Reimagining the frailty review: meaning, metrics, and the missed opportunity in global ageing care

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 expectationDeleted: 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 changing not only in 18 and have shown how older can shift service and When older people are in their own care the review is something done to becomes something done with with older adults reviews that are and all too often is follow-up. reviews, by are But the the patients have a to must review that are with in health or in the of This does not the to review goals or to change of may and relationship such reviews on clinical patients and must have open pathways to review where that with changes in goals and is more than a fixed annual is also time to what are the used to the quality of a frailty review. now focus on process the review get were the primary the get But not many systems capture the the or the emotional of the interaction. widespread of digital few fields for narrative emotional or patient priorities care the patient get the discussion to a meaningful the patient's heard and These are to but not and experience and in frailty care provide information about what and how it was and and not only digital systems must be merely to record the but to its must open questions without responses to design must for goal for are also in health systems where older adults may express in their first 1,5,6 Where there is digital there must be clear in health systems where often similar to . is the systems that support its review must be to the same that and for the of the the frailty the isn't to The review may and should clinical to risk, and reviews, but these must be placed the context of the not just the of the that make them When is the same as the review to be a to be It becomes a relationship. for who with frailty, that may be the most therapeutic intervention of all. reviews are widespread in the personal value of the is For most older the experience is not one of being but one of being and with sense of or care. 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