A Qualitative Exploration of Older Patients' Experiences With Frailty and Related Management Strategies

ABSTRACT Background Frailty is highly prevalent in hospitalized older patients and may increase the risk of adverse health outcomes. Understanding the experiences of older patients and the management strategies they use to recover from frailty is crucial to developing appropriate interventions. Purpose This study was designed to explore the frailty experiences of older adults and the management strategies they use to recover from frailty. Methods Using purposive sampling, semistructured, face-to-face interviews were conducted with 16 older patients with frailty. Data were analyzed using content analysis. Results The experiences of participants were classified into three phases, including the (a) individual sensing phase, (b) daily-living-threatening phase, and (c) acclimatization and acceptance phase. When experiencing frailty, the participants developed management strategies to facilitate recovery, which manifested in three phases: (a) making flexible adjustments to the daily routine, (b) using adequate support systems, and (c) adopting positive thinking. Conclusions/Implications for Practice The results indicate that familial support and positive thinking are important management strategies for successful recovery in frail individuals. Older patients require adequate support systems. Positive thinking was also found to be an effective management strategy for recovery. Healthcare professionals should not only focus on providing supportive resources but also provide support to older patients to facilitate their adoption of positive thinking to face life changes brought on by frailty.


Introduction
Frailty is a state of physiological vulnerability to stressors that results from age-related decline in biological systems and manifests clinically as an increased risk of adverse outcomes such as falls, disability, institutionalization, and death (Hoogendijk et al., 2019). The rapid expansion in the aging population has brought a concomitant rise in the number of older adults with frailty. The results of a previous systematic review and meta-analysis indicate that the prevalence of frailty is around 12% among community-indwelling older adults (O'Caoimh et al., 2021). However, this prevalence increases dramatically in hospitalized older patients, with one study showing a pooled frailty prevalence of 47% in this population (Doody et al., 2022). Moreover, Cunha et al. (2019) reported in their meta-analysis of 28 studies that hospitalized older patients with frailty were associated with a sharper decline in physical function (relative risk [RR] = 1.32, 95% CI [1.04, 1.67]) and increased rates of overall mortality (RR = 3.94, 95% CI [2.09, 5.82]), in-hospital mortality (RR = 8.20), and death in both the medium term (RR = 9.49,95% CI [1.92,46.86]) and long term (RR = 7.95,95% CI [4.88,12.96]) compared with their nonfrail peers. Moreover, average length of hospital stay was higher in older patients with frailty (13.5 days) than those who were nonfrail (8.3 days).
Given the increasingly high prevalence of frailty and its strong association with numerous adverse outcomes, more evidence-based knowledge must be accrued regarding strategies that are effective in promoting frailty recovery. Moreover, these strategies must be assessed in terms of their feasibility, cost-effectiveness, and suitability for use with hospitalized older patients (Dent et al., 2019). Interventions currently available for the clinical management of frailty include comprehensive geriatric assessment, physical activity, nutritional supplementation, and the deprescription of unnecessary medications. However, the effectiveness of recovery in these studies has shown significant variability (Åhlund et al., 2017;Saripella et al., 2021;Vasconcelos et al., 2021). Moreover, recent consensus-based guidelines have also included physical activity and adequate protein intake as first-line therapies for the management of frailty. Examples include the National Institute for Health and Care Excellence guidelines for multimorbidity (National Institute for Health and Care Excellence, 2016), the World Health Organization ICOPE guidelines (World Health Organization, 2017), British Geriatric Society/Age UK/Royal College of General Practitioners (Turner et al., 2014), and the British Columbia guidelines for the early identification and management of frailty (British Columbia Guidelines and Protocols Advisory Committee, 2017). However, the effectiveness of these interventions is not yet supported by sufficient evidence (Dent et al., 2019).
Major evidence gaps in management strategies may be related to the fact that previous interventions were developed by healthcare professionals who did not necessarily consider the unique experiences or needs of older patients (Dent et al., 2019). By considering older patients' frailty-related preferences, priorities, and psychosocial resources in day-to-day clinical practice, healthcare professionals can deliver care that is more patient centered, which, in turn, may help develop more successful and personalized strategies targeting multiple organ systems associated with frailty. Therefore, developing a deeper understanding of why and how some individuals recover from frailty may help facilitate the development of appropriate interventions. Therefore, this study was developed to describe and analyze the experiences of older patients with frailty and the management strategies they use in frailty recovery.

Study Design
A descriptive qualitative approach was used to gain a rich understanding of participants' frailty experiences and recovery management strategies.

Participants and Setting
This study used purposive sampling to select hospitalized patients from a 1,343-bed tertiary care medical center in southern Taiwan. Patients were eligible for inclusion if they were 65 years or older, had Clinical Frailty Scale (CFS) scores between 4 and 6, and were able to communicate independently with the researcher. The exclusion criteria were admission because of severe acute illness (immediately requiring intensive care) or needing hospice care or surgery. To understand the recovery management strategies used by the participants, those who had not recovered by 1 month after hospital discharge (i.e., CFS score 1 month postdischarge ≥ CFS score at admission) were also excluded. The CFS contains nine descriptions representing different levels of frailty (Rockwood & Theou, 2020), and an interviewer scores each participant on each description based on the following: 1 = very fit, 2 = fit, 3 = managing well, 4 = living with very mild frailty, 5 = living with mild frailty, 6 = living with moderate frailty, 7 = living with severe frailty, 8 = living with very severe frailty, and 9 = terminally ill. The number of participants was determined by the principle of data saturation, that is, when the current interview generated no new theme or code (Guest et al., 2020).

Data Collection
First, interview guidelines were developed based on symptom management theory and through panel discussions (Bender et al., 2018). These guidelines focused on determining the experiences of frailty in older patients with acute physical stressors, whereas subsequent questions gradually delved deeper into the management strategies these patients had adopted during hospitalization and at 1 month postdischarge (Table 1).
One researcher visited wards at the study site Monday through Friday during the study period to recruit eligible patients. Written informed consent was obtained before data collection, and potential patients were provided 1 day to consider their willingness to participate. To collect the data, face-to-face, semistructured, individual interviews were conducted using the interview guidelines between August and December 2019. Each older patient was interviewed twice. The first interview was conducted in the patient's room during hospitalization, and the second was conducted in the consulting room of the outpatient department at 1 month postdischarge. All of the interviews were conducted by the same researcher using a voice recorder, and each interview lasted approximately 30-60 minutes. Limited demographic information was collected to ensure confidentiality.

Data Analysis
The audio-recorded interviews were transcribed verbatim in traditional Chinese within 24 hours postinterview and double-checked against the digital recordings. Two researchers analyzed the transcripts independently using qualitative content analysis (Lindgren et al., 2020), and disagreements were resolved through discussion or by consulting a third researcher until consensus was reached. The researchers immersed themselves in the transcripts and developed a list of data-driven codes. Codes were compared and grouped into subcategories, which were then abstracted as generic categories. Finally, the generic categories were grouped into main categories.

Trustworthiness
To establish trustworthiness, this study adapted Lincoln and Guba's (1985) criteria for qualitative research: credibility, dependability, confirmability, and transferability. To achieve credibility, the researcher had the knowledge and research skills required to perform her role. The researcher visited the participants both during their hospitalization and after discharge to ask questions that were specifically targeted to resolve uncertainties and helped facilitate authentic responses. Field notes were also used to increase data credibility. Moreover, investigator triangulation was employed using multiple researchers to complete comparative analyses of individual findings and draw conclusions for team members to share and analyze. To enhance dependability and confirmability, detailed drafts of the study protocol were prepared throughout the study. A detailed track record of the data collection process was also developed. Research meetings were arranged regularly for the team to discuss interpretations, codes, and themes. Furthermore, at every stage of the study, the decision-making process was documented for later tracking and review. To increase data transferability, the demographic and clinical characteristics of the participants were carefully explained, and thick descriptions of the context and setting were provided for readers to assess transferability.

Ethical Considerations
Each participant (or a family member, when a participant was unable to sign) provided written informed consent.
The study protocol was approved by the institutional review board of the participating hospital (IRB No. B-ER-108-064).

Results
Sixteen frail older patients were enrolled as participants. The participants were 67-99 (mean = 80) years old, 68.8% (n = 11) were male, and 56.3% (n = 9) had partners. Eight (50.0%) had an elementary-school-level education. CFS scores during hospitalization, at the time of discharge, and 1 month postdischarge ranged between 4 and 6 (mean = 4.7), 3 and 6 (mean = 4.2), and 3 and 4 (mean = 3.1), respectively. Length of hospital stay was between 4 and 18 (mean = 11.7) days (Table 2). Frailty experience and recovery management strategies were considered separately. Frailty experience was classified into three phases: (a) individual sensing phase, (b) daily-living-threatening phase, and (c) acclimatization and acceptance phase. During the process of recovering from frailty, the management strategies developed by the participants manifested in three phases: (a) making flexible adjustments to the daily routine, (b) using adequate support systems, and (c) adopting positive thinking ( Figure 1).
In this study, the participants initially experienced an individual sensing phase, in which they sensed that aging or disease symptoms aggravated frailty. When frailty led to limitations in daily life and dependency, the frailty experience progressed to the daily-living-threatening phase. This was followed by the acclimatization and acceptance phase, in which the participants gradually learned to cope with threats to their ability to perform activities of daily living (ADLs) and became accustomed to living with frailty. Notably, the three phases were bidirectionally related, and recovery could alternate between phases in accordance with the participants' self-perceived symptoms and management strategies. For example, after one participant experienced further deterioration in their physical functions, they reverted from the acclimatization and acceptance phase back to the daily-living-threatening phase. Patients who are unable to enter the acclimatization and acceptance phase may experience a slower recovery because of difficulties in developing effective management strategies.
The various themes, categories, and subcategories of older patients' frailty experiences and recovery management strategies are described hereinafter (Table 3).

Frailty Experiences
Individual sensing phase This phase refers to subjective experiences of physical deterioration related to aging and disease symptoms. During this phase, the participants expressed a strong sense of decline in physiological function, including poor vitality, fatigue, and weakness. The theme identified was "frailty aggravated by aging and disease symptoms," which comprises the two categories of "aging-aggravated frailty" and "frailty development induced by disease symptoms." 1. Aging-aggravated frailty (subcategories: "lack of vitality" and "weakness") The participants expressed the belief that old age was an important factor of influence on frailty. They were more likely Frailty Experiences and Management Strategies VOL. 31, NO. 4, AUGUST 2023 to feel decreasing vitality and weakness as age increased. This was expressed in the following statements: You can't say for sure. Sometimes it [my vitality] is good. Sometimes I feel weak. It also occurs every now and then during normal times. This is normal when you get old. I'm already more than 70 years old. How much strength can I have? (Mr. D, 83 years old, chronic obstructive pulmonary disease [COPD]) I have a high tolerance for discomfort, so I only came to the hospital because I felt extremely uncomfortable. Your body will definitely be weaker at 100 years old than at 80 years old. It can't be the same. 2. Frailty development induced by disease symptoms (subcategories: "lack of vitality," "increased sense of weakness," and "fatigue") Disease symptoms increased feelings of weakness or even induced a sense of fatigue in the participants. Perceiving lack of vitality made the participants more predisposed to experiencing frailty and discomfort, as expressed in the following statements: I probably feel weaker after coughing. If I'm not short of breath or coughing, I feel normal. If I am short of breath and coughing, it is difficult to feel normal. My vitality will be poorer. (Mr. D, 83 years old, COPD) The biggest difference after getting sick is that I feel weaker and become exhausted easily. (Mr. C, 67 years old, chronic kidney disease) Note. CFS = Clinical Frailty Scale; CKD = chronic kidney disease; AE = acute exacerbation; COPD = chronic obstructive pulmonary disease; BPH = benign prostatic hyperplasia; ARF = acute renal failure; CAUTI = catheter-associated urinary tract infection.

Figure 1 Frailty Experiences and Management Strategies
The Journal of Nursing Research Fang-Ru YUEH et al.
Daily-living-threatening phase Frailty was found to increase dependence on others for ADL assistance, which caused the participants to feel threatened. The theme identified was "frailty posed a threat to ADL," which comprises the two categories of "frailty-caused burdens" and "frailty-limited activities." 1. Frailty-caused burdens (subcategories: "weaknessnecessitated provision of care by others" and "weaknessnecessitated additional monetary expenditures") Weakness was found to cause significant declines in physical function in the participants. Consequently, they experienced increased dependency on family members or formal caregivers to assist with their ADLs, which increased family burdens and/ or expenditures, as expressed in the following statements: [Life] is more troublesome. I need my son to help me. Otherwise, I can't walk far and will fall down. 2. Frailty-limited activities (subcategories: "a lack of vitality causes inconveniences" and "weakness limits space of mobility") Frailty-related lack of vitality and weakness increased the level of inconvenience in the lives of the participants. Consequently, their mobility was more limited, with the participants being largely confined to their homes and unable to go out to shop or exercise, as expressed in the following statements: I cannot even walk to the bathroom due to weakness. (Mr. F, 77 years old, UTI) A lack of stamina has a big impact. You can't say it has no impact. I stay on the first floor, and my activities are mainly confined to the bedroom and the living room. Nowadays, I don't dare ride my scooter.

Acclimatization and acceptance phase
The participants gradually learned to cope with the inconveniences of their frailty and ADL dependency and ultimately adjusted and accepted their current situations. The theme identified was "acclimatization and acceptance," which comprises the two categories of "negative thinking toward frailty" and "acceptance of frailty without misgivings." 1. Negative thinking toward frailty (subcategories: "being worried that weakness brings about negative outcomes" and "weakness causes physical harm") In addition to feeling fearful and anxious, the participants also experienced physical harm as a consequence of their frailty, as expressed in the following statements: I'm worried that I may fall down because I have no strength, so I don't go out. It is safer to stay at home. 2. Acceptance of frailty without misgivings (subcategories: "resigned acceptance of decreasing vitality" and "adjusting one's mindset to live with weakness") The participants experienced decreased vitality that affected their ADL performance. Over time, they adjusted and gradually accepted these frailty-exacerbated changes. Instead of being overwhelmed by negative thoughts, they were determined to adjust their mindset to live with weakness, as expressed in the following statements:

Management Strategies
Flexible adjustments to the daily routine As frailty induces fatigue in older patients, they often cope with discomfort by resting or adjusting their range of activities. The two themes identified were "resting to regain vitality" and "progressive activity to maintain vitality." 1. Resting to regain vitality Older patients reduced their activities and rested at appropriate times to cope with the discomfort caused by frailty and regain their vitality. This adjustment comprises the categories of "reducing strenuous activities" and "resting to cope with frailty," as expressed in the following statements: When I have a meal or go to the bathroom, I have to rest by sitting for a while, lying down for a while, and sitting up again. (Mr. G, 93 years old, BPH) There's nothing much I can do except to sit down for a while. Actually, I feel listless the whole day, so I sit for a while in the living room, go back to my room to rest, then come out to the living room and sit down again. This happens throughout the day. (Mr. F, 77 years old, UTI) 2. Progressive activity to maintain vitality The participants attempted to safely achieve a balance between rest and activity to maintain their vitality. This balance comprises the two categories of "maintaining daily life routine as much as possible" and "gradually adjusting activities to a safe range of activity," as expressed in the following statements: I engage in some activities to get my body moving, but I don't force myself if I don't have enough vitality. (Mr. D, 83 years old, COPD) When I get out of bed to move around, I do it slowly, as I'm afraid that I may suddenly feel weak and lose my balance. (Mrs. N, 79 years old, UTI) The Journal of Nursing Research Fang-Ru YUEH et al. Adequate support systems When the participants experienced frailty-related discomfort or life changes, they sought help from others or used assistive devices to maintain their daily routines. The themes identified were "using assistive devices to assist in activities" and "receiving ADL assistance from family members or caregivers." 1. Using assistive devices to assist in ADL performance The participants required external assistance in addition to flexible adjustments to daily routines. This included aids for mobility and ADL performance such as canes, walkers, and portable urinals. The themes comprise the two categories of "mobility aids for assistance with activities" and "using aids for ADL performance," as expressed in the following statements: Moving around is still okay. I just need a walker for support. (Mr. A, 99 years old, pneumonia) Last week, I felt weak and kept going to the toilet, and I was afraid of falling down at night. After my son got me a portable urinal, it became less troublesome. (Mr. F, 77 years old, UTI) 2. Receiving ADL assistance from family members or caregivers The participants required ADL assistance for activities such as dressing, feeding, transferring, and toileting from family members or caregivers, as expressed in the following statements: My son hired a formal caregiver. She takes care of me at home, as I have no strength. When I go to the bathroom to empty my bowels, I need support [from the caregiver]. I cannot go by myself, as I will fall. (Mr. G, 93 years old, BPH) [Due to frailty,] meals have to be prepared by others, and I need someone to carry and support me when I get up [from the wheelchair]. (Mrs. E, 83 years old, malnutrition)

Positive thinking
The participants adapted to their frailty through acceptance without misgivings, made positive attempts to boost their own morale, and changed their mindset to fight against frailty. The themes identified were "accepting and adapting to frailty" and "confidence boosting to maintain a good mood." 1. Accepting and adapting to frailty This adjustment comprises the categories "resigned acceptance of weakness" and "adjusting one's mindset to adapt to weakness," as expressed in the following statements: When it happens to you, you can't take it too hard. There's nothing else you can do. (Mr. O, 78 years old, pneumonia) As you grow old, you can't say that weakness doesn't trouble you. But, even if it troubles you, you can only accept your fate. If you can't walk, it's okay to use a wheelchair. (Mr. M,80 years old,pneumonia) 2. Confidence boosting to maintain a good mood This adjustment comprises the categories "adjustment of mood to face frailty" and "self-motivation and self-encouragement," as expressed in the following statements: If you are weak, you can't let it affect your mood. When you are sick, you can't stay in a bad mood, or it will affect you. That's not okay.

Discussion
A relationship diagram of older patients' frailty experiences and management strategies was developed in this study (Figure 1). During the individual sensing phase, the participants experienced frailty caused by aging or disease that resulted in decreased vitality. This finding is consistent with those of Archibald et al. (2020) and Schoenborn et al. (2018), who noted that frailty is associated with aging and may be linked to stressful events (e.g., disease). Weakness, fatigue, and lack of vitality in older patients fit within the frailty phenotype proposed by Fried et al. (2001), in which frailty is defined by five components: unintentional weight loss, exhaustion, weakness, slow walking speed, and low physical activity. During the daily-living-threatening phase, the participants experienced frailty that not only caused limitations in ADL performance but also resulted in their dependency on others (especially family members). Similar to previous studies on older adults (e.g., Kawamoto et al., 2004;Singh et al., 2006), frailty was found to promote reductions in physical activity and limb flexibility, leading to higher levels of dependency. Consequently, the participants developed mental distress because of their increased care burden on their family members, which is consistent with the findings of Cousineau et al. (2003) and McPherson et al. (2007) indicating that chronic patients often experience frustration, anxiety, self-perceived burden, or guilt when they lose ADL independence and become reliant on caregivers.
Frailty Experiences and Management Strategies VOL. 31, NO. 4, AUGUST 2023 Previous studies have found that as many as 70.2%-91.6% of older patients develop a sense of self-perceived burden when they experience disease-induced functional impairment that necessitates care from family members (Gee et al., 2019;McPherson et al., 2010). Therefore, it is suggested that healthcare professionals should increase their awareness of psychological, emotional, relationship, and economic burdens that frail older patients may feel they impose upon family members. This will be beneficial to the timely provision of support and interventions to prevent subsequent adverse outcomes. In this study, during the acclimatization and acceptance phase, older patients began to make mental adjustments in response to changes in physical function. Although they were worried about the adverse outcomes brought about by frailty, they learned to adjust their mindset to accept frailty without misgivings. Archibald et al. (2020) reported that individual thoughts and attitudes influenced acclimatization to frailty. As difficulties in acclimatization aggravate frailty, appropriate support should be provided to frail older patients to help them maintain a positive attitude and accept frailty without misgivings.
Although the participants in this study adopted various management strategies for frailty recovery, three major themes were identified, including "making flexible adjustments to the daily routine," "using adequate support systems," and "adopting positive thinking." These themes were also integrated into the three phases of frailty experience, with different management strategies adopted at different phases. This is consistent with the findings of Warmoth et al. (2016), who reported that older patients made flexible lifestyle adjustments, participated in more activities, and adopted a positive approach to cope with frailty (Schoenborn et al., 2018). In addition, Gee et al. (2019) and Li et al. (2020) found frailty to be a multidimensional experience encompassing physical changes, poor mood, social withdrawal, and the need for help. However, positive thinking may guide older adults to accept and cope with frailty without misgivings (Liu & Huang, 2009), suggesting that older adults may utilize resilience and psychological resources (e.g., positive attitudes and reinforcement of personal strengths) to cope with frailty. Therefore, in addition to developing and providing adequate support systems (assistive devices and familial support), positive mental adjustment strategies are also required to effectively assist older patients to manage their frailty.
In this study, it was also observed that family caregiving and filial piety, which are norms largely unique to Chinese culture, resulted in the provision of adequate support by the children of the participants, which effectively helped them cope with frailty. As filial piety is a key behavioral pattern followed by most traditional Chinese families, many older patients believe it is the responsibility of children to care for their parents. Previous research has even shown that individuals in poorer health showed a greater wish for their children to care for them (Teng, 2019). In this study, the participants mentioned that frailty necessitated care from family members, which led them to develop a sense of self-perceived burden. Teng (2019) noted that care recipients tend to develop positive attitudes to deal with adversity, which is consistent with the management strategies adopted by the participants in this study. This suggests that, despite the prevalence of a self-perceived burden on family members among older patients in Chinese society, adequate physical and mental familial support can assist older patients to cope effectively with frailty.

Limitations
This study has several limitations. First, the patient enrollment process was only conducted in the internal medicine ward at a tertiary medical center in southern Taiwan. Thus, data related to surgical patients were unavailable. Second, most of the participants were male. Thus, future studies should be designed to ensure an equitable gender balance among participants to more comprehensively elucidate the frailty experiences of, and the management strategies used to recover from frailty in, the older adult population. Finally, the mostly positive experiences described by the participants in this study regarding the management strategies they used to recover from frailty may reflect selection bias. Positive attitudes may increase the willingness of older patients to participate and share their frailty-related experiences and management strategies.

Conclusions
The frailty-related experiences and recovery management strategies of older adult patients were investigated in this study. In addition to adequate support systems, positive thinking is also an effective management strategy adopted by older patients in Taiwan. Previous studies from a pathophysiological perspective have emphasized the importance of comprehensive geriatric assessment, nutritional supplementation, and resistance exercise as interventions to facilitate recovery from frailty. However, from the viewpoint of patients, adequate support systems and positive thinking are the principal keys to recovery. Therefore, training programs for older patients should include not only medical, physical, nutritional, and environmental interventions but also positive thinking training and connections to support systems that facilitate recovery from frailty after hospitalization.