The Case for Treating Frailty Like a Primary Care Problem

 A primary care-led program that combines supervised exercise, nutrition counseling, and clinician training can improve frailty and physical function among older adults, according to a recent study published in the Journal of the American Geriatrics Society.

Although conducted in Spain, investigators said the findings are highly relevant to primary care in the US, where frailty screening is increasingly recommended but evidence-based, scalable interventions remain limited.

“This improvement in frailty status represents substantial functional recovery in a population at high risk for disability, institutionalization, and mortality,” said Richard Stefanacci, DO, geriatrician and adjunct professor at Thomas Jefferson University in Philadelphia, who was not involved in the research.

Frailty affects as many as 17% of US adults aged 65 years or older and is strongly associated with hospitalization, falls, disability, and potentially avoidable healthcare spending.

The FRAILMERIT study enrolled 273 community-dwelling adults aged 70 years or older with pre-frailty or frailty who remained independent in basic activities of daily living and received care at 12 primary care centers across Spain. Participants were randomly assigned by the clinic to receive either usual care or the multicomponent intervention.

More than 80% of patients receiving the intervention showed improvements in frailty or physical performance at 32 weeks compared with about 52% of patients receiving usual care (absolute risk reduction, 29.8%; P < .001). The number needed to treat was 3.4, meaning roughly 3-4 patients would need to participate for one person to benefit. To compare, programs that offer counseling for smoking cessation, statins for heart disease prevention, and treatment for blood pressure often require dozens of patients to achieve one measurable outcome.

The intervention included twice-weekly, in-person group exercise sessions held at primary care centers led by physiotherapists or trained exercise professionals. Sessions emphasized progressive strength and balance training and were individualized based on baseline function. Patients also received structured nutritional recommendations. Primary care clinicians completed a brief training program focused on how to identify and manage frailty.

The primary endpoint included improvement in any of the five frailty phenotype criteria, such as unintentional weight loss or exhaustion, or a one-point increase in the Short Physical Performance Battery (SPPB) score. A one-point improvement on the scale reflects meaningful gains in gait speed, balance, and sit-to-stand ability, Stefanacci said. 

After the first 12-week intervention period, 70.4% of patients in the intervention group met the primary endpoint compared with 49.5% in the control group. Improvement rates increased further by week 32 to 80% of those in the intervention group and 52% in the control group. No intervention-related harms were reported.

“The SPPB specifically matters because it predicts hospitalization, institutionalization, and mortality,” Stefanacci said. 

The persistence of benefit after an 8-week break between intervention phases suggests lasting behavioral and functional change rather than effects from short-term exercise, Stefanacci said. Patients who improved after the first intervention phase were significantly more likely to maintain gains at final follow-up, and those who did not initially improve often did so after the second intervention period (P < .001).

Still, some geriatricians caution that because the main outcome bundled several different measures, which improvements truly made a difference is not clear.

“I’d love to know among those who had an improvement, for what reason they met criteria,” said Nancy Schoenborn, MD, associate professor of medicine in the Division of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine in Baltimore, who was not involved in the study.

Schoenborn said not all components are equally meaningful in practice.

“Weight loss is one of the five categories of the frailty phenotype,” she said. “It’s less impressive if that’s the bulk of their outcome, and one might achieve the same by what we call liberalizing diet — tell older adults to eat more with less dietary restrictions.”

Improvements in fatigue would be more compelling “if they were able to achieve less fatigue, for example — which is another one of the five categories of the frailty phenotype,” she said. “I’d care a lot more because that is a common and very bothersome complaint in primary care, and we often don’t have much to offer in terms of therapy.” 

While exercise is widely recommended to older adults, few randomized trials have tested programs embedded directly in primary care settings, particularly those combining patient-facing interventions with clinician training.

Schoenborn said adherence may explain much of the observed benefit.

“Someone chasing after you to do these things as part of a trial vs giving you a referral you have to follow through with is different in terms of adherence,” she said.

Stefanacci said there are several challenges to applying the model in the US. The study relied on physiotherapists, small group sessions, repeated contact over months, and team-based care — resources largely absent from most US primary care practices, he said.

“This is not a clinical or educational problem; it’s a systemic healthcare delivery and payment problem,” Stefanacci said, pointing to time constraints, workforce shortages, and fee-for-service reimbursement that does not support supervised group exercise or extended nutritional counseling.

The study did have limitations. Attrition was high, with 43% of participants not completing the full 32-week follow-up, particularly in the control group.

The findings are highly relevant for integrated care settings, such as PACE programs, geriatrics-focused medical homes, and other capitated or value-based models that include multidisciplinary teams. In those environments, FRAILMERIT-style interventions are feasible.

However, extending this approach across US primary care would require broad systemic changes, Steffanci said.

“This is not a clinical or educational problem — it’s a systemic healthcare delivery and payment problem,” he said.

The study was supported by the Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación y Unión Europea, and by CIBER de Fragilidad y Envejecimiento Saludable. The authors and Schoenborn reported having no relevant disclosures.

https://www.medscape.com/viewarticle/case-treating-frailty-primary-care-problem-2026a100024y