Frailty: perceptions of occupational therapists in Ireland

Abstract

Purpose

Ireland’s ageing population has resulted in an increasing number of older adults living with frailty. Despite growing attention towards older adults’ and health professionals’ perspectives of frailty, occupational therapy research is limited. This study aims to explore occupational therapists’ perceptions of frailty and how their perceptions impact their approach to the assessment and management of frailty.

Design/methodology/approach

Using qualitative descriptive design, 19 occupational therapists working with older adults participated in online focus groups. Data were analysed using thematic analysis.

Findings

Perceptions of occupational therapists were constructed into three main themes: conceptualising frailty; management of frailty; and advancing frailty practice. Findings indicate that occupational therapists perceived frailty as a multidimensional concept but highlight a reluctance to use frailty terminology with patients. Findings also suggest that although occupational therapists are involved in provision of care for older adults living with frailty, the profession’s scope is not optimised in the assessment and management of frailty.

Originality/value

Findings provide insight into occupational therapists’ perceptions of frailty. Development of a shared understanding of frailty between clinicians and patients and enhancement of undergraduate frailty education are recommended to progress occupational therapy’s role in frailty management.

Citation

Griffin, N., O’Sullivan, L. and Usher, R. (2024), "Frailty: perceptions of occupational therapists in Ireland", Irish Journal of Occupational Therapy, Vol. 52 No. 1, pp. 36-43. https://doi.org/10.1108/IJOT-08-2023-0018

Introduction

Global ageing population trends have led to growing interest in conceptualising and addressing frailty among older adults (Durepos et al., 2022). Frailty is defined as a clinically identifiable state of heightened vulnerability, caused by a decrease in the reserve capacity of multiple physiological systems (Clegg et al., 2013). Frailty is a common and clinically significant condition among older adults and is associated with premature disability, institutionalisation and mortality (Roe et al., 2017). A recent systematic review of pooled estimates reported the prevalence of frailty and pre-frailty among hospital inpatients aged ≥ 65 years as 47.4% (95% CI 43.7–51.1%) and 25.8% (95%CI 22.0–29.6%), respectively (Doody et al., 2022). Increasingly, it is recognised that frailty is not an inevitable consequence of ageing and with appropriate strategies, it can be avoided, attenuated and even reversed. Thus, the ability of health-care professionals (HCPs) to comprehend, recognise and manage frailty is a pertinent issue.

The optimal and consistent assessment and treatment of older adults living with frailty requires shared understanding of frailty among HCPs (Gwyther et al., 2018). In Ireland, “The National Frailty Education Programme” (NFEP) was established to upskill HCPs and promote effective frailty management (Lang et al., 2023) and Frailty Intervention Therapy (FIT) teams have been established within a number of emergency departments (Maloney et al., 2017). Occupational therapists have skills for screening at-risk individuals and intervening to enhance current reserves, as well as addressing deficits that contribute to frailty development (Provencher et al., 2012). Therefore, it is imperative that occupational therapists commit to developing an understanding of frailty, so their role in early detection, prevention and management can be established and optimised. This study aimed to explore occupational therapists’ perceptions and experiences of addressing frailty in Irish practice.

Defining frailty

In recent years, research focusing on frailty has increased considerably, with three broad models of frailty in use. The Frailty Phenotype model defines frailty as a phenotype, consisting of only physical components including sarcopenia, gait impairments or weight loss (Fried et al., 2001). The Cumulative Deficit model views frailty as an accumulation of deficits, including psychological factors (Rockwood et al., 2005). The Integral Conceptual model views frailty from a bio–psycho–social perspective and defines frailty as losses of physical, psychological or social functioning, leading to increased risk of adverse outcomes (Gobbens et al., 2010). Despite differences in defining frailty, there is general agreement that frailty is complex and a comprehensive, multidisciplinary approach is recommended (Coker et al., 2019; Hurst et al., 2021). Nonetheless, the absence of a universal definition may impede the efficient identification of frailty and subsequent treatment (Roland, et al., 2014).

Treating frailty

Central to successful frailty intervention is the accurate and early screening of the condition. Conflicting theoretical perspectives on how frailty develops and presents have resulted in two distinct categories of frailty screens: frailty phenotype instruments (Fried et al., 2001) and frailty index instruments (Rockwood et al., 2005). According to Fried et al. (2001), losses in body weight, energy, physical activity, grip strength and walking speed should be measured using self-report and performance-based measures to diagnose the syndrome. Meanwhile, Rockwood et al. (2005) proposed frailty tools based on markers such as loss of independence, incontinence and cognitive decline. Because of frailty’s multiple complexities, a combination of assessments should be used (Walston et al., 2018) and a comprehensive, multidisciplinary treatment approach is recommended (Coker et al., 2019; Hurst et al., 2021). Although research is limited, occupational therapy interventions including rehabilitation, education, environmental modification and provision of adaptive equipment offer potential in reducing the disability process associated with frailty and improving functional ability, mobility, social participation and quality of life (De Coninck et al., 2017; De Vriendt et al., 2016; Fisher et al., 2007; Fritz et al., 2019; Gustafsson et al., 2013; Provencher et al., 2012).

Perceptions of frailty

Central to effective multidisciplinary treatment is a common understanding of frailty. Beyond debating models for describing frailty, Nicholson et al. (2017) believes that a broader conversation is needed driven by the accumulating evidence that older adults, HCP, and policymakers dislike the term “frailty”. Warmoth et al. (2016) found that individuals who could be categorised as frail using objective criteria actively refused self-identification as frail. Richardson et al. (2011) assert that HCPs and researchers must be cognisant of the unintended negative repercussions of frailty constructs, as the term is frequently associated with age-related stereotypes and negative psychological and social emotions such as dependency and fear (Age UK, British Geriatrics Society, 2015; Nicholson et al., 2017; Schoenborn et al., 2018).

Disparities in perceptions of frailty have a subsequent impact on provision of care (Walston et al., 2018). Furthermore, although frailty has become a key concept in Irish health care, little is known about occupational therapists’ perceptions of frailty. Thus, this study aimed to explore occupational therapists’ perceptions of frailty and how this influences their approaches to the assessment and management of older adults living with in Ireland.

Methodology

A qualitative descriptive approach (Sandelowski, 2000) was chosen to explore occupational therapists’ perceptions of frailty. Focus groups are effective in exploring opinions and experiences (Bryman, 2016) and were used to allow in-depth exploration of occupational therapist’s perceptions of frailty. Before commencement of this study, ethical approval was obtained from the university’s Social Research Ethics Committee (CT-SREC-2021-13). Consolidated criteria for reporting qualitative research (COREQ) guidance (Tong et al., 2007) was used to guide reporting (Online Supplemental file).

Purposive sampling was used to recruit occupational therapists practising in Ireland and working with older adults. The Association of Occupational Therapists of Ireland distributed study information via email to its membership. Written informed consent was obtained from individuals before their participation on the study. Demographic information regarding each participant’s background and experience was gathered.

Four online focus groups were conducted between February and March 2022 by the first and second authors. The focus groups used open-ended questions to facilitate a natural exploration into the perceptions of occupational therapists on frailty. A topic guide informed by the literature was used to structure discussions, which enabled researchers to fully address the research questions and ensured comparability between focus groups whilst concurrently encouraging participants to discuss individual concerns. Four to six occupational therapists took part in each group discussion, which lasted 45–65 min and was digitally recorded and transcribed verbatim. Data collection continued until saturation was achieved and little new material was generated.

Data were thematically analysed using Braun and Clarke’s (2021) six-step reflexive process. Data familiarisation was achieved by listening to recordings and reading the transcripts to gain an overview of the breadth of content. Preliminary codes were independently produced by the second and third authors and then discussed and compared by all authors. Additional codes were identified and examined in relation to each other. Debriefing between authors was conducted to discuss ambiguous statements and develop provisional themes. A narrative for each theme was written and themes were reviewed by all authors to ensure each theme was distinct. Within-interview member checking was used as participants were invited to summarise, clarify and verify points they discussed at the end of each focus group.

Findings

Study participants

Nineteen participants practising in hospital and community settings across seven different counties in Ireland participated in focus group discussions. Participants had an average of 6.7 years’ experience, with the majority having more than three years of experience working with older adults (63.16%, n = 19). Demographic and professional profiles are outlined in Table 1.

Three themes and six subthemes were identified following data analysis, as presented in Figure 1. Focus group excerpts are used to support the findings.

Theme 1: conceptualising frailty

Occupational therapists’ conceptualised frailty as a multidimensional condition. Participants discussed its impact on health and well-being and highlighted variance between HCPs’ and lay individuals’ understandings of frailty.

Multi-faceted condition

There was a general agreement among participants that frailty is complex and multi-faceted, encompassing numerous interlinked physical, psychological and social domains, thus requiring assessment of multiple factors including cognition, mobility, medication, falls and social participation. “Red flags” for frailty assessment included “being underweight […] limited social supports […] having a fall at home” (FG1P1). Participants stressed that the occupational therapy process cannot target one area alone, rather it requires “getting a general all-round sense of the patient” (FG4P5). At the core of clinician’s perspectives was a commonly held view that “a slight illness can really push somebody who's frail completely off” (FG1P2). Overall, frailty was considered to have “a big impact on the level of assistance someone would need” (FG1P3), ultimately placing one at risk of losing their independence. Indeed, participants associated frailty with poor health outcomes and described a vicious cycle with frailty posing a risk factor for comorbidities, whereas comorbidities are a risk factor for frailty.

Clinicians also recognised that frailty does not merely result in physical disabilities. The psychological impact of frailty on an individual was reported to be substantial, particularly in relation to loss of independence in activities of daily living (ADLs), which participants found typically affected older adult’s living with frailty self-esteem. Specific emphasis was placed on the need to consider the impact of the social domain on frailty, highlighting that:

If that frail older adult doesn’t have the social supports, it makes them even more vulnerable. (FG1P1)

Furthermore, participants highlighted the potentially protective factors of one’s social circumstances whereby physical and psychological frailty may be delayed if an individual lives in an environment that promotes social connections and facilitates opportunity for social engagement.

Misconceptions of frailty

It was evident throughout discussions that clinicians’ professional understanding of frailty was underpinned by clinical knowledge and expertise. However, the impact of socially constructed stereotypes was evident in their practice. Although they generally recognised that frailty is not an inevitable consequence of ageing, participants also related lay perceptions of frailty as a “kyphotic little person with a walking stick” (FG3P2). Despite participants feeling confident in their ability to separate lay and clinical understandings of frailty, they described how negative stereotypes of frailty lead to reticence in use of the term with older adults living with frailty and their families as “it feels like you’re calling them weak” (FG3P3). One clinician noted “I’ve never met anybody who has described themselves as frail” (FG4P1). It was largely felt that referring to someone as “frail” “would do more harm than good to the patients” (FG4P4), with participants noting that it would likely cause offence, provoke fear within a patient and may lead them to think “I’m frail, so I can’t do anything” (FG4P3).

Despite participants understanding that frailty is malleable, they reported that many older adults and their families do not recognise this as “there’s an outside context that paints a stereotype but that’s not a true reflection” (FG2P3). Many participants attributed patient and family member’s negative conceptions of frailty to media depictions of lonely, isolated and dependent individuals: “I think the media portray it as ‘once frail, always frail’” (FG3P4).

Furthermore, participants discussed how HCPs seem reluctant to challenge negative portrayals of older adults living with frailty, further fuelling the misconceptions of frailty. Participants acknowledged that if they are to use the term with patients and their families, it requires “educating them on what frail actually means” (FG4P2).

Theme 2: management of frailty

This theme examines the current assessment and management of frailty within Irish health-care services. Participants discussed commonly used assessments and interventions, as well as the importance of a multidisciplinary approach when working with an older adult living with frailty.

Assessment

Participants highlighted the importance of timely assessment:

“If it’s flagged early, we can improve the outcomes that this patient will have” (FG1P3). They reported that the Clinical Frailty Scale (CFS; Rockwood et al., 2005) is commonly used across settings to identify and assess frailty. In addition to the participants describing the CFS as “time-efficient”, “transferable” and “accepted by other healthcare professionals” (FG4P1), the scale was also reported to facilitate “a broader understanding” (FG1P3) of frailty among the MDT. Clinicians described a number of factors that can influence the scoring of the CFS and stressed the importance of gaining the “full picture” (FG2P6). In addition to standardised assessments, clinicians recommended the use of functional observations to facilitate more comprehensive frailty assessments:

People will often underreport just how they’re managing at home but when you physically get them up on their feet that’s when you get a clearer idea of what their frailty actually is. (FG2P4).

However, participants identified that it is typically not feasible in acute settings to carry out multiple frailty assessments due to resource and time constraints:

Everybody talks about the comprehensive geriatric assessments, but realistically, on an acute ward it’s not done to be honest. (FG1P1)

With this, participants highlighted the importance of a multidisciplinary approach to facilitate comprehensive, holistic assessments and that, ideally, functional frailty screening tools should be administered within the patient’s own home by community occupational therapists. Therefore, participants felt that onward referral to community services was critical.

Intervention

Participants stressed that a multidisciplinary approach to the management of frailty is paramount, resulting in improved patient outcomes, increased open communication among HCPs and reduced workload owing to fewer assessments being duplicated. Participants also stated that as occupational therapists “endeavour to be holistic” (FG4P1), they are well-placed to deliver interventions which would address multiple domains to those who are frail:

I’ve had conversations with consultants being like ‘the hip is okay’, but there’s a person attached to the hip and there’s a bit more that can be done for them. (FG2P1)

Clinicians noted that each “intervention is dependent on how frail the person is” (FG2P2). Typical intervention approaches reported by clinicians included education of patients and families in respect to both the condition and self-management strategies, onward referrals to community services, such as memory clinics, day-centres and respite care, and equipment provision which could make a “world of difference” (FG2P4).

Participants perceived “timely intervention” (FG1P4) as critical to reversing frailty and improving outcomes for the patient, with those working in acute settings also emphasising the importance of minimising the length of time a patient spends in hospital. Participants reported that supporting “positive risk-taking” (FG2P6) is central to enabling occupational participation of older adults living with frailty. Despite this, participants reported that HCPs often over-aid older adults living with frailty and prolong hospital admissions:

You see them in hospital and everyone’s natural instinct is to just kind of wrap all of this care around them […]. Which is actually the opposite of what we should be doing in order to try prevent the patient from deteriorating. (FG4P2)

Theme 3: advancing frailty practice

Participants identified the need to enhance the assessment and management of frailty within the Irish practice context, and this theme addresses the need for improvements to the education of undergraduate students and increased resourcing of health-care settings.

Education and training

Although participants recognised the “national drive” (FG2P5) regarding frailty research and education that has taken place in recent years, participants discussed the need for universities to include frailty education in undergraduate curricula:

I had no awareness of frailty when I was in college and learned all of it when I started working. (FG2P1)

Participants reported engaging in informal learning from social media platforms and podcasts and observing colleagues working with frail patients to educate themselves on frailty. Participants reported completing “The NFEP” training and organisation-based inter-disciplinary training as beneficial in developing their understanding and knowledge of frailty.

Shifting the focus of frailty services

Given the demographic changes in recent decades, participants viewed frailty as a pressing public health issue. It was widely felt among participants that a shift in focus in frailty services from acute care to primary care is required. While they supported the establishment of FIT services in emergency departments, they also recognised “in an ideal world, everybody talks about the comprehensive geriatric assessments, but realistically, on an acute ward it’s not done” (FG2P2). Participants reported that community and primary care services are best placed for the early identification of frailty and subsequent timely intervention. yet participants reported that primary care settings can be “disjointed” (FG3P4) and participants described waiting lists, inadequate staffing and resources as barriers to service provision: “When you’re referring people onto community services, they’re stretched, especially at the minute with staff shortages” (FG2P4). Participants highlighted that these inadequacies in health-care services have unfavourable ramifications such as increased disability, dependence, unnecessary or prolonged hospital admissions and long-term care admissions.

Discussion

This study aimed to explore occupational therapists’ perceptions of frailty and findings were consistent with recent research whereby occupational therapists view frailty as a dynamic, multidimensional condition that is impacted by physical, psychological and social domains (Coker et al., 2019). Participants also associated increased vulnerability with frailty, with older adults living with frailty perceived to be at a greater risk of disability and adverse outcomes. Similar to previous recommendations, occupational therapists advocated a multidisciplinary approach to manage the determinants, features and consequences of frailty (Coker et al., 2019; Hurst et al., 2021). Participants acknowledged the benefits of a collaborative approach among multidisciplinary colleagues such as improved patient outcomes and reduced workload. They also asserted that occupational therapists possess the skill set to provide person-centred care that takes into account the individual complexities of patients’ health within the context of their social environment. Participants placed particular emphasis on the centrality of the social domain to the frailty experience. Social components such as social isolation and loneliness have often been overlooked in definitions of frailty (Robbert J.J. Gobbens et al., 2010), yet they have proven to be important determinants when considering the future likelihood of frailty in older adults (Davies et al., 2021). Despite occupational therapists’ awareness of the need to consider the social aspect of frailty, participants reported that frailty assessments currently used in Irish practice primarily focus on the physical domain. This is consistent with research, which indicates that frailty assessments are often based solely on physical criteria (Sutton et al., 2016). Findings from our study support a need to move beyond considering frailty as a purely physical state, and yet indicates the need to strengthen our understanding of social frailty, the occupational consequences of this condition and impact of the social environment.

Despite widespread use of the term “frailty” in health care, it remains a complex concept with many meanings and interpretations and therefore poses communication challenges (Durepos et al., 2022; Lawless et al., 2020; Provencher et al., 2012). Occupational therapists in our study reported frequently using frailty terminology when communicating with other HCPs, citing enhanced communication and the development of positive working relationships as subsequent outcomes. However, recent literature reflects a discord between how frailty is conceptualised among HCPs and how older adults living with frailty view their own health state (Schoenborn et al., 2018). Participants cited this as a barrier to using frailty terminology, reporting seldom use of the term when communicating with patients and their families due to the stigmatised connotations that lay people associate with frailty. Participants supported claims that labelling someone as frail can lead to the stereotyping of an older adult as failing to age well (Durepos et al., 2022; Nicholson et al., 2017), which may be compounded by negative media portrayals. Participants reported that older adults did not identify with the term “frail”, similar to findings from Age UK (Age UK, British Geriatrics Society, 2015), who also found that older adults articulated their physical and mental well-being in terms of being able to complete everyday tasks independently. Occupational therapy could potentially offer an acceptable way of communicating frailty in clinical practice by framing frailty through an occupational lens and helping older adults identifying specific examples of living with frailty and subsequently encourage engagement with services.

A number of participants felt that positively framed frailty education and awareness could optimise identification and management. This corroborates recent findings by Blair (2023) which found that participating in occupational therapy-led community frailty education could influence older adults’ perceptions of frailty. In support of this, Cluley et al. (2022) suggested that frailty terminology can be used in a cautious and reflexive manner during discussions with patients. Durepos et al. (2022) suggested that clinicians should focus on person-first language and specific elements of frailty when discussing the condition with patients.

Training/education

Effective delivery of high-quality care and services to older adults living with frailty requires an in-depth understanding of the concept (Gee et al., 2019). However, findings from our study indicate that upon commencing employment, occupational therapists felt ill-equipped to deal with the complex needs of older adults living with frailty as they had not received any formal training in frailty during their undergraduate programmes. Similar to findings from a study by Avgerinou et al. (2021), participants attributed their knowledge and understanding of frailty to informal learning and clinical experience.

The need for continuing professional development training programmes for HCPs has been identified as crucial to increasing the uptake of assessment and management of frailty (Ruiz et al., 2020). The NFEP was established to prepare HCPs for a growing demand in older care skills (Lang et al., 2023). Although occupational therapists in our study provided positive feedback on the NFEP, they felt that it is imperative to incorporate frailty education into undergraduate curricula so that occupational therapists can be effective in the assessment, management and communication of frailty.

Strengths and limitations

Frailty is increasingly recognised as a significant public health challenge, and there is a growing body of research exploring how to operationalise, measure and manage frailty. This study provides novel information in relation to occupational therapists’ perceptions of frailty and is the first of its kind to be conducted in Ireland. Limitations of the study pertained to sample selection as participants were mainly from acute settings, with a lack of participants representing community settings. Findings may be transferable to many occupational therapists in Ireland; however, international applicability of the findings should be carefully considered, as this study demonstrated that frailty care is influenced by the availability of health-care resources and education.

Conclusion

In summary, this study provides valuable insights into the perceptions of frailty held by occupational therapists and indicates that such perceptions have an impact on the assessment and management of frailty across Irish health-care settings. Participants regarded occupational therapy as having an important role in the care of older adults living with frailty due to their holistic view and consideration of frailty extending beyond physical function. Notwithstanding occupational therapists’ collective perception of frailty as multidimensional, findings suggest a reluctance to use frailty terminology with patients, which may undermine care. Furthermore, while participants emphasised the importance of early intervention, they also highlighted a lack of resources, staffing and funding as barriers to effective community-based care. Finally, participants perceived the undergraduate education that they had received in relation to frailty to be inadequate, indicating a need for the development of undergraduate frailty education.

Figures

Figure 1

Themes

Table 1

Participant profile

Demographic information	Overall sample (n)	%
Total number of participants Female	19 19	100 100
Current position grade
Clinical specialist Senior grade Staff grade	3 6 10	15.79 31.58 52.63
Years of work experience
Less than 2 years 2–4 years 5–7 years 8–12 years 13–17 years 18+ Mean years’ experience	4 6 3 3 2 1 6.57 (SD: 6.38)	21.05 31.58 15.79 15.79 10.53 5.26
Highest level of education Completed
BSc PG Certificate  MSc	6 2 11	31.58 10.53 57.90
Client group currently working with
Older adults Persons with stroke Persons with dementia/cognitive impairments	15 3 1	78.95 15.79 5.26
Practice setting
Hospital-based (acute) Rehabilitation Community-based	14 4 1	73.68 21.05 5.26

Source:

Table created by authors

Supplementary material

The supplementary material for this article can be found online.