Understanding prevalence and impact of frailty in chronic illness and implications for clinical management

在相对较小的事件（例如感染）后更有可能变得严重不适的人被称为“虚弱”。虚弱的人更容易受到伤害，例如，诊断测试或药物副作用。与没有虚弱的人相比，这使得提供最好的护理变得更加困难。 虽然老年人更容易虚弱，但并非所有老年人都虚弱。年轻人也会受到虚弱的影响，特别是那些患有糖尿病等慢性疾病的人。然而，很少有证据表明，临床管理应如何调整的人与虚弱，特别是年轻人。证据方面的一个主要差距与临床试验有关。临床试验是关于治疗有效性的最重要的证据来源（例如特定药物）。人们普遍认为，身体虚弱的人不太可能被纳入试验。然而，由于试验通常不测量虚弱，我们目前不知道虚弱的人被包括在内的频率，或者虚弱的试验参与者是否与社区中的虚弱者相似。这使得临床医生不确定他们是否可以在决定为虚弱的人提供哪些治疗时使用试验证据。管理虚弱的第二个挑战涉及“自我管理”，这是每个患有慢性病的人都需要学习的。自我管理是指人们根据自己的能力和资源（如财务状况、社会支持、其他承诺），在自己的状况（如诊断测试、参加预约、接受治疗）与生活中的其他优先事项之间进行平衡。对于身体虚弱的人来说，自我管理可能更加困难。然而，没有以前的研究回顾了所有已发表的研究，看看是否以及如何脆弱的存在应该改变卫生专业人员支持自我管理的方式。我们计划解决这两个证据gaps.AimTo识别和测量临床试验中的脆弱性，以及在社区设置，以评估如何最好地应用从试验中的证据时，决定什么治疗提供给虚弱和慢性疾病的人。其次，我们将详细回顾已发表的研究，以确定如何在虚弱的情况下支持自我管理。作为例子，我们将研究三种重要且常见的长期疾病患者的数据：2型糖尿病，类风湿性关节炎和慢性阻塞性肺病。估计虚弱在社区和临床试验参与者中的常见程度2。在社区和临床试验环境中检查虚弱与健康状况恶化（例如呼吸困难增加、住院治疗增加）之间的关系3。为了评估药物治疗的有效性是否是不同的人和没有frailtyAnd为2型糖尿病4。回顾已发表的关于自我管理的研究，以确定在支持自我管理时，如何最好地解释一个人的脆弱性、功能水平和更广泛的社会支持。潜在的应用和好处这项工作将提高对脆弱后果的理解。它还将开发和测试在试验中识别弱点的方法。这将为现有证据如何适用于虚弱的人提供见解。因此，该项目将使虚弱的人，临床医生，指南制定者，医疗保健组织和卫生政策制定者受益，以了解虚弱的含义以及如何最好地治疗虚弱的人，并支持他们管理自己的健康。它还将通过确定目前的研究在多大程度上（例如药物临床试验或自我管理方法）包括虚弱的人。

People who are more likely to become seriously unwell following relatively minor events (e.g. infections) are said to have "frailty". Frail people are more susceptible to harms, for example, from having diagnostic tests or side-effects of medications. Compared to people without frailty, this makes it harder to deliver the best care. Although older people are more likely to be frail, not all older people are frail. Younger people can also be affected by frailty, especially those with chronic illness such as diabetes. However, there is very little evidence about how clinical management should be adjusted in people with frailty, particularly younger people. A major gap in evidence relates to clinical trials. Clinical trials are the most important source of evidence about the effectiveness of treatments (e.g. a particular drug). It is generally believed that frail people are less likely to be included in trials. However, since trials do not usually measure frailty we do not currently know how often frail people are included, or if frail trial participants are similar to people in the community with frailty. This leaves clinicians uncertain about whether they can use the evidence from trials when deciding which treatments to offer frail people.A second challenge in managing frailty concerns "self-management", which is something everyone who has a chronic illness needs to learn. Self-management involves people balancing their condition (e.g. diagnostic tests, attending appointments, accepting treatments) against other priorities in their lives, given their own capacity and resources (e.g. financial circumstances, social support, other commitments). It is likely that self-management is more difficult for frail people. However, no previous study has reviewed all the published research to see if and how the presence of frailty should change the way health professionals support self-management.We plan to address both evidence-gaps.AimTo identify and measure frailty in clinical trials, as well as in community settings, to assess how best to apply evidence from trials when deciding what treatments to offer people with frailty and chronic illness. Secondly, we will undertake a detailed review of published research to determine how to support self-management in the presence of frailty.As examples, we will study data from people with three important and common long-term conditions: type 2 diabetes, rheumatoid arthritis, and chronic obstructive pulmonary diseaseObjectivesFor type 2 diabetes, rheumatoid arthritis, and chronic obstructive pulmonary disease:1. To estimate how common frailty is, in both the community and in participants in clinical trials2. To examine the relationship between frailty and deteriorating health (e.g. increasing breathlessness, increased hospitalisation), for both community and clinical trial settings 3. To assess whether the effectiveness of drug treatments is different for people with and without frailtyAnd for type 2 diabetes4. To review published research on self-management, to determine how best to account for a person's frailty, level of function, and wider social support when supporting self-management. Potential applications and benefitsThis work will improve understanding of the consequences of frailty. It will also develop and test methods for identifying frailty within trials. This will provide insights into how existing evidence applies to frail people. This project will therefore benefit people with frailty, clinicians, guideline developers, healthcare organisations and health policymakers to understand the implications of frailty and how to best treat people with frailty, and support them to manage their health.It will also guide the design of future research by determining the extent to which current research (e.g. clinical trials of drugs or self-management approaches) includes people with frailty.