Care for frail older adults in the community: an integrative review

Gislaine Alves de Souza Karla Cristina Giacomin Josélia Oliveira Araújo Firmo About the authors

Abstract

Objective:

to identify scientific evidence regarding the care of frail older adults in the community, from the perspective of the older adults themselves.

Method:

a descriptive, integrative review study was performed. The search for articles was carried out in the Medline, Lilacs, Web of Science, Scopus and SciELO databases. The inclusion criteria were complete available articles; published between 2014 and 2019; written in Portuguese, English, Spanish or French; which had older adults as participants.

Results:

four categories of analysis emerged from the results: frailty from the perspective of frail older adults; priorities from the perspective of the older adults; the older adults’ perspectives on care by services; and interpersonal relationships in the care of frail older adults. The perception of the older adults has specific characteristics, has maintaining their independence as a focus of care, signals the need to maintain interpersonal relationships, improve communication, and for actions of health education and people-centered services.

Conclusion:

these points demand the attention of care providers and policy services to improve care delivery and provide actions that are welcomed by this public.

Keywords:
Health of the Aged; Frailty; Review Literature as Topic; Culturally competent Care; Perception; Frail Elderly

Resumo

Objetivo:

Investigar as evidências científicas a respeito do cuidado com a pessoa idosa frágil na comunidade, na percepção da pessoa idosa.

Método:

Estudo descritivo, do tipo revisão integrativa. A busca dos artigos foi realizada nas bases de dados da Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs), da Medical Literature Analysis and Retrieval System (Medline), Web of Science, Scopus e Scientific Electronic Library Online (SciELO). Os critérios de inclusão foram: artigos disponíveis completos e de acesso livre; publicados entre 2014 e 2019; escritos em língua portuguesa, inglesa, espanhola ou francesa; condizentes com o tema desta pesquisa.

Resultados:

Emergiram dos resultados quatro categorias de análise: a fragilidade na visão da pessoa idosa frágil; as prioridades na percepção da pessoa idosa; perspectivas das pessoas idosas acerca dos cuidados pelos serviços; as relações interpessoais no cuidado para pessoa idosa frágil. A percepção das pessoas idosas frágeis apresenta especificidades, tem como foco do cuidado a manutenção de sua independência, sinaliza para a necessidade de manutenção de relações interpessoais, melhora da comunicação das ações de educação em saúde e dos serviços que devem ser centrados nas pessoas.

Conclusão:

Evidenciam-se pontos que requerem atenção por parte dos serviços assistenciais e das estratégias políticas para melhorar a oferta de cuidados e para que as ações realizadas sejam acolhidas por esse público.

Palavras-chave:
Saúde do Idoso; Fragilidade; Literatura de Revisão como Assunto; Assistência à Saúde Culturalmente Competente; Percepção; Idoso Fragilizado

INTRODUCTION

The worldwide demographic phenomenon of population aging is a complex and heterogeneous process that, at an individual level, involves the interaction of multiple aspects11 Organização Mundial De Saúde. Resumo Relatório Mundial de envelhecimento e Saúde. Genebra: Suíça; 2015., including the possibility of aging with or without frailty22 D'Avanzo B, Shaw R, Riva S, Apostolo J, Bobrowich-Campos E, Kurpas D, et al. Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty: a meta-synthesis of qualitative evidence. PloS One. 2017;12(7): e0180127 [22 p.].

3 Lim WS, Wong SF, Leong I, Choo P, Pang WS. Forging a frailty-ready healthcare system to meet population ageing. Int J Environ Res Public Health. 2017;14(12):1-16.
-44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36.. Frailty is a polysemic, multidetermined and multidimensional concept33 Lim WS, Wong SF, Leong I, Choo P, Pang WS. Forging a frailty-ready healthcare system to meet population ageing. Int J Environ Res Public Health. 2017;14(12):1-16.

4 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36.
-55 Andrade AN, Fernandes MGM, Nóbrega MML, Garcia TR, Costa KNFM. Análise do conceito fragilidade em idosos. Texto & Contexto Enferm. 2012;21(4):748-56. related to increased susceptibility to unfavorable health outcomes: illness, functional decline, falls, hospitalization and mortality55 Andrade AN, Fernandes MGM, Nóbrega MML, Garcia TR, Costa KNFM. Análise do conceito fragilidade em idosos. Texto & Contexto Enferm. 2012;21(4):748-56.. In old age, biomedical knowledge assumes frailty to be a vulnerability to biopsychosocial and environmental stressors22 D'Avanzo B, Shaw R, Riva S, Apostolo J, Bobrowich-Campos E, Kurpas D, et al. Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty: a meta-synthesis of qualitative evidence. PloS One. 2017;12(7): e0180127 [22 p.].,33 Lim WS, Wong SF, Leong I, Choo P, Pang WS. Forging a frailty-ready healthcare system to meet population ageing. Int J Environ Res Public Health. 2017;14(12):1-16.,55 Andrade AN, Fernandes MGM, Nóbrega MML, Garcia TR, Costa KNFM. Análise do conceito fragilidade em idosos. Texto & Contexto Enferm. 2012;21(4):748-56., correlated with a decrease in functional reserve, limitations in activities of daily living, an increased need for care66 Hoogendijk EO, Muntinga ME, Leeuwen KM, Horst HE, Deeg DJ, Frijters DH, et al. Self-perceived met and unmet care needs of frail older adults in primary care. Arch Gerontol Geriatr. 2014;58:37-42., as well as lower satisfaction with health and quality of life44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36..

Frail older adults make up the majority of those in need of formal, informal and health service care2.7. Therefore, this syndrome is a public health concern, as it requires integrated care22 D'Avanzo B, Shaw R, Riva S, Apostolo J, Bobrowich-Campos E, Kurpas D, et al. Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty: a meta-synthesis of qualitative evidence. PloS One. 2017;12(7): e0180127 [22 p.]., and can be prevented and recoverable through appropriate interventions55 Andrade AN, Fernandes MGM, Nóbrega MML, Garcia TR, Costa KNFM. Análise do conceito fragilidade em idosos. Texto & Contexto Enferm. 2012;21(4):748-56.. Care is a human condition that depends on the point of view of the individual receiving it88 Ayres JRCM. Cuidado: trabalho e interação nas práticas de saúde. Rio de Janeiro: CEPESC; 2009.,99 Pinheiro RM, Mattos R, organizadores. Razões públicas para a integralidade em saúde: o cuidado como valor. Rio de Janeiro: IMS/UERJ; 2007. Furthermore, care models centered on acute treatment are inadequate for the frail older population, as they usually disregard the specific configurations of this phenomenon in the community, its support systems and the individual involved33 Lim WS, Wong SF, Leong I, Choo P, Pang WS. Forging a frailty-ready healthcare system to meet population ageing. Int J Environ Res Public Health. 2017;14(12):1-16..

In addition, studies on this topic focus mainly on the association between the frailty syndrome and adverse outcomes1010 Dury S, Dierckk E, Vorst A, Elst M, Fret B, Duppen D, et al. Detecting frail, older adults and identifying their strengths: results of a mixed-methods study. BMC Public Health. 2018;18(1):1-13.. Studies on the experience of frail older adults are rare and limited44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36.,1111 Warmoth K, Lang I, Phoenix C, Abraham C, Andrew M, Hubbard RE, et al. 'Thinking you're old and frail': a qualitative study of frailty in older adults. Ageing Soc. 2016;36:1483-1500.,1212 Archibald MM, Ambagtsheer R, Beilby J, Chehade MJ, Gill TK, Visvanathan R, et al. Perspectives of failty and frailty screening: protocol for a collaborative knowledge translation approach and qualitative study of stakeholder understandings and experiences. BMC Geriatr. 2017;17(87):1-8., from the perspective of the population receiving care88 Ayres JRCM. Cuidado: trabalho e interação nas práticas de saúde. Rio de Janeiro: CEPESC; 2009. and at the community level1313 Gutierrez DMD, Minayo MCS. Produção de conhecimento sobre cuidados da saúde no âmbito da família. Ciênc Saúde Colet. 2010;15(Suppl 1):1497-1508.. Thus, while fundamental, the perspective of frail older adults is relatively unknown1414 Claassens L, Widdershoven GA, van Rhijn SC, van Nes F, van Groenou MIB, Deeg DJ, et al. Perceived control in health care: a conceptual model based on experiences of frail older adults. J Aging Stud. 2014;31:159-70.. Research that considers the opinions, values, attitudes, understandings, and coping strategies of frail older adults in planning and defining resources, care and interventions in the context of frailty22 D'Avanzo B, Shaw R, Riva S, Apostolo J, Bobrowich-Campos E, Kurpas D, et al. Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty: a meta-synthesis of qualitative evidence. PloS One. 2017;12(7): e0180127 [22 p.].,44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36.,77 Berglund H, Hasson H, Kjellgren K, Wilhelmson K. Effects of a continuum of care intervention on frail older persons' life satisfaction: a randomized controlled study. J Clin Nurs. 2015;24(7-8):1079-90.,1515 Shaw RL, Gwyther H, Holland C, Bujnowska M, Kurpas D, Cano A, et al. Understanding frailty: meanings and beliefs about screening and prevention across key stakeholder groups in Europe. Ageing Soc. 2017:1-30. are relevant to improving care and health care, and to adapting services and policies to the demands of this public5.16 to help achieve integrated care9.16.17. Thus, the experience of frail older adults in care is of vital importance to improvements in care1818 Walker R, Johns J, Halliday D. How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery. Health Soc Care Community. 2015;23(2):216-24..

Therefore, the present study seeks to identify the scientific evidence regarding care for the frail older person in the community, through the perception of older adults via an integrative review. The article aims to contribute to the synthesizing of evidence1919 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64. and improving the care of this population2020 Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546-53.,2121 Stetler CB, Morsi D, Rucki S, Broughton S, Corrigan B, Fitzgerald J, et al. Utilization focused integrative reviews in a nursing service. Appl Nurs Res. 1998;11(4):195-206..

METHOD

To obtain a synthesis of current literature, an integrative review was carried out. This method, performed in a systematic, orderly and evidence-based manner, allows the combination of several theoretical and empirical methodologies (experimental and non-experimental) regarding a particular phenomenon. It starts with a guiding question, used to obtain a comprehensive and relevant picture of health care1919 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64.

20 Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546-53.
-2121 Stetler CB, Morsi D, Rucki S, Broughton S, Corrigan B, Fitzgerald J, et al. Utilization focused integrative reviews in a nursing service. Appl Nurs Res. 1998;11(4):195-206.. This integrative review was based on the following steps: identification of the study problem; establishment of the literature search strategy; study selection based on inclusion and exclusion criteria; critical reading; content evaluation and categorization; analysis and interpretation of results; and presentation of the review19.20.

The guiding question was: what scientific evidence is there about the care process for frail older adults in the community, from the view of such individuals? The Medline, Lilacs, Web of Science, Scopus and SciELO databases were searched. The terms were matched with the use of the Boolean operator “and”: frail elderly, standard of care, culturally competent care, care; elderly, care, frailty; older adults, care, frailty; frail older people, care; frailty, old, care. It was decided to keep the descriptors and keywords relevant to approximate the search to the researched subject. The perception of frail older adults living in the community about care was surveyed from reading the abstracts. The survey, carried out by three researchers, was performed in October and November 2018 and updated in December 2019.

Inclusion criteria were: full and freely available articles; publications from 2014 to 2019; works in Portuguese, English, French or Spanish. The flowchart of the article selection steps is shown in Figure 1.

Figure 1
Flowchart of article selection based on the Prisma model. Belo Horizonte, Minas Gerais, Brazil.

In the screening, carried out by two researchers, articles that dealt with: validation of instruments and protocols; prevalence, interventions/programs and costs assessment; care models; association of frailty with specific symptoms and studies that dealt with the perception of the hospitalized or institutionalized older person. Those that included other participants, but where it was possible to distinguish the perception of older adults person in the community, were considered.

The selected articles were classified according to the levels of scientific evidence as proposed by Stetler et al.2121 Stetler CB, Morsi D, Rucki S, Broughton S, Corrigan B, Fitzgerald J, et al. Utilization focused integrative reviews in a nursing service. Appl Nurs Res. 1998;11(4):195-206., which comprise: level I - meta-analysis of multiple controlled studies; level II - individual experimental studies; level III - quasi-experimental studies; level IV - non-experimental studies such as descriptive correlational research, qualitative studies or case studies; level V - case reports and level VI - opinion of recognized experts.

The articles were categorized by compiling: title; authors; year; periodical; country; language; method; sample; data collection and analysis procedure; key words; objectives; recommendations; limitations and the view of older people on care for frail older adults living in the community.

RESULTS

After reading the 3,556 abstracts, 110 articles were selected. After excluding the duplicate articles found by the different search strategies, 78 articles were found, which were read in full. Of these, 28 were incorporated into this review. The selected articles were all written in English (n=28); mainly from Europe (n=25). Fourteen articles exclusively studied the perception of older adults, and 15 publications included other participants.

Regarding the measurement of frailty, five articles used the Clinical Frailty Scale1111 Warmoth K, Lang I, Phoenix C, Abraham C, Andrew M, Hubbard RE, et al. 'Thinking you're old and frail': a qualitative study of frailty in older adults. Ageing Soc. 2016;36:1483-1500.,1515 Shaw RL, Gwyther H, Holland C, Bujnowska M, Kurpas D, Cano A, et al. Understanding frailty: meanings and beliefs about screening and prevention across key stakeholder groups in Europe. Ageing Soc. 2017:1-30.,2222 Etkind SN, Lovell N, Nicholson CJ, Higginson IJ, Murtagh FEM. Finding a 'new normal' following acute illness: a qualitative study of influences on frail older people's care preferences. Palliat Med. 2019;33(3):301-11.

23 Avgerinou C, Gardner B, Kharicha K, Frost R, Liljas A, Elaswarapu R, et al. Health promotion for mild frailty based on behaviour change: perceptions of older people and service providers. Health Soc Care Community. 2019;27:1333-43.
-2424 Frost R, Kharicha K, Jovicic A, Liljas A, Iliffe S, Manthorpe J, et al. Identifying acceptable components for home-based health promotion services for older people with mild frailty: A qualitative study. Health Soc Care Community. 2018;26:393-403., four used the Frailty Phenotype1414 Claassens L, Widdershoven GA, van Rhijn SC, van Nes F, van Groenou MIB, Deeg DJ, et al. Perceived control in health care: a conceptual model based on experiences of frail older adults. J Aging Stud. 2014;31:159-70.,2323 Avgerinou C, Gardner B, Kharicha K, Frost R, Liljas A, Elaswarapu R, et al. Health promotion for mild frailty based on behaviour change: perceptions of older people and service providers. Health Soc Care Community. 2019;27:1333-43.,2525 Schoenborn NL, Rasmussen SEVP, Xue Q, Walston JD, McAdams-Demarco MA, Segev DL, et al. Older adults' perceptions and informational needs regarding frailty. BMC Geriatr. 2018;18:1-7.,2626 Sjöberg M, Edberg A, Rasmussen BH, Beck I. Being acknowledged by others and bracketing negative thoughts and feelings: Frail older people's narrations of how existential loneliness is eased. Int J Older People Nurs. 2019;14: e12213 [9 p.]., three used the Tilburg Frailty Indicator2727 Vestjens L, Cramm JM, Nieboer AP. Quality of primary care delivery and productive interactions among community living frail older persons and their general practitioners and practice nurses. BMC Health Serv Res. 2019;19(1)1-12.

28 Verver D, Merten H, Robben P, Wagner C. Perspectives on the risks for older adults living independently. Br J Community Nurs. 2017;22(7): 338-45.
-2929 Andreasen J, Lund H, Aadahl M, Sorensen E. The experience of daily life of acutely admitted frail elderly patients one week after discharge from the hospital. Int J Qual Stud Health Well-being. 2015;10:1-11., two used the Comprehensive Frailty Assessment Instrument10.30, five defined frailty without an instrument or objective measurement4.14.31-33, one article used Prisma-766 Hoogendijk EO, Muntinga ME, Leeuwen KM, Horst HE, Deeg DJ, Frijters DH, et al. Self-perceived met and unmet care needs of frail older adults in primary care. Arch Gerontol Geriatr. 2014;58:37-42. and one the Edmonton Frailty Scale3434 Abreu W, Tolson D, Jackson GA, Staines H, Costa N. The relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia. Health Soc Care Community 2019;27:642-53.. Of these, in two articles1414 Claassens L, Widdershoven GA, van Rhijn SC, van Nes F, van Groenou MIB, Deeg DJ, et al. Perceived control in health care: a conceptual model based on experiences of frail older adults. J Aging Stud. 2014;31:159-70.,2323 Avgerinou C, Gardner B, Kharicha K, Frost R, Liljas A, Elaswarapu R, et al. Health promotion for mild frailty based on behaviour change: perceptions of older people and service providers. Health Soc Care Community. 2019;27:1333-43. there was the combination of more than one instrument. In nine articles, the measurement of frailty was not explicit18.35-42.

The evaluated articles predominantly had an evidence level of IV (27 articles), being qualitative, descriptive and cross-sectional studies, and one article corresponded to level III, quasi-experimental. Thus, the evidence level of the articles incorporated in this review is considered reasonable. Among the selected articles, 75% (n=21) used qualitative methodologies, listed in Chart 1. Of these, 90.48% used an interview as an instrument for data collection; one article used observational data and seven used a focus group. Explicitly thematic analysis and category coding was the most recurrent type of analysis (n=12), and the Nvivo (n=7) software package was the most used in these qualitative analyzes, followed by Atlas Ti (n=3).

Chart 1
Qualitative articles analyzed, 2014-2019. Belo Horizonte, Minas Gerais, 2019.

The use of quantitative methodologies represented 17.86% (n=5) of the articles, as summarized in Chart 2. In general, the authors of these articles used questionnaires, health screening instruments and scales to collect data. Four studies were cross-sectional and one quasi-experimental. The SPSS software package was the statistical analysis tool mentioned in all the studies analyzed.

Chart 2
Qualitative articles analyzed, 2014-2019. Belo Horizonte, Minas Gerais, 2019.

Of the quantitative-qualitative articles (n=2), one collected data on the association of interviews and health screening instruments and one used a semi-structured questionnaire, listed in Chart 3.

Chart 3
Quantitative-qualitative articles analyzed, 2014-2019. Belo Horizonte, Minas Gerais, 2019.

DISCUSSION

In response to the guiding question: “what scientific evidence is there about the care process for frail older adults in the community, from the view of such individuals”, it was noted that the literature covers different areas and dimensions of care. Self-, family, community, social and intersectoral care is addressed. The results were organized into four categories of analysis: frailty from the perception of the frail older person; priorities from the perception of older adults; perspectives of older adults regarding care services; interpersonal relationships in care for frail older adults.

Frailty from the perception of the frail older person

This category addresses how older adults perceive frailty. The older adults’ view of frailty is recurrent as a negative, harmful, rejected and associated label, with worsening health conditions, reduced participation and increased stigmatization1111 Warmoth K, Lang I, Phoenix C, Abraham C, Andrew M, Hubbard RE, et al. 'Thinking you're old and frail': a qualitative study of frailty in older adults. Ageing Soc. 2016;36:1483-1500.,1515 Shaw RL, Gwyther H, Holland C, Bujnowska M, Kurpas D, Cano A, et al. Understanding frailty: meanings and beliefs about screening and prevention across key stakeholder groups in Europe. Ageing Soc. 2017:1-30.,2525 Schoenborn NL, Rasmussen SEVP, Xue Q, Walston JD, McAdams-Demarco MA, Segev DL, et al. Older adults' perceptions and informational needs regarding frailty. BMC Geriatr. 2018;18:1-7.,3232 Bujnowska-Fedak MM, Gwyther H, Szwamel K, D'Avanzo B, Holland C, Shaw RL, et al. A qualitative study examining everyday frailty management strategies adopted by Polish stakeholders. Eur J Gen Pract. 2019;25(4):197-204.. A qualitative study on the perception and attitude of older adults towards frailty identified a discrepancy between operationalization in clinical contexts and the understanding of older adults1111 Warmoth K, Lang I, Phoenix C, Abraham C, Andrew M, Hubbard RE, et al. 'Thinking you're old and frail': a qualitative study of frailty in older adults. Ageing Soc. 2016;36:1483-1500.. Older adults did not identify themselves as frail even when they met the objective diagnostic criteria, and this classification did not always coincide with a feeling of frailty1111 Warmoth K, Lang I, Phoenix C, Abraham C, Andrew M, Hubbard RE, et al. 'Thinking you're old and frail': a qualitative study of frailty in older adults. Ageing Soc. 2016;36:1483-1500.. For older adults, frailty was identified based on health levels and participation in physical and social activities, resulting from isolated events, temporary disabilities, old age and physical limitations1111 Warmoth K, Lang I, Phoenix C, Abraham C, Andrew M, Hubbard RE, et al. 'Thinking you're old and frail': a qualitative study of frailty in older adults. Ageing Soc. 2016;36:1483-1500..

Frailty was described as a negative physical and psychological condition, close to disability, and reflective of common stereotypes of old age1111 Warmoth K, Lang I, Phoenix C, Abraham C, Andrew M, Hubbard RE, et al. 'Thinking you're old and frail': a qualitative study of frailty in older adults. Ageing Soc. 2016;36:1483-1500.. For many older adults, frailty was inevitable, permanent and irreversible due to aging, and composed not only of physical elements proposed in the phenotypic definition, but also mental and psychological aspects2525 Schoenborn NL, Rasmussen SEVP, Xue Q, Walston JD, McAdams-Demarco MA, Segev DL, et al. Older adults' perceptions and informational needs regarding frailty. BMC Geriatr. 2018;18:1-7.. Thus, for older adults, changes in health could be the cause or result of self-identification as frail, so that the diagnosis was not only information, but also a determinant for their health1111 Warmoth K, Lang I, Phoenix C, Abraham C, Andrew M, Hubbard RE, et al. 'Thinking you're old and frail': a qualitative study of frailty in older adults. Ageing Soc. 2016;36:1483-1500.. The most frail participants accepted the diagnosis more easily, as they lived with more symptoms than less frail individuals2525 Schoenborn NL, Rasmussen SEVP, Xue Q, Walston JD, McAdams-Demarco MA, Segev DL, et al. Older adults' perceptions and informational needs regarding frailty. BMC Geriatr. 2018;18:1-7.. Even among frail older adults, there is a preference not to use the term to describe their health condition, so programs should innovate to find a form of communication that is acceptable2525 Schoenborn NL, Rasmussen SEVP, Xue Q, Walston JD, McAdams-Demarco MA, Segev DL, et al. Older adults' perceptions and informational needs regarding frailty. BMC Geriatr. 2018;18:1-7. and pay attention to the negative effects of the label of frail for this population1515 Shaw RL, Gwyther H, Holland C, Bujnowska M, Kurpas D, Cano A, et al. Understanding frailty: meanings and beliefs about screening and prevention across key stakeholder groups in Europe. Ageing Soc. 2017:1-30..

It was also found in literature44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36.,55 Andrade AN, Fernandes MGM, Nóbrega MML, Garcia TR, Costa KNFM. Análise do conceito fragilidade em idosos. Texto & Contexto Enferm. 2012;21(4):748-56.,1515 Shaw RL, Gwyther H, Holland C, Bujnowska M, Kurpas D, Cano A, et al. Understanding frailty: meanings and beliefs about screening and prevention across key stakeholder groups in Europe. Ageing Soc. 2017:1-30. that the malleability of frailty is little known among older adults, requiring health education to raise awareness of the reversibility of frailty and modify health behaviors. Older adults, who live in deprived neighborhoods, seemed to be resourceful when dealing with adversities, and were happy with their abilities. This behavior, for the authors, could mask deficits in knowledge, revealing the potential of health education to tackle the difficulties related to aging44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36..

Another study addresses the understanding of frailty by older adults as a dynamic state that combines factors of balance within the scope of the individual, the environment and macrosocial factors, which influence the maintenance of a good quality of life1010 Dury S, Dierckk E, Vorst A, Elst M, Fret B, Duppen D, et al. Detecting frail, older adults and identifying their strengths: results of a mixed-methods study. BMC Public Health. 2018;18(1):1-13.. Therefore, control in the area of health is multidimensional, and external factors are just as important as the active attitudes and cognitive processes used by the subjects themselves1414 Claassens L, Widdershoven GA, van Rhijn SC, van Nes F, van Groenou MIB, Deeg DJ, et al. Perceived control in health care: a conceptual model based on experiences of frail older adults. J Aging Stud. 2014;31:159-70.. In contrast, there are also reports that being frail can facilitate obtaining assistance, care, support and benefits from others, and may function as a means to seeking improvements in care and services1111 Warmoth K, Lang I, Phoenix C, Abraham C, Andrew M, Hubbard RE, et al. 'Thinking you're old and frail': a qualitative study of frailty in older adults. Ageing Soc. 2016;36:1483-1500..

Priorities from the perception of older adults

Identifying evidence of the priorities perceived by older adults is important2828 Verver D, Merten H, Robben P, Wagner C. Perspectives on the risks for older adults living independently. Br J Community Nurs. 2017;22(7): 338-45.. This category shows the interest of frail older adults in remaining at home2828 Verver D, Merten H, Robben P, Wagner C. Perspectives on the risks for older adults living independently. Br J Community Nurs. 2017;22(7): 338-45. and as independent as possible, with autonomy, quality of life and the ability to deal with daily activities2323 Avgerinou C, Gardner B, Kharicha K, Frost R, Liljas A, Elaswarapu R, et al. Health promotion for mild frailty based on behaviour change: perceptions of older people and service providers. Health Soc Care Community. 2019;27:1333-43.,2828 Verver D, Merten H, Robben P, Wagner C. Perspectives on the risks for older adults living independently. Br J Community Nurs. 2017;22(7): 338-45.. From the perspective of older adults, declining physical health is revealed as an accepted aspect of the aging process2828 Verver D, Merten H, Robben P, Wagner C. Perspectives on the risks for older adults living independently. Br J Community Nurs. 2017;22(7): 338-45.,4040 Bielderman A, Schout G, Greef M, Schans C. Understanding how older adults living in deprived neighbourhoods address ageing issues. Br J Community Nurs. 2015;20(8):394-9., with the condition of remaining independent and not disturbing others2828 Verver D, Merten H, Robben P, Wagner C. Perspectives on the risks for older adults living independently. Br J Community Nurs. 2017;22(7): 338-45.. Preserving their capacity for self-care, remaining active social networks, not feeling lonely, manifesting fewer symptoms, as well as maintaining their autonomy, participation in the community and accessing essential services, are listed as priorities44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36.,1010 Dury S, Dierckk E, Vorst A, Elst M, Fret B, Duppen D, et al. Detecting frail, older adults and identifying their strengths: results of a mixed-methods study. BMC Public Health. 2018;18(1):1-13.,2828 Verver D, Merten H, Robben P, Wagner C. Perspectives on the risks for older adults living independently. Br J Community Nurs. 2017;22(7): 338-45..

Even the most frail older adults display engagement in daily activities as a subsidy for building resilience against frailty3232 Bujnowska-Fedak MM, Gwyther H, Szwamel K, D'Avanzo B, Holland C, Shaw RL, et al. A qualitative study examining everyday frailty management strategies adopted by Polish stakeholders. Eur J Gen Pract. 2019;25(4):197-204.. The perspective of frail older adults also demonstrates the experience of anxiety, insecurity, uncertainty and fear regarding frailty, when daily life becomes precarious and challenging1818 Walker R, Johns J, Halliday D. How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery. Health Soc Care Community. 2015;23(2):216-24.,3838 Skilbeck JK, Arthur A, Seymour J. Making sense of frailty: an ethnographic study of the experience of older people living with complex health problems. Int J Older People Nurs. 2018;13(1):e12172 [11 p.].. Thus, the sense of control is reduced, and individuals seek support to adapt to their new levels of frailty1818 Walker R, Johns J, Halliday D. How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery. Health Soc Care Community. 2015;23(2):216-24., to maintain their independence and the continuance of their personality3838 Skilbeck JK, Arthur A, Seymour J. Making sense of frailty: an ethnographic study of the experience of older people living with complex health problems. Int J Older People Nurs. 2018;13(1):e12172 [11 p.]..

Studies have shown that many frail older adults are reluctant to ask for help or support from their social network for fear of disturbing others or concluding that receiving help is impossible2828 Verver D, Merten H, Robben P, Wagner C. Perspectives on the risks for older adults living independently. Br J Community Nurs. 2017;22(7): 338-45.. After experiencing an acute illness, the desire remains to remain independent, to ‘return to normal’ and, if necessary, to find one’s new normal according to preferences in one’s own social context2222 Etkind SN, Lovell N, Nicholson CJ, Higginson IJ, Murtagh FEM. Finding a 'new normal' following acute illness: a qualitative study of influences on frail older people's care preferences. Palliat Med. 2019;33(3):301-11..

From this perspective, priorities from the perspective of the frail older person are not only medical problems, but also include factors that support the maintenance of the ability to take care of oneself44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36.,3838 Skilbeck JK, Arthur A, Seymour J. Making sense of frailty: an ethnographic study of the experience of older people living with complex health problems. Int J Older People Nurs. 2018;13(1):e12172 [11 p.].. Through a logistic regression, in the bivariate analysis, frail older adults who were satisfied with their ability to take care of themselves were about eight times more likely to rate their health as good than those who were not satisfied with their ability to care for themselves44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36..

Among the factors that modulate the perception of control of health care among older adults, the following stand out: self-confidence in the organization of professional and/or informal care and in health management in the home environment; the clarity of the care available; as well as the perceived support of the individual’s social network, health professionals, health organizations, infrastructure and services1414 Claassens L, Widdershoven GA, van Rhijn SC, van Nes F, van Groenou MIB, Deeg DJ, et al. Perceived control in health care: a conceptual model based on experiences of frail older adults. J Aging Stud. 2014;31:159-70.. In contrast, a lack of interest in self-care can be a consequence of the loss of skills, causing expectations to be lowered in this area1414 Claassens L, Widdershoven GA, van Rhijn SC, van Nes F, van Groenou MIB, Deeg DJ, et al. Perceived control in health care: a conceptual model based on experiences of frail older adults. J Aging Stud. 2014;31:159-70.. The perception of impaired independence is associated with the clarification of its different dimensions: relative, special and social4242 Hillcoat-Nallétamby S. The meaning of "independence" for older people in different residential settings. J Gerontol Ser B Psychol Sci Soc Sci. 2014;69(3):419-30..

Perspectives of older adults regarding care services

From the perspectives of frail older adults living in the community, important points can be made about the care provided by health services, indicating the need for more heterogeneous responses1818 Walker R, Johns J, Halliday D. How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery. Health Soc Care Community. 2015;23(2):216-24.. The articles reviewed highlight the focus on the independence of the frail older person, person-centered care and personalized assistance on topics important to the daily life of each individual to maintain their autonomy, despite their disabilities1515 Shaw RL, Gwyther H, Holland C, Bujnowska M, Kurpas D, Cano A, et al. Understanding frailty: meanings and beliefs about screening and prevention across key stakeholder groups in Europe. Ageing Soc. 2017:1-30.,1818 Walker R, Johns J, Halliday D. How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery. Health Soc Care Community. 2015;23(2):216-24.,2424 Frost R, Kharicha K, Jovicic A, Liljas A, Iliffe S, Manthorpe J, et al. Identifying acceptable components for home-based health promotion services for older people with mild frailty: A qualitative study. Health Soc Care Community. 2018;26:393-403.,3838 Skilbeck JK, Arthur A, Seymour J. Making sense of frailty: an ethnographic study of the experience of older people living with complex health problems. Int J Older People Nurs. 2018;13(1):e12172 [11 p.].. The integration of services to minimize fragmentation in the provision of services, improve communication, socialization and mobility are necessary1515 Shaw RL, Gwyther H, Holland C, Bujnowska M, Kurpas D, Cano A, et al. Understanding frailty: meanings and beliefs about screening and prevention across key stakeholder groups in Europe. Ageing Soc. 2017:1-30.,1818 Walker R, Johns J, Halliday D. How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery. Health Soc Care Community. 2015;23(2):216-24.,2424 Frost R, Kharicha K, Jovicic A, Liljas A, Iliffe S, Manthorpe J, et al. Identifying acceptable components for home-based health promotion services for older people with mild frailty: A qualitative study. Health Soc Care Community. 2018;26:393-403.,3434 Abreu W, Tolson D, Jackson GA, Staines H, Costa N. The relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia. Health Soc Care Community 2019;27:642-53.. Emotional aspects to produce comfort and well-being; the adoption of psychosocial and spiritual approaches; and the assessment of care needs and comprehensive geriatric assessments are also essential3434 Abreu W, Tolson D, Jackson GA, Staines H, Costa N. The relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia. Health Soc Care Community 2019;27:642-53..

The multidimensional concept of frailty requires that the subjective perspectives of older adults be considered. One article highlights the salutogenic approach in care planning as beneficial to frail older adults, based on the narratives of this population group about their daily life, in order to support the individual in their living context, allowing them to remain in their social network and to maintain satisfaction with their ability to manage everyday life44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36..

Frail older adults need a wide range of services over a long period of time due to the complex health situation and changes they experience3636 Kurpas D, Gwyther H, Szwarnel K, Shaw RL, D'Avanzo B, Holland CA, et al. Patient-centred access to health care: a framework analysis of the care interface for frail older adults. BMC Geriatr. 2018;18:1-17.. In Poland, the perspective of frail older adults revealed the inadequacy of services for the needs of this population. Among the difficulties encountered when accessing health and social care were: the lack of knowledge about the existence of some services; shortages in the provision of care, lengthy waiting times and the geographical location of the services; the lack of an adequate and trained professional in the area of older adult health, the low operational level for the most vulnerable people, among others3636 Kurpas D, Gwyther H, Szwarnel K, Shaw RL, D'Avanzo B, Holland CA, et al. Patient-centred access to health care: a framework analysis of the care interface for frail older adults. BMC Geriatr. 2018;18:1-17..

The screening of frail older patients by health services must be accompanied by support interventions for older adults and their caregivers1515 Shaw RL, Gwyther H, Holland C, Bujnowska M, Kurpas D, Cano A, et al. Understanding frailty: meanings and beliefs about screening and prevention across key stakeholder groups in Europe. Ageing Soc. 2017:1-30.. In primary care, studies have shown the need to invest in the interaction between patients and professionals to improve the quality of care2727 Vestjens L, Cramm JM, Nieboer AP. Quality of primary care delivery and productive interactions among community living frail older persons and their general practitioners and practice nurses. BMC Health Serv Res. 2019;19(1)1-12.. In this context, the perception of the demand for care provides important information about the real care needs of frail older adults - however, more attention is often paid to physical and environmental issues than those in the psychosocial domain66 Hoogendijk EO, Muntinga ME, Leeuwen KM, Horst HE, Deeg DJ, Frijters DH, et al. Self-perceived met and unmet care needs of frail older adults in primary care. Arch Gerontol Geriatr. 2014;58:37-42.. In the United Kingdom, older people evaluated the care received positively, affirmed their confidence in and the continuity of health care to avoid unplanned hospitalization by including medication, physical aids, adaptations to the home, the adoption of a healthy lifestyle and psychosocial practices3535 Dew R, Wilkes S. Attitudes, perceptions, and behaviours associated with hospital admission avoidance: a qualitative study of high-risk patients in primary care. Br J Gen Pract. 2018:460-8..

Scientific evidence suggests that interventions should focus on the multidimensional perspectives of frail older adults discharged from hospital, be cautious during transition care and reorganize the integration between the primary and secondary care sectors2929 Andreasen J, Lund H, Aadahl M, Sorensen E. The experience of daily life of acutely admitted frail elderly patients one week after discharge from the hospital. Int J Qual Stud Health Well-being. 2015;10:1-11.. The involvement of the frail older person in their care, in decision making, in the transition of care from the hospital to the home requires improving communication and information2929 Andreasen J, Lund H, Aadahl M, Sorensen E. The experience of daily life of acutely admitted frail elderly patients one week after discharge from the hospital. Int J Qual Stud Health Well-being. 2015;10:1-11.. For patients, the type and amount of help, access to and administration of medications, failures in communication, fear of being sick alone and concerns about activities of daily living are relevant2929 Andreasen J, Lund H, Aadahl M, Sorensen E. The experience of daily life of acutely admitted frail elderly patients one week after discharge from the hospital. Int J Qual Stud Health Well-being. 2015;10:1-11.. In transition care, the desire also emerges that the care is individualized, integrated, centered on the needs of the client, with the patient’s involvement in decision-making so that they feel supported when dealing with increased levels of frailty1818 Walker R, Johns J, Halliday D. How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery. Health Soc Care Community. 2015;23(2):216-24.. Conversely, it can be seen that the transition of care can be impaired due to fragmentation in the provision of services, the loss of control over the process in a scenario of reduced functionality, adaptation and uncertainties surrounding future support1818 Walker R, Johns J, Halliday D. How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery. Health Soc Care Community. 2015;23(2):216-24..

For frail older adults, satisfaction with the ability to take care of oneself, having ten or less symptoms and not feeling lonely, had the best explanatory power for the frail experiences of older adults in good health due to the possibility of managing and maintaining their daily lives.44 Ebrahimi Z, Dahlin-Ivanoof S, Eklund K, Jakobsson A, Wilherlmson K. Self-rated health and health-strengthening factors in community-living frail older people. J Adv Nurs. 2015;71(4):825-36.. Frail older adults with more limitations report more need of care, whether received or not received, in all domains. One study found that a younger age and a higher educational level were associated with the presence of unmet needs, a presumed cohort effect as this population is likely to have a higher expectation of health services66 Hoogendijk EO, Muntinga ME, Leeuwen KM, Horst HE, Deeg DJ, Frijters DH, et al. Self-perceived met and unmet care needs of frail older adults in primary care. Arch Gerontol Geriatr. 2014;58:37-42..

Interpersonal relationships in care for frail older adults

This category introduces the various relational aspects that modulate the care of the frail older person in the community. Interpersonal relationships, social contact, intervention in community contexts were particularly valued by this group1414 Claassens L, Widdershoven GA, van Rhijn SC, van Nes F, van Groenou MIB, Deeg DJ, et al. Perceived control in health care: a conceptual model based on experiences of frail older adults. J Aging Stud. 2014;31:159-70.,2323 Avgerinou C, Gardner B, Kharicha K, Frost R, Liljas A, Elaswarapu R, et al. Health promotion for mild frailty based on behaviour change: perceptions of older people and service providers. Health Soc Care Community. 2019;27:1333-43.,3131 Frost R, Nair P, Aw S, Gould RL, Kharicha K, Buszewicz M, et al. Supporting frail older people with depression and anxiety: a qualitative study. Aging Ment Health. 2019:1-9.,3535 Dew R, Wilkes S. Attitudes, perceptions, and behaviours associated with hospital admission avoidance: a qualitative study of high-risk patients in primary care. Br J Gen Pract. 2018:460-8.,3636 Kurpas D, Gwyther H, Szwarnel K, Shaw RL, D'Avanzo B, Holland CA, et al. Patient-centred access to health care: a framework analysis of the care interface for frail older adults. BMC Geriatr. 2018;18:1-17. as fundamental for prevention, adherence to interventions and the reduction of frailty2323 Avgerinou C, Gardner B, Kharicha K, Frost R, Liljas A, Elaswarapu R, et al. Health promotion for mild frailty based on behaviour change: perceptions of older people and service providers. Health Soc Care Community. 2019;27:1333-43..

Having a goal in life, feeling useful and remaining socially active can lead to fewer medical interventions - a perspective desired by this public2323 Avgerinou C, Gardner B, Kharicha K, Frost R, Liljas A, Elaswarapu R, et al. Health promotion for mild frailty based on behaviour change: perceptions of older people and service providers. Health Soc Care Community. 2019;27:1333-43.. The studies highlighted the importance of being interested in the experiences of frail older adults; offering home visits, listening and providing psychosocial support in the community2323 Avgerinou C, Gardner B, Kharicha K, Frost R, Liljas A, Elaswarapu R, et al. Health promotion for mild frailty based on behaviour change: perceptions of older people and service providers. Health Soc Care Community. 2019;27:1333-43.; and recognizing the incidence of anxiety and depression in this population3131 Frost R, Nair P, Aw S, Gould RL, Kharicha K, Buszewicz M, et al. Supporting frail older people with depression and anxiety: a qualitative study. Aging Ment Health. 2019:1-9.. Similarly, another study maintains that the family support network, relatives, neighbors and friends reduced anxiety, hospitalization, and were recognized as fundamental to well-being3535 Dew R, Wilkes S. Attitudes, perceptions, and behaviours associated with hospital admission avoidance: a qualitative study of high-risk patients in primary care. Br J Gen Pract. 2018:460-8.. There is a correlation between social support and resilience, contributing to a better quality of life for older adults3535 Dew R, Wilkes S. Attitudes, perceptions, and behaviours associated with hospital admission avoidance: a qualitative study of high-risk patients in primary care. Br J Gen Pract. 2018:460-8.,3737 Gibb H. Determinants of resilience for people ageing in remote places: a case study in northern Australia. Int J Ageing Later Life. 2018;11(2):9-34.. Social and community life is expressed as a possibility for compensating for losses4242 Hillcoat-Nallétamby S. The meaning of "independence" for older people in different residential settings. J Gerontol Ser B Psychol Sci Soc Sci. 2014;69(3):419-30.. Likewise, social ties with family members, neighbors, caregivers, local authorities emerge as an important source of meaning3030 Duppen D, Machielse A, Verté D, Dury S, Donder L, Consortium D. Meaning in Life for Socially Frail Older Adults. J Community Health Nurs. 2019;36(2):65-77.. The social roles played by older adults and their social networks change over time, with frail older adults tending to maintain a small network because of the difficulty of establishing a new network due to frailty and being selective in the search for relationships3030 Duppen D, Machielse A, Verté D, Dury S, Donder L, Consortium D. Meaning in Life for Socially Frail Older Adults. J Community Health Nurs. 2019;36(2):65-77..

Another factor is to recognize loneliness as a potential clinical problem for the frail older adult, who uses health services more often3939 Taube E, Kristensson J, Sandberg M, Midlov P, Jakobsson U. Loneliness and health care consumption among older people. Scand J Caring Sci. 2015;29(3):435-43.. One study addresses the perception of frail older adults about existential loneliness based on the Emmy van Deurzen theoretical model. In this model the life of older adults is characterized by waiting, experiencing different loss processes: in their social environment, social roles, and in their body, among others3333 Larsson H, Edberg A, Bolmsjö I, Rämgard M. Contrasts in older persons' experiences and significant others' perceptions of existential loneliness. Nurs Ethics. 2019;26(6):1623-37.. In this article, the scientific evidence on the care process for the frail older adult indicates that, in the older person’s view, being connected through social relationships does not mean a great number of contacts, but rather deep conversations about significant issues, while, on the other hand, a feeling of existential loneliness arises when the choices made disregard the opinions of older adults3333 Larsson H, Edberg A, Bolmsjö I, Rämgard M. Contrasts in older persons' experiences and significant others' perceptions of existential loneliness. Nurs Ethics. 2019;26(6):1623-37.. Similarly, the literature recognizes that a feeling of depersonalization can occur when older people are not involved in decisions22 D'Avanzo B, Shaw R, Riva S, Apostolo J, Bobrowich-Campos E, Kurpas D, et al. Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty: a meta-synthesis of qualitative evidence. PloS One. 2017;12(7): e0180127 [22 p.]..

Another study shows that the significant union with relatives, friends and the health team (through person-centered care), as well as the experience of living a meaningful life and of having their feelings recognized, relieve existential loneliness and contribute to the process of care2626 Sjöberg M, Edberg A, Rasmussen BH, Beck I. Being acknowledged by others and bracketing negative thoughts and feelings: Frail older people's narrations of how existential loneliness is eased. Int J Older People Nurs. 2019;14: e12213 [9 p.].. The prevalence of feelings of loneliness in the frail older population is similar to that of other older adults. However, more frail and lonelier older adults had worse general physical and psychosocial health conditions and used health services more than non-lonely individuals3939 Taube E, Kristensson J, Sandberg M, Midlov P, Jakobsson U. Loneliness and health care consumption among older people. Scand J Caring Sci. 2015;29(3):435-43..

The meanings of life for frail older adults may still be within the scope of their different needs. In the light of Derkx’s theoretical model, the needs for the frail older person were: to continue their daily activities, to have a purpose for the future, to pursue hobbies, to maintain a connection with their children and grandchildren; to evaluate their way of life as morally worthy; to maintain the level of control and autonomy in their lives; to value themselves, to be recognized and respected by others; to realize the continuity of their identity; to maintain a connection to relatives and friends as a support to others despite being frail, or a connection in the spiritual realm; feelings of excitement through transcendence via art, culture, nature and the events of life3030 Duppen D, Machielse A, Verté D, Dury S, Donder L, Consortium D. Meaning in Life for Socially Frail Older Adults. J Community Health Nurs. 2019;36(2):65-77.. Thus, the loss or scarcity of meaning manifests itself as a result of aging or a restricted connection network, which may occur due to a lack of purpose, coherence or connection, thus, the importance of the social environment is evident in maintaining the meaning of life3030 Duppen D, Machielse A, Verté D, Dury S, Donder L, Consortium D. Meaning in Life for Socially Frail Older Adults. J Community Health Nurs. 2019;36(2):65-77.. The results and discussion are summarized in Figure 2.

Figure 2
Scientific evidence about the process of care of frail older adults residing in the community, from the perspective of the older adults. Belo Horizonte, Minas Gerais, 2019.

Limitations of the present review include the fact that it does not address the perspectives of other actors involved in the care settings for frail older adults in the community. However, it contributes to considerations of the point of view of frail older adults, which is little known1111 Warmoth K, Lang I, Phoenix C, Abraham C, Andrew M, Hubbard RE, et al. 'Thinking you're old and frail': a qualitative study of frailty in older adults. Ageing Soc. 2016;36:1483-1500.,1818 Walker R, Johns J, Halliday D. How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery. Health Soc Care Community. 2015;23(2):216-24. when planning health actions and public policies aimed at such individuals. Thus, considering the psychosocial needs of frail older adults66 Hoogendijk EO, Muntinga ME, Leeuwen KM, Horst HE, Deeg DJ, Frijters DH, et al. Self-perceived met and unmet care needs of frail older adults in primary care. Arch Gerontol Geriatr. 2014;58:37-42. provides insights into the risks that this population group perceives as a priority2828 Verver D, Merten H, Robben P, Wagner C. Perspectives on the risks for older adults living independently. Br J Community Nurs. 2017;22(7): 338-45. and their coping strategies4040 Bielderman A, Schout G, Greef M, Schans C. Understanding how older adults living in deprived neighbourhoods address ageing issues. Br J Community Nurs. 2015;20(8):394-9..

CONCLUSION

In this review, most studies revealed frailty from the perspective of older adults with various specific characteristics, ranging from clinical operations to influence in care. Frailty appears as a predominantly negative label for the frail older person with little perception of reversibility. Scientific evidence on care from the perspective of the frail older person in the community shows that the focus of care is to maintain their capacity, functionality and participation in decisions. However, this condition also depends on the availability of the support network, community resources and public policies. Thus, the comprehensive care model, support for older adults and their caregivers is necessary to increase assistance for aging with more support and security for the longest possible time.

The review revealed that services need to offer personalized, person-centered assistance, which also includes psychosocial aspects and the narratives and life contexts of the older adults, with special attention to transition care and preventing loneliness among frail older adults. It was also observed that, for the frail older person in the community, it is necessary to improve communication, considering the choices based on the interests of this public. Thus, attention should be paid to the fact that the meaning of life for this population also focuses on communication, and so an ethical posture in caring for the frail older person involves listening to such individuals.

The articles examined in this study reflected the lack of consensus regarding the measurement of frailty. The publications are concentrated in developed countries which have been experiencing the aging process for a longer time, thus focusing on the greater challenges in developing countries. The demand for care for the frail older population is emphasized in the articles that comprised this review, an increasingly important perspective in the current scenario in society. A review of related topics, such as the analysis of interventions with frail older adults in the community, is suggested.

The current knowledge if care for the frail older person from the perspective of care recipients in the community supports decisions and improvements that favor the quality of life of this population. In this way, health professionals and public policies can carry out actions in line with the needs of this public. Furthermore, the meanings and senses of the experiences of frailty and care influence the way older adults perceive and act when dealing with this process, in order to achieve comprehensive care and ensure the quality of life of this population.

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  • Funding:

    Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), bolsa produtividade (Processo 302614/2011-7) e Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Código de Financiamento 001.

Publication Dates

  • Publication in this collection
    12 Oct 2020
  • Date of issue
    2020

History

  • Received
    03 July 2019
  • Accepted
    26 June 2020
Universidade do Estado do Rio Janeiro Rua São Francisco Xavier, 524 - Bloco F, 20559-900 Rio de Janeiro - RJ Brasil, Tel.: (55 21) 2334-0168 - Rio de Janeiro - RJ - Brazil
E-mail: revistabgg@gmail.com