Reimagining the Frailty Review: Meaning, Metrics, and the Missed Opportunity in Global Ageing Care

Waseem Jerjes^1,2*Daniel Harding^1,2Arnoupe Jhass²

• ¹Imperial College London, London, United Kingdom
• ²Hammersmith and Fulham Primary Care Network, London, United Kingdom

Across several health systems, structured frailty reviews have emerged as key tools for proactive care. In the UK, the annual frailty review was intended as a mid-year pause point: a time for mutual reflection, goal setting, and preventive planning for clinician and patient. Its enshrinement in primary care contracts put it as a formalised opportunity for the individualisation of care for the most likely to deteriorate. Ideally, it would shift the focus from crisis-driven response to anticipatory, relationship-based care that responds to the patient's own agenda. 10 However, patient reports indicate that the intended benefits are frequently not realised in practice. In Canada, for instance, a national evaluation of home-based frailty reviews highlighted similar patient dissatisfaction with impersonal assessments and lack of followup. 11 Similarly, recent efforts in China to develop psychological frailty indices have revealed the challenge of connecting metric-driven models with lived experience. 3 Time pressure and target-driven templates often convert the review into a checklist consultation, which narrows space for goals and follow-up. The review can function primarily as an administrative exercise rather than a relational encounter.In one recent national evaluation of frailty management in primary care, patients reported that reviews were felt as surveillance, rather than support, when provided by unfamiliar clinicians or with a lack of follow-up. 12 For others, the experience was not only impersonal, but disorienting: the frailty review marked a shift in the manner in which they understood themselves-not as persons with priorities, but as problems to be fixed. 13 Qualitative metasynthesis of patient experiences described the reviews as "functionally efficient but emotionally absent" capturing the wider tension between system-level measurement and personal meaning. 14 This expanding gap between design and delivery requires urgent action. If frailty reviews must become more than annual exercises, then they must be redesigned as moments of therapeutic opportunity-moments where the patient voice is not just invited but placed centrally, and where continuity, curiosity, and compassion characterise the clinical interaction. Overall, delivery remains template-led and target-driven, with limited continuity and limited follow-up.-When "what matters" becomes a checkbox Few phrases have gained such widespread currency in contemporary frailty care as "what matters to me." It appears across care guidelines in the UK, the US, and the Netherlands as a signal of relational, values-led working. 1,15,16 , personalised care systems, and dozens of quality improvement initiatives as the shorthand for relational, values-led working. But, as with much good intent, its operationalisation risks descending into performance over substance.In the majority of practices, "what matters to me" appears as a question in the frailty review template-often near the end of a structured form. This has the effect of subverting the priorities: rather than being the focus of the discussion, the patient's priorities appear to be an afterthought, added on to pre-gathered clinical information. Some clinicians, rushed for time or uncertain how to respond, put down vague or minimal answers: "remain Deleted: But the patient experience suggests that this promise is all too often lost in translation Deleted: Rather than open-ended discussion, the review becomes all too frequently the checklist consultation. Discontinuity, time pressures, and the requirement to meet administrative targets have led many clinicians to fall into the trap of preset proformas-tackling falls risk, burden of medication, and issues around safeguarding-while leaving aside more in-depth exploration of goals of life or emotional health Deleted: The review risks becoming the tool of compliance, not of connection Deleted: the manner in which that they understood themselves-not as persons with priorities, but as problems to be fixed independent," "avoid hospitalisation," or "no issues raised." In these circumstances, the intent of the question is preserved, but its influence on decisions is limited.Patients also differentiate between being heard and being asked. A recent review on exploration of personalised care planning in older adults found that while the majority of participants were formally invited to express preferences, few thought that their responses were influential in decisions that were then taken. 17 For some, the question was emotionally charged, eliciting considerations of loss, purpose, or dependency-but there wasn't much time and space to explore these lines of thought before the review continued.When questions about what matters are recorded as data points rather than used to organise decisions, they do not shape the plan. Personalisation follows when the answer to what matters orders the subsequent steps. In practice, personalisation is most evident when the plan reflects the answer to what matters.-What we miss when we focus only on risk Risk terms such as falls, delirium and hospitalisation describe only part of frailty. Small functional and social losses reshape daily life to an equal degree. For most patients, frailty isn't the dramatic change but the accumulation of the incremental, unseen losses: not kneeling in the garden, not going down the stairs after dusk, not being able to make it to the family gathering for fear of incontinence. These aren't typically charted, but they remake daily life as much as any measurement.Current frailty reviews, with all the focus on risk stratification, hardly provide space for such quiet stories. Even when patients are questioned about what matters, the general format of the review pulls the discussion back to the measurable outcomes-mobility, nutrition, medication. Emotional aspects of ageing-such as sorrow, anxiety, and frustration-are only partially addressed. In Taiwan, Brazil and many European countries, emotional resilience is increasingly being integrated into frailty models, with frameworks recognising that psychological loss can precede functional decline. 18 This exclusion is not insignificant. Emotional health has been linked with functional decline, compliance, and health-seeking behaviour in older adults. 19,20 The system, however, acts as though emotional responses to frailty are inevitable or immutable, rather than as expressions of unmet need. Without open invitation, patients do not share such experiences-particularly if they are afraid of being seen as burdensome or negative.Continuity of care plays the essential function of spanning this gap. Individuals who retain the same clinician over a period of time are more inclined to discuss emotional or existential concerns, and to be listened to as an individual, rather than a diagnosis. Systematic review has for many years demonstrated that continuity with a known doctor is associated with lower mortality, increased satisfaction, and increased uptake of preventive care. 21 In the context of frailty, such continuity is not a luxury-it is the interpersonal glue that makes it possible to discuss loss and purpose.Non-clinical goals take the central place of what really counts: making one's own tea, getting to the corner shop, attending the wedding of a granddaughter. These are not unimportant Deleted: Here, the spirit of the question exists, but its force does not Deleted: The test isn't procedural but relational. When questions of value are employed as data points rather than as places to start talking, they lose the capacity to produce anything. "What matters" becomes a tick box-answered, recorded, and archived-without changing the trajectory of care. By doing this, the system risks tokenising the very notion it seeks to sustain. True personalisation requires more than scripted prompts. It requires clinicians to pause, to ask, and-to listen critically-to act. Without it, even the most effective questions become another unmet expectation Deleted: has come to be described in the terminology of decline-falls, delirium, hospitalisation, escalation of care, "DNACPR" order or mortality. While all of them are undoubtedly serious, they capture half the lived experience Deleted: Emotional experiences of ageing-sorrow, anxiety, frustration-remain partially covered at best goals. They are about identity, relationship, and independence. When review of frailty omits them, it not only omits what clinically has to take priority, but what gives life its worth. Routine review that attends to functional, social and emotional losses alongside risk metrics offers a more accurate account of lived experience.-Patient agency and the hidden power of being asked In frailty, where the course of health appears predetermined, the reestablishment of agency can be both preventive and therapeutic. For older persons, the shift from independence to dependence can be insidious, gradual, and very personal.Simply being asked what is important has the power to disrupt that dynamic. It repositions the patient not as a person who simply waits for care, but as a person whose preferences and priorities are important. Even where the answer cannot alter the clinical course, the act of asking conveys the message of attention, respect, and acknowledgment. 22 There is mounting evidence that goal-setting, particularly when rooted in the patient's context and words, enhances engagement, satisfaction, and follow-through. Meta-analysis of personalised care planning showed that older adults who were actively involved in the process of setting goals for themselves were more confident in being able to control health and were more likely to utilise support services. 23 Importantly, the most meaningful goals were often humble-getting back to the usual hobbies, joining a social group, walking unaided in the home.When taken seriously, the objectives achieve a shift in how the patient is connected to the system. Care is delivered collaboratively rather than unilaterally. So, asking what is important is not courtesy-it is therapeutic intervention in itself, one that builds autonomy, trust, and therapeutic relationship. It re-establishes something easily lost in long-term care: the sense that one's life story is still being written, not just recorded. When goals are elicited and acted upon, patients' sense of agency and engagement increases.-Redesigning the review around meaning, not metrics The frailty review was intended to be the linchpin of personalised care-a formalised opportunity to stand still, take stock, and plan ahead with the older person as the central figure . To realise that vision, however, it must be more than a decent-intentioned appointment. It should operate as a relational process that integrates the patient's narrative with clinical data. Redesigning the review requires not merely practical changes in delivery but also a deeper shift in the way the healthcare system conceives of time, meaning, and care in later life.One of the simplest but most effective changes is reversing the order of the conversation itself. Too often, "what matters to me" appears after the discussion of falls, blood pressure, and medication-if it appears at all. Added after such items, the question risks seeming perfunctory or redundant. But placed first, it immediately makes the patient voice not peripheral, but central. It also makes it easier for clinical information to be reinterpreted in the context of the patient's goals. For instance, dizziness may mean one thing for someone whose chief aim is to keep dancing, and another for someone who values getting around the house stairs. Presenting the review this way invites more logical and empathic Deleted: What is not noticed is how quickly one becomes known by others-through labelling, assumptions, and systems that reveal more about the patient than to the patient.Deleted: Care is done with them, rather than to them Deleted: It must become an act of relationship that brings the patient's story alongside the patient's score conversation flow. Beginning with goals allows clinical information to be interpreted through that lens. Table 1 illustrates a conceptual comparison between current templateled reviews and a reimagined, narrative-led model, highlighting key differences in structure, clinician role, and patient experience. Figure 1 provides a side-by-side flow of both pathways at a glance.Exercise prescription must be made explicit in the review. Using the patient's own goals, clinicians should co-create a simple, progressive home or class-based programme (e.g. chair rises, step-ups, resistance bands), with clear dosage, safety guidance, and a dated follow-up to review progress. Where appropriate, referral routes (physiotherapy, community strength-and-balance classes) should be offered and recorded alongside the goal. Continuity of care is another pillar that has been undermined in recent years, particularly in rota-based triage and turnover-driven systems. For frail patients, however, continuity is not a luxury-it is often the means of creation of trust, disclosure, and individualised planning. Seeing the same clinician for serial reviews encourages safety in the relationship. It reduces the need for patients to rehearse sensitive or complex histories, and it allows clinicians to follow up on subtle shifts in affect, engagement, or physical status over time. Continuity also enables longitudinal tracking of goals: a patient's stated priorities-such as attending a family event or feeling secure in walking-can be explored, not restarted annually.There is good reason to make goal-tracking integral to the review process. Current systems of recording are adequate for recording QOF targets-blood pressure, changes in medication, referral-but poor for having structured fields for non-clinical or functional goals. To allow patients to nominate goals for themselves and record them in a visible, revisited section of the clinical record would distinguish them from being anecdotal, but actionable. Just as the fall in HbA1c is followed over time, so "to walk to the end of the road without aid" or "to cook twice a week" may be followed, enabled, and cheered for. This mirrors findings from Dutch primary care where structured tracking of personal goals increased motivation and continuity. 16 Such goals may appear humble, but usually get to the point: of identity, of independence, of pleasure. Patient-defined functional goals that are recorded, revisited and progressed become as visible as clinical targets.To achieve this, clinical and admin staff must possess the ability to recognise emotional need-rather than physiological risk. Depression assessment or cognitive testing may be included in frailty reviews, but are done as binary exercises, not relational ones. Staff training may enhance confidence in handling revelations of loss, loneliness, or fear-not with referral scripts, but with listening and being present. Reception and support staff must also be included, as they are often gatekeepers to the review process and may first identify disengagement, frustration, or confusion-signs that frailty isn't just clinical but emotional. A team that recognises emotional need as well as physiological risk aligns process with patient experience.To develop reviews that are both structured and sensitive, co-production with older people must move from recommendation to routine. Experience-Based Co-Design (EBCD), now used in the UK, Australia, and Canada, has shown promise in health service improvement by putting the lived experience of service users at its heart and using this to guide concrete Deleted: Experience-Based Co-Design (EBCD) , now used in the UK, Australia, and Canada system changes. 1,5,6 In frailty care, co-design workshops can show where standard reviews go wrong: confusing jargon, impenetrable digital portals, rigid formats that don't reflect changing conditions. Co-design not only improves usability -similar programs in Europe 18 and New Zealand 33 have shown how older adults' direct input can shift service tone, access, and relevance. When older people are engaged in designing their own care pathways, the review is no longer something done to them-and becomes something done with them. Codesign with older adults produces reviews that are usable, humane and relevant.Another factor all too often overlooked is follow-up. Frailty reviews, by definition, are annual. But the priorities-and the needs-of patients rarely have a 12-month rhythm to them. Systems must facilitate review touchpoints that are aligned with substantive change, whether in health or in the circumstances of life. This does not necessarily involve full rereview; sometimes the periodic check-in to review pre-agreed goals or to acknowledge change of circumstance may sustain momentum and relationship confidence. Systems might automate such reviews based on clinical data; equally, patients and carers must have open pathways to request early review where needed. Follow-up that varies with changes in goals and circumstances is more responsive than a fixed annual rhythm.It is also time to inquire what are the measures used to ascertain the quality of a frailty review. Audits now focus on process completion: did the review get coded, were the primary domains covered, did the medication get reconciled? But not many systems capture the depth, the relevance, or the emotional impact of the interaction. Despite widespread global adoption of digital templates, few include fields for narrative input, emotional content, or patient priorities beyond care escalation. Did the patient get heard? Did the discussion lead to a meaningful action? Was the patient's priority heard and addressed? These are tougher to quantify, but not impossible. Patient-reported outcome and experience measures (PROMs and PREMs) in frailty care provide richer information about what happened and how it was experienced. Including PROMs and PREMs captures perceived usefulness and impact, not only completion.Finally, digital systems must be adapted-not merely to record the review, but to fit its ethos. Templates must invite open questions without restricting responses to pull-down menus. Interface design must accommodate narrative, for goal recording, for collaborative decision-making comments. Multilingual interfaces are also vital in multicultural health systems where older adults may express needs in their first language. 1,5,6 Where there is digital exclusion, there must be clear alternatives-a concern echoed in Nordic health systems where ageing populations often face similar barriers to access . 24 Frailty is multidimensional; the systems that support its review must be adapted to the same flexibility. Templates that invite narrative, multilingual input and alternatives for those digitally excluded better reflect the ethos of the review.In reworking the frailty review, the intention isn't to abandon structure. The review may and should include clinical assessments, interventions to reduce risk, and medication reviews, but these must be placed within the context of the person, not just the sum of the things that might make them frail. When meaning is accorded the same priority as numbers, the review ceases to be a task to be completed. It becomes a relationship. And for individuals who live with frailty, that may be the most therapeutic intervention of all. Frailty reviews are widespread in rouNne pracNce, yet the personal value of the encounter is o_en limited. For most older people, the experience is not one of being reviewed, but one of being processed-rated, screened, and straNfied with lible sense of conNnuity or care. When personalisaNon is mediated by the template, people risk being reduced to data points in systems designed for documentaNon rather than relaNonship. 25,26 We must be ready to pose tougher quesNons. Not whether the frailty assessment is being conducted, but whether it is being perceived as helpful. Not whether it detects risks, but whether it detects the person. The World Health OrganizaNon has called for health systems worldwide to shi_ from disease-focused models to capacity-enhancing care for older persons, of which frailty review is a key component. 27 For paNents whose lives are not characterised by admissions but by incremental, subtle loss-mobility, confidence, roleswhat mabers cannot be elicited from a Nck-box. These losses are not dramaNc, but they are defining. 28,29 The strongest reversible component of frailty is low strength and funcNon; personalised resistance training improves gait speed, chair-rise Nme, and independence when reviewed and progressed over Nme. Embedding this into the frailty review-rather than treaNng it as opNonal advice-aligns the review with measurable funcNonal gains that paNents value. Primary care, long the stronghold of conNnuity and trust, is where the potenNal for relaNonship frailty care sNll resides. General pracNce, in contrast with the models of episodic care, has the potenNal for knowing the paNent over years-not as fall risk or eFI score, but as having fears, relaNonships, hopes, and life story. And even there, system design intrudes: rota staffing, rushed appointments, and fractured follow-up threaten to render the review more like requirement than relaNonship. 30,31 Similar concerns have emerged in US, New Zealand, and South Korean primary care, where team-based models risk diluNng long-term relaNonships. 32,33,34 The danger isn't just underperformance-it's misrecogniNon. Deficit lisNngs without quesNoning may make paNents flat, invisible, or-across cultures where independence is prized-experience the loss as existenNally disorienNng. Emerging research into frailty and idenNty confirms the importance of form and wording: the way clinicians ask, document, and follow up affects the way paNents experience their own ageing. 35,36 If we ask just about falls, meds, or mood, we miss the bigger story-what the paNent conNnues to care about, fears losing, or wants to recover.That is where there needs to be a reframing. Reviewing should not be a staNc audit, but a co-authored one. Frailty, a_er all, is not just about decline-it is about adaptaNon, prioriNes, and how individuals live with uncertainty. Clinical success, in this case, isn't always improvement-it could be stability, dignity, or simply being able to fulfil one promise: to make it to the family reunion, to be able to cook for oneself, or take the morning walk unassisted. Emerging pracNce models such as Experience-Based Co-Design (EBCD) offer pracNcal means to return the review to a relaNonal process. 38 Such approaches illustrate that paNents do not simply want to be consulted-they want to be involved in co-designing the way care is delivered. When older adults help to design reviews, the quesNons change, the tone is less adversarial, and the order is more personalised. Measures sNll maber, but they are placed within a larger narraNve that paNents recognize as their own. OrganisaNonal direcNon is starNng to recognise this shi_. NHS England has consistently demanded the incorporaNon of personalised care planning within frailty pathways. 39 The BriNsh Geriatrics Society and NICE have reaffirmed the need for shared decision-making, conNnuity, and goal-se\ng in older age care. 40,41 ImplementaNon, however, lags behind intenNon. Too o_en, such ideals are aspiraNonal addenda to a template that remains riskfirst, paNent-second.InnovaNon in the care of frailty will not come from more forms or beber so_ware. It will come from what happens between people in moments that are all too easy to miss-how a clinician starts an assessment, how they deal with sorrow, how they work with ambiguity. These are not system inefficiencies; they are the work of care itself. And they require Nme, trust, and educaNon, not protocol. 42,43 The review, reimagined, could then be another thing enNrely: a formal act of recogniNon. Somewhere the paNent's voice controls the tone, where goals, humble though they may be, are documented and spoken to, and where conNnuity of relaNonship is not solely for safety, but for meaning. If the system will accept this-accept fricNon, conversaNon, and slowness-the frailty review could serve as a construcNve interface between paNents and services. Because the quesNon isn't whether frailty reviews are being done. It is whether they maber anymore. And to whom.As frailty frameworks shi_ globally-from risk reducNon to value restoraNon-frailty reviews must follow suit. This paper argues for a new global language of review: one that captures not just what is lost, but what remains important. A review that starts with goals, embeds conNnuity and exercise prescripNon, tracks what mabers, and includes measures of perceived usefulness as well as compleNon is more likely to be experienced as meaningful.