Fifteen orthopaedic Registrars or Pre-Registrars (n = 6), Junior Consultants (n = 4), and Senior Consultants (n = 5) participated in semi-structured interviews (n = 12 telephone and n = 3 in-person). Interview length ranged from 20.5 min—57.3 min (M = 34.0 min). Fourteen of the participants (93%) were male. A majority of the participants (87%) worked within the public sector at major tertiary hospitals in the Adelaide metropolitan region. These participants held the position of Pre-Registrar or Registrar, Medical Fellow, Specialist, Head of Unit /Department, or Medical Officer. One participant worked in both the private and public sectors; one participant was an upper limb specialist working in private practice. The age range of participants in the sample was between 29 and 72 years. Years in practice ranged from less than 1 (i.e., one Registrar entering first year of orthopaedics training program) to 40.
We inductively developed four main themes. First, participants described frailty as a complex and age related multidimensional state involving physical and mental components. They described the development of frailty as a “vicious cycle” with a number of contributing factors and conditions. Second, frailty was regarded as a familiar term but with a context dependent meaning. Participants described associations of frailty with fragility, and identified differences in general (e.g., colloquial) and medical understandings and uses of the term. Third, frailty was understood as preventable and reversible, but only under certain conditions. Participants identified relevant single (e.g., exercise) and bundled (e.g., exercise and nutrition support) programs pertinent to frailty management. Fourth, participants recognised that formal screening has utility, but its value in orthopaedic practices was unclear. Participants described alternative strategies to identifying frail older persons, possible benefits of screening, and desirable characteristics of screening tools for frailty relevant to orthopaedic practice environments.
Theme 1: Frailty was described as a complex and age related multidimensional state of risk involving physical and mental components
Orthopaedic surgeons in our sample generally understood frailty as a complex, age-related, and multi-dimensional condition involving physical and mental components associated with increased dependency. The majority regarded frailty as a state of risk (80%) involving physical and mental components (12/15, 80%), and 80% regarded frailty as a complex, multidimensional condition. Registrars were less likely than junior and senior consultants to identify the multidimensional nature and mental and physical components of frailty.
“Risk” was commonly associated with frailty and was discussed generally. Frail persons were seen as being at risk for numerous conditions and negative outcomes, such as injury (Sr. Consultant, P5), or “a multitude of medical problems” (e.g., JR Consultant, P7). Approximately 33% of participants explicitly identified that frailty increases risk of falls. However, risk was more often discussed generally, as expressed by a Junior Consultant: “it is not exactly a positive state either so it means you are at risk of having problems in every sense probably” (P2).
Participants identified numerous contributing factors associated with the development of frailty. Age was the predominant contributing factor identified by 14 of 15 participants (93%), followed by inactivity (8/15, 53%) and nutrition (7/15, 47%). Approximately 25% of participants described mental status and social support as important contributing factors. Social and environmental factors were identified as central to the occurrence and progression of frailty. Only two senior consultants identified the role of individual attitude in the progression of frailty; a decision to become frail was described by one senior consultant (P3) who drew extensively on his clinical practice to illustrate the relationship between the frailty identity and individual behavior.
Frailty was regarded as related to, but distinct from, common conditions and geriatric syndromes pertinent to ortho-geriatric practice. For instance, sarcopenia, osteoporosis, and fragility are commonly encountered but orthopaedic surgeons acknowledged the breadth and multisystem impact of frailty. As one Senior Consultant expressed, “As orthopaedic surgeons, we’ve always discussed osteoporosis and sarcopenia and all sorts of things by themselves, but I think frailty is more a complex of an elderly patient that has multiple issues that are part of getting older” (P1).
Frailty as a “vicious cycle” was the most common model of frailty presented and was described by 33% of participants. No participants described the onset of frailty as a sudden occurrence. A further 27% of participants described frailty as a natural part of ageing, and 13% of participants viewed frailty as an inevitable aspect of ageing. Two Registrars (P9 & P11) characterised frailty both as a natural and inevitable aspect of aging. In this model, individuals were described as gradually progressing from good health to a generalised state of decline, sometimes influenced by underlying genetic aetiology or latent genetic drivers. As one Registrar explained, “I think part of it is nature and happens in everyone. I’m sure there’s a genetic predisposition for becoming more frail more early in life or developing at a later time. I think happens in everyone eventually” (Registrar, P9).
Theme 2: Frailty is a familiar term but it’s meaning is context dependent
Although overall the orthopaedic surgeons in our sample were familiar with the term frailty, they generally described frailty with a degree of uncertainty. This was reflected in the myriad descriptions, reflecting diverse understandings and misunderstandings of the term, but also in the conditions that participants placed on their own statements. For instance, phrases like "to me” and “it’s probably,” reflected this uncertainty and emphasised relativism in participants’ understanding. Empirical evidence sources were not referred to during the interviews.
The tendency to refer to individual accounts of frailty versus empirical sources reflected that frailty has coexisting dimensions, which result in varied accounts of what frailty “is”. As a Junior Consultant explained, “I think frailty has a medical and a social sort of concept, doesn’t it, really? I think from a medical point of view we think of frailty meaning a multi-system general degeneration of tissue, which would progress with ageing” (P13). The result of the co-existing social (i.e., lay) and medical (i.e., professional) dimension is that the word “frailty” was used in different ways to communicate different things to different people. Participants acknowledged that the meaning and interpretation of frailty varies by profession and by lay understandings.
For instance, participants used the term frail in a general sense between colleagues to refer to a general state of risk (i.e., term “frail” used as a proxy for risk). 66% of orthopaedic surgeons in our sample stated that they would use the term frailty among colleagues. Registrars (100%) were more likely than Jr Consultants (50%) or Sr Consultants (40%) to use frailty in this way. Although the term was used between colleagues, it was regarded as generic rather than a precise clinical term, reflecting “a general public perception rather than a medical terminology” (Sr Consultant, P3). As one Junior Consultant expressed: "[Frailty does not enter into the clinical dialogue with colleagues in] terms of the official case notes. It’s not a colloquial word but it is more of a word that we wouldn’t really use. We wouldn’t write it in the notes or anything like that, but certainly colleague to colleague yes, this patient has got a lot of issues they are pretty frail.” (P8, Jr Consultant)
Participants were less likely to use the term frailty with patients’ families (47%) than with colleagues, and least likely to refer to frailty directly with patients (33%). Junior Consultants were least likely to use frailty with patients and families (0%). Referring to frailty with patients and particularly families reflected a presumed shared understanding that frailty represented a level of risk that could impact future treatment and outcomes. As a Registrar explained “It gives an idea of their overall risk in terms of what the appropriate treatment from them…[the term] comes up [with patients and families] in terms of talking about rehab and those kinds of things” (P10, Registrar).
How participants understood risk factors for frailty and the relationship between co-morbidities and frailty also differed. Approximately half (47%) of participants discussed an association between fragility and frailty. Osteoporosis, dementia/cognitive decline, fractures, and diabetes were recognised as the next most common associations with frailty (33%). Age was regarded as the most important contributing factor (93%), followed by inactivity (53%) and nutrition (47%). Systematic differences between the subgroups were not observed.
Theme 3: Frailty is generally understood as preventable and reversible, but only under certain conditions
Participants generally regarded frailty as a reversible, or at least a malleable condition if the right strategies were used in the right contexts and at the right time. An important condition to reversibility was a belief that improving frailty requires intervention. This perspective was held by 73% of participants, was most common among Senior Consultants (100%), and least common among Registrars (50%). Participants (73%) emphasised physical activity or a combination of physical and mental activity (33%) as critical strategies to preventing and reversing frailty; however, none of the Registrars in our sample explicitly mentioned mental activity. Overall, interventions identified were generic, such as exercise and diet or optimization of physical and mental health (Sr Consultant, P4); however, other factors such as social engagement (Jr Consultant, P13; Sr Consultant P3), mobility aid provision (Registrar, P15), medication management (Jr Consultant, P8), bone health modification (Jr Consultant, P7) and multidisciplinary team involvement were also identified (Sr Consultant, P4; Registrar, P12; Jr Consultant, P13). Improving nutrition (e.g., through meal planning; Registrar, P12) was also identified as an important reversal priority/intervention component (33%), and was most commonly identified by the Registrar subgroup.
A second condition for the modifiability of frailty related to participants mental model; the reversibility of frailty was linked to a perspective of frailty as a “vicious cycle”. Frailty was not modifiable when regarded as an inevitable result of aging. Half of the Registrars (P9, P14, P15) and one Junior Consultant (P2) regarded frailty as irreversible. However, they believed its progression could be slowed (Jr Consultant, P2) or “optimised into areas that make them fragile” (Registrar, P14) if recognised and addressed early. Among these participants, early detection was thought to enable frail patients to reduce their risk of future injury and maintain their activity levels for a longer duration (e.g., Registrar P9). Participants who saw frailty as irreversible after a certain point (i.e., Registrars, P9, P14, P15; Jr Consultant, P2) generally reflected that this understanding was influenced by their clinical experiences of treating vulnerable older patients (e.g., “it comes from clinical experience, every day sort of working, and terms that you hear people use around you”, Registrar, P15). As one Registrar clarified, “the approach that we often have with quite frail people who’ve had hip fractures is that there’s never any goal of getting them better than they were before their fracture. I think that’s…if that was going to be realistic it would be a long, long term thing and I think it’s probably not realistic at all but the goal is to try and get them back to their level of activity that they had before but I think what would actually make more gains is to intervene earlier on” (P9). Participants who described frailty as reversible (66%) generally stated that it is possible to reduce frailty levels in some patients, especially in the early stages, although there was little agreement about how soon intervention should occur. Whether or not frailty was reversible was also tied to circumstances, namely, whether patients have reached “a critical level of accumulated dysregulation and deficits”, which would make reversing frailty “unrealistic” (Registrar, P9). Although participants largely regarded frailty as reversible, many participants were unsure about the distinct role of orthopaedic surgeons in frailty management, prevention, and reversal.
The idea that frailty is generally used and implicitly understood suggested to some participants that education and awareness about frailty is needed. Education could help identify at-risk persons earlier in order to modify a particular frailty trajectory; health education was regarded as necessary for healthcare professionals, patients, and their families. As one Registrar expressed: “I think the main stream is education at different levels, and that also includes patient and patients’ families’ education. And I think involving the primary care physicians within the role is very important” (Jr Registrar, P12). Another Registrar (P11) identified public health education and awareness campaigns for clinicians as useful initiatives, but saw the “lack of glamour” associated with the topic of frailty (in comparison to other public health issues like breast cancer) as a possible barrier to implementation.
Theme 4: Formal screening has utility but its value in orthopaedic practice is unclear
Participants had positive attitudes towards frailty screening in principle (73%), but generally regarded screening as unlikely to be feasible, practical, or useful in orthopaedic practice contexts. A number of factors impacted this perceived utility. Among these were a reliance and trust in non-validated measures such as visual assessment methods and hunches, perceptions of responsibility for screening and alignment with the orthopaedic surgeons’ role, perceived misalignments between frailty screening and the context of orthopaedic practice (e.g., timing of seeing patients, patient status), and concerns regarding the relevance of formal screening to practice settings. Attributes of the screening tools were also pertinent to the perceived relevance and utility of frailty screening in orthopaedic practice contexts.
Views on whether frailty screening would make a difference to practice were mixed. One third of participants believed that frailty screening would make an impact on their clinical practice, one third believed it would not make a difference, and one third were unsure whether it would or would not. There were no differences noted between subgroups. Factors such as the practice context (e.g., trauma, shoulder specialty), the extent of specialization, and practitioners sense of responsibility (or not) for screening influenced whether frailty screening was regarded as potentially impactful to practice. At times, perceptions of impact related to the fit between the orthopaedic surgeons role and the intent of screening, (e.g., “I don’t feel that orthopaedic surgeons should be the ones who are doing that screening for this patient group” (Jr Consultant, P7). Other times, perceptions of impact related to the perceived ability of the practitioner to do something with the result, “I would basically allocate the task of assessing for frailty, and doing the appropriate referrals, and involving the appropriate people to my junior colleagues, and to the nursing staff, who tend to be able to coordinate this care a bit better than myself” (Registrar, P12).
Although numerous factors were identified that impacted the perceived usefulness of frailty screening in orthopaedics, a reliance on visual screening underpinned many participants perspectives. This undermined the apparent value of objective screening. As a Registrar stated, “Potentially, I can’t really see it change at the moment because I kind of come up with my own conclusion that they are frail and that already plays a part.” (Registrar, P14)“. Similarly, a Senior Consultant expressed that he could “say who’s frail and who isn’t without having to go through a 20-point questionnaire” (P4).
In addition to needing to link frailty screening with care coordination and effective interventions, participants identified possible benefits of frailty screening in orthopaedic contexts. The most commonly emphasised benefit was an improved ability to predict a patient outcome, expressed by a Senior Consultant when he stated: “My feeling is that being on the receiving end of issues, that a frailty score would help to…predict the outcome of our treatment” (P1,). The link between frailty status and predicting outcomes from treatment was emphasised (80%) over frailty prevention (27%) and reversing frailty (13%). Preventing adverse outcomes (such as falls and fracture), coordinating care, and guiding intervention planning were also identified as important.
Only two participants (Registrar, P12; Jr Consultant, P2) explicitly stated that it would be useful or feasible to conduct frailty screening in the orthopaedic practice context. Conversely, general practice was identified as the optimal location for screening by 80% of participants. If frailty screening were to occur in orthopaedic contexts, participants identified simplicity (40%), feasibility and accuracy (27%), as the most important attributes of a screening tool. When the frailty screening tools were ranked, The Frail Questionnaire was most commonly ranked as the preferable screening measure based on its feasibility for use in the orthopaedic practice context (6 preferential rankings). Only the Gait Speed test and PRISMA 7 did not receive a first place ranking. Using the composite scoring method, the GFI (46 points) marginally outscored the Edmonton Frail Scale (47 points), Kihon Checklist (48 points) and Frail Questionnaire (48 points). We triangulated the results of the rank-order and composite-scoring methods to determine the tool most favorably viewed by our participant sample: the Frail Questionnaire (Table 1). The Edmonton Frail Scale, GFI and Kihon Checklist were also viewed relatively favorably by our sample. Participants generally viewed purely physical measures unfavorably for use in orthopaedic practice contexts largely based on attributes on the patient population.
Table 1. Feasibility Scoring of Frailty Screening Tools