Frailty as a breakthrough point for multimorbidity management among older adults: challenges and opportunities in China

Frailty assessment: a breakthrough point for multimorbidity management

Frailty and multimorbidity often coexist; approximately 72% of frail people also have multimorbidity, and the prevalence of frailty among those with multimorbidity is estimated at approximately 16%.7 Multimorbidity and frailty are two correlated challenges faced by older people, but with distinct emphases. Multimorbidity involves the accumulation of multiple complex diseases, whereas frailty is characterised by a decline in functional abilities and an increased vulnerability to stressors.8 Despite the overlap and age related nature of multimorbidity and frailty, researchers emphasise the importance of prioritising both functional improvements and treatment of disease when tackling the complex health conditions seen in older people.

Extensive evidence has highlighted the interconnection between frailty and multimorbidity.9 On the one hand, among community dwelling older adults, multimorbidity and chronic diseases are key clinical factors that drive the development of frailty. On the other hand, frailty increases the risk of adverse outcomes for people with multimorbidity. A Chinese cohort study involving patients aged 65 and older with multimorbidity showed that frailty was a significant contributor to adverse outcomes, including falls, pressure injury, deep vein thrombosis, cardiac arrest, aspiration, and unplanned intubation.10 The interconnection between frailty and multimorbidity provides a rationale for linking multimorbidity management with assessment and interventions for frailty. In addition, evidence has highlighted the predictive power of frailty status for clinical outcomes in people with complex health conditions and their mental and physical quality of life.1112 Thus, targeted interventions for the assessment and prevention of frailty may assist in the triage of patients with complex health needs and delay, decelerate, or reverse the cascade of functional decline,13 thereby reducing the risk of multimorbidity and improving quality of life.

Prioritising assessment and intervention for frailty offers a novel perspective and solution for tackling the challenge of multimorbidity. Theoretically, frailty assessments and interventions place individual patients at the centre of prevention and treatment strategies and consider their general health and functional status, as well as the vulnerability of the older population. Early assessment and intervention for frailty could provide appropriate care to older people before the onset of severe disease, shifting the focus of disease management from treatment to prevention. This signifies a conceptual transition from disease centred care to person centred and health oriented care. In practice, frailty assessment serves as the initial step in enabling older people to navigate within the healthcare system, facilitating the communication between physicians and patients in decision making about care.1415 It also aids triage and priority setting for people with multiple and complex health conditions. By prioritising frailty assessment and intervention, healthcare systems can more effectively allocate resources and tailor interventions to the specific needs of each person, ultimately improving the overall management of multimorbidity in the older population.

Global advancement in frailty assessment and multimorbidity management: guidelines, tools, and strategies

Given the importance of frailty assessment in older adults with multimorbidity and its role as a breakthrough point in multimorbidity management, clinical guidelines have been developed to promote frailty assessment for patients with multimorbidity. A review of international guidelines for multimorbidity showed the importance of interactive assessment, including evaluation of physiological and functional status, nutritional requirements, and mental health status, in the context of multimorbidity management.16 For example, the multimorbidity guideline from the UK National Institute for Health and Care Excellence (NICE) recommends the integration of frailty assessment with multimorbidity management strategies,17 and the guidelines developed by the American Geriatrics Society emphasise the importance of meaningful outcomes, such as quality of life, physical function, and independent living, for older adults with multimorbidity.18

In addition to guidelines, various tools and strategies have been developed to assess and intervene in frailty in both community and hospital settings, aiming to prevent the development of multimorbidity and improve functional independence. Table 1 provides an overview of the tools used for frailty assessment and their practical implementation. Despite the lack of standardised tools available, some countries have integrated frailty assessment tools into service delivery pathways and provided decision support for physicians. For instance, in the UK, an electronic frailty index, generated on the basis of routine data with robust predictive validity for mortality and hospital admission, has been incorporated for physicians to assess frailty status. To enhance the feasibility of adoption, simplified programmatic assessment methods, such as the use of gait speed as an indicator of frailty, have also been recommended for general practitioners in the UK.13 Moreover, interventional strategies for frailty and multimorbidity have undergone development and evaluation in clinical trials. Non-drug interventions, notably tailored exercise and nutrition programmes, have been shown to be effective as primary recommended strategies for managing frailty, as well as for preventing and managing chronic diseases.1920 Although drug interventions for frailty are still in their nascent stage, emerging research has begun to explore their potential benefits in preventing and reversing frailty.21

Efforts and challenges in frailty assessment and multimorbidity management in China

However, despite the availability of guidelines, tools, and intervention strategies aimed at integrating frailty assessment into routine practice for multimorbidity management, real world implementation remains challenging in many countries, including China. Major barriers include the lack of localised guidelines and tools with culturally adapted content and limited capacity and insufficient incentives for physicians to adopt these strategies and tools.

China, with one of the world’s largest and most rapidly ageing populations, faces increasing challenges related to multimorbidity. Over the past decade, it has drawn on evidence and tools from developed countries to begin the development of localised frailty assessment tools and multimorbidity management guidelines. Moreover, the Chinese government has implemented many policies and initiatives aimed at improving healthcare services for older people.22 These initiatives include substantial support for research and development to describe the burden and clinical phenotype of multimorbidity, as well as the development of localised tools and guidelines for frailty assessment and multimorbidity management.2324

Another key focus is the development and top down technical diffusion of geriatric medicine and integrated care for older people across China, aligning with broader healthcare reforms.25 Over the past few years, geriatric medicine departments have been expanded to serve as points of care for older people, including those with multimorbidity. According to China’s 14th five year plan for elderly care, approximately 31.8% of general hospitals at the primary level or above had geriatric medicine departments in 2020. This proportion increased to 53.4% by the end of 2021 and is projected to reach 60% by 2025. In primary healthcare facilities, including both community healthcare centres and clinics, healthcare providers administer health screening for major non-communicable diseases and regular health checks for people aged 65 years and older as part of basic public health services.26 Additionally, training programmes focusing on frailty assessment and integrated care for older people have been implemented, with pilot projects evaluating their feasibility and effectiveness in enhancing the functional status and quality of life of older adults.27

Despite notable progress, the adaptation of international guidelines, tools, and interventional strategies to the Chinese context has encountered substantial hurdles. Critical problems remain unresolved, including identifying which patients with multimorbidity should be assessed for frailty, determining who should deliver these assessments, and understanding how to use frailty assessment results to support decision making on multimorbidity treatment. This situation is not unique to China; many countries face similar challenges, necessitating the development of tailored strategies to integrate frailty assessments into routine multimorbidity management effectively. Such strategies seek to prioritise prevention and emphasise functional improvement, reflecting the growing emphasis on holistic approaches to promote healthy ageing.

Looking forward: opportunities

The challenge posed by population ageing has underscored the urgent need to tackle multimorbidity, which is reshaping the demand side of the healthcare landscape regardless of our readiness. This transition requires a shift from merely managing multimorbidity to proactively preventing multimorbidity and enhancing function and quality of life among older people. Reinforcing the healthcare system and identifying effective pathways for implementation are equally crucial to promote a health oriented model of care that prioritises function, using available assessment tools and intervention strategies. Figure 1 illustrates potential strategies for strengthening the key building blocks of the healthcare system in China, including developing culturally adapted guidelines and implementation strategies, building the capacity of healthcare providers, and ensuring financial support. These efforts are essential to balance and sustain services for frailty assessment and interventions, motivating proactive prevention and management of multimorbidity.

Fig 1

Six dimensions to promote multimorbidity management in China

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Practical pathways for assessing frailty and managing multimorbidity are clearly needed. China’s response to the covid-19 pandemic showed its unique ability to deliver healthcare services and monitor diseases by using community resources and digital health technologies. On the one hand, community based initiatives, given their extensive population reach, should spearhead efforts to tackle multimorbidity. This requires training and incentivising community based health workforces, as well as enhancing the referral system between communities and hospitals to ensure timely and proper assessment, triage, and interventions within communities. On the other hand, leveraging digital health technologies, such as decision support systems, wearable devices, and mobile health applications, can facilitate long term monitoring and assessment of functional decline and disease management.28 Similar opportunities have emerged in many other countries where community empowerment and digital health solutions are used to enhance access to and quality of care.