Introduction
1 The meanings of the words “handicap”, “loss of autonomy” or “dependency” are subject to debate and far from being clear and unambiguous, (Ennuyer, 2002). Far from being fixed notions, they are constantly evolving. It is therefore crucial to consider the content of these categories of thought, how they are disseminated, and their implications for the worlds of public and professional action in which they are embedded. In this article, we would like to contribute to this reflexion based on the sociological analysis of one of the categories that is increasingly used in autonomy policies: the notion of “frailty of the elderly”.
2 The notion of “frailty”, popularized since the 1990s by American geriatricians seeking to describe the physiological syndrome of the weakening of the elderly (Fried et al., 2001), has given rise to several hundred scientific publications. Many authors have sought to refine the qualification of this state, considered as unstable and a delicate equilibrium threatened by events presenting the slightest difficulties with the risk of tipping the person into a confirmed loss of autonomy. In assessing the risk of loss of autonomy, the proponents of these approaches have focused on the cognitive status, emotional state, medical prescriptions, or social isolation of individuals. Authors who have studied the emergence of the notion of frailty have emphasized its “enigmatic” character (Bergman et al., 2004, p. 16). “Vague, unstable, multidimensional, and therefore difficult to grasp” (Finielz and Piotet, 2009, p. 155), frailty appears as a category as difficult to define (Bohic, 2013) as it is to apply in operation (Ennuyer, 2004). Nevertheless, there has been growing interest in recent years in this intermediate state between pathology and normality. Internationally, the World Health Organization’s (WHO) World Report on Aging and Health has a formal definition. According to this report, frailty is “a progressive and age-related decline in physiological systems, resulting in lower reserves of inherent capacity, conferring extreme vulnerability to stress, increasing the risk of the occurrence of a set of negative health outcomes” (World Health Organization—WHO, 2015, p. 63). In France, this category is no longer a prerogative limited to geriatrics, as it was at its inception (Dourlens, 2008). In the 2000s, the State Secretariat for the Elderly implemented a programme of preventive medicine and the organisation of care for frail elderly people. Governments have also sought indicators to assess frailty (Renaut, 2004). The concept is now being used on a broader scale, as shown in particular by the publication of a “white paper” (Société française de gériatrie et de gérontologie [SFGG] and International Association of Gerontology and Geriatrics [IAGG], 2015) and by the institutional development of methodological guidelines devoted to identifying frailty (Agence nationale de l’évaluation et de la qualité des établissements et services sociaux et médico-sociaux [ANESM], 2016; Haute Autorité de la santé [HAS], 2013).
3 In other words, frailty is currently becoming an important “public problem” (Gilbert and Henry, 2009). How can we account for the growing influence of this category? Although the notion of frailty may be considered vague, it is important to analyse the issues underlying its use, which have led many actors to adopt it. Like the authors who deconstructed statistical reasoning (Desrosières, 1993) or implicit theorizations of public action instruments (Lascoumes and Le Galès, 2004), the sociological view is equipped to analyse this type of category. It is clear that the renewed interest in the “frailty” of the elderly rests on the development of a set of arguments, of professional actors, and of identification tools and practices, which develop around a certain rationale: action should take place prior to the loss of autonomy so as to improve public and professional intervention. We can clearly see frailty as a “cognitive motivation” through its ambiguous nature, its blurred boundaries, and its explicit orientation towards action. That is, it can be seen as a “composition of parts, integrating cognitive, social, and material elements, whose more or less successful organisation produces effects of conviction”, as a “socially organized system of good intentions” (Benamouzig 2015, p. 11–12). The notion of cognitive motivation was created to study the trajectory of economic reasoning in health care which, although composite and subject to varied uses, is nonetheless endowed with content and a certain autonomy. Studies of the modus operandi of public policy instruments, such as hospital quality indicators, have also used this concept (Bertillot, 2016). Thus, we can analyse in the same light the equivocal dimension of this type of instrument, designed on the basis of varied knowledge and for a plurality of uses, and the rationalisation strategies it fosters. Similarly, an analysis of frailty as a cognitive motivation highlights a critical understanding of the underlying knowledge that legitimizes this category, while at the same time underlining the various social uses to which it is applied. It is then understandable that its development and operational difficulties develop in a tension between the plasticity of the notion, on the one hand, and the normative principles of action that constitute its core, on the other.
4 This article does not pass judgment on the possible normative interest of the notion of frailty. Based on a two-part survey (see box), the aim here is to report on the growing hold of this category and some of the problems it faces. We begin by analysing the composition of the cognitive motivation of frailty before analysing its implementation in practice.
[Box] Methodology: a two-part sociological survey
The first part of the survey objectifies the knowledge, ideas, and actors involved in the notion of frailty. We analyse a corpus of written sources devoted to frailty, including essential international references and works published in France and/or by French authors over the past ten years (n = 200) developed from a review of the scientific literature in the fields of biomedicine, social sciences, integrated care, as well as grey literature devoted to this question. Our goal is not to produce an exhaustive review of the literature, but rather to explore the various contexts of frailty and the issues around which this category emerges. We then classify and organise these sources in a commented bibliography. This work has been completed by the observation of events related to frailty—professional congresses and institutional meetings—to study the debates around this notion (n = 3).
The second part of the survey consists of understanding frailty through the practices of those involved in caring for the elderly, based on a comparative field survey conducted since February 2015. We conducted semi-directive interviews (n = 40) with institutional and professional actors from different sectors (health, social, and medico-social), essentially in two survey territories (in Seine-Saint-Denis and in Paris). It has not been a question of making an identical comparison of the situation in the two regions based on this on-going qualitative survey but rather a question of shedding light on two aspects. On the one hand, we developed an understanding of how the emergence of this category is perceived as such by different professionals. On the other hand, we report on multiple concrete local activities in different spheres of practice that do not necessarily claim a relationship to frailty but refer to concrete actions of assistance or of prevention of the loss of autonomy.
Frailty in the elderly: the components of cognitive motivation
5 To understand the rise of the notion of frailty, it is necessary to look at two closely intertwined characteristics of this cognitive motivation. On the one hand, frailty has the particularity of being heterogeneous in its content, open to varied actors and practices and relatively porous compared to other notions. On the other hand, it is seen as a concept with an operational aim, oriented towards the action of public authorities and professionals that, at its very core, aims at transformation. It thus constitutes both a plastic and normative category involving the commitment of a variety of actors.
Biomedical, social, and demographic approaches: the plasticity of frailty
6 It is interesting to try to understand how the limits of the “frailty” category are “defined” (Goffman, 1974), that is, what is the basic logic at its centre and what elements occupy its margins or are considered to lie outside of its field of action. The plasticity of the concept is important in that it makes it possible to assemble around it a vast array of actors who contribute to its development and can appropriate it according to their differentiated interests and practices. Our literature review makes it possible to analyse the overall picture based on three main frailty frameworks that coexist, each involving specific actors, arguments, and practices. [2]
7 Frailty was first defined using a biomedical approach. Geriatric professionals were the first to have invented this category. They used it to describe a physiological syndrome preceding the loss of autonomy (Fried et al., 2001). Early identification of autonomy loss made it possible to predict health complications, such as increased risk of falls, hospitalisation, and mortality, and to propose appropriate treatments. In the purest sense of frailty in the biomedical sense, we are essentially interested in muscular frailty. Inspired by the construction of osteoporosis as a field of medical intervention, professionals and researchers in geriatrics claimed the discovery of a new syndrome previously not studied, called sarcopenia. Recognition of sarcopenia would have high stakes: it would pave the way for therapeutic trials and marketing authorisations for pharmaceutical products to retard muscle wasting. In a broader biomedical framework, frailty can be seen as an accumulation of deficits, which geriatricians have made their area of investigation and professional action (Rockwood and Mitnitski, 2011). Sarcopenia and frailty are “two sides of the same coin” (Cesari et al., 2014), and the ultimate objective is to find screening methods for this syndrome through tools assessing people’s functional or cognitive abilities, in order to be able to act prior to the loss of autonomy, by proposing treatments, food supplements or fitness workshops. This biomedical frame of reference constitutes the historical framework of the category. It is very widely dominant in the literature. [3] It has been the basis of the success of American geriatricians who have innovated on this theme since the late 1980s. It now finds enterprising professionals in France who have appropriated it, including the medical and scientific team of the gerontopole of Toulouse. If frailty is so successful in the geriatric specialty, it is also because it considerably broadens the “jurisdiction” of this segment of the medical profession (Abbott, 1988), allowing the full development of its competence in the field of prevention: frailty concerns a potentially greater number of people whose loss of autonomy should be delayed. This biomedical framework is also of interest to economic actors, be they producers of home automation, alicaments [4], or medical drugs, for whom the so-called frail elderly constitute a market to be conquered within the framework of the “silver economy” (the economy at the service of the elderly). For example, one of the stands at the 2015 congress on frailty that had focused its marketing on the elderly, offered samples of fortifying yoghurts.
8 Second, the notion of frailty has been defined in relation to the “vulnerability” of the elderly. [5] Unlike the biomedical framework, this social approach to frailty only appears in a limited number of specific references. These have been made by authors who want to move from frailty seen as a “medical problem” to frailty apprehended as a “social and public health fact” (Ennuyer, 2004, p. 154) or from frailty as a “geriatric syndrome” to frailty apprehended as a “polymorphic notion” (Béland and Michel, 2013, p. 7). The concept of vulnerability defines a “de facto situation caused by economic, material, physical and/or psychological precariousness” (Lefeuvre-Darnajou, 2004, p. 156). It makes it possible to describe disadvantaged populations because of their situation of uncertainty, insecurity, or powerlessness, in a given social environment (Schröder-Butterfill, 2013, p. 205). The social approach to frailty places more emphasis on the individual’s background, on understanding how his or her environment—as well as the family and social—context can constitute factors that accelerate or delay the effects of aging (Finielz and Piotet, 2009). Life course analysis makes it possible to understand the relationship between health status, living conditions, financial situation, and the action of the various support networks. This readjustment contributes to a more holistic vision of the frailty of the elderly.
“Our work [today] is in a more global approach of the person. There is a little bit of biomedical, a little psychosocial, etc. It does not seem relevant to me to put up partitions. … Someone who is socially isolated, this will have repercussions on the biomedical aspect, it will accentuate a depression, this depression can be somatised by physical problems that lead to hospitalisation. … Someone who takes antidepressants will fall, break their hip. …”
10 As soon as the situation of vulnerability is accompanied by an increased risk of “incapacitation” (Provencher and Demers, 2013), the category of frailty becomes porous in respect to relational and environmental conceptions of disability (Dourlens and Vidal-Naquet, 2013). This evolution towards a multidimensional approach is important in that it gradually involves a whole range of actors whose activity is far from that of biomedical frailty, but who are very sensitive to questions concerning vulnerability. This includes professionals and managers of social services, home help services, associative structures invested in the fight against social isolation, or pension funds interested in the often difficult living conditions of caregivers [6] who are often themselves relatively elderly and in vulnerable situations. Fundamentally relational, the approach in terms of vulnerability raises the general problem of the coordination of actions carried out in the various professional fields.
11 Third, we can understand frailty at the population level with its significant effects in terms of the costs and organisation of the social protection system. The general framework of the category can thus be seen as a public health problem, arousing interest that is both epidemiological as well as economic. It is an epidemiological problem when it comes to assessing the “prevalence” of frailty (Santos-Eggimann, 2013), establishing its socio-economic determinants, or anticipating increased risks of hospitalisation, cognitive decline, complications, or mortality (Hogan et al., 2012). It is an economic problem when it comes to assessing the costs induced by frailty and modelling the most efficient public policy responses (Rapp and Sirven, 2015; Sirven, 2013). This systemic framework is important, making frailty not only the concern of geriatric professionals or social workers, but also a key issue in the organisation and financing of the health system. Frailty is thus becoming a motive for public action and increasingly concerns the many political and institutional actors involved in the field of autonomy: from the successive ministerial delegations in charge of the elderly and autonomy that have embraced this question, to the pension funds. Financial sponsors—and in particular the the national old-age insurance fund (CNAV) [Caisse nationale d’assurance vieillesse]—seek to use their limited resources efficiently. From this point of view, the notion of frailty arouses their interest because it could make it possible to target socially vulnerable beneficiaries (Bohic, 2013). It is in this logic that in recent years financial sponsors have deployed institutions to study situations of frailty in France and to gather information on social isolation, precariousness, the situation of caregivers, and the population’s state of health (Blanckaert, 2012).
12 Through its plasticity, frailty has been described as a “frail concept”. Associated with old age without being its exclusive domain, the concept suffers from the lack of consensus on simple, relevant, and validated criteria for defining the complex realities it seeks to qualify (Kagan, 2012). Other more optimistic authors see progress in the definitional elements as a “worthwhile challenge” (Rockwood, 2005). It seems to me that this plasticity goes hand in hand with the growing success of the notion, which is made at the cost of equivocal acceptance of the situations encompassed by the word frailty. There is an “ambiguous consensus” around frailty (Palier, 2004). The motivation lends itself to varied interpretations which are sources of misunderstandings and difficulties, but which also give it a broad social base. Cognitive motivation is not neutral. It is the bearer of a transformational ambition, cutting across these multiple interpretations.
Successful Ageing and “Integrated Care”: Normative Dimensions of Frailty
13 This category has a pragmatic dimension, oriented towards the action and mobilisation of professionals and institutions. At its heart, it conveys two closely articulated ambitions, endorsed by most of the actors who have an interest in addressing the question of frailty of the elderly.
14 The first normative dimension lies in its orientation towards the prevention of loss of autonomy, i.e. in its promotion of “successful ageing”. It is not necessary to wait for events marking the onset of autonomy loss—falls, hospitalization, or cognitive problems—before offering specific support in order to reduce risks. Contrary to the state of proven autonomy loss, frailty refers to a process considered largely reversible. At this stage, it is possible to make a frail person more robust and autonomous in order to delay the loss of autonomy. This logic of prevention through the search for “healthy ageing” taking into account the functional capacities of individuals (WHO, 2015) is of international scope. It is also present in France through the law on the adaptation of society to ageing, adopted on 28 December 2015 and the National Action Plan for the Prevention of Loss of Autonomy (Aquino, 2015). Even recent statements by the Secretary of State for the Elderly and Autonomy have presented the notion of frailty as a lever for changing the behaviour of professionals and the elderly (Jeandel and Hanon, 2015):
“Our healthcare system takes good care of pathologies, but struggles a bit when it comes to prevention. This is a real paradigm shift in the draft bill on adapting society to ageing. … You are in the midst of this change: not treating a person’s pathology, but the person himself, including the prevention dimension and personal life course. Successful ageing is a change of outlook on old age, to offer comprehensive, coordinated care for the health of individuals.”
16 Prevention should make it possible to maintain elderly people in their own homes as long as possible in the pursuit of their quality of life and with respect for their autonomy. It is not only a question of acting on material living conditions, but also on the social participation of the elderly. Through this logic of prevention, the objective is also to control the anticipated costs of the rapid ageing of the population in a constrained budgetary context. It is a question of investing upstream—reversible frailty—to make savings downstream—autonomy loss and its high costs. Responses to frailty are being tested: frailty consultations in geriatrics or with the attending physician, making it possible to develop a personalised health plan; workshops set up by pension funds, including adapted physical activities with sports coaching and nutritional advice; or programmes to combat the isolation of the elderly. The frailty category thus involves a large-scale lifestyle transformation initiative that implies making each individual responsible for his or her “successful ageing”.
17 The second normative dimension of the category lies in its orientation towards an integrated care approach that aims at increasing coordination and integration of services in the field of autonomy. Tackling the frailty of the elderly prior to the loss of autonomy aims at improving coordination of those actors involved in home care and at limiting hospitalisation deemed avoidable. The search for integration has been presented internationally as a “revolutionary agenda” and a “fundamental paradigm shift” in the way health services are funded and managed (WHO, 2015, p. 34). In this view, the institutional and professional actors must coordinate their efforts around the needs of the people in proposing a more adapted response. This search for increased coordination and integration has had various institutional and organizational translations over time (Bloch and Hénaut, 2014). It has notably resulted in the development of the “method of action for the integration of support and care services in the field of autonomy” (MAIA) [Méthode d’action pour l’intégration des services d’aide et de soins dans le champ de l’autonomie], which is supposed to involve all those involved in supporting people aged 60 and over who are losing their autonomy and their carers (Somme and de Stampa, 2011). It has also recently resulted in the deployment of the “itinerary of elderly people at risk of loss of autonomy” (PAERPA) [Parcours des personnes âgées en risque de perte d’autonomie] scheme, which aims at improving care for people over 75 years of age. It has formalised a personalised health plan aimed at coordinating municipal interventions with those in hospitals or in the medico-social sector, in order to avoid breakdowns or at limiting recourse to hospitalisation. Scientific observation has regularly demonstrated the links between these integration systems and frailty as a new approach in preventing loss of autonomy.
“There is also an organizational key to acting on frailty that will be enshrined in law: integration. … MAIA, PAERPA, frailty: same fight. ».
19 Moreover, the debates on the various meanings of frailty place the different institutional and professional worlds of the field of autonomy in contact and tension. By creating a space for cognitive exchange, they contribute to initiating the integration of the different components of the field of autonomy.
20 Frailty is thus presented as both a plastic and normative notion, which, far from being implemented smoothly, confronts complex and heterogeneous local systems. The scope and limits of the category of frailty are largely played out in daily life, that is, in the arguments and practices of the many actors whose job it is to accompany the elderly.
Frailty “in action”: a motive tested in practice
21 The frailty of the elderly is not only a category that concerns the work of geriatricians, the research of epidemiologists, and the decisions of public actors. Its promoters try to “implement in practice” (Vellas, Cestac, and Morley, 2012) a motivation perceived in different ways by the multiple actors of an action system that remains fragmented. In this context, acting on frailty implies clarifying the division of tasks, defining responsibilities, and guaranteeing certain professional skills. Frailty thus carries with it a strong ambition for transformation, which explains some of the difficulties it encounters.
Plural meanings of frailty rooted in the fragmentation of the system
22 The field of services for the elderly has long been characterized by its fragmentation (Bloch and Hénaut, 2014). Public action has been organised in a series of closed categories separating the major sectors: health, with hospitals and primary care; medico-social and social, with their establishments and their many domestic help services; multi-purpose services; structures managing the personalised autonomy allowance; structures of animation for the elderly, etc. Far from being self-evident, the articulation of all these services is itself a challenge to public action in the field of autonomy. Therefore, the public action motivation of frailty touches on several professional fields. In this context, each type of actor in the survey field tends to develop his or her own meaning, depending on its place in a universe of knowledge and practices. While some actors perceive frailty as an emerging international and national approach and are aware of the publication of a white paper on the subject, others ignore these institutional developments and present more local definitions, indexed to their own practice. Each one places the cursor of the frail state in a different place on the continuum between autonomy and loss of autonomy. The ambiguity of the category is very perceptible when various professionals are asked by what criteria can an elderly person in a frail situation be recognized, and where the frail state begins or ends.
23 Without being able to analyse each position taken here in detail, it is interesting to show some of these contrasts, since everyone sees frailty in the light of its potential for action. Some professionals, most often those in the health field, insist on the physical dimension of frailty. This is the case of this professor of geriatrics in the hospital sector, who has been deeply involved in promoting “successful ageing” and in research on frailty:
“[Frailty] is a state of vulnerability to stress that is related to a decrease in physiological reserves. It involves elderly people who are independent, even if they have some kind of illness or small handicap, and who suddenly lose weight, or have walking disorders, because they have what is called sarcopenia. A stress such as a severe winter flu, a bereavement, or a fracture of the forearm, can lead them to dependency in cases in which a non-frail person would not become dependent.”
25 Here we can see the weight of the biomedical framework of frailty perceived as a physiological syndrome of vulnerability to stress, prefiguring the entry into the sphere of the loss of autonomy. For their part, homecare workers, domestic-helpers, or self-employed professionals are often in the front lines in assisting elderly people in the period between complete autonomy and proven loss of autonomy. Like this self-employed home-care nurse, they insist on the loss of physical as well as cognitive abilities.
“[Frailty] is first and foremost a loss of autonomy, both physical and mental, because one often goes hand in hand with the other. … As professionals, we see very quickly when things are going to get worse… When the elderly start to lose their heads, at the beginning, it’s: “Ah! You didn’t take your pill last night.” “Oh no, here… I forgot.” Well, it can happen; but when you see that it happens again during the same week… It’s full of little things like that, of acts of daily life, which make you say that at a given moment things are going to decline!”
27 Other actors, often working in social action, give more stress to the socio-economic dimensions of frailty: insecurity, financial difficulties, and social integration problems of frail people themselves or of their carers. This director of a communal social action centre (CCAS) communicates his vision of frailty in terms of social vulnerability:
“For us, it is more the social and financial aspect that will be the introductory point. … The physical, we’ll see that less, it’ll be the last component for us. There is a lot of insecurity [in the city], with quite varied ethnic origins … with heavy linguistic difficulties, with people who absolutely do not master the French language, who do not necessarily come to public services. … With caregivers who are also in great difficulty.”
29 However, we should avoid an overly schematic view when tracing variations in the meanings of frailty that are often porous for the different professionals encountered. Whatever the dimension that seems most central to everyone, interviews often highlight the multidimensional character of frailty, as is the case, for example, of this psychologist working in a Parisian health network:
“Often, there is a small mixture of medical, somatic, and organic problems. … A suggestion of both somatic and medication disorders that start to pose problems; often the patient’s medical follow-up has been interrupted for several months, or even sometimes several years. … There are also many patients who, in addition to cognitive problems, are isolated or suffer from loneliness, depression … Or following a bereavement. … or in isolation from relatives who work, do not have the time … Sometimes the first fall can lead to a cascade of problems … When we say bio-medico-psycho-social, everything is there! It is really the impact of these four factors.”
31 Most actors stress that these weaknesses also result in exposure to possible situations of physical or financial abuse. Practical definitions of frailty most often focus on the different types of disabilities of people with loss of autonomy. The situational nature of frailty, that is that frailty comes less from certain characteristics of individuals than from the inability of their environment to compensate for these fragilities, appears much more implicitly, notably through the question of social isolation and weakness of the family or professional environment.
32 In summary, the survey reveals that the notion of frailty does exist for most actors, but that there are differences in the way this category is understood. In a fragmented policy system, actors are aware of the multidimensional nature of frailty, but everyone is primarily interested in the facets that concern their own field of competence.
Frailty initiatives tested by complexity
33 Acting on situations of frailty implies profound changes in the organisation of the system, clarifying its responsibilities, guaranteeing professional skills, and coordinating interventions more effectively. This is not self-evident in such a complex policy system. The implementation of responses to situations of frailty involves in particular three articulated problems.
First problem: how to identify people in situations of frailty?
34 The support system has historically been built around the care of people with already greatly reduced autonomy. This has meant that workers are often powerless to identify frail people at risk of loss of autonomy. It is also very difficult to identify isolated individuals who, by definition, escape the entire network of actors. This is clearly shown by the example of the file on which people in Paris can register if they wish to be accompanied during heat waves:
In this context, the identification of individuals who need to be accompanied most often occurs later in the course of their lives, at a time when the loss of autonomy is becoming a reality. This identification is often based on the use of capacity assessment tools, which are not specifically designed to identify vulnerabilities, but are nevertheless used by professionals. Tracking devices are currently being developed to overcome this difficulty in identifying frail elderly people. In the absence of a strong consensus on frailty, the actors who develop these tools do not all make the same choices. Table 1 provides a summary of the diversity of titles, criteria, and actors involved in four of these tools. [7]“The files held by the administration, by the local information and gerontological coordination centres—CLIC, and by MAIA—concern people who have already been identified, helped, and followed up. So, the truly frail people are somewhere else, they’re not in the files. … [Taking the example of the heatwave file,] it is a file that actually lists people in non-frail situations, because the people in the file are either aware that they are frail and have registered themselves, or have been registered by their children and their entourage, and therefore, the real frail people, the people who have no entourage, are not on this file.”
A diversity of tools for identifying frailty
A diversity of tools for identifying frailty
35 In addition to the interest of each approach, the articulation between these different tools and between the practices of their users has not been thought out.
Second important problem: who are the legitimate actors in identifying frail elderly people?
36 While the world of geriatrics is gradually taking hold of the issue by proposing frailty consultations in day hospitals or in connection with the mobile geriatric teams of hospital structures, today’s identification of fragilities is less the assigned jurisdiction of one or several professional groups than it is the business of all the interveners. Generally, identification is done through informal processes, involving a wide variety of actors, from pharmacists to social workers, including home care workers and referring physicians. Those who are in contact with them on a daily basis and are able to spot the first signs of frailty often report elderly individuals who have been autonomous up to the present but are now in the process of becoming frail. This includes close relatives or neighbours worried about a change in habits, but also building custodians, alerted by annoyances linked to behavioural disorders. Social services are often the recipients of these reports, which come from the person’s social environment and are relayed by the town administration, the fire brigade, or the police. As this social coordinator summarizes it, when social workers go to the person’s home to assess the situation, it is not always easy to take into account all the dimensions of frailty.
“When you’re a social worker, you don’t make a skin fold to see if there’s dehydration. Does the person have neurological disorders or delirious outbursts, or fever…? The social worker, that’s not her job.”
38 The many home care professionals—from social workers to housekeepers—are in the front line of contact with the elderly. Without necessarily intentionally acting to identify frail people, they often develop informal skills that relate to identifying situations that degrade over the medium or long term, noting, for example, that one person is “no longer able to put on his slippers alone”, that another “has less appetite” or “goes out less often to see his friends”. But beyond these “non-prescribed” skills, acquired through experience in their work, several elements hinder the ability of these professionals to be key players in identifying fragilities. These actors are part of a very heterogeneous and competitive sector, in which employment conditions that are often difficult (low pay, imposed part-time) are at the origin of a high turnover rate. Employment relationships do not provide for any specific remuneration for time spent in tracking or transmitting information. Depending on their level of qualification, which varies widely according to employment structures and contracts, these professionals do not always feel legitimate in identifying a developing frailty. Home support administrators are ambivalent about the professional skills of their employees and do not necessarily recognize their qualifications.
“I don’t want to put the responsibility on the shoulders of a home support worker of raising points that are not within their competence. Okay that she sees that a person being helped eats less, that he has fallen, but I don’t want her to interpret the consequences. I want her to go back to her supervisor and have him call the attending physician. He’s trained as a social worker. … Everyone does his own job.”
40 In this situation, home professionals sometimes prefer to transmit their perceptions orally to relatives, when they exist, rather than to transmit the information, moreover in writing, to the person in charge of the structure. From this point of view, ANESM’s initiative (2016) to make home support workers a key component in identifying loss of autonomy implies not only training them in the use of the tool, but also enhancing this mission for auxiliaries, recognising their tacit skills in this area, and clarifying the division of responsibilities between auxiliaries and service managers. In other words, it seems difficult to radically transform current practices without changing the conditions of employment and qualifications of these people and the internal organisation of their services.
41 Municipal health care could also be at the forefront in identifying frailty (HAS, 2013). However, the approach to screening frail subjects is still far from being integrated in practice. This is not only due to the small number of certified tools. Several obstacles seriously limit the commitment of attending physicians, whether they practice in doctors’ offices or in nursing homes. If one does not limit oneself to sarcopenia alone, inquiring about frail individuals supposes a holistic preventive approach different from the diagnostic and curative approach emphasized in medical training. In other words, it is less a question of responding to a patient’s complaint with a diagnosis, followed by the prescription of the appropriate treatment, than of assessing with the patient the multiple factors of frailty prior to the occurrence of any problem, and the way in which he can act on his lifestyle to limit these risks. This time-consuming identification work is not integrated into the consultation fee structure. In the context of a declining medical population accompanied by an intensification of medical work and a disengagement from certain tasks (home visits in particular), this work can be seen as a burden. It is therefore based solely on the good will of practitioners. [8] In addition, action on frailty raises ethical questions: how far should stakeholders go in the name of public health and “successful ageing” in identifying and working with people who do not want to be cared for?
“We’re not going to start tracking, anticipating everything. We are already doing a lot of things and I sometimes wonder what the limits are in our all-out interventionism. “
Third and final important problem: what useful actions can be undertaken in line with these surveys?
43 Without a thorough assessment of the situation and without an action plan and follow-up in place, there is little point in insisting on identification. The prevention of frailty can only exist within the framework of a transversal organisation of services working with people and their entourage. However, once fragilities have been identified, it is not always clear what combination of care and support should be offered to the person. Action requires lifestyle changes, which can only be achieved with the help of individuals and the support of relevant professionals. While initiatives are emerging, notably through the various workshops offered by pension funds or geriatric day hospitals (physical activity, nutrition, balance disorders, fall prevention), the existing range of services is not always adapted to this vulnerable public for whom intervention is needed. The various professionals may find themselves helpless and not know to whom they should turn when faced with cases of developing frailty. Acting on frailty also means finding relays on which to rely, which implies increased coordination between front-line actors and other actors who intervene in the field of prevention or who are likely to take over when frailty is observed. What happens then depends a lot on the relationship that is built up with the environment of the vulnerable person. Coordination involves mobilizing second-line structures, such as local gerontological information and coordination centres (LINC) or health networks, capable of bringing actors together. Here we find the question of service integration, which remains far from complete (Bloch and Hénaut, 2014).
Conclusion: what perspectives for taking frailty into account?
44 The notion of frailty has long been marked by a very biomedical approach, in the hands of the great names in geriatrics, whose knowledge and evaluation criteria remain dominant in the debates and organization of research on the subject. This has led some authors to argue that “the notion of frailty does not lead to any reorientation in the conception of public policy” (Ennuyer, 2004, p. 145). With a decade’s hindsight, however, our analysis suggests looking twice at this question. Today, the category no longer makes sense only for geriatricians. It also encourages the commitment of a broader set of actors. Carried forward by a small world of professional and institutional entrepreneurs, the frailty of the elderly has become a motivation for public action for a number of reasons. In a tight budgetary context, frailty is in line with a general trend towards targeting policies at the most vulnerable groups. The category has also become a legitimate register of action to find funding. Targeting people for whom it is a question of restoring autonomy, taking into account actions related to their frailty also makes it possible to develop a rewarding facet of professional activities. The success of this word comes as much from its plasticity as from its normative content: it includes prevention and integration logics that have already begun to transform the autonomy sector. However, these transformations are taking place in small steps and not without tension. The opening of the notion of frailty to other more social, systemic and less medical approaches has begun, but is far from complete. The operational deployment of this motivation is seriously tested by the fragmentation of intervention in the field of autonomy, as it is organized today, which itself can induce or increase the fragility of situations.
45 The trajectory of this category evokes that of definitions of disability, which have moved from the WHO biomedical model (International Classification of Disabilities—ICH in 1980) to the situational model with the WHO “International Classification of Functioning” (2001). The promoters of taking frailty into account are today faced with an alternative that risks marking the fate of this category in the years to come. On the one hand, some are looking to tightening the biomedical framework of the category, involving the recognition of sarcopenia as a real pathology (which would therefore give rise to drug treatments), as well as the establishment of strict and restricted definition criteria opening the way to the deployment of certified and consensual screening tools. This search for operational implementation of the category is likely to be made at the sacrifice of less biomedical approaches and of the actors who are the furthest from medicine. This tendency of developing identification grids evokes from a new angle the long-standing problem of the risks of stigmatisation of the so-called frail elderly, whose situation might only be assessed on the basis of a list of formal criteria, whereas there are almost as many forms of frailty as there are people. On the other hand, a set of actors promotes the further opening of the notion of frailty to its social, environmental and demographic dimensions. Such an evolution would make it possible to enrol in this approach an ever-increasing number of actors from a plurality of worlds of practice. However, this evolution is likely to come at the cost of new ambiguities, misunderstandings, and difficulties in the operational implementation of the category, unless this evolution is accompanied by an in-depth and realistic reflexion on the role that each type of actor can play in actions to prevent the loss of autonomy.
Notes
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[1]
Les termes «fragile» et «fragilité» peuvent être traduits par «fragile» ou «frail». Les deux sont utilisés dans des textes scientifiques. Après quelques hésitations, j’ai choisi «frail» et «frailty».
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[2]
This article does not aim at proposing an inventory of the different definitions of frailty. Readers may refer to the article by Dramé et al (2004) which is a review of the literature or, for more recent sources, the white paper on frailty (SFGG and IAGG, 2015) or the proceedings of a seminar organized at the Interdisciplinary Laboratory for Applied Research in Health Economics (LIRAES) in 2014 (Institute for Research and Documentation in Health Economics—IRDES, 2016).
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[3]
This predominance can be explained by the precedence of geriatrician’s activity in the category and also by greater incentives for publication in the biomedical field than in the social sciences.
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[4]
A food product containing elements considered particularly beneficial to health.
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[5]
Vulnerability is a category of public action that is new and unclear and involves related fields, such as family or mental health policies (Brodiez-Dolino, 2015).
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[6]
Persons caring for dependent persons.
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[7]
These tools are currently being developed, tested, or have been recently deployed. Their scientific validity is currently controversial.
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[8]
To remedy this problem, the PAERPA system provides for the creation of a personalized health plan, carried out by the attending physician and other professionals, with additional remuneration.
