Definitions of Frailty in Qualitative Research: A Qualitative Systematic Review

Table 1

Description of the qualitative research articles in the study sample (N = 25).

	First author, date; 1^st author discipline; country of origin; [ID]	Aim/purpose	Conceptual description or definition of frailty	Operational definition of frailty	Sample N; age mean (range) in years; gender; race
1	Andreasen et al., 2015; occupational therapy; Denmark; [34]	To validate the Tilburg Frailty Indicator on content by exploring the experience of daily life of community-dwelling frail elderly shortly after discharge from an acute admission, in relation to the physical, psychological, and social domains of the TFI.	A dynamic state affecting an individual who experiences losses in one or more domains of human functioning (physical, psychological, social) that are caused by the influence of a range of variables, which increases the risk of adverse outcomes and negatively impacts well-being.	Tilburg Frailty Indicator, a 15-item self-administered questionnaire: physical domain (8 items), psychological domain (4 items), social domain (3 items). Frailty cutoff score accounts for five of the 15 frailty indicators.	N = 14; 80.6 (69–93); 7 men, 7 women; Caucasian
2	Becker, 1994; social science; USA; [35]	To explore the meanings older persons attach to autonomy and decreases in physical abilities associated with frailty.	Chronically dependent older people, those who are living with a variety of physical and/or cognitive impairments and experiencing functional losses and decrease in physical ability that interfere with ability to maintain autonomy in everyday life.	80 years of age and older; frailty determined by opinion of health professional including presence of chronic impairments that health professionals would view as putting people at risk.	N = 19; ≥80; 12 men, 16 women; Hispanic and Caucasian, 2 African American women
3	Claassens et al., 2014; medicine; Netherlands; [36]	To investigate the concept of healthcare-related perceived control from the viewpoint of frail older adults >65 years.	Frail older adults cope with multiple and/or chronic health conditions that likely require more extensive forms of healthcare.	Frail determined by scoring below cutoff scores, on at least two of the six following domains: BMI <23; cognitive function (MMSE <24); vision and hearing acuity; grip strength (handheld dynamometers); physical activity (how often & how long they walked, cycled, performed household activities, played sports) during 2 past weeks.	N = 32; 80.5 (65–96); 13 men, 19 women; Caucasian
4	Donlan, 2011; social work; USA; [37]	To identify how frail Mexican American elders socially constructed the meaning of community-based care they received.	Not described; frailty and disability often accompany old age, especially among marginalized immigrant populations.	Age ≥65 years and having a disability. Requiring assistance with ADLs.	N = 6; 77.5 (66–89); 3 men, 3 women; Hispanic
5	Ebrahimi et al., 2012; nursing; Sweden; [16]	To discover and reveal the meaning of experienced health through the analysis of frail elders’ descriptions.	As people age, their reserve capacity decreases, and the risk of morbidity and frailty increases; a multidimensional geriatric syndrome of disability; vulnerability and reduced capacity.	Age ≥80 years or ≥65 years with one or more chronic diseases; those who depended on help in at least one ADL and sought emergency treatment in a hospital.	N = 22; 79.5 (67–92); 11 men, 11 women; Caucasian
6	Ebrahimi et al., 2013; nursing; Sweden; [17]	To explore and identify what influences frail older adults’ subjective experiences of good health.	A biological geriatric syndrome of reductions in physiological reserve capacity and impairment of defense mechanisms against stress and disease which implies a risk of multimorbidity and dependence on others.	Age ≥80 years or ≥65 years with one or more chronic diseases; those who depended on help in at least one ADL and sought emergency treatment in a hospital. Frailty determined by a count.	N = 22; 79.5 (67–92); 11 men, 10 women; Caucasian
7	Ekelund et al., 2014; occupational therapy; Sweden; [38]	To explore community-living frail older persons’ conceptions of self-determination.	A physiological state of increased vulnerability to stressors that result from decreased physiological reserve; related to risk for disability and comorbidity; the presence of various diseases, age discrimination, and paternalism impact frailty; dependency is an important aspect of frailty.	Age ≥80 years or ≥65 years with one or more chronic diseases; those who depended on help in at least one ADL and sought emergency treatment in a hospital.	N = 15; 80.5 (68–92); 8 men, 7 women; Caucasian
8	Evans et al., 2001; radiology; USA; [39]	To investigate whether frail older women with a positive perception of health would desire to take a more active role in their healthcare.	Frail older adults are defined as those individuals who suffer major physical, mental, or social losses and require a range of supportive and restorative services.	Frailty criteria/measures not clearly specified, but older women were “…categorized by age as frail older adults.” Convenience sample of frail older women who were scheduled for ultrasound examination and whose health status indicates ability to participate in interviews.	N = 4; 82.25 (76–90); 4 women; not reported
9	Grenier & Hanley, 2007; social work; Canada; [19]	To explore the life experiences of frailty.	Definition derived from the social label of frailty and not physical function and was related to the presence of comorbidities. The social context of frailty as the “little old lady” of small stature, being fragile and weak, is associated with assumptions that shape the gendered experience of older women. Frailty framed in context of resistance to dominant notions of aging and gender, to challenge social constructs and expectations for aging and frailty. Frailty is also a term used by health professionals to assess a person’s need for public services to meet physical needs.	Frailty criteria/measures not specified. Frailty determination is based on clinical judgment and home care eligibility by health professionals for half of the sample, and the other half were active in an advocacy organization but fell outside the classification because they did not receive public services due to lack of physical need, interest, or financial resources to pay privately.	N = 12; >55; 12 women; not reported
10	Grenier, 2006; social work; Canada; [18]	To explore the distinction within older women’s narratives which represent a clash between the professional construct of frailty and the lived experiences of older women.	Frailty is contextually and socially located; one aspect of the person’s appearance (i.e., of “being frail”) comes to stand for the total identity. “Being” frail is related to the imposition of a classification that is medical and functional in nature; there are emotional aspects of frailty that lie within the experiences of impairment, disability, and decline in later life that may contradict the medical and social nature of frailty. “Feeling” frail may or may not correspond with experiences of impairment or disability. Certain events may trigger frailty: new impairment, loss, bereavement, evolving chronic illness.	Diverse older women in sources of inequalities, e.g., ability, age, race, ethnicity, culture, and socioeconomic status; six were considered frail based on clinical judgment and home care eligibility and six women were classified as not frail because they did not receive public services due to lack of physical need, interest, or financial resources to pay privately.	N = 12; not reported; 12 women; “diverse”
11	Hammar et al., 2014; neuroscience; Sweden; [40]	To explore experiences of self-determination when developing dependence in daily activities among community-dwelling persons 80 years and older.	Frailty is a continuum of 3 phases: robust prefrail, fully frail; a dynamic concept; directly related to decreased ability to perform daily activities independently.	80 years and older; frailty based on eight frailty indicators: weakness, fatigue, weight loss, physical activity, poor balance, slow gait speed, visual impairment, and cognition; classified as nonfrail (0 indicators), prefrail (1–2 indicators), and frail (3 or more indicators).	N = 11; 87 (84–95); 5 men, 6 women; Caucasian
12	Jett, 2002; nursing; USA; [20]	To explore the process of help-seeking and help giving by older rural African Americans and how certain of the most vulnerable and least known elders seek help for day-to-day needs.	Frailty not defined; survival of frail elders and role of ADLs and IADLs for day-to-day functioning described; frail elders are most vulnerable with the least known needs and at greater risk for losses and unmet needs which can be mitigated with help-seeking behaviors.	Age ≥65 years, living alone, and evidence of at least one ADL (range 6 [complete independence] to 36 [complete dependence]) or IADL deficit (range 8 [complete independence] to 24 [complete dependence]), and “knowledgeable about aging and frailty.”	N = 41, 9 frail; not reported; 9 women; African American
13	Jett, 2003; nursing; USA; [21]	To examine the meaning of aging from the perspective of older African American women living in rural areas.	Frailty not defined; the study focused on ethnography of the aging, fragility, and survival of rural elderly African Americans and learning who is identified as aged, how aging is defined and culturally determined, and what it means to be old.	Age ≥65 years, living alone, and frail based on at least one ADL or IADL deficit; ADL score: 6 (complete independence) to 36 (complete dependence), and IADL score 8 (complete independence) to 24 (complete dependence).	N = 9; 84 (77–94); 9 women; African American
14	Kaufman, 1994; nursing; USA; [41]	To investigate ways in which frailty is defined, framed, and understood by older persons, their family members, and healthcare providers in the context of a multidisciplinary geriatric assessment service; to explore the process of increasing of frailty in advanced old age, how they attempt to understand, accept, manage, and combat frailty within the context of the American healthcare system and the mechanisms employed to cope with and solve the variety of problems it creates.	Frailty increases with advancing age; a dynamic adaptational process that is open to multiple interpretations. The medicalization of frailty overshadows psychological, emotional, and behavioral aspects of aging and frailty. Frailty is socially produced in response to powerful discourses in American culture. Frailty is proposed when someone conceives there to be a lived problem with a very old person; either the old person has a condition that is worsening or spreading to other body systems or areas of the person’s life, or family members can no longer cope with caring for the person and focus on symptoms or behaviors as problems.	Age ≥80 years; receiving geriatric assessment services; and perceived by family members, friends, or health professionals to be at risk with a change in condition, health decline, and need for medical care, social support, and/or supervision so that they could remain in the community.	N = 3; ≥80; 3 women; not reported
15	Kuo et al., 2012; nursing; Taiwan; [42]	To cross-examine results between perception of frailty and physical assessment outcomes then try to establish frailty indicators for elderly people in Taiwan.	Frailty indicates a dynamic model and a balance of psychological and physical strength to counterthreats to health; a decline in physical reserve capacity and ability to resist stress.	65 years and older; Barthel index for ADL, IADL, grip strength (handheld dynamometer), timed-up-and-go test, paper folding test, spirometry, vision test, incontinence, body mass index, waist-hip ratio, body fat composition, Mini-Mental State Exam, Geriatric Depression Scale.	N = 10; 69.5 (65–74); 10 women; Asian
16	Moss et al., 2007; sociology/anthropology; USA; [43]	To learn the meanings and themes that underlie attitudes of frail old men who live in the community and behaviors in relation to food and eating.	Not described.	Frailty based on eight-item screener of mobility (e.g., use of walker or wheelchair) and activities of daily living (e.g., meal preparation, light housework, and bathing).	N = 21; 83 (76–95); 11 men, 10 women; 12 Caucasian, 3 African American
17	Nicholson et al., 2012; nursing; United Kingdom; [22]	To understand the experience of home-dwelling older people living with frailty over time in order to develop the empirical evidence base for this group and to consider more fully how narratives of frailty can shape person-centered care provision.	Frailty is an antonym for successful aging and a synonym for the increasing infirmities that accompany aging and the slow dwindling dying trajectory of many elders. This trajectory is gradual and unpredictable, encompassing accumulated and multiple health problems, which at some point tips the person into the dying phase. The social construction of the fourth age as a loss of agency and bodily self-control is linked to frailty.	Frail persons were defined by the interdisciplinary care team based on advancing age, unable to carry out IADLs and considered to be vulnerable to physical decline.	N = 17; 94 (86–102); 5 men, 12 women; Caucasian
18	Nicholson et al., 2013; nursing; United Kingdom; [23]	To understand the experience over time of home-dwelling older people deemed frail, in order to enhance the evidence base for person-centered approaches to frail elder care.	Frailty describes the condition of people vulnerable to adverse health outcomes in later life and includes a broader definition that includes social functioning, social relationships, and psychological frailty, e.g., anxiety and loneliness encompassing social, psychological, and physical domains.	Frail elders were purposively selected by the multidisciplinary care team (community nurses, speech therapist, physiotherapists, occupational therapists, care support workers, geriatricians) based on age ≥85 year, unable to carry out IADLs and considered to be vulnerable to physical decline.	N = 15; 94 (86–102); 5 men, 10 women; Caucasian
19	Niesten et al., 2012; dental science; Netherlands; [25]	To identify and examine how natural teeth contribute to the quality of life of dentulous people who are elderly and frail and how frailty influences the impact of having natural teeth on quality of life.	Frailty is a state of reduced psychological or physical reserve in combination with an increased risk for adverse outcomes such as falls, disability, and institutionalization. Frailty impacts health in general and the value that people ascribe to their oral health and their subjective dental care needs and demands.	Age ≥65 years and frailty score based on eight domains: social coping, psychosocial function, personal care, mobility, motor function, medical care, behavior disorders, and care needs per week. Score ranged from 0 to 10, where score of “1” indicated mild frailty and “6” severe frailty; persons scoring 7–10 were excluded. Scoring was determined by a medical authority.	N = 38; 79.9 (65–97); 11 men, 27 women; 2 Indonesian women, 25 Caucasian women, and 11 Caucasian men.
20	Niesten et al., 2013; dental science; Netherlands; [24]	To explain how frailty influences dental service use and oral self-care by older people.	A state of reduced psychological or physical reserve in combination with an increased risk for adverse outcomes such as falls, disability, and institutionalization; a dynamic state affecting an individual who experiences losses in one or more domains of human functioning (physical, psychological, social) which likely negatively affects dental service use and oral hygiene-related behaviors.	Age ≥65 years and a frailty score based on eight domains: Social coping, psychosocial function, personal care, mobility, motor function, medical care, behavior disorders, and care needs per week. Score ranges from 0 to 10, where scores of “1” indicated mild frailty and “6” severe frailty; persons scoring 7–10 excluded. Scoring determined by a medical authority.	N = 51; 24 being 65–80, 27 being ≥80 years; 16 men, 35 women; not reported
21	O’Connor, 1994; social work; England; [44]	To recognize the affective reality of elderly persons' experiences in the life review of frail elderly people who are living alone.	Frail elderly people who are living alone, housebound, and/or in need of assistance with basic activities of daily living and/or have emotional and/or social problems (which may include perceived inability to care for themselves) are in a socially vulnerable position.	Randomly selected homebound social work clients who need ADL assistance. Frailty markers to describe the sample: falling in the past year, having partial or total loss of use of an arm or a leg, prone to heart attacks and/or acute attacks of bronchitis or asthma, unable to get out of bed, walk indoors or outside, climb stairs, and/or bathe.	N = 134; ≥65; 28 men, 114 women; not reported
22	Porter, 1999; nursing; USA; [26]	To explore a neglected realm of frail older women’s experience of falling to the floor and trying to get up while at home alone.	Not defined, but it was stated that frail older persons are at risk for falls and participants had physical function deficits that were indicators of frailty.	Women aged 80 years and older, living alone at home, self-rated health of less than excellent, history of a fall. Frailty determined by three criteria: inability to walk 10 blocks, need for assistance to climb stairs, and need for assistive device to walk.	N = 18; 89.5 (83–96); all women; not reported
23	Puts et al., 2009; nursing; Netherlands; [28]	To describe the meaning that older community-dwelling persons attach to frailty.	Frailty is often used to describe a state in which older persons are, in a delicate balance, at risk for many adverse outcomes such as falls, disability, institutionalization, and death, which may have a negative effect on quality of life.	Frailty determined by eight frailty markers: low body mass index, low peak expiratory flow, poor vision and hearing ability, incontinence, low sense of mastery, depressive symptoms, and physical inactivity. Frailty defined as having three or more markers and nonfrail defined as no frailty markers.	N = 25; 78.7 (67–90); 14 men, 11 women; Caucasian
24	Puts et al., 2007; nursing; Netherlands; [29]	To describe the meaning of quality of life from the perspective of frail and nonfrail older community-dwelling persons in Netherlands.	A state in which older persons are in a delicate balance and at risk for many adverse outcomes such as falls, disability, institutionalization, and death.	Frailty determined by eight frailty markers: low body mass index, low peak expiratory flow, poor vision and hearing ability, incontinence, low sense of mastery, depressive symptoms, and physical inactivity. Frailty defined as having three or more markers and nonfrail defined as no frailty markers.	N = 25; 78.7 (67–90); 14 men, 11 women; Caucasian
25	Schoenborn et al., 2018; medicine; USA; [45]	To examine perceptions and informational needs about frailty among older adults.	A medical syndrome consisting of specific physical symptoms, leading to multiple adverse outcomes including falls, hospitalization, functional dependence, and death.	Age 65 years and older. Frailty based on Fried frailty criteria: weakness (handgrip strength), exhaustion, weight loss, physical activity, gait speed, and cognition (Mini-Mental State Exam); classified as nonfrail (0 indicators), prefrail (1–2 indicators), or frail (3 or more indicators).	N = 29; 76.3 (>65); 8 men, 21 women; Caucasian (21), African American (7), other (1)