[[Slovenian approach for promoting healthy ageing through a frailty prevention approach - Recommendations and a roadmap from the ADVANTAGE Joint action group]]

Introduction

The percentage of European citizens aged over 65 years is predicted to rise from 18% to 28% by 2060; the percentage of over-80s will increase from 5% to 12% during the same time period, becoming as numerous as young people were in 2016 (1). These demographic trends suggest that there will be an increase in age-related disability and functional dependence, which will ultimately impact not only the wellbeing of the individuals affected (disability being a major factor determining quality of life), but also the sustainability of healthcare systems (2). This implies that there is a need to re-shape healthcare systems in order to better address emerging public health challenges, particularly the needs of older people, independent of socioeconomic background. Consequently, the models of care should take into account the need to approach older people not just in terms of curing diseases, but also in terms of care and support to prevent functional decline, disability and especially frailty. In fact, the process of frailty can potentially be prevented and treated, particularly if interventions occur early (3)(4)(5)(6)(7)(8), and is to some degree reversible (9).Therefore, it is important to know how to manage older adults with frailty or those at risk of developing it (3).

There are several definitions of frailty and the consortium of the ADVANTAGE Joint Action (JA), one of the initiatives supported by the European Commission (EC) in order to tackle frailty, recognised the definition of the World Health Organisation (WHO) as being most representative. According to WHO, frailty is a progressive age-related decline in physiological systems that results in decreased reserves of intrinsic capacity, which confers extreme vulnerability to stressors and increases the risk of a range of adverse health outcomes (9).

ADVANTAGE JA was co-founded by the EC under the third European Union (EU) Health Programme 2014–2020, with 22 Member States (MS) and 35 organizations involved. Partners worked together to summarize the current state of the art of the different components of frailty and its management, both at individual and population level, and to increase knowledge in the field of frailty to build a common understanding of frailty to be used by the MS. The final output of the project was intended to be the “Frailty prevention approach”, a common European model to tackle frailty and indicate what should be prioritized in the upcoming years at European, national and regional level and, on which to base a common management approach of older people who are frail or at risk of developing frailty in the EU (10). The identification of the core components of frailty and its management should promote the needed changes in the organization and implementation of health and social systems (4)(11). ADVANTAGE JA addresses a) policy makers involved in planning and developing health and social care policies and strategies for older people; b) health and social care professionals; c) formal and informal carers, who implement the necessary changes in everyday practice; and d) people – those who are frail, those at risk for developing frailty, as well as the EU population at large (12)(13).

1.1 Prevalence of frailty

The prevalence of frailty reported in multiple studies on community cohort samples globally ranges from 2% to 60%, contingent on factors such as the age of the population studied and the frailty assessment instrument or classification used. Nine out of ten studies reviewed, reported prevalence rates below 30% and half reported rates above 11% (13)(14). This is consistent with the global weighted prevalence of 11% reported in a recent systematic review of community-dwellers over 65 years old (13). There are far fewer studies from other settings. These studies indicate that frailty is more frequent (≥ 30%) in primary care and outpatient settings, reaching more than 50% of inpatients in hospital wards and over 60% of residents in long-term care facilities (15). Among the Slovenian population of older adults aged 65 years and older, the age-standardized prevalence of frailty is 15% and 4-year incidence of frailty is 7%. Regional differences in Slovenia show the lowest prevalence in central Slovenian regions (10%) and the highest in northeastern Slovenian regions (over 20%) (16).

Regarding the involvement of the countries in the ADVANTAGE JA, not all MSs were equally represented in these frailty prevalence studies. Most of the studies reviewed were conducted in France, Germany, Italy, the Netherlands and Spain, while Bulgaria, Croatia, Cyprus, Lithuania and Malta do not have any published information available (17).

1.2 Aims and Objectives

Aim: To define the situation and needs in the field of frailty management in Slovenia.

Objective: To prepare the recommendations and a roadmap for Slovenia based on the results of the analysis of data obtained by using different methodological approaches.

2 Methods

The methods used in the development of recommendations and roadmaps of activities for different EU MS, including Slovenia were the following:

• Systematic literature review;

• Survey regarding the approaches (strategies, policies, programmes, actions, unmet needs) related to frailty management in the participating MS;

• Consensus meetings on roadmaps of activities at MS level.

2.1 Systematic literature review

A narrative literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA-P) 2015 guidelines (18), as it enables to obtain data from various sources, and ensures a holistic understanding of the research subject. The scientific literature reviews were performed analysing papers from the following databases: PubMed, The Cochrane Library, Embase, UpToDate, Cumulative Index to Nursing and Allied Health Literature (CINAHL). The descriptive research methodology was used to review the peer-reviewed medical literature. The selection criterion was that articles were published in a time period of 15 years, from January 2002 to December 2017. Key words were selected from a proposed list of key words that was prepared by task leaders and the working group on six tasks: Prevention, Clinical management, Nutrition, Physical activity, Drugs and Information and communication technologies (ICTs). Several combinations of selected search words in English and their synonyms were prepared and used with Boolean operators AND or OR, searching by title, key words and in abstract. Articles regarding current policies and guidelines on six tasks, which were published in peer-reviewed scientific journals, as well as in international documents, standards, guidelines, and research studies performed in the EU, were reviewed. Information from editorials, letters, interviews, posters and articles with no access to full text was not included in the review. Grey documents, which were identified and proposed by task leaders, were also reviewed and included in the review. They were identified through an opportunistic search, meaning a targeted or focused one, based on the information that each partner was able to find regarding their own country.

2.2 Survey regarding the approaches (strategies, policies, programmes, actions, unmet needs) related to frailty in the participating MS

Information about the approaches (strategies, policies, programmes, actions, unmet needs) related to management of frailty in the participating MS and their regions using a specific survey targeting key informants was collected. The survey was prepared in the project working group and was test-piloted in Greece and Spain. Finally, the survey was approved by the ADVANTAGE JA Steering Committee on 18 December 2017 and conducted from January to March 2018 in participating MS. 22 Member States were included in the survey. Descriptive methodology was used for the analysis of the completed surveys. The methodology for the final classification of MS was adopted by the ADVANTAGE JA Steering Committee on 19 April 2018. The levels of implementation/categories for the classification of the MS based on the survey results (levels of developed activities in the field of frailty prevention and management) were defined, namely 1 = Basic, 2 = Fair, 3 = Well-developed, 4 = Advanced, 5 = Sustainable.

2.3 Consensus meetings and roadmaps of activities at MS level

The ADVANTAGE JA Consortium meetings and discussions were planned due to the decision to conceptualize and build the rationale for a common European framework for frailty prevention and management approach. Consensus conferences are meetings designed to inform the public and present participants the opportunity to actively engage in learning and expressing their opinions, aiming to find common ground regarding contentious issues. The so called Frailty prevention approach was intended to provide guidance on how to strengthen national/regional capacities and accelerate national/regional efforts to set up or further develop a frailty prevention policy in any MS to enhance healthy ageing. It was meant to be a practical tool to combat the inequities that currently exist in Europe, not only between countries but also within them.

3 Results

In the frame of the ADVANTAGE JA The State of the Art Report on Frailty (SoAR) and the Report on the prevention and management of frailty in EU MS were prepared. Consortium MS, stakeholders and External advisory board partners met in several meetings and discussed the draft of the Frailty approach document. Considering their baseline situation and circumstances and using State of the Art Report (SoAR) as the gold standard, each MS, including Slovenia, was asked to develop a roadmap of activities for the next four years to enhance the promotion of healthy ageing and address frailty. Two Consortium meetings were organised in order to discuss the common actions and activities to be incorporated as recommendations to all MS. Recommendations for the improvement of the frailty situation in Slovenia were developed.

3.1 The State of the Art Report on Frailty (SoAR)

Based on the literature review the so called The State of the Art Report on Frailty (SoAR) document was prepared, which provided an overview of evidence on what works and what doesn't work in the relation to prevention and management of frailty. The SoAR document was released in December 2017 and updated during 2019. Many articles and documents were analysed in order to prepare the SoAR. Regarding the task Prevention, in total 391,910 search results were identified and 31 articles/sources were included in the analysis. For the task Clinical management, 67,432 search results were identified and 27 articles/sources were analysed. Regarding the task Nutrition, 39,885 search results were identified and 28 articles/sources were included in the analysis. For the task Physical activity, in total 620,043 search results were identified and 25 articles/sources were analysed. Furthermore, for the task Drugs, 28,796 search results were identified and 25 articles/sources were analysed. Finally, regarding the task ICTs, 124,634 search results were identified and 33 articles/sources were analysed.

3.2 Report on the development of the prevention and management of frailty in EU MS

The completed surveys regarding the approaches (strategies, policies, programmes, actions, unmet needs) related to frailty in the participating MS were analysed by the end of May 2018 using descriptive methodology and the Report on the prevention and management of frailty was prepared. MS were classified into five different levels/grades of implementation according to the level of development of frailty action in their country, which was based on 20 variables including definition of frailty, management of frailty, integrated care, education and research. The most advanced countries were Spain with 85 cumulative points and France with 74 points. Slovenia with 35 points was well under EU average (45.63 points; places 15th out of 22 MS).

The comparison between the two most developed countries in the field of managing frailty, Slovenia and EU average is presented in Figure 1.

Slika 1 Figure 1: Comparison between Spain, France, Slovenia and EU average.

In the case of Slovenia, the important deficit is based on the lack of the definition of frailty and screening programmes, both individual and opportunistic and population screening. The survey showed fair interventions in the field of frailty management (diagnostic tools, nutrition, physical activity, ICT’s) and well developed area of tackling inappropriate drugs prescriptions. Integrated care is fairly developed, but training of healthcare professionals and research are lacking.

3.3 Roadmap of activities for Slovenia

Ten activities based on the survey results to be implemented in Slovenia collected in the so called roadmap of activities were identified:

1. Awareness and stakeholders’ engagement including older people empowerment.

• Involve key stakeholders from relevant sectors.

• Organize intersectoral working group on ageing and frailty that includes older people and caregivers.

• Define frailty as a national priority in the healthcare plan.

2. Commitment to action on frailty (Policy alignment).

• Develop a Strategy on ageing that includes frailty using WHO concept (2015).

3. Promotion of healthy ageing and frailty prevention.

• Prepare Guidelines to prevent frailty/promote healthy ageing.

4. Population surveillance, screening and early diagnosis.

• Adopt risk stratification strategies based on a sound epidemiological data of frailty.

• Organize systematic and periodical early detection (case finding/screening).

5. Appropriate evaluation and interventions.

• Use Comprehensive geriatric assessment as a main tool to assess frail people in all settings in order to develop an individual care plan.

• Develop guidelines in specific management aspects (polypharmacy, physical activity, nutrition programmes, falls, immunization).

• Develop guidelines to manage frailty (early detection and management).

6. Establish and continually improve an integrated model of care to comprehensively address frailty.

• Develop National recommendations aligned with the SoAR, to improve the model of care for older people.

• Evaluate and improve ongoing programmes for older people, scale-up the ones with positive results pilot new programmes of integrated care for frail patients based on the SoAR recommendations.

• Evaluate existing programmes.

• Improve pathways.

• Develop geriatric facilities (inpatient and outpatient units and services).

7. Ensure a sustainable and appropriately trained workforce (education training).

• Include Frailty prevention approach recommendations as core capabilities in undergraduate, postgraduate and continuing education curricula in all Health and Social disciplines.

• Provide recommendations for all health sciences.

8. Strengthen research capacities on frailty.

• Identify research capacities in the field of frailty in Slovenia.

• Promote frailty studies in research institutions.

• Facilitate the establishment of multidisciplinary research networks.

• Facilitate international cooperation of national research groups.

• Ensure research calls on frailty covering national cohorts follow up, testing efficiency of interventions to avoid and managing frailty and creation of biobanks to study biomarkers of frailty.

9. Implementation support (finance, data sharing and ICTs).

• Develop information sharing to enhance integrated care.

• Find ICT solutions to address frailty.

• Provide continuous education by using ICT.

• Provide finance support for research of frailty.

• Provide specific financial support to promote the frailty approach implementation.

10. Monitoring quality and evaluating value/cost-effectiveness.

• Include frailty in the Health indicators.

• Use indicators to support those who deliver strategies to improve the health and well-being of citizens.

3.4 Recommendations for the improvement of the frailty situation in Slovenia

• Slovenia should start collecting information to describe the situation of frailty in the country. It is recommended that it starts to collect prevalence data at national level. This could be done with the inclusion of the results of frailty parameters measurements recommended in the ADVANTAGE SoAR in health surveys carried out at a national level.

• Slovenia should consider piloting community-based two-step frailty screening programmes and the use of future electronic health records, particularly in primary care. It would be wise to incorporate monitoring activities to these pilots.

• To address frailty management at individual level, national guidelines including proven strategies should be developed. For practical reason WHO definition of frailty should be adopted.

• Slovenia could start pilot programmes of integrated care for frail patients based on the ADVANTAGE SoAR recommendations and the experience achieved in transitional care by the Centre for Geriatric Medicine at University Medical Centre Ljubljana and the Institute of Oncology. Currently developing health promotion centres in alliance with primary care physicians and district nurses would play an essential role there. Barriers for this initiative are a low physician density affecting also general practitioners (GPs), an unequal geographical distribution of GPs and poor coordination of PC with specialized outpatient and inpatient services. This issue has been addressed by the National Health Plan 2016–2025 (19).

• It is advisable that undergraduate training on frailty is included in medicine, nursing and social work faculties in Slovenia. It is recommended that the existing postgraduate training curricula of all professionals involved in the prevention and management of frail population are re-evaluated. Competence and expertise levels for the different professionals dealing with frailty may be addressed. Training programmes need to be adapted in a nationally aligned process to ensure adequate health care workforce development. Multi-professional training may be fostered in under-graduate, post-graduate and continuing education of professionals.

• There is a necessity to increase the funding of research in the different domains of frailty, from better identification to the best understanding of the origin, mechanisms and factors related to progression, as well as on the best care models and tailored clinical approaches, both at regional and national level.

4 Discussion

Frailty is undoubtedly one of the most serious global public health challenges that most countries will face in the coming century (20). With the ageing of the population and a larger proportion of the elderly, complications and diseases associated with ageing are increasing in many countries in the world, including Slovenia. So far, we addressed ageing-related complications such as falls and disabilities only partially. In the future it will be necessary to tackle frailty broadly. Research clearly indicates that prevention and managing of frailty are among the most serious public health challenges of the future. However, the process of frailty can be prevented and treated, especially if interventions are adopted early on (3)(4)(5)(6)(7)(8). It is therefore of key importance to know how to manage older adults with frailty or those at risk of developing it (3).

The EC is aware of the seriousness of ageing and frailty problem and for many years it has supported and co-financed various projects involving European countries addressing frailty. Healthcare professionals in Slovenia and the Ministry of Health of the Republic of Slovenia, are aware of the issue and participate in various European projects in the field of frailty. The recently concluded ADVANTAGE JA was one of the most important projects in the field. The results of the survey conducted in the frame of ADVANTAGE JA regarding the approaches adopted in relation to frailty in the participating MS showed that Slovenia lacks the definition of frailty, screening programmes, specific training of healthcare professionals and research in frailty. Furthermore, the interventions in the field of frailty management, such as diagnostic tools, adequate nutrition, physical activity, ICT’s, as well as integrated care are fairly developed. Slovenia was therefore placed well under the EU average. However, based on the Recommendations for the improvement of the frailty situation in Slovenia and a roadmap of activities that were developed in the frame of the common work of the ADVANTAGE JA it is possible to improve the situation in our country’s many domains and level up with, for example the problem of inappropriate drugs prescribing, which is well tackled in our country. Recommendations reinforce the goals of Slovenian Active Ageing Strategy (21) in order to maintain and improve physical and mental health of the population of all ages.

5 Conclusion

The aim of the common work of interdisciplinary expert group in the frame of ADVANTAGE JA was to define the situation and the needs in the field of frailty management in participating EU countries, including Slovenia. Based on the results of the analysis of data obtained by using different methodological approaches the recommendations and a roadmap of activities to be adopted in Slovenia were prepared.

Participating in this recently concluded project, Slovenia for the first time obtained the insight in the situation regarding the frailty management in the country, as well as the comparison with other European MS. It was shown that Slovenia lacks some of the key elements in the field of frailty prevention and is placed well under the EU average.

The Recommendations for the improvement of the frailty situation in Slovenia and a roadmap of activities represent a starting point and a quality base for the beginning of intensive work in the field of frailty prevention in Slovenia. In addition, recommendations reinforce the goals of Slovenian Active Ageing and the Resolution on the National Health Care Plan 2016–2025.

Acknowledgements

Reference