Frailty screening: Doing good and avoiding harm

Around the world, the number and proportion of older people in the population is increasing. By 2050, 22% of the global population is predicted to be 60 years or older. Ageing is often associated with a decline in health and function, and consequently, greater care needs. With this comes increased uncertainty about the benefits and harms of health interventions to address needs. It is timely that the World Health Organisation (WHO) has designated 2020 – 2030 the ‘Decade of Healthy Ageing’ to support action to enable well-being in older age and ensure everyone can fully participate in society.

The past two decades have seen a great deal of attention focused on understanding the variability of ageing. Why do some people remain fit throughout a long lifespan while others become increasingly vulnerable? How we understand and respond to variability in the rate of ageing will go a long way toward meeting the WHO goals. These questions are considered in a context of growing concern about ageism – discrimination based on age directed at older people (or, “the perceived elderly”).

Symptoms of frailty
While ageing may be driven by evolutionary and molecular processes which remain uncertain and often out of our control, researchers and clinicians advocate that we recognise and evaluate vulnerability to the negative impacts of ageing, i.e. frailty, in order to better understand and address the needs of older adults. A general definition of frailty is the increased vulnerability to adverse outcomes as a result of physical decline and overall health deterioration among people of the same chronological age. Frail people are less able to cope with illnesses or stressors compared to others of the same age, and this frailty can lead to rapid and dramatic deterioration, hospitalisation, need for long-term care and even premature death. As a result of ageing populations, frailty is increasingly common but often under-recognised, and the negative impacts on well-being are underestimated.

The most common physiological symptoms of frailty are unintentional weight loss, muscle loss and wasting (sarcopenia), fatigue, slow walking speed and low levels of activity. Crucially, these intrinsic biological aspects of frailty also interact with extrinsic factors in the physical and social environment of older adults. Socioeconomic status, social support, living situation, social engagement, social capital and social cohesion will all contribute and/or interact to determine a person’s vulnerability to declines in physical health.

Inadequate understanding and recognition of frailty can lead to practices being followed without sufficient consideration of the additional risk for a frail person. For example, data on coronary heart bypass procedures suggests that although considered to be a safe and standard practice, for frail patients the risks are extremely high and, in many cases, result in severe disability or even death. This illustrates the clinical rationale for screening for frailty. In a 2018 paper, Profs Reid, Lahey and McNally of Dalhousie University, Nova Scotia, Canada, highlight the need for thorough consideration of the potential benefits and harms to ensure frailty screening is ethically defensible and leads to support that reflects people’s needs, circumstances and capacity to benefit from the care provided.

Screening for frailty
Health screening can identify individuals who may have an increased risk of developing a condition and inform decisions about earlier treatment or interventions. Advocates of screening for frailty are aiming to create a more holistic approach to healthcare for this group of older adults. They propose that screening for frailty would enable the extent and impacts to be recognised and addressed by care systems and society. The key goals of screening for frailty are a) to promote healthy ageing and prevent frailty, b) improve the social and medical responses for those who are frail and c) prevent inappropriate medicalisation. However, past screening programmes for chronic disease have highlighted that they can lead to unintended harmful effects.

Screening that is ethically defensible will situate and support healthcare that is consistent with people’s needs, circumstances and capacity to benefit.

In medical ethics, the duty of promoting the best interests of the patient ‘beneficence’ is complemented by that of ‘non-maleficence’: the responsibility to do no harm. Screening for chronic disease is an example of an area where the harms of screening are recognised, for example in the potential overdiagnosis of non-clinically significant cancers, when screening too often or in the wrong population has led to overtreatment along with increased morbidity and mortality.

Risks of harm
A primary concern for the introduction of screening for frailty is medicalisation. Medicalisation of a condition involves defining the boundaries of a disease and understanding and distinguishing between precursors or risk factors and clinically significant presentation of the disease. This can be valuable in improving care responses; however, it also carries the risk of a group of people being labelled as ‘unhealthy’ and for the categorisation to become stigmatising. Frailty brings with it increasing vulnerability and disadvantage which a medical label could reinforce rather than address. Not only does being labelled “frail” by healthcare providers risk exposing older adults to heightened negative associations, it could change people’s self-conception and lead them to limit activities to the detriment of their health. Medicalisation can also cause social problems to be reframed as medical problems and enable social structures and inequalities to remain unacknowledged and unaddressed. Instead of contributing to the provision of more of the non-medical care older adults often need, screening could have the contrary effect by medicalising frailty and minimising their claim to appropriate as well as inappropriate care. For medicalisation to be beneficial, it must not undermine an individual’s own, or others, view of their health, but empower them to claim support from health and social care systems.

Equality laws protect people against discrimination on the basis of personal characteristics, including race, religion, sex, disability, as well as age. In addition, equality is often viewed as more than preventing discrimination but as fundamental to every persons’ human right to flourish and fully participate in society. Older adults often face discrimination, ageism, as a result of societal stereotypes which assume they are weak, needy and diminished in capacity or potential. By labelling an older adult as frail, there is considerable concern that it would validate this stereotype and associated discrimination. This has the potential to lead to this group in society being considered as less deserving of often limited services and for frailty to be seen as a criterion for the withholding of care.

Informed consent is a fundamental obligation prior to treatment to ensure a person is provided with all pertinent information, has the capacity to understand a decision and its consequences and that the decision is voluntary without undue influence or coercion. Screening for frailty also raises important concerns regarding the autonomy of older adults, particularly when a label of ‘frail’ also carries the risk of implying incapacity and the removal of decisions from the individual to a family member. If a key aim is to ensure care is appropriate, it is fundamental that the healthcare system supports individuals and their family caregivers to make the best decision for that individual, rather than refusing services based on standardised cut-offs. Highlighting the increased risk associated with some treatments for frail people, particularly if combined with provision of the alternatives to those treatments, should improve the ability to make an informed choice rather than remove the choice.

Doing good and avoiding harm
Screening for frailty has the potential to ensure that care and social needs are identified and met for a significant and growing proportion of the population. However, it also raises crucial ethical and legal questions that must be carefully considered by both policy-makers and practitioners, alongside patients and the public, to design initiatives that can achieve their goal of matching the right resources to the needs of an ageing population.