Review Article
Frailty and Spousal/Partner Bereavement in Older
People: A Systematic Scoping Review Protocol
Vseteckova J*, Mahon A, Boyle G, Jones K and Garcia Ro
Author Affiliations
Senior Lecturer Health, Wellbeing and Social Care, Faculty of Wellbeing, Education and Language Studies, The Open University, UK
Received: January 04, 2020 | Published: January 13, 2020
Corresponding author: Vseteckova J, Senior Lecturer Health, Wellbeing and Social Care, Faculty of Wellbeing, Education and
Language Studies, The Open University, Room 024, Horlock Building, Walton Hall, Milton Keynes, MK7 6AA, UK
DOI: 10.26717/BJSTR.2020.24.004075
Aims of the Proposed Review
The aim of this project is to conduct a systematic review that will identify and collate
published information relating to frailty and spousal/partner bereavement (i.e. the
death of a life partner whether married or unmarried co-habiting) in older people (aged
60 years and above). The review will include all relevant national (UK) and international
research. This review aims to identify any gaps in literature that can help inform future
healthcare policies and models.
Keywords: Frailty Research; Spectrum Syndrome; Psychological Distress; Frailty Index
According to the World Health Organisation, 900 million people
globally were aged 60 years or more in 2015 [1]. This is predicted
to reach 2 billion by 2050 [2]. The population of the United
Kingdom is getting older. It is projected that by 2036, over half of
all local authorities in the UK will have 25% or more of their local
population aged 65 and over (Office for National Statistics, 2017).
The increasing number of international ageing populations has
resulted in a growing interest in frailty research. The syndrome
known as ‘frailty’ does not have an agreed operational definition
nor agreed diagnostic criteria [3-5]. Frailty is an ambiguous term
however; it generally refers to an increased vulnerability to adverse
health outcomes and is most commonly identified in older adults.
Frailty is not determined by old age. Frailty is a spectrum syndrome
that can encompass a myriad of environmental, psychological
and physiological diagnosis. While it is estimated that up to three
quarters of people over 85 years might not be frail, individuals who
are frail have significantly increased risks of falls, disability, longterm
care and death [6-7]. How frailty develops and how it can be
prevented remains unclear.
Research examining the specific relationship between marital
status and frailty appears to be limited [8]. Trevisan and colleagues
found a gender-specific difference in the onset of frailty, which
were also noted in marital-status and mortality and psychological
wellbeing studies, reporting increased risk for divorced, single,
widowed or never married males compared to females [9,10].
While frailty appears to universally affect females more than
males, Trevisan and colleagues found that widowed or single
males have a higher risk of developing frailty compared to married
males while widowed women carry a significantly lower risk of
becoming frail compared to married women. There is extensive
research demonstrating a negative impact of widowhood on health
outcomes including higher risk of disability [11] and higher rates
of depression and psychological distress [10,12] and mortality
in separated individuals compared to married individuals [10].
Following the PICO framework [13] and PRISMA-P methodology
[14], this systematic review aims to synthesise existing knowledge,
identify gaps in the literature and provide recommendations for
future research relating to frailty and spousal/partner bereavement (i.e. the death of a life partner whether married or unmarried cohabiting)
in older people (aged 60 years and above).
Employing a systematic review methodology, we aim to identify
and collate published information relating to frailty and spousal/
partner bereavement (i.e. the death of a life partner whether
married or unmarried co-habiting) in older people (aged 60 years
and above). While preliminary searches suggested that research
on this topic is limited it appears to indicate a negative association
between marital-status (i.e. widowhood) and frailty. The review
followed the Preferred Reporting Items for Systematic Reviews
and Meta-analysis for Protocols (PRISMA-P) guidelines with
the PRISMA-P checklist being used to draft the current protocol
[14]. The PICO framework was used to establish the questions
the review will address. The review aims to collate all available
information. Therefore, all research methodologies, including
possible intervention studies, will be included i.e. RCTs, quantitative
studies, observational studies, qualitative studies, mixed-method
studies and any other form of study that specifically examines the
relationship between frailty and marital status. Interventions may
include medical/physical, social, psychological or a combination
of all three. While a systematic review methodology was used, the
review was broad in its scope. For this reason, the protocol and
review design included the methodological framework proposed
by Arksey and O’Malley [5]. The Arksey and O’Malley’s framework
consists of five stages:
1. identifying the research question,
2. identifying relevant studies,
3. study selection,
4. charting the data,
5. collating, summarising and reporting results.
Each stage is discussed in further detail below. The last optional
stage, consultation, was not included in the current review.
Identifying the Research Question
The aim of the current review is to collect and synthesise
current knowledge on frailty and spousal/partner bereavement
(i.e. the death of a life partner whether married or unmarried cohabiting)
in older people (aged 60 years and above). This includes
determining the outcomes, if any, of spousal/partner bereavement
on frailty, identifying the factors that protect against and/or
increase frailty in older bereaved populations and identifying the
barriers and facilitators that can influence access to interventions to
reduce, slow-down or reverse frailty in these bereaved populations
(if any interventions exist and if a relationship between frailty and
spousal/partner bereavement is identified). The review aims to
synthetize existing knowledge, identify gaps in the literature and
provide recommendations for future research, which may lead to
improved interventions.
To meet these objectives, this review asked the following
questions:
1) Is there a relationship between spousal/partner
bereavement and frailty?
2) What factors influence frailty in bereaved older adults?
(protective or other)
3) What interventions are available within the UK and
internationally, that prevent any impact of spousal/partner
bereavement and frailty?
Identifying Relevant Studies
The review included a search of electronic databases (see
section 3.2.4), reference lists (ancestor searching), website
organisations and conference proceedings. Articles and evaluation
reports related to the topic of spousal/partner bereavement and
frailty were identified through an initial exploratory online search
using the electronic databases MEDLINE (PubMed) and CINAHL.
The text words in the title and abstract of relevant retrieved papers
were then analysed as well as the index terms used to describe
the articles. All identified keywords and index terms were used
to develop a rigorous search strategy that was undertaken across
all included databases. The reference list of identified reports and
articles was also searched for additional studies. The search was
limited to literature written in English. The search strategy can be
found in Appendix.
Inclusion Criteria
Types of Participants
Eligible participants included:
1) Older adults (60 years and above)
2) Marital status as married, civil partnership, widow,
widower, widowed or single if referring to the bereavement of a
co-habiting spouse/partner (unmarried un-cohabiting)
3) Participants must have co-habited with their spouse
prior to bereavement (with the exception of short-term
hospitalisations prior to death)
Concept
A. Types of Outcome Measures
The primary outcome of interest was frailty. All frailty
definitions and assessment tools are included in addition to studies
that included subjective definitions of frailty or studies that do not
detail the frailty criteria used. The two most frequently used frailty
definitions and assessment tools are the frailty phenotype (also
known as Fried’s definition or Cardiovascular Health Study (CHS)
definition [6] and the frailty [16] The frailty phenotype classifies
frailty as a syndrome that has three or more of five phenotypic
criteria: weakness as measured by low grip strength, slowness by
slowed walking speed, low level of physical activity, low energy or self-reported exhaustion, and unintentional weight loss. Pre-frailty
is defined as having one or two criteria present. Non-frail older
adults are classified as having none of the above five criteria.
The frailty index is a measure of the number of deficits
identified during a comprehensive geriatric assessment, including
diseases, physical and cognitive impairments, psychosocial risk
factors, and common geriatric syndromes other than frailty [16,17].
Variables are identified as meeting the FI inclusion deficit criteria
if the variable needs to be acquired, is age-associated, is associated
with an adverse outcome, and should not saturate too early [17-19].
Context/Setting: The review is international in scope.
Types of studies: To provide a comprehensive overview of this
research topic all existing literature will be included, e.g. primary
research studies, systematic reviews, meta-analyses, letters,
guidelines, websites etc.
Electronic Searches
The following electronic databases will be searched:
a) CINAHL
b) British Nursing Index
c) Web of Knowledge
d) Cochrane library
e) PsychInfo
f) SocIndex
g) University of York Centre for Reviews and Dissemination
(DARE, NHS EED, HTA)
h) JBI Database of Systematic Reviews and Implementation
Reports,
i) MEDLINE
j) EPPI
k) Epistemonikos
>
Searching other resources
Grey literature will be searched in OpenGrey, Google, and Google
Scholar. A full citation and reference search will be conducted for
any papers included in the final review.
Stage 3: Study Selection
Study Screening and Selection: Initial screening selection
(title and abstract screening) will be distributed amongst four
reviewers divided into two groups. Each group will screen the
full initial screening selection, with hits divided amongst both
reviewers in each group. The screening selection for reviewer
one from group A will be paired with reviewer one from Group
B and similarly for reviewer two from group A and reviewer two
from Group B. This allows a measure of inter-rater relability, using Cohen’s kappa coefficient (κ), for both sets of paired reviewers.
After eliminating the duplicates (studies identified more than once
by the search engines), an initial screening of titles, abstracts, and
summaries (if applicable) will be undertaken to exclude records
that clearly do not meet the inclusion criteria. Each record will be
classified as ‘include’ or ‘exclude’ to identify relevant and exclude
irrelevant literature. The researchers will be inclusive at this stage
and, if uncertain about the relevance of a publication or report, it
will be left in. Any disagreements in studies shortlisted for full text
screening will be solved by consensus or by the decision of a fifth
reviewer where necessary.
The full text will be obtained for all the records that potentially
meet the inclusion criteria (based on the title and abstract/
summary only), as agreed by all reviewers. In this second step, all
the full text papers will be screened against the inclusion criteria,
using a standardised tool. Studies that do not meet the inclusion
criteria will be listed with the reasons for exclusion. Multiple
publications and reports on the same interventions will be linked
together and compared for completeness. The record containing the
most complete data on any single intervention will be identified as
the primary article in the review, which can usually be the original
study or most recent evaluation report. A PRISMA-P flow-chart of
study selection will be included in the review.
Stage 4: Charting the Data
Data Extraction and Management: Data for analysis will
be extracted from the included studies and managed in an Excel
spread sheet. A data extraction sheet will be developed, tailored
to the requirements of the review. The data extraction sheet will
be tested on three included papers and, where necessary, it will be
revised to ensure it can be reliably interpreted and could capture
all relevant data from different study designs. Extracted data will
include authors, year of study/report, aim/purpose, type of paper
(e.g. journal article, annual evaluation report, etc), country/location,
study population (e.g., age of participants, gender, marital status,
living arrangements, health status pre-bereavement), average
length of relationship (in years), average length of bereavement (in
years) sample size, study design, frailty definition/criteria, frailty
rate, factors that impact on frailty rate (protective and negative
factors), description of any interventions/services/support for
study population, description of the interventions/services/
support (if any), factors that facilitate and/or hinder access to
interventions/services/support (if any), key findings that relate to
the review questions.
Stage 5: Collating, Summarising and Reporting the
Results
Presentation of the Results (Data Synthesis): Findings from
included studies will be synthesised narratively. First, a preliminary
synthesis will be conducted to develop an initial description of the
findings of included records and to organise them so that patterns
across records could be identified. In a second step, thematic analysis will be used to analyse the findings. The following five
steps of thematic analysis will be followed adopting a recursive
process [17]:
1. Familiarisation with the extracted data
2. Generation of initial codes
3. Searching for themes
4. Reviewing themes
5. Defining and naming themes.
Following Arksey and O’Malleys (2005) suggested framework, a
template (using Microsoft Excel) will be used to gather the themed
findings, and the final outcomes from the systematic scoping
review will be published in the academic literature. Depending on
the findings available the reviewers will aim to provide a flow chart
mapping the available information relating to frailty and spousal/
partner bereavement including the needs identified.
- (2018) Ageing and health. World Health Organization.
- (2017) Global strategy and action plan on ageing and health. World Health Organization p. 1-46.
- Bergman H, Ferrucci L, Guralnik J, Hogan DB, Hummel S, et al. (2007) Frailty: an emerging research and clinical paradigm-issues and controversies. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 62(7): 731-737.
- Buckinx F, Rolland Y, Reginster JY, Ricour C, Petermans J, et al. (2015) Burden of frailty in the elderly population: perspectives for a public health challenge. Archives of Public Health 73(1): 19.
- Hogan DB, MacKnight C, Bergman H (2003) Models, definitions, and criteria of frailty. Aging Clin Exp Res 15(3 suppl): 1-29.
- Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, et al. (2001) Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 56(3): 146-156.
- Song X, Mitnitski A, Rockwood K (2011) Nontraditional risk factors combine to predict Alzheimer disease and dementia. Neurology 77(3): 227-234.
- Trevisan C, Veronese N, Maggi S, Baggio G, De Rui M, et al. (2016) Marital status and frailty in older people: gender differences in the Progetto Veneto Anziani Longitudinal Study. Journal of Women's Health 25(6): 630-637.
- Hu YR, Goldman N (1990) Mortality differentials by marital status: An international comparison. Demography 27(2): 233-250.
- Gove WR (1973) Sex, marital status, and mortality. AJS 79(1): 45-67.
- Goldman N, Korenman S, Weinstein R (1995) Marital status and health among the elderly. Soc Sci Med 40(12): 1717-1730.
- Pearlin LI, Johnson JS (1977) Marital status, life-strains and depression. Am Sociol Rev 42(5): 704-715.
- Richardson WS, Wilson MC, Nishikawa J, Hayward RS (1995) The well-built clinical question: a key to evidence-based decisions. ACP journal club 123(3): A12-A13.
- Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, et al. (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. Bmj 349: 7647.
- Arksey H, O Malley L (2005) Scoping studies: towards a methodological framework. Int J Soc Res Methodol 8(1): 19-32.
- Jones DM, Song X, Rockwood K (2004) Operationalizing a frailty index from a standardized comprehensive geriatric assessment. J Am Geriatr Soc 52(11): 1929-1933.
- Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K (2008) A standard procedure for creating a frailty index. BMC Geriatr 8(24).
- Chen X, Mao G, Leng SX (2014) Frailty syndrome: an overview. Clinical interventions in aging 9(9): 433-441.
- Shor E, Roelfs DJ, Curreli M, Clemow L, Burg MM, et al. (2012) Widowhood and mortality: a meta-analysis and meta-regression. Demography 49(2): 575-606.