How many frailties exist?
Authors: Matteo Cesari, Marco Canevelli
Journal: The Lancet Healthy Longevity (2021)

We have read with interest the systematic review by Vittorio Dibello and colleagues1Dibello V Zupo R Sardone R et al.Oral frailty and its determinants in older age: a systematic review.Lancet Healthy Longev. 2021; 2: e507-e520Summary Full Text Full Text PDF Scopus (8) Google Scholar in The Lancet Healthy Longevity, discussing the condition of oral frailty. We strongly agree with the authors that oral health is highly relevant, and its assessment should always be part of the clinical routine in older people. However, we are sceptical about the rationale and benefits underlying the introduction of another version of frailty. In the future, should we expect the birth of cardiovascular frailty or lifestyle frailty, to add to the the many frailties already present in the literature? Why is oral health such an important aspect to justify its isolation from the syndromic nature of frailty,2Morley JE Vellas B Abellan van Kan G et al.Frailty consensus: a call to action.J Am Med Dir Assoc. 2013; 14: 392-397Summary Full Text Full Text PDF PubMed Scopus (1913) Google Scholar especially over other domains similarly contributing to a person's excess of vulnerability? Do we need all these frailties (and the others to come)? Is there a risk that we are simply generating chimeras with the false belief that these can capture the multidimensional complexity of the older person?3Sánchez-Garrido N Cesari M Sgaravatti A et al.The chimeric nihilism of geriatrics.J Am Geriatr Soc. 2016; 64: e213-e214Crossref PubMed Scopus (6) Google Scholar Frailty should always be explored in older people. If screening is positive, then a comprehensive assessment follows. On the other hand, poor oral health in an older person does not necessarily mean that frailty is present. The identification of oral problems in an older person should lead to the screening of frailty to discriminate between robust individuals (those who can benefit from usual care) and frail individuals (those in need of adapted or personalised interventions). Still, this second group will not present with oral frailty, but instead frailty characterised by poor oral health. Thus, the individual's frailty will lead to a comprehensive assessment and exploration of the underlying causes. The person-tailored intervention targeting a clinical issue in a frail individual cannot be planned without comprehensively examining all the residual capacities and reserves. For example, intervening on an oral condition without knowing whether the person is also presenting with social issues could represent malpractice and lead to negative outcomes.4Marzetti E Sanna T Calvani R Bernabei R Landi F Cesari M Brand new medicine for an older society.J Am Med Dir Assoc. 2016; 17: 558-559Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar The holistic approach recommended for the older individual is also a prerequisite for the evolution of care systems based on integrating services and multidisciplinarity.5WHOIntegrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity. World Health Organization, Geneva2017Google Scholar Partial constructs, such as oral frailty, might not help. The risk is that clinicians will continue to work as usual, each one using his or her own self-built definition of frailty. At best, a new term in the medical vocabulary will be introduced for aesthetic purposes. Although disseminating geriatric medicine principles is essential, this should not be pursued via the generation of artificial nosological constructs. Instead, more substantial changes are needed, particularly the implementation of a holistic approach to the older person and the integration of care. MCe has received honoraria from Nestlé Health Sciences for presentations at scientific meetings and to serve as member of expert advisory boards. We declare no other competing interests. Oral frailty and its determinants in older age: a systematic reviewPoor oral health is common among older adults and can impair essential activities of daily living and contribute to frailty. We did a systematic review of studies on the relationship between oral health factors and frailty among older adults (>60 years), consulting six different electronic databases for studies published from database inception to March 20, 2021. In total, 39 articles met the eligibility requirements, including 12 different indicators of poor oral health related to frailty, which we grouped in four different categories: oral health status deterioration; deterioration of oral motor skills; chewing, swallowing, and saliva disorders; and oral pain. Full-Text PDF Open AccessHow many frailties exist? – Authors' replyWe thank Matteo Cesari and Marco Canevelli for their interest in our systematic review. Of course, behind their observations lies a theoretical debate on frailty that is being held among researchers worldwide. In fact, after more than 20 years of intensive clinical research, although a consensus on the theoretical foundations of frailty has been established, a consensus about a single operational definition is still lacking, and over 70 different operational definitions still exist. Full-Text PDF Open Access