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“There’s More to Frail than That”: Older New Zealanders and Health Professionals Talk about Frailty

“There’s More to Frail than That”: Older New Zealanders and Health Professionals Talk about Frailty Hindawi Journal of Aging Research Volume 2019, Article ID 2573239, 13 pages https://doi.org/10.1155/2019/2573239 Research Article “There’s More to Frail than That”: Older New Zealanders and Health Professionals Talk about Frailty 1 2 1 1 Susan B. Gee , Gary Cheung, Ulrich Bergler , and Hamish Jamieson University of Otago, Christchurch New Zealand, Canterbury District Health Board, Christchurch 8083, New Zealand University of Auckland, Auckland 1023, New Zealand Correspondence should be addressed to Susan B. Gee; susan.gee@cdhb.health.nz Received 25 June 2019; Revised 15 October 2019; Accepted 26 October 2019; Published 1 December 2019 Academic Editor: F. R. Ferraro Copyright © 2019 Susan B. Gee 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. *ere is general agreement that frailty is common and important in later life, but there is less agreement about what frailty is. Little is known about the extent to which practicing health professionals and older people hold a mutual understanding of frailty. Focus groups were held to engage older people and health professionals in discussion about what made them think that someone was frail. Eighteen older people took part across three focus groups, and se’venteen health professionals took part across another three focus groups. Both the health professionals and the older people talked about the experience of frailty as an interplay of physical, psychological, and social dimensions. Older people with frailty were seen as needing help and being vulnerable to adverse outcomes, but accepting help was positioned by older people as an adaptive choice. *e experience of frailty was described as being mediated by the individual’s psychological mindset, highlighting the importance of approaches that recognise strengths and resilience. A broader and more balanced understanding of frailty may help create more rounded and appropriate approaches to assessment and management. Identifying frailty is seen as clinically useful to more ef- 1. Introduction fectively and appropriately target and facilitate access to care Frailty has variously been described in the medical field as “a pathways, interventions, and individualised treatment plans syndrome in desperate need of description” ([1], p. 134) and to prevent or delay adverse outcomes [5, 8, 9]. in the social sciences as “one of those complex terms. . .with While clinicians generally agree that they can recognise multiple and slippery meanings” ([2], p. 48). How frailty is frailty and it is useful to do so, there is no consensus as to the conceptualised and understood is not merely an academic operational definition of frailty in everyday clinical practice. exercise: it will shape policies and access to services, care One common approach is that frailty is a unidimensional practices, and social responses and in turn the experience of medical syndrome (or phenotype) with an underlying bi- frailty [3]. ological cause. Frailty can therefore be measured by simple Within the health sector, there is a common underlying criteria-based screening tools that commonly include understanding of frailty as an elevated state of risk or vul- shrinking, weakness, exhaustion, slowness, and low activity nerability [4]. Older people with frailty are more vulnerable [5, 10]. In some models, this is linked to a defining char- to a sudden decline in health and negative outcomes (such as acteristic of a loss of independent capacity to carry out hospitalisation, entry to residential care, or death) in re- practical and social activities of daily living [11]. A second sponse to seemingly small trigger events or changes—from a approach gaining popularity is that frailty represents an bout of influenza to a hip replacement [5–7]. *e rates of accumulation of a range of deficits, so that the more things a frailty are recognised as increasing with age as a consequence person has wrong with them, the more likely that person is of age-related physiological declines, with estimates that a to be frail. Frailty, from this perspective, is best measured quarter to a half of people aged 85 are considered frail [6]. using a broad index [12]. Research has found that both 2 Journal of Aging Research approaches can usefully predict negative outcomes [13–15]. importance of the group effect [31]. *e researcher acts as a *ere are variations and positions on a continuum between facilitator, generating interaction and discussion amongst these biomedical approaches, with Hogan and colleagues the group [31–33]. *e group dynamics can “spark” clari- cataloguing 30 different sets of criteria for what constitutes fication, reflection, justification, and exploration of the frailty. *ey begin their review with a quote from Lewis participants’ own views. *is allows focus group research to Carroll’s Humpty Dumpty: “When I use a word it means just uncover insights and depth of discussion that may not be what I choose it to mean—neither more nor less” and end with generated by individual interviews [31, 33–35]. It should be a call for a framework that is relevant for both clinicians and noted that the academic form of focus groups used in social researchers [16]. science research has diverged markedly from the tightly *e aim of mutual understanding and usefulness can be structured quantitative forms of focus groups used in market taken a step further, to work towards an understanding of research [30, 31, 35]. *e academic focus group process is frailty that is meaningful not only to clinicians and re- particularly appropriate for research that involves explora- searchers, but also to older people [17]. *is meshes with a tion and hypothesis building around collective views on potentially complex topics and the similarities and differ- recognition that research can be a way to listen to and re- spect service users’ experience and knowledge [18]. Com- ences in these [33–35], as in the present study. pared to the extensive biomedical literature on frailty, insider perspectives on the experiences and meaning of 2.2. Participants. Purposive sampling was used to recruit frailty for older people are relatively scarce. Some exceptions both older people and health professional participants. A are qualitative studies using interviews in Canada [3, 19, 20], total of 18 older participants took part in the current study the United Kingdom [2, 21–23], and the United States of across three focus groups. All the older people identified as America [2] and focus groups in Holland [17] and the being New Zealand European. One focus group targeted United States of America [24, 25]. younger senior citizens and was recruited through an over Within this international literature on the perspectives of 65s social group and a self-improvement network. *e seven older people, calls have arisen for approaches to frailty that participants in this group were all female, with ages ranging better recognise the social and emotional expressions of from 68 to 75 (average age 73.4). *e remaining two focus frailty and reflect the lived experience of older people groups targeted older-old people and were recruited from an [2, 3, 17]. *ese social understandings also highlight that the independent living retirement village associated with an label or social construction of frailty can be imposed on older aged residential care facility. *e eleven participants in these people unwillingly and can contribute to negative stereo- groups included three males and eight females, with ages typing and the associated perceived implausibility of a good ranging from 77 to 89 (average age 84.2). Overall, the older old age [2, 3, 23, 26, 27]. While there is an explicit contrast participants had an average age of 80.0 years. with the biomedical literature on frailty, what is less clear is A total of 17 health professional participants took part the extent to which older peoples’ perspectives on aging across three focus groups. *e health professionals were diverge or overlap with the approach of the health pro- recruited from the local older person’s health and re- fessionals working with this age group [28, 29]. habilitation service and from relevant community organi- *is qualitative study explores the meaning of frailty sations by a general e-mail invitation. *e participants from the perspectives of both older people and health included health professionals from both inpatient and professionals. Recognising that older people may not have community settings. Across the three groups, there were preformed articulated thoughts and opinions about frailty, a three doctors, six nurses, four allied health professionals, one focus group method was used to help participants to explore supporting role professional, and four individuals working and articulate their views through group interaction [30, 31]. with older people within community-based organisations. *e aim of the present study was to explore the potential for One of the health professionals identified as M�aori (in- mutual understandings amongst the perspectives of older digenous people of New Zealand) with the remainder being people and health professionals to help inform clinical New Zealand European. *ere was one male health pro- practice and assessment. fessional participant. 2. Methods 2.3. Procedure. *e focus groups gathered together people who shared a key characteristic of similar age or of having a 2.1. Focus Group Methodology. *e primary aim of this qualitative study was to describe and understand meanings professional role serving older people, with a maximum group size of eight. Larger groups may fragment or frustrate and interpretations of frailty amongst older people and health professionals, which allied with using focus group participants waiting to have their say [32, 35]. Separate focus discussion to gather data. As Nyumba and colleagues assert groups were held for older people and for health pro- “*e most compelling reason for using focus group dis- fessionals to help provide an “even playing field” to facilitate cussion is the need to generate discussion or debate about a comfortable collective discussion [30, 31]. A total of six research topic that requires collective views and the groups were held, three with older people and three with meanings that lie behind those views”([32], p. 28) (a., p. 28). health professionals. *is was deemed sufficient as no new themes emerged at the third older person or health pro- *e defining feature of the focus group is its con- ceptualisation as a collective conversation and the fessional group [32]. Journal of Aging Research 3 between the groups involving older people and those in- *e groups were held at meeting rooms at locations that were familiar to the participants. For the older people, they volving health professionals. *is paper focuses on the themes related to the concept of frailty. *e illustrative were held at a retirement village/aged care facility and a public library, and for the health professionals, they were quotes provided use pseudonyms, and some have been held at the hospital that provides specialist older person abbreviated for length and clarity. health and rehabilitation services for the region. *e dis- cussions took place within a 90-minute session with light 3. Results and Discussion refreshments offered. One to two hours is a recommended length for focus groups to enable in-depth discussions *is study was able to compare and contrast the way without overfatiguing participants [32]. *e discussions multidisciplinary health professionals and the older people were facilitated by a researcher with experience in focus talked about the frailty and found that the similarities were group research [33] and were audio-recorded and tran- more pronounced than the differences in their un- scribed verbatim. derstandings of what is involved in living with frailty. *e A discussion guide or “questioning route” was developed collective perspective of the experience of frailty that to enable consistency in the core questions used to support emerged in the present study was developed and is repre- comparability across the groups [33]. *e basic format was sented in Figure 1. Figure 1 illustrates the breadth and introduction, engagement focusing on what makes them complexity of considerations that may need to be taken into think of a person as “frail,” exploration focusing on what account to more fully understand the meaning and expe- makes frailty better or worse, and exit. *e focus group rience of frailty. Two overarching themes emerged. began with a welcome and introduction to the purpose of the 1: It seems to me that frailty has quite a few dimensions study and explaining the focus group process and expec- tations. *is was followed by an “ice breaker” question Frailty was discussed as a multidimensional experience encompassing challenges and losses in complexly answered around the group to encourage all participants to be comfortable talking and to facilitate the identification of interlinked physical, psychological, social, and func- tional domains: the speakers when transcribing. *e key question in the discussion guide for the current (i) Physical: physical changes and mobility issues and paper was “What’s involved in being frail?” *e discussion of poor health this topic began by the facilitator describing a scenario where (ii) Psychological: cognitive changes and poor mood they met two people they have not seen for some time, Jan and confidence and Pam. *ey think “Jan is getting quite frail,” but this is (iii) Social: isolation and withdrawal not the case for Pam. *e participants were invited to share (iv) Functional: needing help the “things that you think of when you think of an older person being frail.” *e ensuing discussion was summarised Each of these subthemes emerged in every group discussion. *ey are represented in Figure 1 by a circle on a whiteboard, with clustering of ideas and lines con- necting clusters as interrelationships were discussed. *e of rings. An outer band represents the interplay and discussion guide suggested further prompts for the facili- reciprocity of influence amongst these components. tator, who paraphrased and encouraged discussion, and the 2: People can have a lot of this stuff but I wouldn’t call group participants themselves also facilitated the discussion them frail through their interactions. *e experience, impact, and acceptance of frailty were *is study was approved by the University of Otago’s not considered to be explicable by objective losses Human Ethics Committee (reference 17/151). All partici- alone. *e label of frailty was contested by older people pants gave informed consent. and used with caution by health professionals. Across all the groups, the experience and severity of frailty were seen as moderated by resilience and psychological 2.4. Analysis. *e data were analysed using the framework resources such as a positive attitude and personality approach, as outlined in Table 1 [36–39]. *e structure and strengths. process of the framework method of analysis offered the Resilience and psychological resources are represented ability to easily compare data across the groups as well as in Figure 1 by an inner hexagon interlinking with the within the groups [38]. *e flexibility of the framework dimensions of loss. *e experience of frailty in the method enabled the researchers to begin the analysis during centre of Figure 1 can be seen as being defined in the focus group data collection. *e data were then read and concert by portions of the greater dimensions of loss reread and then coded (conceptual/descriptive labels were and by individual resilience. While any given facet, applied to sections of the text) and charted. Charting is the whether sarcopenia or isolation may be part of the hallmark of the framework approach and involves entering experience of frailty for many people with frailty, not the data into a matrix with rows (cases) and columns (codes) everyone who has sarcopenia or isolation is frail. [38]. In the present study, the cases were the individual group discussions. *e final stage involved mapping, in- *e visual representation in Figure 1 also provides a terpretation, and discussion of the themes and subthemes, visual shorthand for comparing the understanding of with particular attention to the similarities and differences the experience of frailty that emerged in the present h b r Resilience Resilience Physical Social 4 Journal of Aging Research Table 1: Steps in the framework analysis used in the present study. Stage Process *rough the process of note-taking in the focus groups and reading and rereading the transcripts of the discussion and the whiteboard summaries, the 1. Familiarisation researchers became aware of the recurring themes and key ideas. Initial thematic notes were made and discussed. *e key ideas and themes that were identified in the familiarisation stage formed the basis for an initial thematic framework that was used to classify the data. 2. Identifying a thematic framework Open coding ensured that any important themes from the data that had not been captured initially were able to be included and the framework was adapted as necessary. *e transcripts were annotated to identify sections 3. Indexing that were relevant to the different codes or labels. An excel spreadsheet was used to generate a matrix, with the groups as rows and the labels as columns. 4. Charting Quotations identified in the indexing were entered into the matrix in the appropriate cell using verbatim words. *e matrix was reviewed with reference to the transcripts and team discussion to clarify the main themes and subthemes and the interrelationship 5. Mapping and interpretation between these. *e matrix structure enabled easy recognition of patterns, in particular whether there was consistency of a theme across the groups versus some empty cells. the narrative that emerged, neither are sufficient in themselves to represent the overall understanding of frailty that emerged in the present study. A shared understanding of frailty that balances deficits and strengths is an important foundation to integrated and person-centred care [41]. Resilience 3.1. “It Seems to Me 7at Frailty Has Quite a Few Di- mensions”: Multiple Domains of Loss. Frailty was discussed Experience as involving challenges and losses in complexly interlinked of frailty themes across physical, psychological, social, and functional dimensions. *is consistency in perspectives on what is involved in the experience of frailty was apparent despite ambiguity and differences in the definition of “frailty” per se. Resilience *is more holistic biopsychosocial perspective has also emerged from interviews with Dutch elders conducted by Puts and her colleagues [17] and has been suggested in previous work with health professionals [28, 29]. Figure 1: Visual summary of the thematic analysis. 3.1.1. Physical Dimensions. “Looking frail”: physical changes and mobility study with dominant approaches to frailty. *e pale blue ring representing physical changes could be In their seminal work, Fried and colleagues identified a considered to encompass Fried’s phenotype definition cluster of changes, which were then crystallised into the of frailty [10]. *e circle of losses and challenges has Cardiovascular Health Study frailty scale to become one of similarities with summaries of the superset of deficits the most widely used frailty measures in research: un- that might be included in a frailty index approach (e.g., intentional weight loss, exhaustion, low energy expenditure, [40]). While both approaches are recognisable within slow gait speed, and weakness. It is striking that this process Functional Resilience Resilience Psychological C Journal of Aging Research 5 Greta: Can I just bring up one other thing, people talking was echoed in mental image of someone with frailty for not only the health professionals but also the older people about shrinking and losing weight and things like that. Now I don’t believe I’ll ever look frail because I’m big and themselves. Observable changes around weight shrinkage and my mother was the same, I mean she lived to 91, today is weakness were articulated across the focus groups. People the day she died, I mean seven years ago she died and, but with frailty were described as “thin,” “drawn,” and “wasted,” she was big and she never looked frail, never looked frail. with “not much meat on their bones” so the “skin just hangs,” . . . with the impression of getting “smaller” or “shrinking.” *is Interviewer: So you [to Lyn] were saying it’s not just appearance of shrinking can be compounded by “poor about having a walker and you’re saying [to Greta] it’s posture” and “being bent over.” not just about looking small. . . Some older people and health professionals identified Greta: 7at’s right, yes there’s more to frail than that “weakness” or decreased “strength” with the term “sarcopenia” (Older person group) also being used by health professionals to refer to the loss of muscle mass and strength. In two of the elder groups, this was Patrick, a retirement village resident in another group, exemplified by finding it hard to get up from the floor, as was very clear about making this point, for example, in the Margaret raised in the context of getting up after a fall: context of a fellow resident: Margaret: Well I find if I have a fall, I can’t get myself up unless I crawl over to something to pull myself up. I think that’s perhaps being restricted, there’s one particular lady in this village who uses it [a walking aid] more but, and Elizabeth: Now that’s the problem. 7at’s the strength I wouldn’t describe her as frail I think she’s very. . .alert, she’s gone in your legs. cheerful and she’s accepting a physical disability but oth- Judy: We’ve certainly lost strength, yeah, you certainly erwise is well. So it seems to me that frailty has quite a few might look alright but the strength isn’t there anymore. dimensions, it’s got the physical dimension but it’s also got *ere was awareness of “low energy levels” with the the social and then mental . . . the lady I’m thinking of in the village certainly has no mental or social. health professionals also using terms such as “fatigue,” “decreased exercise tolerance,” and “poor energy to maintain daily living.” Walking noticeably slower was mentioned on *e health professionals also talked about the physical occasion by both older people and health professionals. A symptoms of frailty as only being one part of the experience of lack of physical activity was generally discussed in the the individual. For example, Claire talked about how she likes to context of other concepts such as a way to combat frailty or work “in a holistic manner. . . you’re looking at the family, the lack of social involvement. *ere was however an image physical health, mental health, spiritual . . .” and as the con- that people with frailty may “just sit” and this contrasts with versation continued, Kate raised the core question for consid- those at the same age who do not have frailty, as articulated ering and intervention as being “What does that do to the whole by Patrick (who is himself a member of a walking group): person?” *e desire for more integrated care was expressed by both older persons and health professionals groups. In contrast, in one of the health professional focus It’s certainly not necessary so you only have to see [masters] games where people of a substantial age are doing all sorts groups, there was the suggestion that the physical changes of of innovative and physical and social activities. Fried’s phenotype were definitive of frailty. Jane, a nurse, suggested that *e older people and health professionals in all the groups talked about mobility as a facet of frailty including a . . .the weight loss, the lack of strength, the decreased ex- lack of mobility, slowness in walking, and needing aids such ercise tolerance and the falls have varied degrees. And I as a stick or walker. *ey noted that people with frailty may think, like all four of those things . . .[are there]they are frail be “unsteady,” “wobbly,” or “losing balance.” *is was as- and then there is degrees of it. . . sociated with an increased risk of “more” and “ongoing” falls. *e role of these physical changes in determining who Although she at times struggled to articulate her con- ceptualisation, Jane felt that the physical changes were the was frail was an area where there were divergent views. Amongst the older people, there was an explicit discussion core of frailty. While Jane’s doubt about whether social that these features of physical changes and mobility are not interventions would reduce frailty was refuted by one of the in themselves enough to differentiate who is experiencing other health professionals: “I thought the evidence was very frailty: strong that it did help,” Megan could understand the point she was trying to make . . .but you can’t do that, that’s really unfair to think somebody’s frail just because they’ve got a walker. (Lyn, . . .You can put in social stuff but they just haven’t got the older person) exercise tolerance. Greta later raised the opposite logical fallacy, where her In the same group Karen also acknowledged that her biomedical background, “my main physical side,” biased her mother was frail but did not look it: 6 Journal of Aging Research slower to recover or unable to return to baseline levels of towards prioritising the physical changes as the core with the other dimensions as potentially preventable consequences: health, for example: . . . as a [physician] I think about that [the physical side] Each episode takes more and more. . .they don’t manage to but I would be constantly thinking, what can I do about recover (Kate, health professional) these things to stop them impacting as much. In the older persons’ groups, frailty was occasionally Despite this definitional tension, this health professional linked to death in the discussions, for example, involving an group discussed the same multiple dimensions of the ex- awareness of “mortality” or causing death: perience of frailty as the other groups. *ese narratives of the commonality of the phenotype of “my personal experience of one of my parents, my dad died young, of being frail” (Merle, older person) frailty offset against its limited ability to encapsulate the experience of frailty that resonates with the argument of *e health professionals talked more extensively about Cesari and colleagues: “Although we praise this approach, our gerontological souls are still bleeding” ([42], p. 260). *e people with frailty as being more “vulnerable” and “closer to physical phenotype of frailty has proven validity but wider death and having “decreased reserve” and “less resilience,” approaches are also needed to identify individualised targets with even a “minor insult causing deterioration.” One of the for interventions in practice [43]. health professionals used the word “teetering,” while Raewyn described it as being “on the edge”: “Poor health”: Health decline, comorbidity, and risk . . .in an emergency situation, like you are looking at them Amongst the many alternate views of frailty in the and you think, they could have a fall or they could not be here tomorrow, medically, physically (Raewyn, health clinical and research literature, there is a common un- derlying core that frailty is an increased risk of vulnerability professional). [44], that is, frailty increases the risk of poor health outcomes and creates concern for the prognosis of the individual. 3.1.2. Psychological Dimensions. “Confused and muddled”: Comorbidity is commonly recognised as an important part Cognitive changes of the frailty experience, as evidenced by its inclusion in over half of the most popular frailty measures [36]. *e pre- *ere have been differing opinions in the literature over the ponderance of health conditions amongst people with frailty conceptual role of cognitive changes in frailty [44, 45]. *ere consistently arose in the discussions across all the groups. is increasing recognition of reduced cognitive reserve as- Older people talked about “poor health” and being “not well,” sociated with physical frailty and its potential to improve along with raising specific issues such as sleep, pain, prediction of vulnerability and outcomes such as marked shortness of breath, continence, hearing, and vision. *e declines in functioning and increased likelihood of long- health professionals also talked about comorbidities and term care [46–48]. specific conditions and additionally noted that this is often *e older people and health professionals in all the focus marked by multiple medications and increased hospital- groups talked about cognitive changes with terms such as isations. As with many of the dimensions, there was a vicious “forgetfulness” or memory “failing” or “slipping”; “confusion” cycle with frailty as a risk for comorbidities and comor- or being “muddled,” “vague,” “away with the fairies”; “unable bidities as a risk for frailty: to make decisions” or “plan”; and cognitively “slow.” As with Lekan and colleagues [24], the cognitive changes described . . .but it was mentioned something earlier, that sort of by the participants were often were broader than dementia: multiple medical stuff, you just pick up. But they kind of have surgery and then something goes wrong and then they . . . confused and muddled. Because sometimes it’s not, it’s get an infection and that doesn’t go and then just, so they’ve not actually confusion . . . . . ., well I was just thinking of a gone from this healthy person previously to this frail person. gentleman who I saw last week. Um, and I would have (Marie, health professional) described him as frail from when, when I met him he was out pruning the roses but he looked to me, he, I would When Greta was asked to talk more about her mother’s describe him as frail from the outset. 7e way he sort of frailty despite a robust appearance, she highlighted sus- shuffled when he walked . . .. And he was, . . ., muddled ceptibility to multiple health issues: inside. You know so I was asking about his medications and he was kind of you know um, trying, almost trying to look She was very susceptible to getting things wrong with her, for things and that sort of thing. And interestingly, um, pneumonia. . .or germs yes and emphysema and yeah, and there was a whole lot that I was concerned about and he she had gout, bad gout. . .(Greta, older person) passed away on Saturday morning at home. (Kate, health professional) Alongside the recognition that people with frailty were . . .it’s a mental thing and memory is an indication of frailty susceptible to accumulating health conditions, there was also discussion that people with frailty were more likely to be and lots of people who I would class as becoming frail have a Journal of Aging Research 7 great deal of particularly memorising not only faces which Greta: . . .I sometimes feel people go quiet, I don’t know we all forget but routine things like turning the stove off or why I think that switching the lights off or doing those sort of things. Jill: 7ey seem to take up less space don’t they (Patrick, older person) Older participants and health professionals also talked about frailty involving losing “confidence” and “self-esteem” While noting that people with dementia can be physi- and being “fearful.” For some people, this was related to cally “robust” rather than frail, there was also recognition things becoming harder with memory and everyday tasks so that the progression of dementia typically compromises that they: other domains related to frailty: Definitely get more nervous that they might do something . . .It is very frequent that the, you know, the end stage wrong. . . lose your confidence and feeling a bit more in- dementia patient will be frail as well. (Karen, health secure (Brenda, older person) professional) For example, Judy talked about losing confidence in In one of the older persons’ groups, Virginia, Greta, and making decisions and worrying more and at one stage talked Judy discussed some of the ways dementia can impact on about this in the context of cooking: other domains such as through physical changes, mobility, and social engagement: I used to be able to put on a dinner party for eight or nine Virginia: And a lot of dementia too, I’ve got a couple of people [or] my family. Yeah well I had three of four courses friends with dementia which is you know, not good. with nibbles and the whole, now I’m a mess if I’ve got Greta: And they’re frail aren’t they? someone coming for afternoon tea I’m trying, I have to organise it the day before and I just about lose sleep over it. . . . (Judy, older village resident) Virginia: Well I s’pose it can because I watch, I watch this friend of mine and she doesn’t really, I think she’s for- *is loss of confidence could be pervasive and lead to gotten how to walk properly, you know it’s like she’s limitations in the life lived: bending, she’s bending over the top, you know quite sad really. . . . loss of confidence, um, with everything really. Could be, Greta: 7at’s really sad. managing at home. Day to day living. It could be a loss of confidence in, you know leading to isolation. (Amanda, Judy: Well my aunt lost her voice, she’s got her thoughts and she can’t express herself, yeah she just, she wants to health professional) say it but she can’t. . . On occasion, older people and health professionals Virginia: . . .and she’s probably trying to find the words. linked this with a loss of “self-esteem” and sense of self- Greta: But you were saying you had to think very hard identity, for example, one of the health professionals Fiona about how you’re getting up but if you’ve got dementia, noted that people may think “I’m not sure who I am. . .I’m you actually can’t think about how you’re going to get afraid to come out.” up. . . 3.1.3. Social Dimension. “Increasingly isolated”: Isolation and withdrawal “loss of confidence. . . with everything really”: Mood and confidence *e importance of the social dimension of the frailty expe- rience emerged strongly from the focus groups. *is re- *ere was some limited discussion of being “de- inforces previous evidence of the centrality of the social pressed,” both as a feature of frailty and its role in re- domain to the lived experience of older people. When von ducing the motivation for self-care and increasing risk. Faber and colleagues [51] talked with octogenarians, they *is bidirectional relationship echoes the overall con- found that it was the impact of limitations on social op- clusions reached by Mezuk and colleagues following their portunities that created the greatest distress rather than the review of the literature [49]. Based on their latent variable physical changes themselves. Likewise, preparatory focus approach study, Lohman and colleagues suggested that groups by Studenski and colleagues as part of a process to psychological frailty, as measured by depressive symp- develop a measure of frailty found that older people and their toms, may be an integral part of what it means to be frail families prioritised the social and emotional aspects of frailty [50]. [52]. Social vulnerability and loneliness have reciprocal re- *e older participants and health professionals talked lationships with cardiovascular disease, depression, and de- more about subclinical changes, describing people with mentia [53] and independently predict high rates of entry into frailty as being “introverted,” “withdrawn” reduced “vitality” aged residential care [54] and mortality [55]. and “engagement,” and “less interested in life in general”: 8 Journal of Aging Research whatever, and then increasingly isolated. Just has such a big Older people with frailty were described as “lonely” and “isolated,” lacking “social networks,” “social connections,” impact on people. (Claire, health professional) and “social stimulation.” *ere was description of a “nar- rowing in the world,” or what Studenski and colleagues [52] *e importance of the social dimension of frailty in this call the life space and social world. *ere was considerable and previous work suggests that not addressing this di- discussion amongst the older participants about the complex mension may run the risk of misalignment with what interplays between the different facets of frailty and social matters most to some older individuals. For example, a difficulties whether physical features such as loss of mobility, recent publication on assessment of frail older people in hearing, sight, or continence; psychological features such as acute settings recommends an assessment package cognitive changes, confidence, and social withdrawal; or encompassing a physical exam, psychiatric exam, functional environmental factors such as lack of transport or social assessment, and a history of gait and falls, continence, sensory problems, and medications—noticeably absent from opportunities where they live or the loss of an enabling partner or roles. Hearing was often a particularly salient this summary of recommendations is assessment of the social dimension [56]. example to the older people. For example: I’m wondering about people who, in their life have been 3.1.4. Functional Dimension. “Need help”: Dependence social and yet now because they’re deaf and they can’t see and they can’t drive and you know, and they’ve got lonely Both the community participants and health professionals because in the past they’ve gone out to volunteer wherever talked about people with frailty not being able to do the same and suddenly they can’t so yeah. . .. . .there’s something things independently, particularly day-to-day tasks, with the more where they haven’t got the choice because there’s common understanding that part of frailty is needing more something that happens (Jill, older person) “support” and “help” from family and health services, or more pejoratively being more of a “burden”: In another example, one of the older groups talked about how some older people do not take up social opportunities: It gets to the stage where you really do need help” (Mar- garet, older village group) Elaine: Well they could have other problems, like hearing problems, sight, problems, that if they can’t hear they I think it’s probably when they start to lose the, yeah the don’t enjoy. . . processing and the ability to manage independently Judy: No that’s right, or it’s just a jumble and my . . .More of an effort. Because they could be all that and husband used to have a hearing aid and said it was they’d be fine. . .But it’s when they start not being able to terrible, he used to turn them off . . . manage that independence. (Megan, health professional) Prue: 7ere’s certain things in your life too that when you *e need for help as a marker of frailty arose in every lose your partner. . .it’s very hard to make that effort to focus group, echoing the emphasis that Rockwood and come on your own when you’ve always been togeth- colleagues have placed on dependence as the crux of clinical er. . .You just feel quite lost, some people go into judgement about frailty [57]. As Landi et al. [45] note, the themselves and withdraw ability to maintain independent has multiple determinants *ere was also talk amongst the health professionals of and is sensitive to changes in cognition, mood, mobility, and how social engagement is impacted by multiple factors. For functional performance. example, Shona noted the interplay amongst sensory issues, Accepting help can key into pervasive narratives that mobility, continence, self-esteem, cognitive skills, and needing help is a marker of adverse outcomes or un- socialisation and summed up: successful aging in Western cultures that prioritise independence: . . .it’s really [being] vulnerable isn’t it? You’re kind of saying that you know if you have problems with any of these sometimes that, I would think are reluctant to accept [factors], it becomes so much harder to get out and support is that, ah well if they accept support then they’ve socialise. . . (Shona, health professional) given up (Claire, health professional) For Claire, social isolation was the apex of the frailty *ere was resistance to this narrative amongst the older experience: participants. Butler and colleagues have argued [58] accepting help can be an adaptation to improve quality of Social stimulation. I think is such a big one. Like um, life, rather than resisting help and risking exacerbating whether it’s, you know if they’re at home and they have problems. *ey have labelled this adaptation “responsible difficulty getting out but if they’re still being visited. . . But I dependency.” Accepting help is a choice: would say isolation is, is almost the, the thing that breaks the camel’s back almost. Yeah. 7at, you know a lot of these I’m thinking all these things, everything . . .the people concerned have to make the decision to use all the facilities, other things will affect their ability to get out of the house or you know they might have lost their drivers licence or all the help. . . (Beth, older person) Journal of Aging Research 9 was not a word that they would use; “I’ve gotta say I don’t use Judy was aware that her own habit of declining help to maintain independence and not be a burden could mean the word frail” (Keith). Christine, in particular, questioned the imposition of frailty as a label: “who has the right to say turning down help that would have had a positive impact: you’re frail in any way?,” while William railed against his I think it’s our own fault ‘cause we’ve always been so health concerns being written off: “Yeah I’d like people not to independent. . .we’ve never asked them for help. . . if they use the phrase. . .What do you expect at your age.” say you know, oh can we, oh no no we’re alright, yeah and *e health professionals were aware of these tensions that, and [my husband] and I, that’s what we decided, we’d and cautious about using the term. Some of the health come in here, we wouldn’t be a drain on them and that’s professionals would not tell an individual that they were what I think is a bit of a trouble. . . frail or only if they were sure of the relationship. Some professionals noted that they had been involved in dis- Some of the women felt that men found it particularly cussions about avoiding using the term frailty in in- difficult to seek help, with concomitant risks: terdisciplinary team meetings or in materials. Raewyn was aware that the frailty label was affixed to older people by I think they’re more fearful about admitting and more health professionals, sometimes inaccurately in her opin- fearful about what might happen to them. My husband ion, and that this could have implications for clinical de- died at 68 and he was obviously having heart problems but cision making and the older person’s hope for a more didn’t say so and dropped down dead on the pavement so positive future: had he sought medical help, whether it was for fragility or anything else, he’d still be here today. (Lyn older person) . . . a lot of that is happening where people are being given that label and um, is that impacting on what health care William explained the aspect of responsibility clearly in they have been given as well. You know, um, oh she is old relation to using mobility aids: and frail and we see that a lot, actually, oh they are frail.. . .Um, some of them laugh it off, oh he doesn’t know I think one has to accept as one gets older that one is going what he is talking about or whatever. But um, no it does to have certain problems and if you can take precautions so have an impact because they almost give up on some things. that you don’t injure yourself or others, you take those Oh, we can’t, I am not going to bother to push for that um precautions, in other words, you use a stick or an aid of show the surgery or whatever or you know, getting that some sort. fixed up because I am told that um, I am old and frail. “They are still cheerful and they are still resilient”: feeling frail vs. resilience 3.2. “People Can Have a Lot of 7is Stuff but I Wouldn’t Call 7em Frail”: Resistance, Resilience, and Psychological Markle-Reid and Brown [11] have argued that any Resources. Frailty index models view frailty as a multifac- understanding of frailty must recognise that the degree of torial accumulation of deficits that places the person at risk frailty depends in part on the context and can be highly of adverse outcomes, and offer an approach which can in- influenced by the subjective interpretations of the individual. corporate physical, psychological, and social dimensions *is was dramatically highlighted in Merle’s story about her (e.g., [7]) (although not all authors incorporate the full mother: range). While the emphasis on the prediction of adverse outcomes by cataloguing objective limitations can be useful, Well my mum lived till nearly 101. . .. . .[at 96] she was still arguably this approach in isolation is not geared to un- not frail, she was robust. . .but at 96. . . the doctor said she derstand and reflect the holistic lived experience and had bowel cancer, well she just took to the bed, I mean we meaning of frailty for the individual [11, 19]. Lived expe- were absolutely amazed and “you girls can do what you like rience is more than a problem list [27]. with me,” she became old. . .rapidly and then I went to see her next time, she’d lost a lot of weight and had a walking “I don’t use the word frail”: Resistance to the label of stick so you know, within no time at all. However once she frailty discovered she didn’t have bowel cancer. . .She immediately felt better. . .so then she leapt out of bed and got on with her Authors have explored how the focus on defining frailty life again. . . by deficits has unwittingly positioned frailty as the repository for negative stereotypes and visions of a feared and un- successful old age—what once would have been termed *e importance of this subjective context-dependent perception was a key theme emerging from Grenier’s in- senescence or infirmity [26, 27]. *is echoes the distinction between a healthy third age and a fourth age marked by loss terviews with older women, which she called “feeling frail” [19]. Grenier [19] noted from her qualitative work that of capacity, with frailty as the boundary [26]. Little wonder then perhaps that as with previous studies [2, 17, 19, 23] we moments of feeling frail do not always result in a final state of being frail. *is is illustrated by Virginia in the present study found resistance to the label of frailty. *e older people made who shared her own experience of “feeling frail” after an comments that rejected the label as applying to them: “We don’t think we’re frail anyway so” (Elizabeth); and that frailty illness requiring hospitalisation: 10 Journal of Aging Research lived environment into the central focus of the helping I just recently got quite ill and I felt very frail, my children were wanting to put me in a you know, retirement process, rather than the client’s problems, diagnoses, or deficits [64]. [home]. . . and I’ve now come right so I’m feeling much but I was staying at home and feeling quite old. . .and yet I’m very active and healthy and outgoing and can speak my 4. Limitations mind and all the rest of it but I just felt, oh someone come and look after me, please. . .but I didn’t [call it] being frail *e present study adds a New Zealand perspective to the but now that we’re talking about it, that was actually how I growing literature base that both older people and health felt at the time, I don’t anymore but. . .Yes it can be a bit of professionals commonly view the experience of frailty as a mindset too, a bit in your mind I felt afterwards. . . more than just a physical change. While the study involved a range of health professionals, there are discipline and spe- From her work, Grenier [19] has suggested that there is ciality differences that remain unexplored in this study. *e an “emotional threshold” for frailty and not just a medical- groups of health professionals each included a range of functional threshold. One of the health professionals puts it disciplines reflecting the multidisciplinary nature of their this way: older persons’ health work environments. *eir multidis- ciplinary experiences in this field may have made it more there’s a whole lot of these things that can happen, people likely that they held more holistic views of the experience of can have a lot of this stuff but I wouldn’t call them frail, not ageing than health professionals who work with the general necessarily because it’s depends on how they see life (Marie, population. It would be particularly useful for future re- health professional) search to explore the perspectives of general practitioners. *e older participants were limited to individuals from the Feeling frail is not just a consequence of a change in majority New Zealand European population and to those health and functioning but also a determinant [23]. *is who felt comfortable with coming to a group to talk about allows recognition of the role of emotional resilience in frailty and were able to attend. *e groups may not reflect understanding individual differences in outcomes in the face the views of the most vulnerable older people such as those of major challenges, as in this discussion: who have severe frailty or isolation. Comparing and con- trasting the perspectives of older people with frailty with Jane: It’s a funny thing, I mean you look at the level of those who are robust may be a possible area for future function they have and they are still cheerful and they are research. Future studies with ethnic minority groups would still resilient and independent and they are making do be useful, as would studies from non-Western countries. For . . .they look like they would blow over in the next wind a better understanding of the experience and meaning of but still somehow pushing in through frailty to impact on the well-being of older people, that Raewyn: So, strong in mind would jump into that understanding must be reflected in practice. How to ef- category. . . fectively structure, encourage, and evaluate communication Karen: and some have really one thing wrong with them and needs assessment processes about frailty that are holistic and they give up and allow themselves to fall into the sick and strength-based will be an important area for future role and very quickly become frail because that is how research. they believe, that is their role in life (health professionals group) 5. Conclusions Participants talked about being “a strong person” and the *e medical and social perspectives on frailty have tended to impact of “personality.” *e concept of resilience can be described as a personal characteristic that enables an indi- be in separate siloes; however, integrating these approaches may provide an impetus to strengthen person-centred vidual to sustain, regain, or achieve physical or emotional health in the face of illness or loss [59, 60]. However, still a services [59]. As Nicholson and colleagues remind us, a shared understanding of frailty between older people and developing research area, a resilience-based approach may help to counteract the potential for negativity and stigma- health professionals is a good basis for shared decision making [64]. *e findings of the present study support calls tization [61] and mesh with a strength-based approach to services for older people. *e foundation of a strength-based for a more holistic approach to the assessment of the needs approach is that each person has abilities and resources that of frail older people that includes psychological and social domains [24]. *is study was distinctive asking the same can help them to cope with challenges. Dury and her col- leagues have talked with older frail people about the multiple questions of older people and health professionals, and the discussion suggests that embedding a more holistic ap- positive balancing factors that the experience of frailty, including from the individual themselves [62]. *ey can use proach will support the broader understandings of the ex- perience of frailty already held by many of the health their experience and capabilities to identify their own concerns and be involved in the process of regaining, professionals who work with older people [28, 29]. *is is exemplified in the British Geriatrics Society’s “Fit for Frailty” maintaining, or adapting to their level of health [63]. 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“There’s More to Frail than That”: Older New Zealanders and Health Professionals Talk about Frailty

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Copyright © 2019 Susan B. Gee et al. This 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.
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10.1155/2019/2573239
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Hindawi Journal of Aging Research Volume 2019, Article ID 2573239, 13 pages https://doi.org/10.1155/2019/2573239 Research Article “There’s More to Frail than That”: Older New Zealanders and Health Professionals Talk about Frailty 1 2 1 1 Susan B. Gee , Gary Cheung, Ulrich Bergler , and Hamish Jamieson University of Otago, Christchurch New Zealand, Canterbury District Health Board, Christchurch 8083, New Zealand University of Auckland, Auckland 1023, New Zealand Correspondence should be addressed to Susan B. Gee; susan.gee@cdhb.health.nz Received 25 June 2019; Revised 15 October 2019; Accepted 26 October 2019; Published 1 December 2019 Academic Editor: F. R. Ferraro Copyright © 2019 Susan B. Gee 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. *ere is general agreement that frailty is common and important in later life, but there is less agreement about what frailty is. Little is known about the extent to which practicing health professionals and older people hold a mutual understanding of frailty. Focus groups were held to engage older people and health professionals in discussion about what made them think that someone was frail. Eighteen older people took part across three focus groups, and se’venteen health professionals took part across another three focus groups. Both the health professionals and the older people talked about the experience of frailty as an interplay of physical, psychological, and social dimensions. Older people with frailty were seen as needing help and being vulnerable to adverse outcomes, but accepting help was positioned by older people as an adaptive choice. *e experience of frailty was described as being mediated by the individual’s psychological mindset, highlighting the importance of approaches that recognise strengths and resilience. A broader and more balanced understanding of frailty may help create more rounded and appropriate approaches to assessment and management. Identifying frailty is seen as clinically useful to more ef- 1. Introduction fectively and appropriately target and facilitate access to care Frailty has variously been described in the medical field as “a pathways, interventions, and individualised treatment plans syndrome in desperate need of description” ([1], p. 134) and to prevent or delay adverse outcomes [5, 8, 9]. in the social sciences as “one of those complex terms. . .with While clinicians generally agree that they can recognise multiple and slippery meanings” ([2], p. 48). How frailty is frailty and it is useful to do so, there is no consensus as to the conceptualised and understood is not merely an academic operational definition of frailty in everyday clinical practice. exercise: it will shape policies and access to services, care One common approach is that frailty is a unidimensional practices, and social responses and in turn the experience of medical syndrome (or phenotype) with an underlying bi- frailty [3]. ological cause. Frailty can therefore be measured by simple Within the health sector, there is a common underlying criteria-based screening tools that commonly include understanding of frailty as an elevated state of risk or vul- shrinking, weakness, exhaustion, slowness, and low activity nerability [4]. Older people with frailty are more vulnerable [5, 10]. In some models, this is linked to a defining char- to a sudden decline in health and negative outcomes (such as acteristic of a loss of independent capacity to carry out hospitalisation, entry to residential care, or death) in re- practical and social activities of daily living [11]. A second sponse to seemingly small trigger events or changes—from a approach gaining popularity is that frailty represents an bout of influenza to a hip replacement [5–7]. *e rates of accumulation of a range of deficits, so that the more things a frailty are recognised as increasing with age as a consequence person has wrong with them, the more likely that person is of age-related physiological declines, with estimates that a to be frail. Frailty, from this perspective, is best measured quarter to a half of people aged 85 are considered frail [6]. using a broad index [12]. Research has found that both 2 Journal of Aging Research approaches can usefully predict negative outcomes [13–15]. importance of the group effect [31]. *e researcher acts as a *ere are variations and positions on a continuum between facilitator, generating interaction and discussion amongst these biomedical approaches, with Hogan and colleagues the group [31–33]. *e group dynamics can “spark” clari- cataloguing 30 different sets of criteria for what constitutes fication, reflection, justification, and exploration of the frailty. *ey begin their review with a quote from Lewis participants’ own views. *is allows focus group research to Carroll’s Humpty Dumpty: “When I use a word it means just uncover insights and depth of discussion that may not be what I choose it to mean—neither more nor less” and end with generated by individual interviews [31, 33–35]. It should be a call for a framework that is relevant for both clinicians and noted that the academic form of focus groups used in social researchers [16]. science research has diverged markedly from the tightly *e aim of mutual understanding and usefulness can be structured quantitative forms of focus groups used in market taken a step further, to work towards an understanding of research [30, 31, 35]. *e academic focus group process is frailty that is meaningful not only to clinicians and re- particularly appropriate for research that involves explora- searchers, but also to older people [17]. *is meshes with a tion and hypothesis building around collective views on potentially complex topics and the similarities and differ- recognition that research can be a way to listen to and re- spect service users’ experience and knowledge [18]. Com- ences in these [33–35], as in the present study. pared to the extensive biomedical literature on frailty, insider perspectives on the experiences and meaning of 2.2. Participants. Purposive sampling was used to recruit frailty for older people are relatively scarce. Some exceptions both older people and health professional participants. A are qualitative studies using interviews in Canada [3, 19, 20], total of 18 older participants took part in the current study the United Kingdom [2, 21–23], and the United States of across three focus groups. All the older people identified as America [2] and focus groups in Holland [17] and the being New Zealand European. One focus group targeted United States of America [24, 25]. younger senior citizens and was recruited through an over Within this international literature on the perspectives of 65s social group and a self-improvement network. *e seven older people, calls have arisen for approaches to frailty that participants in this group were all female, with ages ranging better recognise the social and emotional expressions of from 68 to 75 (average age 73.4). *e remaining two focus frailty and reflect the lived experience of older people groups targeted older-old people and were recruited from an [2, 3, 17]. *ese social understandings also highlight that the independent living retirement village associated with an label or social construction of frailty can be imposed on older aged residential care facility. *e eleven participants in these people unwillingly and can contribute to negative stereo- groups included three males and eight females, with ages typing and the associated perceived implausibility of a good ranging from 77 to 89 (average age 84.2). Overall, the older old age [2, 3, 23, 26, 27]. While there is an explicit contrast participants had an average age of 80.0 years. with the biomedical literature on frailty, what is less clear is A total of 17 health professional participants took part the extent to which older peoples’ perspectives on aging across three focus groups. *e health professionals were diverge or overlap with the approach of the health pro- recruited from the local older person’s health and re- fessionals working with this age group [28, 29]. habilitation service and from relevant community organi- *is qualitative study explores the meaning of frailty sations by a general e-mail invitation. *e participants from the perspectives of both older people and health included health professionals from both inpatient and professionals. Recognising that older people may not have community settings. Across the three groups, there were preformed articulated thoughts and opinions about frailty, a three doctors, six nurses, four allied health professionals, one focus group method was used to help participants to explore supporting role professional, and four individuals working and articulate their views through group interaction [30, 31]. with older people within community-based organisations. *e aim of the present study was to explore the potential for One of the health professionals identified as M�aori (in- mutual understandings amongst the perspectives of older digenous people of New Zealand) with the remainder being people and health professionals to help inform clinical New Zealand European. *ere was one male health pro- practice and assessment. fessional participant. 2. Methods 2.3. Procedure. *e focus groups gathered together people who shared a key characteristic of similar age or of having a 2.1. Focus Group Methodology. *e primary aim of this qualitative study was to describe and understand meanings professional role serving older people, with a maximum group size of eight. Larger groups may fragment or frustrate and interpretations of frailty amongst older people and health professionals, which allied with using focus group participants waiting to have their say [32, 35]. Separate focus discussion to gather data. As Nyumba and colleagues assert groups were held for older people and for health pro- “*e most compelling reason for using focus group dis- fessionals to help provide an “even playing field” to facilitate cussion is the need to generate discussion or debate about a comfortable collective discussion [30, 31]. A total of six research topic that requires collective views and the groups were held, three with older people and three with meanings that lie behind those views”([32], p. 28) (a., p. 28). health professionals. *is was deemed sufficient as no new themes emerged at the third older person or health pro- *e defining feature of the focus group is its con- ceptualisation as a collective conversation and the fessional group [32]. Journal of Aging Research 3 between the groups involving older people and those in- *e groups were held at meeting rooms at locations that were familiar to the participants. For the older people, they volving health professionals. *is paper focuses on the themes related to the concept of frailty. *e illustrative were held at a retirement village/aged care facility and a public library, and for the health professionals, they were quotes provided use pseudonyms, and some have been held at the hospital that provides specialist older person abbreviated for length and clarity. health and rehabilitation services for the region. *e dis- cussions took place within a 90-minute session with light 3. Results and Discussion refreshments offered. One to two hours is a recommended length for focus groups to enable in-depth discussions *is study was able to compare and contrast the way without overfatiguing participants [32]. *e discussions multidisciplinary health professionals and the older people were facilitated by a researcher with experience in focus talked about the frailty and found that the similarities were group research [33] and were audio-recorded and tran- more pronounced than the differences in their un- scribed verbatim. derstandings of what is involved in living with frailty. *e A discussion guide or “questioning route” was developed collective perspective of the experience of frailty that to enable consistency in the core questions used to support emerged in the present study was developed and is repre- comparability across the groups [33]. *e basic format was sented in Figure 1. Figure 1 illustrates the breadth and introduction, engagement focusing on what makes them complexity of considerations that may need to be taken into think of a person as “frail,” exploration focusing on what account to more fully understand the meaning and expe- makes frailty better or worse, and exit. *e focus group rience of frailty. Two overarching themes emerged. began with a welcome and introduction to the purpose of the 1: It seems to me that frailty has quite a few dimensions study and explaining the focus group process and expec- tations. *is was followed by an “ice breaker” question Frailty was discussed as a multidimensional experience encompassing challenges and losses in complexly answered around the group to encourage all participants to be comfortable talking and to facilitate the identification of interlinked physical, psychological, social, and func- tional domains: the speakers when transcribing. *e key question in the discussion guide for the current (i) Physical: physical changes and mobility issues and paper was “What’s involved in being frail?” *e discussion of poor health this topic began by the facilitator describing a scenario where (ii) Psychological: cognitive changes and poor mood they met two people they have not seen for some time, Jan and confidence and Pam. *ey think “Jan is getting quite frail,” but this is (iii) Social: isolation and withdrawal not the case for Pam. *e participants were invited to share (iv) Functional: needing help the “things that you think of when you think of an older person being frail.” *e ensuing discussion was summarised Each of these subthemes emerged in every group discussion. *ey are represented in Figure 1 by a circle on a whiteboard, with clustering of ideas and lines con- necting clusters as interrelationships were discussed. *e of rings. An outer band represents the interplay and discussion guide suggested further prompts for the facili- reciprocity of influence amongst these components. tator, who paraphrased and encouraged discussion, and the 2: People can have a lot of this stuff but I wouldn’t call group participants themselves also facilitated the discussion them frail through their interactions. *e experience, impact, and acceptance of frailty were *is study was approved by the University of Otago’s not considered to be explicable by objective losses Human Ethics Committee (reference 17/151). All partici- alone. *e label of frailty was contested by older people pants gave informed consent. and used with caution by health professionals. Across all the groups, the experience and severity of frailty were seen as moderated by resilience and psychological 2.4. Analysis. *e data were analysed using the framework resources such as a positive attitude and personality approach, as outlined in Table 1 [36–39]. *e structure and strengths. process of the framework method of analysis offered the Resilience and psychological resources are represented ability to easily compare data across the groups as well as in Figure 1 by an inner hexagon interlinking with the within the groups [38]. *e flexibility of the framework dimensions of loss. *e experience of frailty in the method enabled the researchers to begin the analysis during centre of Figure 1 can be seen as being defined in the focus group data collection. *e data were then read and concert by portions of the greater dimensions of loss reread and then coded (conceptual/descriptive labels were and by individual resilience. While any given facet, applied to sections of the text) and charted. Charting is the whether sarcopenia or isolation may be part of the hallmark of the framework approach and involves entering experience of frailty for many people with frailty, not the data into a matrix with rows (cases) and columns (codes) everyone who has sarcopenia or isolation is frail. [38]. In the present study, the cases were the individual group discussions. *e final stage involved mapping, in- *e visual representation in Figure 1 also provides a terpretation, and discussion of the themes and subthemes, visual shorthand for comparing the understanding of with particular attention to the similarities and differences the experience of frailty that emerged in the present h b r Resilience Resilience Physical Social 4 Journal of Aging Research Table 1: Steps in the framework analysis used in the present study. Stage Process *rough the process of note-taking in the focus groups and reading and rereading the transcripts of the discussion and the whiteboard summaries, the 1. Familiarisation researchers became aware of the recurring themes and key ideas. Initial thematic notes were made and discussed. *e key ideas and themes that were identified in the familiarisation stage formed the basis for an initial thematic framework that was used to classify the data. 2. Identifying a thematic framework Open coding ensured that any important themes from the data that had not been captured initially were able to be included and the framework was adapted as necessary. *e transcripts were annotated to identify sections 3. Indexing that were relevant to the different codes or labels. An excel spreadsheet was used to generate a matrix, with the groups as rows and the labels as columns. 4. Charting Quotations identified in the indexing were entered into the matrix in the appropriate cell using verbatim words. *e matrix was reviewed with reference to the transcripts and team discussion to clarify the main themes and subthemes and the interrelationship 5. Mapping and interpretation between these. *e matrix structure enabled easy recognition of patterns, in particular whether there was consistency of a theme across the groups versus some empty cells. the narrative that emerged, neither are sufficient in themselves to represent the overall understanding of frailty that emerged in the present study. A shared understanding of frailty that balances deficits and strengths is an important foundation to integrated and person-centred care [41]. Resilience 3.1. “It Seems to Me 7at Frailty Has Quite a Few Di- mensions”: Multiple Domains of Loss. Frailty was discussed Experience as involving challenges and losses in complexly interlinked of frailty themes across physical, psychological, social, and functional dimensions. *is consistency in perspectives on what is involved in the experience of frailty was apparent despite ambiguity and differences in the definition of “frailty” per se. Resilience *is more holistic biopsychosocial perspective has also emerged from interviews with Dutch elders conducted by Puts and her colleagues [17] and has been suggested in previous work with health professionals [28, 29]. Figure 1: Visual summary of the thematic analysis. 3.1.1. Physical Dimensions. “Looking frail”: physical changes and mobility study with dominant approaches to frailty. *e pale blue ring representing physical changes could be In their seminal work, Fried and colleagues identified a considered to encompass Fried’s phenotype definition cluster of changes, which were then crystallised into the of frailty [10]. *e circle of losses and challenges has Cardiovascular Health Study frailty scale to become one of similarities with summaries of the superset of deficits the most widely used frailty measures in research: un- that might be included in a frailty index approach (e.g., intentional weight loss, exhaustion, low energy expenditure, [40]). While both approaches are recognisable within slow gait speed, and weakness. It is striking that this process Functional Resilience Resilience Psychological C Journal of Aging Research 5 Greta: Can I just bring up one other thing, people talking was echoed in mental image of someone with frailty for not only the health professionals but also the older people about shrinking and losing weight and things like that. Now I don’t believe I’ll ever look frail because I’m big and themselves. Observable changes around weight shrinkage and my mother was the same, I mean she lived to 91, today is weakness were articulated across the focus groups. People the day she died, I mean seven years ago she died and, but with frailty were described as “thin,” “drawn,” and “wasted,” she was big and she never looked frail, never looked frail. with “not much meat on their bones” so the “skin just hangs,” . . . with the impression of getting “smaller” or “shrinking.” *is Interviewer: So you [to Lyn] were saying it’s not just appearance of shrinking can be compounded by “poor about having a walker and you’re saying [to Greta] it’s posture” and “being bent over.” not just about looking small. . . Some older people and health professionals identified Greta: 7at’s right, yes there’s more to frail than that “weakness” or decreased “strength” with the term “sarcopenia” (Older person group) also being used by health professionals to refer to the loss of muscle mass and strength. In two of the elder groups, this was Patrick, a retirement village resident in another group, exemplified by finding it hard to get up from the floor, as was very clear about making this point, for example, in the Margaret raised in the context of getting up after a fall: context of a fellow resident: Margaret: Well I find if I have a fall, I can’t get myself up unless I crawl over to something to pull myself up. I think that’s perhaps being restricted, there’s one particular lady in this village who uses it [a walking aid] more but, and Elizabeth: Now that’s the problem. 7at’s the strength I wouldn’t describe her as frail I think she’s very. . .alert, she’s gone in your legs. cheerful and she’s accepting a physical disability but oth- Judy: We’ve certainly lost strength, yeah, you certainly erwise is well. So it seems to me that frailty has quite a few might look alright but the strength isn’t there anymore. dimensions, it’s got the physical dimension but it’s also got *ere was awareness of “low energy levels” with the the social and then mental . . . the lady I’m thinking of in the village certainly has no mental or social. health professionals also using terms such as “fatigue,” “decreased exercise tolerance,” and “poor energy to maintain daily living.” Walking noticeably slower was mentioned on *e health professionals also talked about the physical occasion by both older people and health professionals. A symptoms of frailty as only being one part of the experience of lack of physical activity was generally discussed in the the individual. For example, Claire talked about how she likes to context of other concepts such as a way to combat frailty or work “in a holistic manner. . . you’re looking at the family, the lack of social involvement. *ere was however an image physical health, mental health, spiritual . . .” and as the con- that people with frailty may “just sit” and this contrasts with versation continued, Kate raised the core question for consid- those at the same age who do not have frailty, as articulated ering and intervention as being “What does that do to the whole by Patrick (who is himself a member of a walking group): person?” *e desire for more integrated care was expressed by both older persons and health professionals groups. In contrast, in one of the health professional focus It’s certainly not necessary so you only have to see [masters] games where people of a substantial age are doing all sorts groups, there was the suggestion that the physical changes of of innovative and physical and social activities. Fried’s phenotype were definitive of frailty. Jane, a nurse, suggested that *e older people and health professionals in all the groups talked about mobility as a facet of frailty including a . . .the weight loss, the lack of strength, the decreased ex- lack of mobility, slowness in walking, and needing aids such ercise tolerance and the falls have varied degrees. And I as a stick or walker. *ey noted that people with frailty may think, like all four of those things . . .[are there]they are frail be “unsteady,” “wobbly,” or “losing balance.” *is was as- and then there is degrees of it. . . sociated with an increased risk of “more” and “ongoing” falls. *e role of these physical changes in determining who Although she at times struggled to articulate her con- ceptualisation, Jane felt that the physical changes were the was frail was an area where there were divergent views. Amongst the older people, there was an explicit discussion core of frailty. While Jane’s doubt about whether social that these features of physical changes and mobility are not interventions would reduce frailty was refuted by one of the in themselves enough to differentiate who is experiencing other health professionals: “I thought the evidence was very frailty: strong that it did help,” Megan could understand the point she was trying to make . . .but you can’t do that, that’s really unfair to think somebody’s frail just because they’ve got a walker. (Lyn, . . .You can put in social stuff but they just haven’t got the older person) exercise tolerance. Greta later raised the opposite logical fallacy, where her In the same group Karen also acknowledged that her biomedical background, “my main physical side,” biased her mother was frail but did not look it: 6 Journal of Aging Research slower to recover or unable to return to baseline levels of towards prioritising the physical changes as the core with the other dimensions as potentially preventable consequences: health, for example: . . . as a [physician] I think about that [the physical side] Each episode takes more and more. . .they don’t manage to but I would be constantly thinking, what can I do about recover (Kate, health professional) these things to stop them impacting as much. In the older persons’ groups, frailty was occasionally Despite this definitional tension, this health professional linked to death in the discussions, for example, involving an group discussed the same multiple dimensions of the ex- awareness of “mortality” or causing death: perience of frailty as the other groups. *ese narratives of the commonality of the phenotype of “my personal experience of one of my parents, my dad died young, of being frail” (Merle, older person) frailty offset against its limited ability to encapsulate the experience of frailty that resonates with the argument of *e health professionals talked more extensively about Cesari and colleagues: “Although we praise this approach, our gerontological souls are still bleeding” ([42], p. 260). *e people with frailty as being more “vulnerable” and “closer to physical phenotype of frailty has proven validity but wider death and having “decreased reserve” and “less resilience,” approaches are also needed to identify individualised targets with even a “minor insult causing deterioration.” One of the for interventions in practice [43]. health professionals used the word “teetering,” while Raewyn described it as being “on the edge”: “Poor health”: Health decline, comorbidity, and risk . . .in an emergency situation, like you are looking at them Amongst the many alternate views of frailty in the and you think, they could have a fall or they could not be here tomorrow, medically, physically (Raewyn, health clinical and research literature, there is a common un- derlying core that frailty is an increased risk of vulnerability professional). [44], that is, frailty increases the risk of poor health outcomes and creates concern for the prognosis of the individual. 3.1.2. Psychological Dimensions. “Confused and muddled”: Comorbidity is commonly recognised as an important part Cognitive changes of the frailty experience, as evidenced by its inclusion in over half of the most popular frailty measures [36]. *e pre- *ere have been differing opinions in the literature over the ponderance of health conditions amongst people with frailty conceptual role of cognitive changes in frailty [44, 45]. *ere consistently arose in the discussions across all the groups. is increasing recognition of reduced cognitive reserve as- Older people talked about “poor health” and being “not well,” sociated with physical frailty and its potential to improve along with raising specific issues such as sleep, pain, prediction of vulnerability and outcomes such as marked shortness of breath, continence, hearing, and vision. *e declines in functioning and increased likelihood of long- health professionals also talked about comorbidities and term care [46–48]. specific conditions and additionally noted that this is often *e older people and health professionals in all the focus marked by multiple medications and increased hospital- groups talked about cognitive changes with terms such as isations. As with many of the dimensions, there was a vicious “forgetfulness” or memory “failing” or “slipping”; “confusion” cycle with frailty as a risk for comorbidities and comor- or being “muddled,” “vague,” “away with the fairies”; “unable bidities as a risk for frailty: to make decisions” or “plan”; and cognitively “slow.” As with Lekan and colleagues [24], the cognitive changes described . . .but it was mentioned something earlier, that sort of by the participants were often were broader than dementia: multiple medical stuff, you just pick up. But they kind of have surgery and then something goes wrong and then they . . . confused and muddled. Because sometimes it’s not, it’s get an infection and that doesn’t go and then just, so they’ve not actually confusion . . . . . ., well I was just thinking of a gone from this healthy person previously to this frail person. gentleman who I saw last week. Um, and I would have (Marie, health professional) described him as frail from when, when I met him he was out pruning the roses but he looked to me, he, I would When Greta was asked to talk more about her mother’s describe him as frail from the outset. 7e way he sort of frailty despite a robust appearance, she highlighted sus- shuffled when he walked . . .. And he was, . . ., muddled ceptibility to multiple health issues: inside. You know so I was asking about his medications and he was kind of you know um, trying, almost trying to look She was very susceptible to getting things wrong with her, for things and that sort of thing. And interestingly, um, pneumonia. . .or germs yes and emphysema and yeah, and there was a whole lot that I was concerned about and he she had gout, bad gout. . .(Greta, older person) passed away on Saturday morning at home. (Kate, health professional) Alongside the recognition that people with frailty were . . .it’s a mental thing and memory is an indication of frailty susceptible to accumulating health conditions, there was also discussion that people with frailty were more likely to be and lots of people who I would class as becoming frail have a Journal of Aging Research 7 great deal of particularly memorising not only faces which Greta: . . .I sometimes feel people go quiet, I don’t know we all forget but routine things like turning the stove off or why I think that switching the lights off or doing those sort of things. Jill: 7ey seem to take up less space don’t they (Patrick, older person) Older participants and health professionals also talked about frailty involving losing “confidence” and “self-esteem” While noting that people with dementia can be physi- and being “fearful.” For some people, this was related to cally “robust” rather than frail, there was also recognition things becoming harder with memory and everyday tasks so that the progression of dementia typically compromises that they: other domains related to frailty: Definitely get more nervous that they might do something . . .It is very frequent that the, you know, the end stage wrong. . . lose your confidence and feeling a bit more in- dementia patient will be frail as well. (Karen, health secure (Brenda, older person) professional) For example, Judy talked about losing confidence in In one of the older persons’ groups, Virginia, Greta, and making decisions and worrying more and at one stage talked Judy discussed some of the ways dementia can impact on about this in the context of cooking: other domains such as through physical changes, mobility, and social engagement: I used to be able to put on a dinner party for eight or nine Virginia: And a lot of dementia too, I’ve got a couple of people [or] my family. Yeah well I had three of four courses friends with dementia which is you know, not good. with nibbles and the whole, now I’m a mess if I’ve got Greta: And they’re frail aren’t they? someone coming for afternoon tea I’m trying, I have to organise it the day before and I just about lose sleep over it. . . . (Judy, older village resident) Virginia: Well I s’pose it can because I watch, I watch this friend of mine and she doesn’t really, I think she’s for- *is loss of confidence could be pervasive and lead to gotten how to walk properly, you know it’s like she’s limitations in the life lived: bending, she’s bending over the top, you know quite sad really. . . . loss of confidence, um, with everything really. Could be, Greta: 7at’s really sad. managing at home. Day to day living. It could be a loss of confidence in, you know leading to isolation. (Amanda, Judy: Well my aunt lost her voice, she’s got her thoughts and she can’t express herself, yeah she just, she wants to health professional) say it but she can’t. . . On occasion, older people and health professionals Virginia: . . .and she’s probably trying to find the words. linked this with a loss of “self-esteem” and sense of self- Greta: But you were saying you had to think very hard identity, for example, one of the health professionals Fiona about how you’re getting up but if you’ve got dementia, noted that people may think “I’m not sure who I am. . .I’m you actually can’t think about how you’re going to get afraid to come out.” up. . . 3.1.3. Social Dimension. “Increasingly isolated”: Isolation and withdrawal “loss of confidence. . . with everything really”: Mood and confidence *e importance of the social dimension of the frailty expe- rience emerged strongly from the focus groups. *is re- *ere was some limited discussion of being “de- inforces previous evidence of the centrality of the social pressed,” both as a feature of frailty and its role in re- domain to the lived experience of older people. When von ducing the motivation for self-care and increasing risk. Faber and colleagues [51] talked with octogenarians, they *is bidirectional relationship echoes the overall con- found that it was the impact of limitations on social op- clusions reached by Mezuk and colleagues following their portunities that created the greatest distress rather than the review of the literature [49]. Based on their latent variable physical changes themselves. Likewise, preparatory focus approach study, Lohman and colleagues suggested that groups by Studenski and colleagues as part of a process to psychological frailty, as measured by depressive symp- develop a measure of frailty found that older people and their toms, may be an integral part of what it means to be frail families prioritised the social and emotional aspects of frailty [50]. [52]. Social vulnerability and loneliness have reciprocal re- *e older participants and health professionals talked lationships with cardiovascular disease, depression, and de- more about subclinical changes, describing people with mentia [53] and independently predict high rates of entry into frailty as being “introverted,” “withdrawn” reduced “vitality” aged residential care [54] and mortality [55]. and “engagement,” and “less interested in life in general”: 8 Journal of Aging Research whatever, and then increasingly isolated. Just has such a big Older people with frailty were described as “lonely” and “isolated,” lacking “social networks,” “social connections,” impact on people. (Claire, health professional) and “social stimulation.” *ere was description of a “nar- rowing in the world,” or what Studenski and colleagues [52] *e importance of the social dimension of frailty in this call the life space and social world. *ere was considerable and previous work suggests that not addressing this di- discussion amongst the older participants about the complex mension may run the risk of misalignment with what interplays between the different facets of frailty and social matters most to some older individuals. For example, a difficulties whether physical features such as loss of mobility, recent publication on assessment of frail older people in hearing, sight, or continence; psychological features such as acute settings recommends an assessment package cognitive changes, confidence, and social withdrawal; or encompassing a physical exam, psychiatric exam, functional environmental factors such as lack of transport or social assessment, and a history of gait and falls, continence, sensory problems, and medications—noticeably absent from opportunities where they live or the loss of an enabling partner or roles. Hearing was often a particularly salient this summary of recommendations is assessment of the social dimension [56]. example to the older people. For example: I’m wondering about people who, in their life have been 3.1.4. Functional Dimension. “Need help”: Dependence social and yet now because they’re deaf and they can’t see and they can’t drive and you know, and they’ve got lonely Both the community participants and health professionals because in the past they’ve gone out to volunteer wherever talked about people with frailty not being able to do the same and suddenly they can’t so yeah. . .. . .there’s something things independently, particularly day-to-day tasks, with the more where they haven’t got the choice because there’s common understanding that part of frailty is needing more something that happens (Jill, older person) “support” and “help” from family and health services, or more pejoratively being more of a “burden”: In another example, one of the older groups talked about how some older people do not take up social opportunities: It gets to the stage where you really do need help” (Mar- garet, older village group) Elaine: Well they could have other problems, like hearing problems, sight, problems, that if they can’t hear they I think it’s probably when they start to lose the, yeah the don’t enjoy. . . processing and the ability to manage independently Judy: No that’s right, or it’s just a jumble and my . . .More of an effort. Because they could be all that and husband used to have a hearing aid and said it was they’d be fine. . .But it’s when they start not being able to terrible, he used to turn them off . . . manage that independence. (Megan, health professional) Prue: 7ere’s certain things in your life too that when you *e need for help as a marker of frailty arose in every lose your partner. . .it’s very hard to make that effort to focus group, echoing the emphasis that Rockwood and come on your own when you’ve always been togeth- colleagues have placed on dependence as the crux of clinical er. . .You just feel quite lost, some people go into judgement about frailty [57]. As Landi et al. [45] note, the themselves and withdraw ability to maintain independent has multiple determinants *ere was also talk amongst the health professionals of and is sensitive to changes in cognition, mood, mobility, and how social engagement is impacted by multiple factors. For functional performance. example, Shona noted the interplay amongst sensory issues, Accepting help can key into pervasive narratives that mobility, continence, self-esteem, cognitive skills, and needing help is a marker of adverse outcomes or un- socialisation and summed up: successful aging in Western cultures that prioritise independence: . . .it’s really [being] vulnerable isn’t it? You’re kind of saying that you know if you have problems with any of these sometimes that, I would think are reluctant to accept [factors], it becomes so much harder to get out and support is that, ah well if they accept support then they’ve socialise. . . (Shona, health professional) given up (Claire, health professional) For Claire, social isolation was the apex of the frailty *ere was resistance to this narrative amongst the older experience: participants. Butler and colleagues have argued [58] accepting help can be an adaptation to improve quality of Social stimulation. I think is such a big one. Like um, life, rather than resisting help and risking exacerbating whether it’s, you know if they’re at home and they have problems. *ey have labelled this adaptation “responsible difficulty getting out but if they’re still being visited. . . But I dependency.” Accepting help is a choice: would say isolation is, is almost the, the thing that breaks the camel’s back almost. Yeah. 7at, you know a lot of these I’m thinking all these things, everything . . .the people concerned have to make the decision to use all the facilities, other things will affect their ability to get out of the house or you know they might have lost their drivers licence or all the help. . . (Beth, older person) Journal of Aging Research 9 was not a word that they would use; “I’ve gotta say I don’t use Judy was aware that her own habit of declining help to maintain independence and not be a burden could mean the word frail” (Keith). Christine, in particular, questioned the imposition of frailty as a label: “who has the right to say turning down help that would have had a positive impact: you’re frail in any way?,” while William railed against his I think it’s our own fault ‘cause we’ve always been so health concerns being written off: “Yeah I’d like people not to independent. . .we’ve never asked them for help. . . if they use the phrase. . .What do you expect at your age.” say you know, oh can we, oh no no we’re alright, yeah and *e health professionals were aware of these tensions that, and [my husband] and I, that’s what we decided, we’d and cautious about using the term. Some of the health come in here, we wouldn’t be a drain on them and that’s professionals would not tell an individual that they were what I think is a bit of a trouble. . . frail or only if they were sure of the relationship. Some professionals noted that they had been involved in dis- Some of the women felt that men found it particularly cussions about avoiding using the term frailty in in- difficult to seek help, with concomitant risks: terdisciplinary team meetings or in materials. Raewyn was aware that the frailty label was affixed to older people by I think they’re more fearful about admitting and more health professionals, sometimes inaccurately in her opin- fearful about what might happen to them. My husband ion, and that this could have implications for clinical de- died at 68 and he was obviously having heart problems but cision making and the older person’s hope for a more didn’t say so and dropped down dead on the pavement so positive future: had he sought medical help, whether it was for fragility or anything else, he’d still be here today. (Lyn older person) . . . a lot of that is happening where people are being given that label and um, is that impacting on what health care William explained the aspect of responsibility clearly in they have been given as well. You know, um, oh she is old relation to using mobility aids: and frail and we see that a lot, actually, oh they are frail.. . .Um, some of them laugh it off, oh he doesn’t know I think one has to accept as one gets older that one is going what he is talking about or whatever. But um, no it does to have certain problems and if you can take precautions so have an impact because they almost give up on some things. that you don’t injure yourself or others, you take those Oh, we can’t, I am not going to bother to push for that um precautions, in other words, you use a stick or an aid of show the surgery or whatever or you know, getting that some sort. fixed up because I am told that um, I am old and frail. “They are still cheerful and they are still resilient”: feeling frail vs. resilience 3.2. “People Can Have a Lot of 7is Stuff but I Wouldn’t Call 7em Frail”: Resistance, Resilience, and Psychological Markle-Reid and Brown [11] have argued that any Resources. Frailty index models view frailty as a multifac- understanding of frailty must recognise that the degree of torial accumulation of deficits that places the person at risk frailty depends in part on the context and can be highly of adverse outcomes, and offer an approach which can in- influenced by the subjective interpretations of the individual. corporate physical, psychological, and social dimensions *is was dramatically highlighted in Merle’s story about her (e.g., [7]) (although not all authors incorporate the full mother: range). While the emphasis on the prediction of adverse outcomes by cataloguing objective limitations can be useful, Well my mum lived till nearly 101. . .. . .[at 96] she was still arguably this approach in isolation is not geared to un- not frail, she was robust. . .but at 96. . . the doctor said she derstand and reflect the holistic lived experience and had bowel cancer, well she just took to the bed, I mean we meaning of frailty for the individual [11, 19]. Lived expe- were absolutely amazed and “you girls can do what you like rience is more than a problem list [27]. with me,” she became old. . .rapidly and then I went to see her next time, she’d lost a lot of weight and had a walking “I don’t use the word frail”: Resistance to the label of stick so you know, within no time at all. However once she frailty discovered she didn’t have bowel cancer. . .She immediately felt better. . .so then she leapt out of bed and got on with her Authors have explored how the focus on defining frailty life again. . . by deficits has unwittingly positioned frailty as the repository for negative stereotypes and visions of a feared and un- successful old age—what once would have been termed *e importance of this subjective context-dependent perception was a key theme emerging from Grenier’s in- senescence or infirmity [26, 27]. *is echoes the distinction between a healthy third age and a fourth age marked by loss terviews with older women, which she called “feeling frail” [19]. Grenier [19] noted from her qualitative work that of capacity, with frailty as the boundary [26]. Little wonder then perhaps that as with previous studies [2, 17, 19, 23] we moments of feeling frail do not always result in a final state of being frail. *is is illustrated by Virginia in the present study found resistance to the label of frailty. *e older people made who shared her own experience of “feeling frail” after an comments that rejected the label as applying to them: “We don’t think we’re frail anyway so” (Elizabeth); and that frailty illness requiring hospitalisation: 10 Journal of Aging Research lived environment into the central focus of the helping I just recently got quite ill and I felt very frail, my children were wanting to put me in a you know, retirement process, rather than the client’s problems, diagnoses, or deficits [64]. [home]. . . and I’ve now come right so I’m feeling much but I was staying at home and feeling quite old. . .and yet I’m very active and healthy and outgoing and can speak my 4. Limitations mind and all the rest of it but I just felt, oh someone come and look after me, please. . .but I didn’t [call it] being frail *e present study adds a New Zealand perspective to the but now that we’re talking about it, that was actually how I growing literature base that both older people and health felt at the time, I don’t anymore but. . .Yes it can be a bit of professionals commonly view the experience of frailty as a mindset too, a bit in your mind I felt afterwards. . . more than just a physical change. While the study involved a range of health professionals, there are discipline and spe- From her work, Grenier [19] has suggested that there is ciality differences that remain unexplored in this study. *e an “emotional threshold” for frailty and not just a medical- groups of health professionals each included a range of functional threshold. One of the health professionals puts it disciplines reflecting the multidisciplinary nature of their this way: older persons’ health work environments. *eir multidis- ciplinary experiences in this field may have made it more there’s a whole lot of these things that can happen, people likely that they held more holistic views of the experience of can have a lot of this stuff but I wouldn’t call them frail, not ageing than health professionals who work with the general necessarily because it’s depends on how they see life (Marie, population. It would be particularly useful for future re- health professional) search to explore the perspectives of general practitioners. *e older participants were limited to individuals from the Feeling frail is not just a consequence of a change in majority New Zealand European population and to those health and functioning but also a determinant [23]. *is who felt comfortable with coming to a group to talk about allows recognition of the role of emotional resilience in frailty and were able to attend. *e groups may not reflect understanding individual differences in outcomes in the face the views of the most vulnerable older people such as those of major challenges, as in this discussion: who have severe frailty or isolation. Comparing and con- trasting the perspectives of older people with frailty with Jane: It’s a funny thing, I mean you look at the level of those who are robust may be a possible area for future function they have and they are still cheerful and they are research. Future studies with ethnic minority groups would still resilient and independent and they are making do be useful, as would studies from non-Western countries. For . . .they look like they would blow over in the next wind a better understanding of the experience and meaning of but still somehow pushing in through frailty to impact on the well-being of older people, that Raewyn: So, strong in mind would jump into that understanding must be reflected in practice. How to ef- category. . . fectively structure, encourage, and evaluate communication Karen: and some have really one thing wrong with them and needs assessment processes about frailty that are holistic and they give up and allow themselves to fall into the sick and strength-based will be an important area for future role and very quickly become frail because that is how research. they believe, that is their role in life (health professionals group) 5. Conclusions Participants talked about being “a strong person” and the *e medical and social perspectives on frailty have tended to impact of “personality.” *e concept of resilience can be described as a personal characteristic that enables an indi- be in separate siloes; however, integrating these approaches may provide an impetus to strengthen person-centred vidual to sustain, regain, or achieve physical or emotional health in the face of illness or loss [59, 60]. However, still a services [59]. As Nicholson and colleagues remind us, a shared understanding of frailty between older people and developing research area, a resilience-based approach may help to counteract the potential for negativity and stigma- health professionals is a good basis for shared decision making [64]. *e findings of the present study support calls tization [61] and mesh with a strength-based approach to services for older people. *e foundation of a strength-based for a more holistic approach to the assessment of the needs approach is that each person has abilities and resources that of frail older people that includes psychological and social domains [24]. *is study was distinctive asking the same can help them to cope with challenges. Dury and her col- leagues have talked with older frail people about the multiple questions of older people and health professionals, and the discussion suggests that embedding a more holistic ap- positive balancing factors that the experience of frailty, including from the individual themselves [62]. *ey can use proach will support the broader understandings of the ex- perience of frailty already held by many of the health their experience and capabilities to identify their own concerns and be involved in the process of regaining, professionals who work with older people [28, 29]. *is is exemplified in the British Geriatrics Society’s “Fit for Frailty” maintaining, or adapting to their level of health [63]. A person-centred strength-based approach places the unique best practice guidelines [65]. *ese guidelines recommend conducting a holistic and comprehensive review of needs, strengths and preferences of the client in the context of their Journal of Aging Research 11 Journals of Gerontology Series A: Biological Sciences and not just medical but also functional, psychological, and Medical Sciences, vol. 62, no. 7, pp. 738–743, 2007. social, to inform a personalised care and support plan which [8] H. E. J. Senior, M. Parsons, N. Kerse et al., “Promoting in- incorporates the individual’s goals. *e older people and dependence in frail older people: a randomised controlled health professionals in this study strongly identified the role trial of a restorative care service in New Zealand,” Age and of psychological resilience and recognised that the degree Ageing, vol. 43, no. 3, pp. 418–424, 2014. and impact of frailty, and the support that is appropriate, is [9] R. 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