Older people's perception of being frail: a qualitative exploration

Key points

1. 01None of the participants openly identified themselves as frail, despite all meeting clinical criteria on the Clinical Frailty Scale.
2. 02Frailty was universally perceived as a highly negative state linked to severe physical and cognitive decline and reduced quality of life.
3. 03Many participants viewed frailty as transient or reversible, believing exercise and staying active could reduce or prevent it.
4. 04Participants often justified not being frail by pointing to preserved cognitive function, even when physical limitations were evident.
5. 05The disconnect between clinical classification and self-identification has practical implications for engagement with frailty services.

How it was conducted

Design

Qualitative secondary analysis of a process evaluation embedded within the HERO randomised controlled trial

Participants

93 HERO trial participants classified as mildly to severely frail (Clinical Frailty Scale scores 5-7), aged 65 and older, community-dwelling

Data collection

60 observational home visits and 35 semi-structured interviews conducted approximately 6 months after trial entry

Analysis

Thematic analysis using both inductive and deductive approaches, guided by Social Cognitive Theory; NVivo 11 used for data organisation

Setting

Participants' own homes across multiple NHS trust sites in the UK

Sampling

Maximum variation purposive sampling by frailty level, age, sex, intervention level, and NHS site

What they found

• 93 HERO trial participants were sampled for the process evaluation; 60 observational home visits and 35 interviews were completed.
• None of the participants overtly recognised themselves as being frail despite all being classified as frail on the Clinical Frailty Scale (scores 5-7).
• Participants with severe frailty (CFS 7) showed the greatest disconnect between clinical classification and self-identification compared to those with milder frailty.
• Multiple participants described frailty as something associated with extreme decline, malnourishment, and cognitive impairment, not their own condition.
• Exercise participation in the HOPE programme was reported by intervention participants to reduce feelings of frailty and improve functional ability.
• Two sampled participants refused interview, both citing illness.

Limitations

• Secondary analysis of a process evaluation not primarily designed to study frailty perceptions, limiting depth of frailty-specific questioning.
• Participants were self-selecting volunteers in an exercise RCT, likely more positive toward rehabilitation than the broader frail older adult population.
• Most participants were mildly to moderately frail; findings may not fully represent those with severe frailty.
• Single-country study (UK NHS context); findings may not transfer to settings where frailty services are labelled or delivered differently.

Why it matters

For patients

Older adults classified as frail often do not see themselves that way, which may cause them to avoid or delay using services labelled as frailty services that could genuinely help them.

For clinicians

Using the word 'frail' with patients should be done carefully, as the label carries strong negative meaning for older adults and may reduce engagement with rehabilitation or preventive care.

For readers

This study highlights a communication gap between clinical frailty classification and patient self-perception, with implications for how frailty services are named, explained, and promoted.