Frailty and its consequences: Introduction

Abstract

The term frailty has been used widely in reference to chronically dependent older people with a variety of physical and/or cognitive impairments that impede daily functioning. As a group, frail elders command attention from policy makers worldwide because of two major, commonly held assumptions. First, it is assumed that as the size of the older adult population-particularly the oldest old-increases, the number of disabled elders needing long-term care assistance will also increase. Although recent U.S. data [I] call this assumption into question, it continues to fuel public policy concern in Europe, North America, and elsewhere. Second, in most developed countries it is also thought that the state has, or rapidly is, reaching its limits in financial resources for the care of frail elders. Even those countries (e.g. Scandinavia) to whom we often turn for model systems of publicly-funded long-term care are reexamining these systems in light of changing demographic and economic trends [2]. The major issue of concern is projected increases in public costs for this care. In the United States, recognized on one hand for innovative program models but also on the other hand for glaring lack of a national policy in long-term care, estimates of the costs of physical frailty to individuals and to the national economy range from $54 billion to $80 billion per year [3]. Estimates such as these have resulted in widespread interest in the ‘partnership’ concept, in the U.S. and elsewhere. With partnership generally described as public-private, the private component can consist of non-public formal services (either for-profit or voluntary organizations) as well as the family [ 1,461. The proportion of frail elder care coming from each component varies cross-nationally-from predominantly public in Scandinavia [l] and Great Britain [5] to predominantly private in other European countries [7] and the United States [8,9]. The balance of care from the two sources appears influenced most by political ideology. However, even in those countries, such as the United States, where the majority of care is provided informally (estimated value of $30 billion a year [3]), concern with potential increases in demand for public long-term care has shifted more attention to the contribution of private or informal care [lo, 1 I]. The papers in this issue speak to the importance of frailty as an organizing theme for the worldwide concern with the increasing size of the older adult population. The frailty status of older populations is addressed from the perspective of needs for care and public policies regarding that care; the definition or measurement of frailty as it influences policy and provision of care; factors-both physical and socialthat influence the development and course of frailty over time; and the relationship of frailty and provision of care and well-being of the care recipient. Several authors in this issue have addressed the status of public long-term care policy in their respective countries. Daatland [2] describes ongoing changes in the Scandinavian system of care. Usually admired for ‘highly developed public engagement,’ Scandinavian countries are now faced with the challenge of increasing demand for long-term care in the face of diminishing resources. Daatland points out an interesting phenomenon in which the state’s welfare system has actually functioned to create a demand for services that, in turn, has been reinforced by the service system itself. Families are seen as a ‘reserve’ source of care, with elders preferring formal services to family help. Because Scandinavian countries have actively discouraged the development of the for-profit sector, these formal services are primarily public. Economic recession and increasingly scarce public resources are forcing a re-examination of this system of care. Attention is being directed to families as a source of this care yet concern is raised about family solidarity, i.e. will families care for the very dependent? Greece represents a situation at the other end of the long-term care spectrum. Community and residential services are not generally available. Families truly are the primary source of care, reinforced and facilitated by the fact that most elders co-reside with their adult offspring. Triantafillou and Mestheneo’s [7] description of the situation in Greece suggests that the lack of appropriate community services has led to the inappropriate and costly use of what services are available, i.e. hospitals and emergency rooms. Often with the collusion of hospital personnel. these facilities are used to respond to acute non-medical needs or to provide respite to burdened families.