Clinics in geriatric medicine, 33 3
L. Claassens, Guy Widdershoven, S. Rhijn, F. Nes, M. Groenou, Dorly Deeg, Martijn Huisman (2014)
Perceived control in health care: a conceptual model based on experiences of frail older adults.Journal of aging studies, 31
(2005)
ree approaches to qualitative content analysis
C. Nicholson, A. Gordon, A. Tinker (2017)
Changing the way “we” view and talk about frailty…Age and Ageing, 46
(2018)
e essence of frailty: a systematic review and qualitative synthesis on frailty concepts and definitions
M. Kuo, Ching-Min Chen, C. Jeng (2012)
Development of Frailty Indicators for the Community-Dwelling Older AdultsJournal of Nursing Research, 20
J. Andreasen, H. Lund, M. Aadahl, R. Gobbens, E. Sørensen (2015)
Content validation of the Tilburg Frailty Indicator from the perspective of frail elderly. A qualitative explorative study.Archives of gerontology and geriatrics, 61 3
K. Evans, L. Mazzei, Margaret Teaford (2001)
Removing Some of the Gray Concerning the Health of Frail Older WomenJournal of Diagnostic Medical Sonography, 17
K. Seers (2015)
Qualitative systematic reviews: their importance for our understanding of research relevant to painBritish Journal of Pain, 9
I. Kinchin, D. Streatfield, D. Hay (2010)
Using Concept Mapping to Enhance the Research InterviewInternational Journal of Qualitative Methods, 9
R. Gobbens, M. Assen, K. Luijkx, J. Schols (2012)
Testing an integral conceptual model of frailty.Journal of advanced nursing, 68 9
D. Niesten, K. Mourik, W. Sanden (2012)
The impact of having natural teeth on the QoL of frail dentulous older people. A qualitative studyBMC Public Health, 12
Z. Ebrahimi, K. Wilhelmson, K. Eklund, C. Moore, A. Jakobsson (2013)
Health despite frailty: exploring influences on frail older adults' experiences of health.Geriatric nursing, 34 4
Caroline Nicholson, Julienne Meyer, M. Flatley, Cheryl Holman, K. Lowton (2012)
Living on the margin: understanding the experience of living and dying with frailty in old age.Social science & medicine, 75 8
S. Oostrom, D. A, M. Rietman, H. Picavet, M. Lette, W. Verschuren, S. Bruin, A. Spijkerman (2017)
A four-domain approach of frailty explored in the Doetinchem Cohort StudyBMC Geriatrics, 17
M. Jones (2004)
Application of systematic review methods to qualitative research: practical issues.Journal of advanced nursing, 48 3
M. Andrew (2015)
Frailty and Social Vulnerability.Interdisciplinary topics in gerontology and geriatrics, 41
Nancy Schoenborn, S. Rasmussen, Q. Xue, J. Walston, M. McAdams‐DeMarco, D. Segev, C. Boyd (2018)
Older adults’ perceptions and informational needs regarding frailtyBMC Geriatrics, 18
D. Sezgin, M. O'Donovan, N. Cornally, A. Liew, R. O’Caoimh (2019)
Defining frailty for healthcare practice and research: A qualitative systematic review with thematic analysis.International journal of nursing studies, 92
Christina Ekelund, L. Mårtensson, K. Eklund (2014)
Self-determination among frail older persons – a desirable goal older persons’ conceptions of self-determinationQuality in Ageing and Older Adults, 15
K. Rockwood, Xiaowei Song, C. MacKnight, H. Bergman, D. Hogan, I. Mcdowell, A. Mitnitski (2005)
A global clinical measure of fitness and frailty in elderly peopleCanadian Medical Association Journal, 173
K. Bandeen-Roche, C. Seplaki, Jin Huang, Brian Buta, R. Kalyani, R. Varadhan, Q. Xue, J. Walston, J. Kasper (2015)
Frailty in Older Adults: A Nationally Representative Profile in the United States.The journals of gerontology. Series A, Biological sciences and medical sciences, 70 11
(2007)
Older women and ‘frailty’: aged, gendered and embodied resistance
M. Puts, N. Shekary, G. Widdershoven, J. Heldens, P. Lips, D. Deeg (2007)
What does quality of life mean to older frail and non-frail community-dwelling adults in the Netherlands?Quality of Life Research, 16
S. Freitag, S. Schmidt (2016)
Psychosocial Correlates of Frailty in Older AdultsGeriatrics, 1
A. Clegg, Luke Rogers, John Young (2014)
Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review.Age and ageing, 44 1
D. Niesten, K. Mourik, W. Sanden (2013)
The impact of frailty on oral care behavior of older people: a qualitative studyBMC Oral Health, 13
Z. Ebrahimi, K. Wilhelmson, C. Moore, A. Jakobsson (2012)
Frail Elders’ Experiences With and Perceptions of HealthQualitative Health Research, 22
S. Searle, A. Mitnitski, E. Gahbauer, T. Gill, K. Rockwood (2008)
A standard procedure for creating a frailty indexBMC Geriatrics, 8
S. Espinoza, Myla Quiben, H. Hazuda (2018)
Distinguishing Comorbidity, Disability, and FrailtyCurrent Geriatrics Reports, 7
E. Porter (2001)
An Older Rural Widow’s Transition From Home Care to Assisted LivingCare Management Journals, 3
K. Jett (2003)
The meaning of aging and the celebration of rural African-American women,Geriatric Nursing, 24
I. Hammar, S. Dahlin-Ivanoff, K. Wilhelmson, K. Eklund (2014)
Shifting between self-governing and being governed: a qualitative study of older persons’ self-determinationBMC Geriatrics, 14
L. Fried, L. Ferrucci, J. Darer, J. Williamson, G. Anderson (2004)
Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care.The journals of gerontology. Series A, Biological sciences and medical sciences, 59 3
S. Sidani (2008)
Handbook for Synthesizing Qualitative ResearchCanadian Journal of Nursing Research Archive, 40
(2001)
Conceptualizing stigma
Steven Bunt, N. Steverink, J. Olthof, C. Schans, J. Hobbelen, J. Hobbelen (2017)
Social frailty in older adults: a scoping reviewEuropean Journal of Ageing, 14
Enzo Yaksic, V. Lecky, S. Sharnprapai, T. Tungkhar, Kelly Cho, Jane Driver, A. Orkaby (2019)
Defining Frailty in Research Abstracts: A Systematic Review and Recommendations for StandardizationThe Journal of Frailty & Aging, 8
(2007)
BMC Medical Research Methodology
J. Thomas and A. Harden (2008)
Methods for the thematic synthesis of qualitative research in systematic reviews,BMC Medical Research Methodology, 8
M. Canevelli, M. Cesari (2015)
Cognitive frailty: What is still missing?The journal of nutrition, health & aging, 19
S. Kirby, P. Coleman, D. Daley (2004)
Spirituality and well-being in frail and nonfrail older adults.The journals of gerontology. Series B, Psychological sciences and social sciences, 59 3
G. Becker (1994)
The oldest old; autonomy in the face of frailty.Journal of aging studies, 8 1
S. Kaufman (1994)
The social construction of frailty: An anthropological perspectiveJournal of Aging Studies, 8
(2017)
WHO Clinical Consortium on Healthy Ageing Topic Focus: Frailty and Intrinsic Capacity, e World Health Organization
P. O’Connor (1994)
Salient themes in the life review of a sample of frail elderly respondents in London.The Gerontologist, 34 2
K. Jett (2002)
Making the Connection: Seeking and Receiving Help by Elderly African AmericansQualitative Health Research, 12
C. Tocchi (2015)
Frailty in Older Adults: An Evolutionary Concept AnalysisResearch and Theory for Nursing Practice, 29
L. Rodríguez-Mañas, C. Féart, G. Mann, J. Viña, S. Chatterji, W. Chodzko-Zajko, M. Harmand, H. Bergman, L. Carcaillon, C. Nicholson, A. Scuteri, A. Sinclair, M. Pelaez, T. Cammen, F. Béland, J. Bickenbach, P. Delamarche, L. Ferrucci, L. Fried, L. Gutiérrez-Robledo, K. Rockwood, F. Artalejo, G. Serviddio, Enrique Vega (2013)
Searching for an operational definition of frailty: a Delphi method based consensus statement: the frailty operative definition-consensus conference project.The journals of gerontology. Series A, Biological sciences and medical sciences, 68 1
(2017)
Fit for frailty-a consensus best practice guidance for the care of older people living in community and outpatient settings
Sigrid Mueller-Schotte, N. Zuithoff, Y. Schouw, M. Schuurmans, N. Bleijenberg (2018)
Trajectories of Limitations in Instrumental Activities of Daily Living in Frail Older Adults With Vision, Hearing, or Dual Sensory Loss.The journals of gerontology. Series A, Biological sciences and medical sciences, 74 6
Patrik Aspers, Ugo Corte (2019)
What is Qualitative in Qualitative ResearchQualitative Sociology, 42
M. Grant, A. Booth (2009)
A typology of reviews: an analysis of 14 review types and associated methodologies.Health information and libraries journal, 26 2
R. Nicholson, Julienne Meyer, M. Flatley, C. Holman (2012)
e experience of living at home with frailty in old age : A psychosocial alitative study
R. Gobbens, M. Assen, K. Luijkx, M. Wijnen-Sponselee, J. Schols (2010)
The Tilburg Frailty Indicator: psychometric properties.Journal of the American Medical Directors Association, 11 5
S. Moss, M. Moss, Janet Kilbride, R. Rubinstein (2007)
Frail men's perspectives on food and eatingJournal of Aging Studies, 21
Audai Hayajneh (2019)
The Psychometric Properties of the Arabic Version of the Tilburg Frailty IndicatorGlobal Journal of Health Science
(2018)
Perceptions of frailty among African American men and women
Susan Gee, G. Cheung, Ulrich Bergler, H. Jamieson (2019)
“There's More to Frail than That”: Older New Zealanders and Health Professionals Talk about FrailtyJournal of Aging Research, 2019
(2018)
Oxford Centre for the Triple Value Healthcare Ltd
B. Paterson, S. Thorne, C. Canam, C. Jillings (2001)
Meta-Study of Qualitative Health Research
Shu-Fang Chang, Gi-Mi Wen (2016)
Association of frail index and quality of life among community-dwelling older adults.Journal of clinical nursing, 25 15-16
P. Chatterjee (2019)
Understanding Frailty: The Science and BeyondHealth and Wellbeing in Late Life
A. Chamberlain, J. Sauver, D. Jacobson, S. Manemann, Chun Fan, V. Roger, B. Yawn, L. Rutten (2016)
Social and behavioural factors associated with frailty trajectories in a population-based cohort of older adultsBMJ Open, 6
W. Donlan (2011)
The meaning of community-based care for frail Mexican American eldersInternational Social Work, 54
E. Porter (1999)
'Getting up from here': frail older women's experiences after falling.Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses, 24 5
Xujiao Chen, Genxiang Mao, S. Leng (2014)
Frailty syndrome: an overviewClinical Interventions in Aging, 9
Jossiana Faller, David Pereira, Suzana Souza, F. Nampo, F. Orlandi, S. Matumoto (2019)
Instruments for the detection of frailty syndrome in older adults: A systematic reviewPLoS ONE, 14
Hindawi Journal of Aging Research Volume 2021, Article ID 6285058, 20 pages https://doi.org/10.1155/2021/6285058 Review Article Definitions of Frailty in Qualitative Research: A Qualitative Systematic Review 1 1 2 Deborah A. Lekan , Susan K. Collins, and Audai A. Hayajneh University of North Carolina at Greensboro, School of Nursing, Nursing and Instructional Building, Greensboro, NC 27402, USA Jordan University of Science and Technology, Faculty of Nursing, Ar Ramtha, Jordan Correspondence should be addressed to Deborah A. Lekan; dalekan@uncg.edu Received 2 July 2020; Accepted 21 May 2021; Published 2 June 2021 Academic Editor: He´lio J. Coelho-Ju´nior Copyright © 2021 Deborah A. Lekan et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. (e purpose of this qualitative systematic review was to examine how frailty was conceptually and operationally defined for participant inclusion in qualitative research focused on the lived experience of frailty in community-living frail older adults. Search of six electronic databases, 1994–2019, yielded 25 studies. Data collection involved extracting the definition of frailty from the study aim, background, literature review, methods, and sampling strategy in each research study. Quality appraisal indicated that 13 studies (52%) demonstrated potential researcher bias based on insufficient information about participant recruitment, sampling, and relationship between the researcher and participant. Content analysis and concept mapping were applied for data synthesis. Although frailty was generally defined as a multidimensional, biopsychosocial construct with loss of resilience and vulnerabilitytoadverseoutcomes,moststudiesdefinedthestudypopulationbasedonolderageandphysicalimpairmentsderived from subjective assessment by the researcher, a healthcare professional, or a family member. However, 13 studies (52%) used objective or performance-based quantitative measures to classify participant frailty. (ere was no consistency across studies in standardized measures or objective assessment of frailty. Synthesis of the findings yielded four themes: Time, Vulnerability, Loss, and Relationships. (e predominance of older age and physical limitations as defining characteristics of frailty raises questions about whether participants were frail, since many older adults at advanced age and with physical limitations are not frail. Lack of clear criteria to classify frailty and reliance on subjective assessment introduces the risk for bias, threatens the validity and interpretation of findings, and hinders transferability of findings to other contexts. Clear frailty inclusion and exclusion criteria and a standardized approach in the reporting of how frailty is conceptually and operationally defined in study abstracts and the methodology used is necessary to facilitate dissemination and development of metasynthesis studies that aggregate qualitative research findings that can be used to inform future research and applications in clinical practice to improve healthcare. andwell-being[3].Frailtyisaclinicalconditionthathasbeen 1. Introduction usedtodescribeapersonwhoisveryoldandwhomayappear thin, weak, fragile, and feeble. However, frailty is also rec- (e rapid growth in the aging population globally in terms of bothnumber andincreasinglongevityhasdrawnattentionto ognized as a state of vulnerability that may not be visibly apparent but is associated with reduced resilience and poor the needs of older persons, especially those who are frail [1]. Frailty has been characterized as nonresilient or accelerated response to and recovery from acute illness and other aging and the cumulative effect of detrimental physiologic stressors. Although some hold the opinion, “I know it when I changes and failed integrative responses [2]. Although frailty seeit,”itisalsoacknowledgedthatnoteveryoneseesthesame increaseswithage,itdiffersfromnormalagingandrepresents thing when it comes to frailty [4]. Managing frailty is rec- the cumulative effect of aging processes, morbidity, and ognized as an important component in tailoring healthcare psychosocial,behavioral,andenvironmentalfactorsonhealth for frail older adults. 2 Journal of Aging Research qualitative research found that there is no consensus about 1.1. Literature Review. A growing body of research has contributed new understanding about frailty; however, the specific qualitative methods or data analysis guidelines [12]. Considering this and the insights from our initial scan of the views of older adults who are frail may not be included in this scientific work. Despite a proliferation of frailty literature raised concerns about potential methodological frameworks and some agreement on aspects of physical issuesrelatedtoresearcherperspectivesaboutfrailtythatmay frailty, the precise defining characteristics and clinical in- contribute to bias in ways that would impact the validity, dicators for frailty and how to measure them in diverse care interpretation, and transferability of study findings. Meth- contexts (e.g., community, nursing home, and acute care odological deficits would also prevent inclusion of many hospital)arestillevolving[2,4].Muchofthefrailtyliterature articles in qualitative metasynthesis studies. (e purpose of this qualitative systematic review was to perform an in-depth follows a biomedical paradigm focused on pathophysio- logical etiology, physical function, and phenotypic features analysis of conceptual and operational definitions of frailty applied in participant sampling and inclusion criteria in offrailty[2,5].Despitealargevarietyofframeworksonways to assess frailty, the value of frailty assessment is undisputed qualitative research studies that focused on the lived expe- rience of frailty in community-living, frail older adults. because of the serious nature of this condition and its consequences. A previous consensus conference on frailty endorsedtheusefulnessof definingfrailtyinclinicalsettings 2. Method and the need for a clear conceptual framework, indicating thatfrailtywasaclinicalsyndromeassociatedwithincreased 2.1. Study Design. (is study used a qualitative systematic vulnerability and potential for preventing, delaying, or re- review[13,14].(isreviewusesaprocesswhichsummarizes versing frailty with interventions [5]. (ere is also recog- primary qualitative research studies on a topic derived from nition that there is no ideal frailty assessment tool; the asystematicandrigorousliteraturesearch[13].(eresearch selection of a tool is based on the population characteristics, evidence is integrated, compared, and synthesized into a available data, clinical context, and purpose of the assess- holistic interpretation informed by existing theory and re- ment [4, 6, 7]. search to more fully comprehend the multiple levels of What is frailty and how it should be assessed have not understanding around a topic [11, 14]. Methods for sys- been informed by qualitative literature in meaningful ways tematic reviews of quantitative research are well established; that capture the voice of older adults who are frail [2, 8, 9]. however, the first publication of a systematic review of (e development of quantitative methodologies for as- qualitative research was not until 2013 [13]. (e qualitative sessmentofaphenomenonsuchasfrailtyisideallypreceded systematic review could be an important contribution to the by qualitative research to explore concepts and correlates. science of frailty since the findings can serve as a foundation (e validity of concepts used in quantitative research can be to develop new insights and propose strategies for future strengthened by being grounded in real-life experiences and knowledge development [15]. Sandelowski and Barroso’s verified in first person encounters through interviews and [10] methodology was employed to synthesize primary focus groups derived from qualitative research [10, 11]. qualitative research study findings into a holistic interpre- Current operational definitions of frailty in the empirical tation about the researchers’ definitions of frailty that was literature typically focus on physical aspects of frailty and used for participant inclusion criteria in qualitative research overlook psychosocial aspects and other factors that may be on the lived experience of frailty among frail older adults more meaningful to frail older adults [5, 8]. living in the community. An understanding of how frailty is defined in qualitative researchstudiescouldinformthedialogueanddevelopment of frailty assessment frameworks that can be applied in 2.2. Literature Search Strategy. A systematic search of six research investigations and in clinical practice. Qualitative databases was conducted: Cumulative Index to Nursing and research provides insights that are difficult to produce with Allied Health Literature (CINAHL), MEDLINE (PubMed), quantitative measures by providing detailed descriptions of ProQuest, PsycINFO, Scopus, and Sociological Abstracts, phenomenon of concern such as frailty in real-life contexts. from their inception through June 2019. (e appropriate Synthesized qualitative research findings in the format of a medical subject headings (MeSH), search terms, and key- metasynthesis provide new knowledge about a topic with words for each database were applied and included the greater influence compared to singular studies. An initial following: “frail elderly” and “qualitative research” scan of the qualitative research literature on the lived ex- (PubMed); “frail”and “middle aged 45–64 years,” “aged 65+ perience of frailty in community-living frail, older adults years,”“aged,80andover”(CINAHL);“healthimpairment,” yieldedaverysmallnumberofarticlesandnometasynthesis “aging,” “middle age (40–64 years),” “aged (65 years & studies.Followingscreeningofasetofarticles,wenotedthat older),” “very old (85 years & older),” “qualitative” (Psy- manylackedaclearconceptualandoperationaldefinitionof cINFO); and “aging,” “elder,” “frail,” “gerontology,” “geri- frailty, and inclusion criteria for sample selection were atric,” “senior,” and “qualitative methods” (Sociological ambiguous and often based on older age or the presence of Abstracts). (e search was limited to human subjects and physical impairments. English language. Additional citations were located through By design, qualitative research can be less structured and hand search of reference lists. Citations were excluded if more open-ended and flexible compared to quantitative re- there was no evidence of the older adult’s perspective on search; indeed, a recent systematic review of definitions of frailty.Unpublishedpapers(e.g.,abstracts,dissertations,and Journal of Aging Research 3 Records identified through database searches (n = 785) Additional records identified through manual search (n = 46) Records screened by title and abstract (n = 831) Duplicates (n=55) and irrelevant articles (n = 613) Records aer duplicates, title and abstract screening (n = 163) Articles excluded due to lack of relevance (n = 24) Articles screened, full-text review (n = 139) Articles not looking at community-dwelling frail older adults excluded (n = 70) Full-text articles reassessed for eligibility (n = 69) Full-text articles not clearly identifying participant sample as frail older adults excluded Articles included in review (n = 44) (n = 25) Figure 1: Search strategy flow diagram. conference proceedings) were excluded. Study populations questions were examined in the same participant sample that focused on older adults in acute care hospitals or long- [16–29]. (e search strategy is shown in Figure 1. term care settings (e.g., assisted living, nursing homes, and rehabilitation facilities) were excluded since the experience of frailty in these contexts would be different. Studies that 2.3. Data Abstraction. A first review of the article was addressed end-of-life, advance directives, and failure-to- conducted byonecoauthor. Articleswerereadindetailwith thrive were excluded because these issues are associated a focus on the study aim or purpose, background and lit- with the latest stages of frailty and not the focus of this erature review, and methods. Data abstraction included the review. following: authors, year of publication, first author profes- (esearchyielded784citations;anadditional46articles sional discipline, country of origin of the research, study wereidentifiedmanuallyfromauthorsearchesandreference aim, conceptual and operational definition of frailty, par- lists. Two reviewers independently screened titles and ab- ticipant recruitment and characteristics, study setting, and stracts and rated each citation as meeting screening criteria. ethicalconsiderations.Statementsusedtodefinefrailtywere Full-text reviews of 138 articles were conducted with ex- extracted and entered verbatim into individual data forms. clusion of 70 articles that were not focused on community- (e conceptual definition of frailty referred to how the term dwelling frail older adults. A total of 69 articles underwent a frailty was used by the researcher to describe the construct secondroundoffull-textreview,withexclusionsapplieddue andguidethesampleselection.(eoperationaldefinitionof tothestudysamplenotclearlyidentifiedasfrail,and44were frailty identified how frailty was measured and classified for excluded. (e final sample included 25 articles. Fourteen of inclusion in the study. Specific attention was directed to the thesearticleswereauthoredbysevenresearchergroups(two methods section (e.g., recruitment, sampling, and inclusion different studies for each group) in which different research and exclusion criteria) of the article. When an explicit Inclusion Screening Eligibility Identification 4 Journal of Aging Research definition of frailty could not be determined, descriptive spreadsheets, and meeting notes were maintained for an terminology for frailty was identified. Care was taken not to audittrailandrevisitedasneededtofollowdecision-making. confound the researcher’s definition of frailty for the pur- pose of the study with the study findings and interpretation. 3. Results Frailty statements and terminology were transferred into a 3.1. Systematic Review Findings. (e 25 articles in Table 1 Microsoft Excel spreadsheet to facilitate grouping into represented various disciplines including nursing (11), topical areas. A second review of the article was performed medicine and neuroscience (3), sociology and social work byanothercoauthortoverifythedataabstractioninthedata (6), occupational therapy (2), dentistry (2), and radiology forms and the spreadsheet, making any additions or cor- (1). (ere was a diverse representation by country of origin, rections needed. with the majority of articles originating from the United States (10) and the Netherlands (5), followed by Sweden (4), 2.4. Quality Appraisal. Each article underwent quality ap- United Kingdom/England (3), Canada (2), Denmark (1), praisal with a focus on the research question, methods, and and Taiwan (1). Twenty articles provided a clear conceptual ethicsusingtheCriticalAppraisalSkillsProgramme(CASP) and/or operational definition of frailty, of which 13 articles Qualitative Studies Checklist [30]. (ere are varying opin- (52%) included quantitative objective or performance-based ionsabouthowqualityshouldbeassessed,whoshouldassess measures for frailty. Frailty definitions were sometimes quality,andwhetherqualityshouldbeassessedinqualitative difficult to locate and were embedded in the background or research at all given the nature of this research genre [31]. It literature review; articulation of participant inclusion/ex- isalsoproposedthatqualitativeresearchisnotgeneralizable clusion criteria in the methods was sometimes unclear. and is specific to a certain context and participant group Critical appraisal of the articles using CASP checklist [31]. In accordance with these and other opinions, we did identified 13 studies (52%) at risk for researcher bias due to not exclude any articles based on quality [10], especially insufficient information about participant recruitment; re- since this review was prompted by methodological concerns lationship between the researcher and the participant; re- about how researchers classified participants as frail for liance on subjective judgment of the researcher, ahealthcare qualitative studies on the lived experience of frailty. (is professional, or a family member to classify or identify frail qualitative systematic review was undertaken to provide a participants; and lack of clear operational criteria for frailty synthesisofarticlesthatmetourinclusioncriteriabecauseof (see Table 2, questions 4 and 5). its potential to inform the design of future qualitative re- search on frailty. 3.2. Older Age and Physical Impairment. Researchers cited older age and physical impairments as the primary frailty 2.5. Data Analysis: Content Analysis and Concept Mapping. markers in the articles in this review. While all articles cited Content analysis [32] was undertaken to identify insights 65yearsofageandolderastheagecutoff,agegreaterthan80 and concepts from statements extracted from each article years was a primary frailty indicator in nine articles (36%) and coded in the spreadsheets. Coding is the process in [16, 17, 22, 23, 35, 38, 41]. In eight articles, frailty was which data are reduced into manageable units and cate- subjectively determined by the researcher or a proxy such as gorizedformeaningfuluse.Conceptmappingwasemployed a health professional or family member tofacilitatereflectionandunderstandingaboutfrailtyandto [18, 19, 22, 23, 35, 38, 39, 41]. For example, Becker [32] graphically organize and represent key concepts in the data described frailty as the presence of chronic physical im- aggregation and reduction process [33]. Concept maps are pairments in older individuals that the health professional graphical tools for organizing and representing concepts to wouldviewasputtingthematrisk.Nicholsonandcolleagues facilitate identification of similarities, differences, and pat- [22, 23] determined frailty based on recommendations from terns in the data [33]. Colored-coded sticky notes with an interdisciplinary care team that considered old age, in- concepts/statements for the conceptual and operational ability to carry out activities of daily living, dependence, and definitions of frailty from the spreadsheet were clustered on vulnerability to physical decline. In several articles, de- a white board for the initial graphical organization of the pendence on caregivers and the healthcare system was a concepts; this visual display was then replicated in a frailty indicator [16, 17, 19, 36, 41, 44]. A majority of articles Microsoft PowerPoint format. inthisreviewcitedimpairmentsinactivitiesofdailylivingas For the synthesis, the color-coded concept groupings inclusion criteria for frailty. However, most did not include were compared, contrasted, and organized into categories. information about assessment parameters and how mea- Finally,bycollapsingandexpandingcategories,topicalareas sures for physical function were administered (self-reported emerged, and themes were formed. An iterative process of or provider-administered) or scored [20, 21, 26, 27]. analysisofconceptsproducedfurtherrefinementsleadingto classification of data into categories and themes. To ensure validity, the articles were re-reviewed to ensure accurate 3.3. Operational Definition for Frailty and Objective Measures. representation of the concepts, categories, and themes. About half of the articles employed objective or perfor- Regular meetings among our team fostered discussion and mance-based measures to characterize frailty in the par- ticipantsample(n �13,56%)(seeTable3).Fourarticlesused interrogation of the data and development of consensus on the categories and themes. (e concept map, date-stamped validated screening tools for frailty such as grip strength, Journal of Aging Research 5 Table 1: Description of the qualitative research articles in the study sample (N �25). First author, date; Sample N; age mean st 1 author Conceptual description or Operational definition of Aim/purpose (range) in years; discipline; country definition of frailty frailty gender; race of origin; [ID] To validate the Tilburg A dynamic state affecting an Tilburg Frailty Indicator, a Frailty Indicator on content individual who experiences 15-item self-administered by exploring the experience losses in one or more domains questionnaire: physical Andreasen et al., of daily life of community- of human functioning domain (8 items), N �14; 80.6(69–93); 2015; occupational dwelling frail elderly shortly (physical, psychological, 1 psychological domain (4 7 men, 7 women; therapy; Denmark; after discharge from an social) that are caused by the items), social domain (3 Caucasian [34] acute admission, in relation influence of a range of items). Frailty cutoff score to the physical, variables, which increases the accounts for five of the 15 psychological, and social risk of adverse outcomes and frailty indicators. domains of the TFI. negatively impacts well-being. Chronically dependent older 80 years of age and older; people, those who are living frailty determined by To explore the meanings with a variety of physical and/ N �19;≥80; 12 men, opinion of health Becker, 1994; older persons attach to or cognitive impairments and 16 women; Hispanic professional including 2 social science; autonomy and decreases in experiencing functional losses and Caucasian, 2 presence of chronic USA; [35] physical abilities associated anddecreaseinphysicalability African American impairments that health with frailty. that interfere with ability to women professionals would view as maintain autonomy in putting people at risk. everyday life. Frail determined by scoring below cutoff scores, on at leasttwoofthesixfollowing domains: BMI <23; Toinvestigatetheconceptof Frail older adults cope with cognitive function (MMSE Claassens et al., healthcare-relatedperceived multipleand/orchronichealth <24); vision and hearing N �32; 80.5(65–96); 3 2014; medicine; control from the viewpoint conditions that likely require acuity; grip strength 13 men, 19 women; Netherlands; [36] of frail older adults more extensive forms of (handheld dynamometers); Caucasian >65years. healthcare. physical activity (how often & how long they walked, cycled, performed household activities, played sports) during 2 past weeks. To identify how frail Not described; frailty and Donlan, 2011; Mexican American elders disabilityoftenaccompanyold Age ≥65 years and having a N �6; 77.5 (66–89); 4 social work; USA; socially constructed the age, especially among disability. Requiring 3 men, 3 women; [37] meaning of community- marginalized immigrant assistance with ADLs. Hispanic based care they received. populations. As people age, their reserve Age ≥80 years or ≥65 years capacity decreases, and the with one or more chronic To discover and reveal the Ebrahimi et al., risk of morbidity and frailty diseases; those who N �22; 79.5(67–92); meaning of experienced 5 2012; nursing; increases; a multidimensional depended on help in at least 11 men, 11 women; health through the analysis Sweden; [16] geriatric syndrome of one ADL and sought Caucasian of frail elders’ descriptions. disability; vulnerability and emergency treatment in a reduced capacity. hospital. A biological geriatric Age ≥80 years or ≥65 years syndrome of reductions in with one or more chronic To explore and identify physiological reserve capacity diseases; those who Ebrahimi et al., N �22; 79.5(67–92); what influences frail older and impairment of defense depended on help in at least 6 2013; nursing; 11 men, 10 women; adults’ subjective mechanisms against stress and one ADL and sought Sweden; [17] Caucasian experiences of good health. disease which implies a risk of emergency treatment in a multimorbidity and hospital. Frailty determined dependence on others. by a count. 6 Journal of Aging Research Table 1: Continued. First author, date; Sample N; age mean st 1 author Conceptual description or Operational definition of Aim/purpose (range) in years; discipline; country definition of frailty frailty gender; race of origin; [ID] A physiological state of increased vulnerability to stressors that result from Age ≥80 years or ≥65 years decreased physiological with one or more chronic To explore community- Ekelund et al., reserve; related to risk for diseases; those who N �15; 80.5(68–92); 2014; occupational living frail older persons’ 7 disabilityandcomorbidity;the depended on help in at least 8 men, 7 women; therapy; Sweden; conceptions of self- presence of various diseases, one ADL and sought Caucasian [38] determination. age discrimination, and emergency treatment in a paternalism impact frailty; hospital. dependency is an important aspect of frailty. Frailtycriteria/measuresnot clearly specified, but older women were Frail older adults are defined “. . .categorized by age as To investigate whether frail asthoseindividualswhosuffer frail older adults.” Evans et al., 2001; olderwomenwithapositive N �4; 82.25 (76–90); major physical, mental, or Convenience sample of frail 8 radiology; USA; perception of health would 4 women; not social losses and require a older women who were [39] desire to take a more active reported range of supportive and scheduled for ultrasound role in their healthcare. restorative services. examination and whose health status indicates ability to participate in interviews. Definition derived from the social label of frailty and not physical function and was related to the presence of Frailtycriteria/measuresnot comorbidities. (e social specified. Frailty context of frailty as the “little determination is based on old lady” of small stature, clinical judgment and home being fragile and weak, is care eligibility by health associated with assumptions professionals for half of the Grenier & Hanley, that shape the gendered sample, and the other half N �12; >55; 12 To explore the life 9 2007; social work; experience of older women. were active in an advocacy women; not experiences of frailty. Canada; [19] Frailty framed in context of organization but fell outside reported resistance to dominant the classification because notions of aging and gender, they did not receive public to challenge social constructs services due to lack of andexpectationsforagingand physical need, interest, or frailty. Frailty is also a term financial resources to pay used byhealthprofessionalsto privately. assess a person’s need for public services to meet physical needs. Journal of Aging Research 7 Table 1: Continued. First author, date; Sample N; age mean st 1 author Conceptual description or Operational definition of Aim/purpose (range) in years; discipline; country definition of frailty frailty gender; race of origin; [ID] Frailty is contextually and socially located; one aspect of the person’s appearance (i.e., of “being frail”) comes to stand for the total identity. Diverse older women in “Being” frail is related to the sources of inequalities, e.g., imposition of a classification ability, age, race, ethnicity, To explore the distinction that is medical and functional culture, and socioeconomic within older women’s in nature; there are emotional status; six were considered narrativeswhich represent a aspectsoffrailtythatliewithin frail based on clinical Grenier, 2006; clash between the the experiences of judgment and home care N �12;notreported; 10 social work; professional construct of impairment, disability, and eligibility and six women 12 women; “diverse” Canada; [18] frailty and the lived decline in later life that may were classified as not frail experiences of older contradict the medical and because they did not receive women. social nature of frailty. publicservicesduetolackof “Feeling” frail may or may not physical need, interest, or correspond with experiences financial resources to pay of impairment or disability. privately. Certain events may trigger frailty: new impairment, loss, bereavement,evolvingchronic illness. 80 years and older; frailty based on eight frailty indicators: weakness, To explore experiences of Frailty is a continuum of 3 fatigue, weight loss, physical Hammar et al., self-determination when phases: robust prefrail, fully activity, poor balance, slow N �11; 87(84–95); 5 2014; developing dependence in frail; a dynamic concept; 11 gait speed, visual men, 6 women; neuroscience; daily activities among directly related to decreased impairment, and cognition; Caucasian Sweden; [40] community-dwelling ability to perform daily classified as nonfrail (0 persons 80years and older. activities independently. indicators), prefrail (1–2 indicators), and frail (3 or more indicators). Frailty not defined; survival of Age ≥65 years, living alone, frail elders and role of ADLs and evidence of at least one To explore the process of and IADLs for day-to-day ADL (range 6 [complete help-seeking and help functioning described; frail independence] to 36 givingbyolderruralAfrican N �41, 9 frail; not Jett, 2002; nursing; elders are most vulnerable [complete dependence]) or 12 Americans and how certain reported; 9 women; USA; [20] with the least known needs IADL deficit (range 8 of the most vulnerable and African American and at greater risk for losses [complete independence] to least known elders seek help andunmetneedswhichcanbe 24 [complete dependence]), for day-to-day needs. mitigated with help-seeking and “knowledgeable about behaviors. aging and frailty.” Age ≥65 years, living alone, Frailty not defined; the study focused on ethnography of the and frail based on at least aging, fragility, and survival of one ADL or IADL deficit; To examine the meaning of rural elderly African ADL score: 6 (complete N �9; 84 (77–94); 9 Jett, 2003; nursing; aging from the perspective 13 Americans and learning who independence) to 36 women; African USA; [21] of older African American isidentifiedasaged,howaging (completedependence),and American women living in rural areas. is defined and culturally IADL score 8 (complete determined, and what it independence) to 24 means to be old. (complete dependence). 8 Journal of Aging Research Table 1: Continued. First author, date; Sample N; age mean st 1 author Conceptual description or Operational definition of Aim/purpose (range) in years; discipline; country definition of frailty frailty gender; race of origin; [ID] Frailty increases with advancing age; a dynamic adaptational process that is Toinvestigatewaysinwhich open to multiple frailty is defined, framed, interpretations. (e and understood by older medicalization of frailty persons, their family overshadows psychological, Age ≥80 years; receiving members, and healthcare emotional, and behavioral geriatric assessment providers in the context of a aspects of aging and frailty. services; and perceived by multidisciplinary geriatric Frailty is socially produced in family members, friends, or assessment service; to response to powerful health professionals to be at explore the process of N �3; ≥80; 3 Kaufman, 1994; discourses in American risk with a change in 14 increasing of frailty in women; not nursing; USA; [41] culture. Frailty is proposed condition, health decline, advanced old age, how they reported when someone conceives and need for medical care, attempt to understand, there to be a lived problem social support, and/or accept,manage, andcombat with a very old person; either supervision so that they frailty within the context of the old person has a condition could remain in the the American healthcare that is worsening or spreading community. system and the mechanisms to other body systems or areas employed to cope with and of the person’s life, or family solve the variety of members can no longer cope problems it creates. with caring for the person and focus on symptoms or behaviors as problems. 65 years and older; Barthel index for ADL, IADL, grip To cross-examine results Frailty indicates a dynamic strength (handheld between perception of model and a balance of dynamometer), timed-up- Kuo et al., 2012; frailty and physical psychological and physical and-go test, paper folding N �10; 69.5(65–74); 15 nursing; Taiwan; assessment outcomes then strength to counterthreats to test, spirometry, vision test, 10 women; Asian [42] try to establish frailty health; a decline in physical incontinence, body mass indicators for elderly people reserve capacity and ability to index, waist-hip ratio, body in Taiwan. resist stress. fat composition, Mini- Mental State Exam, Geriatric Depression Scale. To learn the meanings and Frailty based on eight-item Moss et al., 2007; themes that underlie screener of mobility (e.g., N �21; 83 (76–95); sociology/ attitudes of frail old men use of walker or wheelchair) 11 men, 10 women; 16 Not described. anthropology; who live in the community and activities of daily living 12 Caucasian, 3 USA; [43] and behaviors in relation to (e.g., meal preparation,light African American food and eating. housework, and bathing). Frailty is an antonym for successful aging and a synonym for the increasing To understand the infirmities that accompany experience of home- aging and the slow dwindling Frail persons were defined dwelling older people living dying trajectory of many by the interdisciplinary care Nicholson et al., with frailty over time in elders. (is trajectory is team based on advancing N �17; 94 (86–102); 2012; nursing; order to develop the gradual and unpredictable, 17 age, unable to carry out 5 men, 12 women; United Kingdom; empirical evidence base for encompassing accumulated IADLs and considered to be Caucasian [22] this group and to consider and multiple health problems, vulnerable to physical morefullyhownarrativesof which at some point tips the decline. frailty can shape person- person into the dying phase. centered care provision. (e social construction of the fourth age as a loss of agency and bodily self-control is linked to frailty. Journal of Aging Research 9 Table 1: Continued. First author, date; Sample N; age mean st 1 author Conceptual description or Operational definition of Aim/purpose (range) in years; discipline; country definition of frailty frailty gender; race of origin; [ID] Frailty describes the condition Frail elders were of people vulnerable to purposively selected by the To understand the adverse health outcomes in multidisciplinary care team experience over time of later life and includes a (community nurses, speech Nicholson et al., home-dwelling older people broader definition that therapist, physiotherapists, N �15; 94 (86–102); 2013; nursing; deemed frail, in order to includes social functioning, occupational therapists, 18 5 men, 10 women; United Kingdom; enhance the evidence base social relationships, and care support workers, Caucasian [23] for person-centered psychological frailty, e.g., geriatricians) based on age approaches to frail elder anxiety and loneliness ≥85year,unabletocarryout care. encompassing social, IADLs and considered to be psychological, and physical vulnerable to physical domains. decline. Age ≥65 years and frailty score based on eight Frailty is a state of reduced domains: social coping, psychological or physical psychosocial function, To identify and examine reserve in combination with personal care, mobility, N �38; 79.9(65–97); how natural teeth an increased risk for adverse motor function, medical 11 men, 27 women; contribute to the quality of outcomes such as falls, Niestenetal.,2012; care, behavior disorders, 2 Indonesian lifeofdentulouspeoplewho disability, and 19 dental science; and care needs per week. women, 25 areelderlyandfrailandhow institutionalization. Frailty Netherlands; [25] Score ranged from 0 to 10, Caucasian women, frailty influences the impact impacts health in general and where score of “1” indicated and 11 Caucasian of having natural teeth on thevaluethatpeopleascribeto mild frailty and “6” severe men. quality of life. their oral health and their frailty; persons scoring 7–10 subjective dental care needs were excluded. Scoring was and demands. determined by a medical authority. A state of reduced Age ≥65 years and a frailty psychological or physical score based on eight reserve in combination with domains: Social coping, an increased risk for adverse psychosocial function, outcomes such as falls, personal care, mobility, disability, and motor function, medical N �51; 24 being To explain how frailty Niestenetal.,2013; institutionalization;adynamic care, behavior disorders, 65–80, 27 being ≥80 influences dental service use 20 dental science; state affecting an individual and care needs per week. years; 16 men, 35 and oral self-care by older Netherlands; [24] who experiences losses in one Score ranges from 0 to 10, women; not people. or more domains of human where scores of “1” reported functioning (physical, indicated mild frailty and psychological, social) which “6” severe frailty; persons likely negatively affects dental scoring 7–10 excluded. service use and oral hygiene- Scoring determined by a related behaviors. medical authority. Randomly selected homebound social work Frail elderly people who are clients who need ADL living alone, housebound, assistance. Frailty markers and/or in need of assistance to describe the sample: To recognize the affective with basic activities of daily falling in the past year, O’Connor, 1994; reality of elderly persons’ N �134; ≥65; 28 living and/or have emotional havingpartialortotallossof 21 social work; experiences in the life men, 114 women; and/or social problems (which useofanarmoraleg,prone England; [44] reviewoffrailelderlypeople not reported may include perceived toheartattacksand/oracute who are living alone. inability to care for attacks of bronchitis or themselves) are in a socially asthma, unable to get out of vulnerable position. bed, walk indoors or outside, climb stairs, and/or bathe. 10 Journal of Aging Research Table 1: Continued. First author, date; Sample N; age mean st 1 author Conceptual description or Operational definition of Aim/purpose (range) in years; discipline; country definition of frailty frailty gender; race of origin; [ID] Women aged 80 years and older, living alone at home, Toexploreaneglectedrealm Not defined, but it was stated self-rated health of less than of frail older women’s that frail older persons are at excellent, history of a fall. N �18; 89.5(83–96); Porter, 1999; 22 experience of falling to the risk for falls and participants Frailty determined by three all women; not nursing; USA; [26] floor and trying to get up had physical function deficits criteria: inability to walk 10 reported while at home alone. that were indicators of frailty. blocks, need for assistance to climb stairs, and need for assistive device to walk. Frailty determined by eight frailty markers: low body Frailty is often used to mass index, low peak describe a state in which older expiratory flow, poor vision persons are, in a delicate and hearing ability, To describe the meaning Puts et al., 2009; balance, at risk for many incontinence, low sense of N �25; 78.7(67–90); that older community- 23 nursing; adverseoutcomessuchasfalls, mastery, depressive 14 men, 11 women; dwelling persons attach to Netherlands; [28] disability, institutionalization, symptoms, and physical Caucasian frailty. and death, which may have a inactivity. Frailty defined as negative effect on quality of having three or more life. markers and nonfrail defined as no frailty markers. Frailty determined by eight frailty markers: low body mass index, low peak expiratory flow, poor vision To describe the meaning of A state in which older persons and hearing ability, quality of life from the are in a delicate balance and at Puts et al., 2007; incontinence, low sense of N �25; 78.7(67–90); perspective of frail and risk for many adverse 24 nursing; mastery, depressive 14 men, 11 women; nonfrail older community- outcomes such as falls, Netherlands; [29] symptoms, and physical Caucasian dwelling persons in disability, institutionalization, inactivity. Frailty defined as Netherlands. and death. having three or more markers and nonfrail defined as no frailty markers. Age 65 years and older. FrailtybasedonFriedfrailty A medical syndrome criteria:weakness(handgrip consisting of specific physical strength), exhaustion, N �29; 76.3 (>65); 8 Schoenborn et al., To examine perceptions and symptoms, leading to multiple weight loss, physical men, 21 women; 25 2018; medicine; informational needs about adverse outcomes including activity, gait speed, and Caucasian (21), USA; [45] frailty among older adults. falls, hospitalization, cognition (Mini-Mental African American functional dependence, and State Exam); classified as (7), other (1) death. nonfrail (0 indicators), prefrail (1–2 indicators), or frail (3 or more indicators). Journal of Aging Research 11 Table 2: Quality appraisal: CASP Qualitative Studies Checklist and evaluative criteria. Criteria 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 1. Was there a clear statement of the aims of the research? Considering the goal of Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y the research, why it is thought it is important, relevance. 2. Is a qualitative methodology appropriate? If the research seeks to interpret or illuminate the actions and/or Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y subjective experiences of research participants. 3. Was the research design appropriate to address the aims of the research? Did the Y Y Y Y Y Y Y N C C Y Y Y Y Y N C C Y Y Y C Y Y Y researcher justify the research design? 4. Was the recruitment strategy appropriate to the aims of the research? Researcher explained how the participants were selected, why the participants Y C Y Y Y Y C N N N Y N N N Y N N N Y Y N N Y Y Y selected were the most appropriate to provide the type of knowledge sought by the study, and why some people chose not to participate. 5. Has the relationship between researcher and participants been adequately considered? Has the researcher critically examined their own role, potential bias, Y N Y Y Y Y N N N N Y N N N Y N N N Y Y N N Y Y Y and influence during (a) formulation of the research questions and (b) data collection, including sample recruitment and choice of location. 6. Have ethical issues been taken into consideration? Approval has been sought Y Y Y Y Y Y Y Y C C Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y from the ethics committee Rating: Y:yes; N:no; C:cannot answer. CASP: Critical Appraisal Skills Programme, https://casp-uk.b-cdn.net/wp-%20content/uploads/2020/10/ CASP_RCT_Checklist_PDF_Fillable_Form.pdf. timed-up-and-go test, chair stands, and gait speed [3]; conditionwastemporallydescribedasanevolvingtrajectory with accumulation of health problems and impairments. however, information about the tool and its scoring was absent. Measures for psychological function (e.g., cognition Frailty wasalso characterized as adynamic state thatfollows and mood) were included in seven articles, whereas three a continuum from robust to end-of-life. (ere is also a articlesincorporatedsocialfactorssuchaslivingalone,social tipping point in the frailty trajectory in which the accu- isolation, social support, and hours of care needed. Eight mulated burden of disease and psychosocial challenges lead articles differentiated frail and nonfrail status to transition from frailty risk to frailty as a reality. Transi- [24, 25, 28, 29, 34, 36, 40, 45]. tional points on the frailty continuum signal opportunities to prevent, delay, or reverse frailty and accelerate its progression. 3.4. Synthesis of Conceptual Definitions of Frailty. How re- searchers conceptually defined frailty in the qualitative re- 3.4.2. 4eme 2: Vulnerability. Vulnerability was portrayed search studies was examined using concept mapping. as impaired resilience, a precarious state, and psychological Synthesis of the 25 articles in this review yielded 10 cate- and social coping. Frailty is highly unstable and unpre- gories and four themes: Time, Vulnerability, Loss, and dictable, with waning reserve, loss of resilience, and reduced Relationships. (e themes, categories, and exemplar state- capacity to resist stressors. Frailty is marked by increased ments are summarized in Table 4. Figure 2 provides an risk for adverse outcomes, with differential risk appreciated example of concept mapping and data reduction for one of in marginalized, minority, and immigrant populations and the themes, and Figure 3 provides a graphical display of the subgroups of older men and women. Frailty is a personal, concept map for the four themes. subjectiveexperiencethatcouldbetriggeredorworsenedby negative emotions such as worry, sadness, fear, and anger. 3.4.1. 4eme 1: Time. Time was characterized by older age, Psychological vulnerability arising from negative emotional aging process, dynamic trajectory, and progressive physio- experiencessupersedesthephysicalexperienceandincreases logic dysregulation.Frailtyas anage-related andprogressive the risk for frailty. Social vulnerability was characterized by 12 Journal of Aging Research Table 3: Quantitative measurement of frailty in qualitative research studies (N �13). Author, year; frailty cut Cognition Mood-self- Physical performance tests Metrics Self-report questionnaire point function report TFI: physical domain (feeling healthy, weight loss, vision, hearing, walking, balance, hand strength, tiredness), Andreasen et al., 2015; psychological domain frailty �5/15 (memory, mood, anxiety, coping), social domain (living alone, social isolation, social support) Claassens et al., 2014; Grip strength, vision, MMSE BMI Physical activity frailty �2/6 hearing Hammar et al., 2014; Grip strength, gait speed, Endurance/physical activity, MMSE frailty �3/8 indicators balance, vision fatigue, weight loss Jett, 2002; 2003 frailty ADL and IADL, measurement cut point �one ADL not specified deficit Barthel index for ADL, IADL, grip strength, timed BMI, waist-hip Kuo et al., 2012; frailty up-and-go test, vision, MMSE GDS ratio, body fat Incontinence cut point not specified hearing, paper folding test, composition spirometry Motor function, mobility, Niesten et al., 2012, Behavior personal care needed, medical 2013; slight, moderate, disorders, care needed, hours of care severe frailty based on psychosocial needed per week; social level of care needed function coping Inability to walk 10 blocks, Porter et al., 1999, 2001; need for assistance to climb measurement not stairs, need for assistive device specified to walk Physical activity, vision, Puts et al., 2007, 2009; Depression, Peak expiratory flow BMI hearing, incontinence, sense frailty �3/8 indicators CES-D of mastery Physical activity, weight loss, Schoenborn et al., 2018; Hand grip strength, gait exhaustion, health literacy, MMSE frailty �3/5 indicators speed numeracy, self-reported health status Note:ADL:activitiesofdailyliving(controllingbowelandbladder,grooming,toileting,feeding,transferring,walking,bathing,climbingstairs,anddressing); IADL: instrumental activities of daily living (telephone use, meal prep, money & medication management, light & heavy housekeeping, shopping, and local travel); BMI: body mass index; CES-D: Center for Epidemiologic Studies Depression Scale; MMSE: Mini-Mental State Exam; GDS: Geriatric Depression Scale; TFI: Tilburg Frailty Indicator. increasing dependency and insufficient social support and control, autonomy, and self-determination. Frailty could resources. Vulnerability associated with frailty requires also be triggered by losses due to bereavement and new coping strategies to counteract deterioration. functionalimpairment.Medicalclassificationoffrailtycould be interpreted by individuals who frail as a threat to psy- chological well-being and loss of identity. 3.4.3. 4eme 3: Loss. Loss was reflected as a physical function decline, cascading pathway with negative conse- quences, and negative psychological and social identity. A 3.4.4. 4eme 4: Relationships. Finally,Relationshipsreferred to biopsychosocial domains of function, quality of life and central feature of frailty is the loss of capacity across biopsychosocial domains of function with increasing de- well-being, and connections and interdependence. Limita- pendence.Loss-relatedmarkersoffrailtyincludedweakness, tions of the dominant biomedical model that frames frailty low energy, fatigue, weight loss, instability, vision and in the empirical literature were acknowledged; frailty does hearing deficits, impaired mobility, and need for mobility not fit the medical model and is best represented as a aids or human assistance. From a psychosocial perspective, complex system forming an integrated whole. (ere is a frailtywasadepersonalizingexperiencewithlossofidentity, blurring of boundaries between frail and nonfrail states. Journal of Aging Research 13 Table 4: Frailty concept map themes, categories, and statements. Frailty (eme Category Sample statements Risk for frailty is age-related and increases over time Over age 80; greater than 65 years; “old-old”; fourth age Older age and aging process Aberrancies in biologic and physiologic systems lead to frailty Gradual and unpredictable in the aging process Aging and impaired homeostasis and defense mechanisms adversely impact function Progressive physiologic Ambiguous boundaries and cause-effect relationships exist between morbidity, Time dysregulation disability, and frailty Progressive, time-dependent changes in structure and function Malleable and may be prevented, mitigated, or reversed Frailty usually worsens over time; slow dwindling dying trajectory Dynamic trajectory Transitional; constantly changing and evolving Exists on a continuum from robust to end-of-life Domainsareinterrelated;mutuallyinteractingandinextricablylinked;adverseevents in one domain impact the other domains Biopsychosocial domains of Frailty is used to classify people to prioritize care and health and social services function Frailty has many forms due to deficits in biopsychosocial domains of function Blurred boundaries between frail and nonfrail state; distinctions between feeling frail and being frail Relationships Frailty is a threat to emotional integration and wholeness Quality of life and well-being Frailty is associated with social isolation, weakened social position Unstable social support or psychological states can precipitate or worsen frailty Dependence/interdependencebetweensocialnetwork,services,resources,technology Transactional process requiring negotiation of interdependency and care receiving Connections and interdependence needs Failed adaptation to manage frailty and changing biopsychosocial needs Observable frailty markers: weight loss, weakness, low energy, unstable balance, slow movement, and mobility aids Physical function decline Accumulation of chronic diseases Sensory losses in vision or hearing Losses are exacerbated across biopsychosocial domains of function Cascading pathway with negative Leads to impaired physical mobility and dependence Loss consequences Falls, disability, hospitalization, institutionalization, quality of life, self-care deficits, early mortality Stigma and negative connotations and labeling as frailty erode self-esteem and threaten identity Psychological and social identity Medical classification denies psychological and social aspects Disempowerment; loss of autonomy, control, and inner drive Reduced reserve capacity and ability to resist and overcome intrinsic and extrinsic stressors Impaired resilience Failing homeostasis and risk for adverse outcomes Increased healthcare needs and utilization Instability, uncertainty, fragility Vulnerability Precarious state Delicate balance and tipping point; fragility Frailty precipitates increased healthcare needs and service utilization Negative emotional reactions to frailty; diminished autonomy High psychological and social support needs; negatively impacted by social isolation, Psychologic and social coping living alone Antonym for successful aging 14 Journal of Aging Research Categories eme Concepts Individual who experiences losses in one or more domains of human functioning (physical, psychological, social). (1;5; 6; 8; 12; 13; 17; 18; 20) Frail older adults are those who are living with impairment, i.e., experiencing functional losses and decrease in physical ability. (3) Functional loss Frailty was determined by evidence of at least one ADL or instrumental ADL deficit (26) Reported one or more significant difficults in an 8-item screened of mobility (e.g., use of walker or wheelchair), and activities of daily living (e.g., meal preparation, light housework, bathing). Most of the study respondents had multiple difficulties Loss in mobility and ADL. (36; 59; 60) Inability to walk 10 blocks, need for assistance to climb stairs, and need for an assistive device to ambulate. (44; 54) Functional losses that interfere with the ability to maintain autonomy in everyday life. (3) Loss of control, self- determination, autonomy, self-identity “Frail older adults are defined as those individuals who suffer major physical, mental, or social losses and require a range of supportive and restorative services.” (14) Figure 2: Data aggregation and classification of concepts into categories and themes. Negative emotional reactions to frailty High psychological and social support needs Reduced reserve capacity and ability to resist and overcome Instability, uncertainty, fragile intrinsic and ectrinsic stressors Antonym for successful aging Failing homeostasis Delicate balance and tipping point Increased healthcare needs and utilization Frailty precipitates increased health care needs and service utilization Psychologic and social coping Impaired resilience Precarious state Observable frailty markers: weight loss, weakness, low energy, unstable balance,slow movement, and mobility aids Risk for frailty is age-related and increases over time Accumulation of chronic diseases Physical function Older age and Over age 80; greater than 65 year with at least one chroic disease decline Vulnerability aging process Sensory losses in vision or hearing Aberrancies in biologic and physiologic systems lead to frailty Losses are exacerbated across eme biopsychosocial domains of function Malleable and may be prevented, mitigated, or reversed Leads to impaired physical mobility and Cascading pathway with Time Frailty usually worsens over time Loss dependence Dynamic trajectory negative consequences THEME eme Frailty Transitional; constantly changing and evolving Falls, disability, hospitalization, institutionalization, Exists on a continuum from robust to end of life quality of life, self-care deficits, early mortality eme Aging and impaired homeostasis and defense mechanisms Stigma and negative connotations and labeling as frailty erode adversely impact function self-esteem and threaten identify Progressive physiologic Ambiguous boundaries and cause-effect relationships exist between Psychological and Dysregulation morbidity, disability, and frailty Medical classification denies psychological and social aspects social identity Progressive, time-dependent changes in structure and function Relationships Disempowerment; loss of autonomy, control, and inner drive Connections and Quality of life interdependence Dependence/interdependence between social network, sevices, and well-being resources, technology Fraility is a threat to emotional integration and wholeness Biopsychosocial domains Transactional process requiring negotiation of interdependency and care receiving needs Fraility contributes to a weakened social position Failed adaptation to manage frailty and changing biopsychosocial Mutually interacting and lnextricably linked adverse events or circumstances in needs Unstable social support or psychological states can precipitate one domain impact the other domains or worsen frailty Frailty is used to classify people to prioritize care and health and social services Frailty has many forms due to deficits in biopsychosocial domains of function Blurred boundaries between frail and non-frail state Figure 3: Concept map for frailty from the synthesis. Journal of Aging Research 15 Yaksic et al. [48] found that, out of 490 research study Frailty threatens quality of life through compromised emotional integration, unstable social support, and weak- abstractsreviewed,only348(16%)hadacompletedefinition of frailty that included the name of the frailty measure, the ened social position: frailty affects not only the individual, but also the social network and requires new connections to variables used in the measure, and the scoring for levels of manage changing needs. frailty. In a systematic review of frailty definitions applied in 78 quantitative research studies, Junius-Walker et al. [46] found that many studies lacked clear frailty definitions and 4. Discussion inclusion criteria and recommended five components that constituted a comprehensive definition of frailty. In 4.1. Concordance in Conceptual Definitions of Frailty. In this agreement with our findings, these investigators endorsed qualitative systematic review of 25 articles, researchers con- conceptssuchasmultipledimensionsoffrailty,emphasison ceptually defined frailty as a complex, multidimensional a function focused, holistic approach, intrinsic vulnerability syndrome that evolves from underlying vulnerability, phys- and capacities, and interacting environmental factors that iologic derangements, and loss of resilience manifested influence frailty over a focus on the physical and biological through dynamic interactions across the biopsychosocial aspects [49].Sezginet al.[50]conducted asystematicreview domains of human function with greater risk for adverse and thematic analysis of frailty definitions in quantitative outcomes. (e four themes yielded in the synthesis identified research and review articles (N �86) and found an over- concepts that align with the WHO Clinical Consortium on emphasis on physical aspects of frailty with few studies Healthy Aging Report [1] in which frailty is “. . .a clinically addressing psychosocial domains; here, only three studies recognizable state in which the ability of older people to cope were cited from the qualitative literature. Taken together, with every day or acute stressors is compromised by an in- this body of work, including the present systematic review, creased vulnerability brought by age-associated declines in reinforces the importance of clearly defining and oper- physiological reserve and function across multiple organ ationalizing frailty in qualitative research as this will facil- systems” (p. viii). Similarly, a concept analysis of frailty in the itate accurate interpretation of study findings and facilitate quantitative literature defined frailty as a tenuous state of the transferability of this knowledge in future research and health resulting from the complex interplay of physiological, clinical practice. Articulating specific inclusion criteria is psychosocial, and environmental stressors and is associated importantinqualitativeresearchbecauseithelpsensurethat withnumerousadversehealthoutcomes[46].(econceptual participants can provide the information necessary to ad- definitionsoffrailtyelaboratedbyresearchersinthesynthesis dress the research question and facilitates cross-study highlight human wholeness and the fact that psychological comparisons [51]. Deficits in participant sampling limits the andsocialfactorsareasimportantasphysicalfactorsinfrailty number of qualitative research studies that would be eligible [47]. (is evidence supports the growing body of evidence for inclusion in a qualitative metasynthesis, which is a that articulates the relevance of a biopsychosocial model for mechanism to aggregate findings from qualitative research frailty and provides a basis for moving away from organ- and in order to yield new information [10]. disease-based approaches to frailty toward a more holistic, health-andwellness-basedapproachingeriatriccare[1,6,7]. 4.3. Older Chronological Age as Synonymous with Frailty. 4.2. Methodological Deficits. A major finding is that many Although research indicates that advancing age increases risk for frailty, chronologic age is only loosely correlated articles in this systematic review suffered from poor methodological quality. Lack of specificity in detailing how with biological age and is not the most reliable indicator for frailty [4]. In addition, although older age, comorbidity, and frailty was operationally defined raised questions as to whetherthestudypopulationwasfrail.(equalityappraisal disability may overlap in the frailty experience, particularly in more advanced stages, they are distinctly different usingtheCASPchecklistdeterminedoverhalfofthearticles [52, 53]. Similarly, while advanced age brings a higher (n �13) could be considered biased and potentially ageist likelihood of multiple and interacting chronic diseases that due to reliance on age and physical impairments as primary may lead tofrailty,it is notablethat notall older peoplewith frailty criteria; there is strong evidence that all older adults comorbidity are frail, and younger persons may experience who experience physical limitations are not frail [5]. frailty [2, 54, 55]. Importantly, a hallmark of aging is the Qualitative investigations can improve the description of a complex, real-world phenomenon such as frailty. However, wide diversity of the aging experience; there is no typical older person [1]. Frailty is also found in middle-aged adults, if study participants are misjudged as frail, their reflections on frailty would be based on their own opinions and not especiallyminoritygroupssuchasAfricanAmericanswhere frailty not only develops earlier but also follows a more personal, direct experience, which threatens the veracity of severe course due to health disparities and disadvantages in the findings. opportunities for developing healthy lifestyles and good To our knowledge, this qualitative systematic review health across the life course [1, 2]. Accelerated aging and provides the first synthesis of conceptual and operational frailty may be evidenced in individuals younger than 70 definitions of frailty that were used for participant selection years due to health disparities arising from economic, ed- inqualitativeresearchontheexperienceoflivingwithfrailty among frail community-living older adults. Recent similar ucational, and health disadvantages in contrast to more robust 85-year-old individuals with lifelong access to efforts have been undertaken in the quantitative literature. 16 Journal of Aging Research exhaustion, slowness, and low physical activity) [53]; (2) resources and healthy lifestyles [56]. (us, qualitative re- search that studies frailty only in older adults risks failing to accordingtoadeficitaccumulationframeworkrepresentedby the proportion of a range of deficits (30–70) that are present, detect frailty in younger, vulnerable populations who may experience different health circumstances and a steeper which reflects greater frailty [65, 66]; and (3) as a multidi- frailty trajectory [56]. mensional biopsychosocial construct based on comprehen- sive geriatric assessment [7]. (e present systematic review included articles dating back to 1994 since the search strategy 4.4. Physical Impairment. (e most common operational extendedtodatabaseinception.Whilethisallowedforabroad definitionoffrailtyinthisreviewfocusedprimarilyonphysical representation of articles for the synthesis, methodologies for function and limitations in activity of daily living. (is finding bothqualitativeresearchandfrailtyassessmenthavechanged. contrastswithinvestigationsandpositionpapersthatarticulate More recent articles included empirical indicators and distinctions between frailty and disability [5, 53]. An inter- quantitative measures for frailty, such as handgrip strength, disciplinary consensus conference of international experts gait speed, and validated chair stand tests for frailty with conferredthatthemostoftenuseddefinitionofphysicalfrailty demonstratedpredictive properties [3].Several articlesin this involved the evaluation of five physical-function-related do- review included tests for vision and hearing since there is mains (nutrition, energy, physical activity, mobility, strength) evidence linking frailty and sensory deficits [67]. However, toidentifyolderadultsathighriskforadversehealthoutcomes; measures for pulmonary function such as spirometry and however, there was agreement that frailty is different from peak expiratory flow were used in two articles without jus- disabilityuntil its laterstages[57]. Deficitsin physical function tification for their relevance to frailty. Tests for cognitive oftenaccompanycomorbiditiesandmayalsobeduetobarriers function and mood were also used in some of the more in physical environments. contemporary articles. Increasingly, opinions about frailty in the scientific literature indicate that focusing exclusively on physical frailty hinders a full understanding of frailty and its 4.5. Holistic, Biopsychosocial Perspectives on Frailty. impact on the individual [68]. Despite the predominance of older age and physical im- pairmentsaskeyempiricalindicatorsforfrailtyinthisreview, the conceptual definitions and descriptions of frailty in the 4.7. Racial, Ethnic, and Cultural Diversity. Although the qualitative research studies endorsed a more holistic per- articles in this review displayed some cultural diversity by spective that recognizes the psychosocial domains in the authorship and country of origin, cultural aspects of frailty scientificliteratureonfrailtyassessment[5,6,46,51]although were addressed in only two articles that included African there is no agreement on which indicators [58–60]. Psy- American participants [20, 21]. (ese findings concur with chosocial factors such as depression, anxiety, quality of life, recent systematic reviews of frailty that observe deficits in stressfullifeevents,andresiliencearerecognizedascorrelates addressing cultural factors in definitions of frailty in the of frailty [47]. Cognitive frailty is characterized by the co- quantitative literature [49, 50]. A study that translated the occurrence of physical frailty and cognitive impairment [61]. Tilburg Frailty Indicator for use in the Jordanian population Socialfrailtyistheaccumulationofmultiplesocialriskfactors found that the psychometric properties were similar for related to socioeconomic status, social support, social en- physical frailty, but not for psychological or social frailty; thus, gagement, and social behaviors that can adversely impact modification for cultural relevance was required [69]. For health outcomes [62]. example, in Jordanian culture, close-knit families help com- Notably, none of the articles in this review included pensate for the decline in aging and frailty; thus, to be con- spirituality as a factor in frailty, although research indicates sistent with Jordanian culture, items such as “Do you live thatspiritualitymaybeanimportantaspectofpsychological alone?” and “Do you sometimes miss having people around health that moderates the negative effects of frailty [63]. you?” were revised as “Have you felt alone?” because older Spirituality may be especially salient in certain population; adults often live with family members [69]. In a study of older for example, in a study using focus groups of African Taiwanese adults, feedback about a frailty assessment tool American men and women, spirituality was identified as a determined that they felt it was not effective in addressing significant driver in the prevention and mitigation of frailty quality of life [70]. Future research is needed to ensure that [64]. Qualitative research on frailty assessment that incor- frailty measures used in qualitative research are culturally and porates measures for psychosocial function and spirituality sociallyrelevantandsensitivetovariationsinlifeexperienceto is needed, because frailty is about not only physical changes more comprehensively assess the frailty experience. but also psychological, social, and spiritual factors that may precipitate and mediate such changes. 4.8. Stigma Associated with Frailty. One interesting finding in this review was the extent to which researchers discussed negative connotations and stigma associated with frailty 4.6. Empirical Indicators of Frailty. (ereiscontinueddebate abouttheidealfrailtyassessmentthatisapplicableinresearch [18, 19, 21, 23, 35, 38, 39, 41] 2003. Stigma is the co-oc- currence of labeling, stereotyping, separation, status loss, and clinical practice. In the scientific literature, frailty has beenoperationallydefinedinthreemajorframeworks:(1)the anddiscriminationandmayresultinfeelingsofshame,fear, phenotype for physical frailty quantified by objective criteria guilt, suffering, depression, isolation, reluctance to seek andperformance-basedmeasures(e.g.,weightloss,weakness, treatment, and decreased self-esteem [71]. (e language of Journal of Aging Research 17 suchasAfrica,low-andmiddle-incomecountries,andsome frailty used to classify a person’s health status is socially constructed based on prevailing norms and stereotypes and of the most populous countries such as China, India, and Russia. (ere were contributions from diverse disciplines; may have a detrimental impact on the individual due to stigma.InrecentinitiativesbyAgeUKandBritishGeriatrics however, in the era of globalization and team science, future Society [8] to address the public health impact of frailty, the research enterprises should adopt transdisciplinary collab- “Fit for Frailty” campaign reported that the vocabulary of orations to advance frailty science. While this review in- frailty was a barrier to involving older individuals in their volved a comprehensive search of multiple databases, care.Whilethereisutility forthetermfrailty,thereisaneed potentiallyrelevantarticlesmayhavebeenmissed,andthere to change how it is viewed and talked about by using dif- may be an unintended bias toward articles published in the peer-reviewed English language literature. (equality of the ferent terminology [9]. Furthermore, negative emotions engendered by the term frailty that is used in participant included articles varied, but we retained all relevant articles for a more enriched synthesis. We employed a systematic, recruitment may also hinder participation in research. Nonstigmatizingsynonymsforfrailtyareneededtofacilitate rigorous method for data extraction, content analysis, and concept mapping for the synthesis; however, the possibility communication and recruitment in research contexts, since the term frailty may offend, frighten, or turn away potential of overlooking key information or misinterpretation during participants. Several strategies are recommended for com- these processes exists. Finally, this review concentrated on municating with frail individuals that include avoidance of definitions of frailty in qualitative research focused on the term “frailty” and using language that promotes inde- studies in community-living frail older adults; how re- pendence, enablement, and resilience [68, 72]. (e concept searchers define frailty in qualitative research in other of intrinsic capacity as posited by the World Health Or- contexts such as acute care hospitals and long-term care nursing homes may differ and merits further inquiry. ganization is central to the prevention and mitigation of frailty; dialogue that frames frailty using perspectives of empowerment,capacity, and capabilitymay foster resilience 5. Conclusion and resistance to frailty [1]. Public service messaging and Frailty is a compelling global public health issue that sig- health education should be tailored for subgroups based on nificantly impacts individuals, families, communities, and gender, since the frailty experience among men and women society. (e anticipated increase in the incidence and prev- differs [47]. Qualitative research can elaborate on these is- alenceoffrailtyanditsadverseconsequencesunderscoresthe suesanduncoverhowresiliencemediatesfrailtyandidentify need to better understand frailty. (e findings from this terminology to incorporate a broader and more balanced systematicreviewofthequalitativeliteratureondefinitionsof understanding of frailty [68, 72]. frailty in qualitative research on the lived experience of frailty (e purpose of this review was not to discern or endorse among frail older adults indicate that frailty was conceptually a definition of frailty, but to represent how it is defined in defined as a multidimensional, biopsychosocial, holistic qualitative research for participant selection inclusion criteria. constructbutwasoftenoperationallydefinedbyolderageand Qualitative research including metasynthesis of qualitative re- functional impairment. Over half of the studies were ap- search findings can inform understanding of a complex, am- praised to be at risk for researcher bias due to lack of clear biguous phenomenon such as frailty and contribute new criteria to operationalize frailty in the study methodology. knowledge about this condition from insights provided by the (is review underscores the need for clear articulation of persons who are affected by it. Future research is needed in frailty defining characteristics and objective indicators in different age, racial, ethnic, and cultural groups to elucidate study abstracts and methods in future qualitative research. what is frailty, how a person becomes frail, what is its natural Suchtransparencywillfacilitatecross-studycomparisonsand history, how is it managed, and what can be done to prevent it. development of qualitative metasynthesis and meta-analysis To achieve these objectives, qualitative research should clearly studies which are necessary to expedite the development of articulate the conceptual and operational definition of frailty, the science base that is necessary to drive future research and the inclusion and exclusion criteria, and how the data will be guide improvements in the care for frail older adults. analyzed to differentiate the voices of participants who are frail or nonfrail. Our findings signal a call to action for the use of a Data Availability standardized approach to reporting how frailty is defined in abstractsandstudiesasproposedbyYaksicetal.[48]whichwill No data were used to support this study. facilitate qualitative metasynthesis studies to capture the in- creasingvolumeofqualitativeresearchandfacilitateknowledge Conflicts of Interest transferandaccuratereportingofscientificworkinfrailtythatis needed to catalyze initiatives to improve healthcare. (e authors declare that there are no conflicts of interest regarding the publication of this article. 4.9. Strengths and Limitations. (is qualitative systematic Authors’ Contributions review included qualitative research from multiple geo- graphic regions and professional disciplines. A majority of All authors have made substantial contributions to (1) the articleswerefromEuropean,Asian,andAmericancountries conception and design of the study, acquisition of data, or with a lack of representation of global geographic regions analysis and interpretation of data, (2) drafting of the article 18 Journal of Aging Research Information & Libraries Journal, vol. 26, no. 2, pp. 91–108, orrevisingitcriticallyforimportantintellectualcontent,and (3) final approval of the manuscript submitted. [15] B. L. Paterson, S. E. (orne, C. Canam, and C. Jillings, Meta- study of Qualitative Health Research, Sage Publications, Inc, Acknowledgments (ousand Oaks, CA, USA, 2001. [16] Z. Ebrahimi, K. Wilhelmson, C. D. Moore, and A. Jakobsson, (e authors would like to thank Julie Barroso, Ph.D., RN, “Frail elders’ experiences with and perceptions of health,” FAAN,forassistancewithstudydesign;MonaShatell,Ph.D., Qualitative Health Research, vol. 22, pp. 1513–1523, 2012. RN, FAAN, and Susan Letvak, Ph.D., RN, FAAN, for review [17] Z. Ebrahimi, K. Wilhelmson, K. Eklund, C. D. Moore, and of the manuscript; Sarah Abrams, MSN, RN, and Hyewon A. Jakobsson, “Health despite frailty: exploring influences on Shin, MSN, RN, for assistance with data abstraction; and frail older adults’ experiences of health,” Geriatric Nursing, Peggy Markham, MSLS, for editorial assistance in the vol. 34, pp. 289–294, 2013. [18] A. Grenier, “(e distinction between being and feeling frail: preparation of the manuscript. exploring emotional experiences in health and social care,” Journal of Social Work Practice, vol. 20, pp. 299–313, 2006. References [19] A. Grenier and J. Hanley, “Older women and ‘frailty’: aged, gendered and embodied resistance,” International Sociology, [1] World Health Organization (WHO), WHO Clinical Con- vol. 55, no. 2, pp. 211–228, 2007. sortium on Healthy Ageing Topic Focus: Frailty and Intrinsic [20] K.Jett,“Makingtheconnection:seekingandreceivinghelpby Capacity, (e World Health Organization, Geneva, Swit- elderly African Americans,” Qualitative Health Research, zerland, 2017, https://apps.who.int/iris/bitstream/handle/ vol. 12, no. 3, pp. 373–387, 2002. 10665/272437/WHO-FWC-ALC-17.2-eng.pdf?ua=1. [21] K. Jett, “(e meaning of aging and the celebration of rural [2] M. Cesari, R. Calvani, and E. Marzetti, “Frailty in older African-American women,” Geriatric Nursing, vol. 24, no. 5, persons,” Clinics in Geriatric Medicine, vol. 33, pp. 293–303, pp. 290–320, 2003. [22] C.Nicholson,J.Meyer,M.Flatley,andC.Holman,“Livingon [3] A Clegg, J. Rogers, and J. Young, “Diagnostic test accuracy of the margin: understanding the experience of living and dying simple instruments for identifying frailty in community- with frailty in old age,” Social Science & Medicine, vol. 75, dwelling older people: a systematic review,” Age and Ageing, pp. 1426–1432, 2012. vol. 44, no. 1, pp. 148–152, 2015. [23] C. Nicholson, J. Meyer, M. Flatley, and C. Holman, “(e [4] X. Chen, G. Mao, and S. X. Leng, “Frailty syndrome: an experience of living at home with frailty in old age: a psy- overview,” Clinical Interventions in Aging,vol.9,pp.433–441, chosocial qualitative study,” International Journal of Nursing Studies, vol. 50, pp. 1172–1179, 2013. [5] J.E.Morley,B.Vellas,G.A.vanKanetal.,“Frailtyconsensus: [24] D. Niesten, K. van Mourik, and W. van der Sanden, “(e a call to action,” Journal of the Medical Directors Association, impact of frailty on oral care behavior of older people: a vol. 14, no. 6, pp. 392–397, 2013. qualitative study,” BMC Oral Health, vol. 13, no. 61, 2013. [6] R.J.Gobbens,M.A.vanAssen,K.G.Luijkx,andJ.M.Schols, [25] D. Niesten, K. van Mourik, and W. van der Sanden, “(e “Testing an integral conceptual model of frailty,” Journal of impact of having natural teeth on the QoL of frail dentulous Advanced Nursing, vol. 68, pp. 2047–2060, 2012. older people. A qualitative study,” BMC Public Health, vol.1, [7] R. J. Gobbens, M. A. van Assen, K. G. Luijkx, M. T. Wijnen- p. 839, 2012. Sponselee, and J. M. Schols, “(e Tilburg frailty indicator: [26] E. J. Porter, ““Getting up from here”: frail older women’s psychometric properties,” Journal of the American Medical experiences after falling,” Rehabilitation Nursing, vol. 24, Directors Association, vol. 11, pp. 344–355, 2010. no. 5, pp. 201–211, 1999. [8] British Geriatrics Society, “Fit for frailty-a consensus best [27] E. J. Porter, “An older rural widow’s transition from home practice guidance for the care of older people living in care to assisted living,” Care Management Journal, vol. 3, community and outpatient settings,” British Geriatrics no. 1, pp. 25–32, 2001. Society, London, UK, 2017, https://www.bgs.org.uk/sites/ [28] M. Puts, N. Shekary, G. Widdershoven, J. Heldens, and default/files/content/resources/files/2018-05-23/fff_full. D. Deeg, “(e meaning of frailty according to Dutch older pdf. frail and non-frail persons,” Journal of Aging Studies, vol. 23, [9] C. Nicholson, A. L. Gordon, and A. Tinker, “Changing the pp. 258–266, 2009. way“we”viewandtalkabout frailty,” Age and Ageing,vol.46, [29] M.Puts,N.Shekary,G.Widdershoven, J.Heldens,P.Lips,and pp. 349–351, 2017. D.Deeg,“Whatdoesqualityoflifemeantoolderfrailandnon- [10] M. Sandelowski and J. Barroso, Handbook for Synthesizing frail community-dwelling adults in (e Netherlands?” Quality Qualitative Research, Springer Publishing Company, Inc., of Life Research, vol. 16, no. 2, pp. 263–277, 2007. New York, NY, USA, 2007. [30] Critical Appraisal Skills Programme (CASP), CASP Quali- [11] M. L. Jones, “Application of systematic review methods to tative Studies Checklist, Oxford Centre for the Triple Value qualitative research: practical issues,” Journal of Advanced Nursing, vol. 48, pp. 271–278, 2004. Healthcare Ltd.,Oxford,UK,2018,https://casp-uk.b-cdn.net/ wp-content/uploads/2020/10/CASP_RCT_Checklist_PDF_ [12] P. Aspers and U. Corte, “What is qualitative in qualitative research,” Qualitative Sociology, vol. 42, no. 2, pp. 139–160, Fillable_Form.pdf. [31] J. (omas and A. Harden, “Methods for the thematic syn- [13] K.Seers,“Qualitativesystematicreviews:theirimportancefor thesis of qualitative research in systematic reviews,” BMC Medical Research Methodology, vol. 8, p. 45, 2008. our understanding of research relevant to pain,” British Journal of Pain, vol. 9, no. 1, pp. 36–40, 2015. [32] H.-F. Hsieh and S. E. Shannon, “(ree approaches to qual- itative content analysis,” Qualitative Health Research, vol.15, [14] M. J. Grant and A. Booth, “A typology of reviews: an analysis of 14 review types and associated methodologies,” Health no. 9, pp. 1277–1288, 2005. Journal of Aging Research 19 [33] I. M. Kinchkin, D. Streatfield, and D. B. Hay, “Using concept detection of frailty syndrome in older adults: a systematic mapping to enhance the research interview,” International review,” PLoS One, vol. 14, no. 4, Article ID e0216166, 2019. Journal of Qualitative Methods, vol. 9, no.1, pp. 52–68, 2010. [52] S.E.Espinoza,M.Quiben,andH.P.Hazuda,“Distinguishing [34] J. Andreasen, H. Lund, M. Aadahl, R. J. J. Gobbens, and comorbidity, disability, and frailty,” Current Geriatrics Re- E. E. Sorensen, “Content validation of the Tilburg frailty ports, vol. 7, no. 4, pp. 201–209, 2018. indicator from the perspective of frail elderly. a qualitative [53] L. P. Fried, L. Ferrucci, J. Darer, J. D. Williamson, and explorative study,” Archives of Gerontology and Geriatrics, G. Anderson, “Untangling the concepts of disability, frailty, vol. 61, no. 3, pp. 392–399, 2015. and comorbidity: implications for improved targeting and [35] G. Becker, “(e oldest old: autonomy in the face of frailty,” care,” Journals of Gerontology. Series A, Biological Sciences and Journal of Aging Studies, vol. 8, no. 1, pp. 59–76, 1994. Medical Sciences, vol. 59, no. 3, pp. 255–563, 2004. [36] L. Claassens, G. A. Widdershoven, S. C. Van Rhijn et al., [54] K. Bandeen-Roche, C. L. Seplaki, J. Huang et al., “Frailty in “Perceived control in health care: a conceptual model based older adults: a nationally representative profile in the United on experiences of frail older adults,” Journal of Aging Studies, States,” Journals of Gerontology Series A: Biological Sciences & vol. 31, pp. 159–170, 2014. Medical Sciences, vol. 70, pp. 1427–1434, 2015. [37] W. T. Donlan, “(e meaning of community-based care for [55] L.Lafortune,S.Martin,S.Kellyetal.,“Behaviouralriskfactors frail Mexican American elders,” International Social Work, in mid-life associated with successful ageing, disability, de- vol. 54, no. 3, pp. 388–403, 2011. mentiaandfrailtyinlaterlife:arapidsystematicreview,” PLoS [38] C. Ekelund, L. Martensson, and K. Eklund, “Self-determi- One, vol. 11, no. 2, Article ID e0144405, 2016. nation among frail older persons - a desirable goal older [56] P. Chatterjee, “Understanding frailty: the science and be- persons’ conceptions of self-determination,” Quality in yond,” in Health and Wellbeing in Late LifeSpringer, Ageing and Older Adults, vol. 15, pp. 90–101, 2014. Singapore, 2019. [39] K. D. Evans, L. A. Mazzei, and M. H. Teaford, “Removing [57] L. Rodr´ıguez-Mañas, C. Feart, ´ G. Mann et al., “Searching for some of the gray concerning the health of frail older women,” an operational definition of frailty: a Delphi method based Journal of Diagnostic Medical Sonography, vol. 17, no. 4, consensus statement. (e Frailty Operative Definition-Con- pp. 203–211, 2001. sensus Conference Project,” Journals of Gerontology Series A: [40] I. Hammar, S. Dahlin-Ivanoff, K. Wilhelmson, and Biological Sciences and Medical Sciences, vol. 68, pp. 62–67, K. Eklund, “Shifting between self-governing and being governed: a qualitative study of older persons’ self-deter- [58] S. Bunt, N. Steverink, J. Olthof, C. P. van der Schans, and mination,” BMC Geriatrics, vol. 14, no. 126, pp. 1–8, 2014. J. S. M. Hobblen, “Social frailty in older adults: a scoping [41] S. R. Kaufman, “(e social construction of frailty: an an- review,” European Journal of Ageing, vol. 14, no. 3, thropological perspective,” Journal of Aging Studies, vol. 8, pp. 323–334, 2017. no. 1, pp. 45–58, 1994. [59] A.M.Chamberlain,J.L.StSauver,D.J.Jacobsonetal.,“Social [42] M. Kuo, C. Chen, and C. Jeng, “Development of frailty in- andbehaviouralfactorsassociatedwithfrailtytrajectoriesina dicators for the community-dwelling older adults,” Journal of population-based cohort of older adults,” BMJ Open, vol. 6, Nursing Research, vol. 20, no. 4, pp. 261–271, 2012. no. 5, Article ID e011410, 2016. [43] S. Z. Moss, M. S. Moss, J. E. Kilbride, and R. L. Rubinstein, [60] S. H. van Oostrom, A. D. L. van der, M. L. Rietman et al., “A “Frail men’s perspectives on food and eating,” Journal of four-domain approach of frailty explored in the Doetinchem Aging Studies, vol. 21, no. 4, pp. 314–324, 2007. cohort study,” BMC Geriatrics, vol. 17, no. 1, p. 196, 2017. [44] P. O’Connor, “Salient themes in the life review of a sample of [61] M. Carnevelli and M. Cesari, “Cognitive frailty: what is still frail elderly respondents in London,” Gerontologist, vol. 34, missing?” Journal of Nutrition, Health & Aging, vol.19, no. 3, pp. 224–230, 1994. pp. 273–275, 2015. [45] N. L. Schoenborn, S. E. Van Pilsum Rasmussen, Q. Xue et al., [62] M. K. Andrew, “Frailty and social vulnerability,” Frailty in “Older adults’ perceptions and informational needs regarding Aging, vol. 41, pp. 186–195, 2015. frailty,” BMC Geriatrics, vol. 18, p. 46, 2018. [63] S. E. Kirby, P. G. Coleman, and D. Daley, “Spirituality and [46] C. Tocchi, “Frailty in older adults: an evolutionary concept well-being in frail and nonfrail older adults,” Journals of analysis,” Research in 4eory for Nursing Practice: An Inter- Gerontology B Psychological Science Social Science, vol. 59, national Journal, vol. 29, no. 1, pp. 66–84, 2015. no. 3, pp. P123–P129, 2004. [47] S.FrietagandS.Schmidt,“Psychosocialcorrelatesoffrailtyin [64] D.A.Lekan,E.Hoover,andS.Abrams,“Perceptionsoffrailty older adults,” Geriatrics, vol. 1, no. 4, p. 26, 2016. among African American men and women,” Journal of [48] E. Yaksic, V. Lecky, S. Sharnprapai et al., “Defining frailty in Psychosocial Nursing and Mental Health Services, vol. 56, research abstracts: a systematic review and recommendations no. 7, pp. 20–29, 2018. forstandardization,” Journal of Frailty and Aging,vol.8,no.2, [65] K. Rockwood, X. Song, C. MacKnight et al., “A global clinical pp. 67–71, 2019. measure for fitness and frailty in elderly people,” CMAJ, [49] U.Junius-Walker,G.Onder,D.Soleymanietal.,“(eessence vol. 173, no. 5, pp. 489–495, 2005. of frailty: a systematic review and qualitative synthesis on [66] S. D. Searle, A. Mitnitski, E. A. Gahbauer, T. M. Gill, and frailtyconcepts and definitions,” European Journal of Internal K. Rockwood, “A standard procedure for creating a frailty Medicine, vol. 56, pp. 3–10, 2018. index,” BMC Geriatrics, vol. 8, p. 24, 2008. [50] D. Sezgin, M. O’Donovan, N. Cornally, A. Liew, and [67] S. Mueller-Schotte, N. P. Zuithoff, Y. T. van der Schouw, R. O’Caoimh, “Defining frailty for healthcare practice and M. J. Schuurmans, and N. Bleijenberg, “Trajectories of lim- research: a qualitative systematic review with thematic analysis,” International Journal of Nursing Studies, vol. 92, itations in instrumental activities of daily living in frail older adults with vison, hearing, or dual sensory loss,” Journals of pp. 16–26, 2019. [51] J. W. Faller, D. N. Pereira, S. de Souza, F. K. Nampo, Gerontology A Biological Science Medical Science, vol. 74, F. S. Orlandi, and S. Matumoto, “Instruments for the no. 6, pp. 936–942, 2019. 20 Journal of Aging Research [68] S. B. Gee, G. Cheung, U. Bergler, and H. Jamieson, ““(ere’s more to frail than that”: older New Zealanders and health professionals talk about frailty,” Journal of Aging Research, vol. 2019, Article ID 2573239, 2019. [69] A. A. Hayajneh, “(e psychometric properties of the Arabic version of the Tilburg frailty indicator,” Global Journal of Health Science, vol. 11, no. 9, pp. 123–133, 2019. [70] S. F. Chang and G. M. Wen, “Association of frail index and quality of life among community-dwelling older adults,” Journal of Clinical Nursing, vol. 25, pp. 2305–2316, 2016. [71] B.G.LinkandJ.C.Phelan,“Conceptualizingstigma,” Annual Review of Sociology, vol. 27, pp. 363–385, 2001. [72] Age-UK, Don’t Call Me Frail, 2015, https://www.ageuk.org. uk/latest-press/archive/using-the-word-frailty-could-stop- older-people-accessing-vital-services/.
Journal of Aging Research – Hindawi Publishing Corporation
Published: Jun 2, 2021
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