Beyond Frailty: Reframing Healthy Ageing Around What Matters Most
- Paresh Dawda
- Jun 5
- 4 min read
Across health systems, there is a growing focus on identifying frailty in older people. This is understandable. Frailty is associated with increased vulnerability to adverse outcomes, including falls, hospitalisation, disability and mortality. Earlier identification can help clinicians intervene before a significant decline occurs.
But there is an important question we should ask:
Is frailty the right organising principle for healthy ageing?
Frailty matters. However, if frailty becomes the dominant lens through which we view older people, we risk defining ageing primarily in terms of deficits, risks and deterioration. In doing so, we may miss something more important: the capabilities, goals, relationships and life roles that older people themselves value most.
The limitations of a frailty-centred approach
Frailty has proven valuable as a clinical construct because it helps identify people at increased risk of poor outcomes. Yet frailty measures are, by design, largely focused on vulnerability and accumulated deficits.
The challenge is that older people do not experience their lives as a collection of deficits.
Two individuals with similar frailty scores may have profoundly different experiences, priorities and outcomes. One may be socially connected, physically active and living independently with a strong sense of purpose. Another may be isolated, anxious and struggling with daily activities.
Research increasingly suggests that ageing is multidimensional and cannot be fully understood through a single summary measure. Recent work exploring subdimensions of frailty found that different domains—including mobility, daily functioning, mental health and cognition—have distinct relationships with quality of life, suggesting that a more nuanced understanding is required.
The question, therefore, becomes not simply:
How frail is this person?
but rather:
What capabilities are most important to this person, and how can we help preserve or restore them?
Margaret's story
Consider Margaret, an 78-year-old woman living alone whose recent assessment placed her in the moderately frail range. On paper, she presented as a falls risk with declining grip strength, reduced walking speed and multiple comorbidities. The clinical instinct was to focus on fall prevention, medication review and a referral to physiotherapy.
But when asked what mattered most to her, Margaret's answer had nothing to do with frailty scores. She wanted to keep attending her weekly book club. She wanted to be well enough to travel interstate for her granddaughter's birthday in three months. And she was quietly terrified of losing her driver's licence — not because of the practical inconvenience, but because it represented her independence.
A care plan built around Margaret's goals looked quite different from one built around her frailty score. Physiotherapy was still part of it, but the focus shifted to building the specific strength and confidence she needed to move safely in the world she wanted to live in — not simply to reduce her risk of a hospital admission.
A shift towards healthy ageing
The World Health Organisation has proposed a broader framework for healthy ageing centred on the concepts of intrinsic capacity and functional ability. Intrinsic capacity refers to the combination of an individual's physical and mental capacities, while functional ability reflects what a person is actually able to do within their environment.
This represents an important shift away from disease-centred and deficit-centred models of care.
The WHO Integrated Care for Older People (ICOPE) framework explicitly promotes a person-centred approach focused on optimising function and maintaining independence rather than simply managing disease. The framework identifies key domains including mobility, cognition, psychological well-being, nutrition and sensory function.
Importantly, this approach recognises that healthy ageing is influenced not only by medical conditions but also by social environments, support networks and the ability to participate in meaningful activities.
What should we measure?
One of the most significant developments in recent years has been the work of the International Consortium for Health Outcomes Measurement (ICHOM), which developed a standard set of outcomes for older people based on international expert and patient consensus.
The ICHOM Older Person Standard Set was an important step forward because it moved beyond disease-specific metrics and sought to measure outcomes that matter to older people themselves. These include aspects of function, emotional health, autonomy and carer burden.
In fact, early implementation studies suggest that the ICHOM framework provides an opportunity to move from a disease-centred paradigm towards whole-person goals.
However, there remains an opportunity to go further.
If our ambition is truly healthy ageing, we should consider measuring not only clinical risk and functional decline but also:
Personal goals and what matters most to the individual
Independence and confidence
Social connectedness and loneliness
Carer wellbeing
Ability to participate in valued activities
Sense of purpose and contribution
Quality of life over time
Days spent at home and in the community
These outcomes often matter as much as, or more than, traditional healthcare metrics.
From frailty programmes to healthy ageing programmes
Many current programmes begin with frailty identification and then focus on reducing admissions or preventing deterioration.
A healthy ageing model would begin differently.
It would start by understanding what matters to the person and identifying early changes in capability, function and wellbeing. Frailty would remain an important component of assessment, but it would sit within a broader framework that includes physical, cognitive, psychological and social dimensions.
Such an approach might be structured around five domains:
What matters to the person
Intrinsic capacity
Functional ability
Social and carer context
Clinical risk and complexity
The goal would not simply be to reduce frailty scores. The goal would be to help people maintain independence, relationships, participation and quality of life for as long as possible.
A different question
Perhaps the most important shift is conceptual.
Frailty asks:
How vulnerable is this person?
Healthy ageing asks:
What capabilities, relationships and life roles are most important to this person, and how can we help sustain them?
Health systems will continue to need frailty identification. The evidence supporting its use is strong.
But frailty should be a starting point rather than the destination.
If we want truly person-centred care for older people, our ambition should extend beyond preventing decline. It should focus on enabling people to live the lives they value, with the greatest possible independence, dignity and wellbeing.
That is a healthier and ultimately more human vision of ageing.
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