The role of speech-language pathologists in frailty: An Australian qualitative study of perceptions, practices, and opportunities

Abstract

Purpose

Frailty is an important geriatric syndrome, yet the role of speech-language pathologists (SLPs) in identifying and managing frailty remains unclear. The purpose of this study was to explore the perspectives of SLPs regarding frailty, including enablers, barriers, and opportunities for multidisciplinary improvements to frailty prevention and management.

Method

In this exploratory qualitative study, data were collected from SLPs through online semi-structured interviews and analysed using a qualitative descriptive approach.

Result

Seven Australian SLPs from acute, rehabilitation, geriatric, and community settings were interviewed. Three overarching themes were created: (1) SLPs understand the clinical manifestation of frailty but do not use explicit language to describe it; (2) SLPs acknowledged the importance of addressing knowledge gaps and barriers in frailty management; and (3) SLPs do not currently have an established identity within the frailty field, but do have a role within the multidisciplinary team and the care of people living with frailty.

Conclusion

Participants’ understandings of frailty varied and highlighted the lack of education about frailty as barriers to effective service provision. Additional research is required to produce formal recommendations for SLPs regarding frailty management, which may include frailty education to SLPs and awareness of SLPs’ role within the multidisciplinary team.

Keywords:

• frailty
• older adults
• qualitative
• ageing

Introduction

Frailty is a complex geriatric syndrome characterised by increased vulnerability to stressors, predisposing individuals to adverse outcomes including falls, disability, decreased mobility, delirium, and increased hospitalisation (Cicutto, 2018; Clegg et al., 2013). An individual is classified as frail when three of the five following characteristics are met: slow walking speed, impaired grip strength, a self-reported decrease in activity levels, unintended weight loss, or exhaustion (Fried et al., 2001). Frailty is closely linked to sarcopenia, which is the wastage of skeletal muscle, including the muscles involved in swallowing and speech (Cichero, 2018). This suggests an association between frailty, sarcopenia, and communication as well as swallowing disorders, which can have significant impacts on an individual’s health and quality of life (Dibello et al., 2021; Dodds & Sayer, 2016). Effective interventions for frailty require multidomain and multidisciplinary approaches to address the diverse needs of older adults. By understanding the dynamic, multidimensional nature of frailty and its associated conditions, healthcare professionals can collaborate and coordinate care to provide more effective support for individuals with frailty and promote healthy ageing (Chen et al., 2018). This common understanding of frailty among healthcare providers, including speech-language pathologists (SLPs), can improve timely recognition and diagnosis, facilitate communication and coordination, standardise care approaches, and ultimately improve outcomes for people with frailty, including reducing the risk of falls, hospitalisations, and mortality.

SLPs are uniquely qualified to assess and manage communication and swallowing disorders, which are common in older adults and can contribute to frailty (Dibello et al., 2021). Swallowing disorders are recognised as having a complex inter-relationship with frailty and the associated complications of malnutrition, dehydration, and aspiration pneumonia (Robison et al., 2023; Smithard et al., 2020). There is also a connection between communication and cognitive impairment and frailty resulting in unexpressed and unmet care needs for older adults and social isolation, further exacerbating risk for morbidity for frail individuals (Ning et al., 2023; Palmer et al., 2016; Rockwood & Mitnitski, 2011). SLPs can play an important role in recognising and managing frailty through screening and/or assessing communication and swallowing disorders, developing re-enablement and functional activities as part of a swallowing or communication rehabilitation program, and providing education and counselling to individuals and families (Windhaber et al., 2018). Furthermore, SLPs can work within multidisciplinary teams to provide education on communication and swallowing strategies to other healthcare professionals and develop comprehensive care plans (Mosadeghrad, 2014). Clinical guidelines, such as the Royal Australian College of General Practitioners’ (RACGP) Aged Care Clinical Guide (Silver Book; RACGP, 2019), recommend that SLPs form part of the multidisciplinary team involved in managing frailty.

Research on healthcare providers’ perceptions of frailty has explored the views of various professional groups, including nurses, general practitioners (GPs), orthopaedic surgeons, and allied health disciplines, such as physiotherapists and occupational therapists (e.g. Ambagtsheer et al., 2019; Arc-Chagnaud et al., 2019; Archibald et al., 2020; Cameron & Kurrle, 2015; Gobbens et al., 2022). This previous research conducted within the National Health and Medical Research Council (NHMRC) Centre of Research Excellence (CRE) in Transdisciplinary Frailty Research to Achieve Healthy Ageing (GNT 1102208) had a central objective to understand the perspectives of healthcare consumers and healthcare provider groups, including practice nurses, GPs, emergency department physicians, and orthopaedic surgeons regarding frailty and frailty screening to inform a coordinated approach (Ambagtsheer et al., 2019; Archibald et al., 2017, 2020). This research has highlighted the need for targeted education that attends to the biological, psychological, and social aspects of frailty, prepares healthcare providers to consider patients’ comprehensive needs, and provides a foundation for integrated, person-centred care for older people (Warren et al., 2022; World Health Organization [WHO], 2017). However, despite SLPs’ integral role in multidisciplinary, person-centred care, to our knowledge no previous qualitative study focused specifically on SLPs’ perspectives and understandings of frailty and their role in frailty identification and management.

To address this gap, this study builds on previous work by the CRE aiming to:

1. explore the perspectives of SLPs regarding frailty,

2. identify reported enablers and barriers to frailty prevention and management,

3. understand SLPs’ perceptions of multidisciplinary teamwork within frailty care, and

4. identify opportunities for knowledge translation and health service improvements related to frailty prevention, care, and management.

The objective is to broaden knowledge of this complex issue and provide valuable insights that could inform the development of more effective interprofessional strategies for prevention and management, and improve outcomes for older people with frailty.

Method

An exploratory qualitative descriptive design was used, which involved conducting individual semi-structured interviews. This approach has been shown to be effective in health research in generating initial data around topics with limited previous investigation or published evidence (Hunter et al., 2019). The primary goal of this design is to generate a comprehensive understanding of experiences, events, and perceptions by utilising low-inference interpretations during data analysis (Kim et al., 2017; Sandelowski, 2000). This means that the findings are reported in a concrete and tangible manner, including verbatim accounts of what participants said rather than researchers’ reconstructions and interpretations. By remaining close to the data and using the participants’ language, qualitative description can provide practical and relevant information to inform clinical practice and health service improvements.

Participants and recruitment

Practising SLPs were invited to participate in the study. Purposive sampling was used to recruit SLPs from a range of settings, locations, and levels of experience, with relevant expertise and experience to address the research topic. The study was advertised via email through the e-newsletter of Speech Pathology Australia (SPA) and the distribution list of other speech-language pathology professional networks and interest groups across Australia, with a reminder sent after 2 weeks of the initial invitation. No incentive or compensation was offered for participation. Whilst the invitation to participate had the potential to reach over 11 000 SPA members, it is unknown how many read and considered the invitation, therefore, clinician response rate could not be calculated. Potential participants expressed their interest via email to the first author. After signed informed consent was obtained, interviews were conducted at a suitable time and day nominated by each participant.

Data collection

A semi-structured interview guide (Appendix 1, Supplementary Material) was developed that focused on three topic areas related to the study’s objectives: (1) SLPs’ perspectives and understandings of frailty; (2) barriers to providing frailty services; and (3) opportunities for improvements to frailty services. All interviews were conducted between May and June 2022 by one Bachelor of Speech Pathology Honours degree student (KC), who was supported and supervised by psychology and speech-language pathology professionals. Microsoft Teams software (Microsoft, Washington, USA) was chosen over in-person interviews to accommodate the everchanging COVID-19 climate and to enable clinicians to participate remotely from their workplaces, which were dispersed across Australia. Each interview was audio- and visually-recorded using the software, and field notes were taken during and after the interviews to capture key concepts and patterns and to gain a deeper understanding of the data. Verbatim transcripts were generated using the built-in transcription feature in Microsoft Teams and checked for accuracy against the audio recording by the first author.

Data analysis

Data collected from the interviews were analysed using a qualitative descriptive approach to develop themes (Sandelowski, 2000). To ensure accuracy, two team members (KC, ML) read each transcript multiple times and manually removed any errors. A flexible coding framework was created in Microsoft Excel, using both deductive and inductive approaches. The initial coding framework was created by becoming familiar with the data and identifying key concepts and variables, which were used to create a set of code categories and labels. This framework was then applied to a subset of transcripts, allowing for necessary adjustments and refinements. Inductive coding was used to generate additional codes based on participants’ responses. These codes were subsequently organised into categories. Qualitative data was open coded and numerical codes were tabulated to identify patterns in the data through descriptive statistical analysis (i.e. counting the frequency of codes), including similarities and differences between subgroups of SLPs. This is a common analysis strategy in qualitative descriptive studies (Kim et al., 2017). A narrative summary of codes including illustrative quotes was then created, allowing the research team to develop major themes. Following deliberation with the team and referring to supportive data, the themes were discussed and agreed upon. The use of a team-based approach to data analysis enabled the researchers to reduce bias and gain a more comprehensive understanding of the data.

Rigour and trustworthiness

This study was reported using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist (Tong et al., 2007; Supplementary Material). We considered criteria for credibility, transferability, dependability, and confirmability to ensure trustworthiness. Transferability has been enabled by providing details about the study participants, the context where the research was undertaken, and a detailed description of the research process and findings (Nowell et al., 2017). Credibility has been established through extended engagement with the data, independent data analysis, and peer debriefing to compare concepts and themes. For confirmability and dependability, the first author kept an audit trail throughout the research process, which was checked by the other two authors, to ensure that the findings were supported by the data. The findings of the study were distributed to participants for their perusal and feedback.

Ethical approval

Ethical approval for this study was provided by the Flinders University Social and Behavioural Research Ethics Committee (project number 5311). Ethical principles of anonymity, informed consent, and the right to withdraw were maintained throughout the study.

Result

Seven Australian SLPs (6 females, 1 male) from the public and private sectors working within acute, rehabilitation, and geriatric wards, and community settings were interviewed. Participants were located across South Australia (SA), New South Wales (NSW), and Victoria (VIC). Each of the participants in this study had experience working with clients over the age of 65 years. Participants’ experience as an SLP ranged from less than 2 years to more than 20 years. The mean length of each interview was 28:09 minutes, ranging from 17:08 minutes to 47:55 minutes. Table I shows an overview of participant demographic information.

Table I. Participant demographic information (n = 7).

Participant ID	Gender	Public/ private setting	Work setting(s)	Years in role	Client age	Australian state/territory
1	Female	Public	Acute	18	18+	SA
2	Male	Public	Acute, geriatrics	4.5	65+	SA
3	Female	Public	Rehabilitation, geriatrics	3	65+	NSW
4	Female	Public	Rehabilitation, geriatrics	1.5	18+	SA
5	Female	Public	Rehabilitation, geriatrics	25	65+	NSW
6	Female	Private	Rehabilitation	1	18+	VIC
7	Female	Public	Geriatrics, community	4	65+	SA

Note: SA = South Australia; NSW = New South Wales; VIC = Victoria.

Three major themes were developed following data collection and analysis, reflecting the perspectives of SLPs regarding frailty. These were: (1) SLPs understand the clinical manifestation of frailty but do not use explicit language to describe it; (2) SLPs acknowledged the importance of addressing knowledge gaps and barriers in frailty management; and (3) SLPs do not currently have an established identity within the frailty field, but do have a role within the multidisciplinary team and the care processes of people living with frailty.

Theme 1: SLPs understand the clinical manifestation of frailty but do not use explicit language to describe it

When asked to define frailty in general terms, several participants expressed that they lack a clear understanding of the term (e.g. “I don’t know that I would clearly define it,” P1). Many participants did not provide a formal definition of frailty but instead described its defining attributes and clinical manifestation. Most participants associated frailty with older age (e.g. “you’d think like a little elderly person … generally a geriatric patient,” P3) or as a state of risk and increased vulnerability to poor health outcomes (e.g. “vulnerability that comes with frailty,” P7). In addition, most participants associated frailty with dysphagia, with two participants also associating it with a lack of interest in oral intake (e.g. “not eating very much or very limited, swallowing disorders of varying degrees, self-limiting in terms of certain food and drinks,” P2). Participants associated frailty with a variety of attributes and health conditions, such as functional decline or decreased independence (e.g. “requiring a carer or assistance,” P4), fatigue (P5), being homebound and/or bedridden (P7), reduced mobility (P2), decreased strength (P6), and weight loss (P5). Other ideas were also commented on, including a thin or skinny appearance (e.g. "a tiny, skinny little person that looks like they’re about to snap,” P3) and sarcopenia (e.g. "sarcopenic, losing muscle mass,” P2).

Some participants associated frailty with impaired communication, and more specifically with the larynx and voice changes present within the syndrome (e.g. “it does also impact their communication, so they often really like doing the voice exercises,” P5). One participant countered this association between frailty and communication impairment, stating, "people will have a communication impairment, whether they’ve got frailty or not. I think they’re not necessarily related” (P6). Whilst all participants described the clinical manifestation and associated comorbidities of frailty, most participants viewed the syndrome as being a natural or inevitable part of ageing. As one participant explained, “usually it’s an older adult who has sort of functional or cognitive decline that tends to be age related” (P6).

Theme 2: SLPs acknowledged the importance of addressing knowledge gaps and barriers in frailty management

Almost all participants identified the lack of targeted education or awareness of frailty among SLPs as a barrier to effective service provision (e.g. “lack of awareness of frailty, how it’s diagnosed, what its effects are on an individual,” P1), highlighting a lack of knowledge, specifically within the SLP profession, regarding how frailty can be addressed and managed. Participants commented on organisational and policy factors that can present barriers to frailty service provision. These included limited funding (e.g. “I think its chronically underfunded,” P3) and limited staffing (e.g. “we are always struggling with not having enough staffing to cover caseloads,” P1). One participant contradicted the idea of understaffing as a barrier, but reinforced the notion of lack of awareness, stating, “staffing alone won’t solve things, because I think you can have people on board, but if they aren’t familiar, aware, and educated about the demographic [older people], they will still miss things or misunderstand the value of things” (P7).

SLPs commented on how they actively intervene to manage frailty in their current practice, but some highlighted that they manage the syndrome within a reactive model, rather than taking proactive and preventative action. As one participant stated, “we probably don’t do a lot of prophylactic intervention in terms of trying to prevent frailty” (P1). Another participant explained, “we’re not necessarily actively going to prevent that [frailty]” (P2). Several participants commented that they recommend specific treatment programs for older adults with frailty based on their perceived communication and swallowing needs, with one participant stating, “I usually put people onto a program of intervention based on what I think their areas of issue are. And in frailty it’s often about strength” (P5). Another participant explained, “whilst we’re focused on safe swallowing, if things need to be tweaked a little bit so that someone has intake full stop, then that’s what we’re trying to facilitate” (P7). Some participants discussed the role of SLPs in preventing frailty (e.g. “I think there’s a really big role for speech pathology in the prevention and the turning around of the symptoms of frailty,” P5). However, several participants expressed that frailty is not preventable or reversible, and that there is little that SLPs can do to manage its progression (e.g. “I don’t know that we have a lot of control over that,” P7).

Some participants stated that they that they do not treat people with frailty any differently from other client groups in terms of treatment approaches (P6). Other participants acknowledged being unaware of specific interventions for the frail population, expressing uncertainty about what they currently do (e.g. P4). Participants noted that they generally follow usual assessment and intervention protocols based on the patient’s presentation, without necessarily tailoring them to the specific needs of people with frailty. Participants also commented on current measures regarding new patient referrals within frailty, stating, “it just feels like when we get people, they’re already past the point of being able to help” (P4). Several SLPs expressed a willingness to learn more about their role within frailty, indicating an interest in expanding their knowledge and capabilities (e.g. P4).

Theme 3: SLPs lack an established identity within the frailty field, but do have a role within the multidisciplinary team and the care process of people living with frailty

Participants in our sample expressed diverse perspectives on potential improvements to frailty services. Some participants emphasised the importance of anticipatory care or early intervention (e.g. “early intervention there could potentially help from a speech pathology perspective, looking at diet and fluid modification earlier in the piece may assist with maintaining their weight,” P1). Participants also highlighted the importance of increasing frailty screening uptake (e.g. “I think there could be ways that we could be doing some screening for, you know, malnutrition risk,” P2). Participants also emphasised the value of providing education in a multidisciplinary or interprofessional setting to enhance the understanding of the unique contributions of SLPs (P4, P5; e.g. “letting our team know what our role is and what we can do for the patient, I think sometimes people don’t understand exactly what we do,” P4). Participants further stressed the need for speech-language pathology involvement within multidisciplinary team meetings (e.g. “I think we just need to be willing to speak up … making sure that we’re involved in like multidisciplinary meetings … we just need to as a profession to make sure we have a voice in these kinds of areas,” P3).

Improving staffing resources was identified as another important consideration. Participants noted that having appropriate staff can make a significant difference in delivering effective care for people with frailty (P7). Moreover, participants suggested raising awareness of frailty within healthcare settings and the community through targeted education strategies. As one participant stated, “I think there’s also a place for us to provide more education around that to other disciplines in terms of how we can support” (P2). Another participant commented, “ideally you would have education that people could come to, to discuss risk factors for becoming frail” (P4), highlighting a need for education within the community.

Although the three themes have been described separately, they are interconnected and mutually reinforcing. SLPs’ knowledge and awareness of frailty can impact their care practices and treatment approaches for frail individuals, while their experiences in providing care can further shape their perception of their role and responsibilities in the interdisciplinary management of frailty. This relationship is illustrated in Figure 1.

Figure 1. Cyclical relationship between the three major themes.

Discussion

This study aimed to explore SLPs’ understanding of frailty and its impact on their service provision to older adults. The research identified three main themes. Firstly, participants showed an understanding of frailty’s clinical manifestation but lacked explicit language to describe it. Secondly, participants acknowledged the lack of targeted education or awareness of frailty among SLPs as a barrier to effective service provision. They also identified organisational and policy factors that hindered service provision, aligning with findings from previous studies (Warren et al., 2022). Lastly, the participants discussed their role within the multidisciplinary team and the care process of people living with frailty. While most participants stated that they manage older adults with frailty within their practice, some highlighted that they manage the frailty within a reactive model, rather than taking proactive and preventative action. Participants also discussed the role of SLPs in preventing frailty. However, other participants expressed that frailty is not preventable or reversible, and there is little that SLPs can do to manage its progression. Participants varied in their perceptions of potential improvements to frailty services, with some commenting on the importance of anticipatory care or early intervention within frailty. The study suggests that SLPs lack an established identity within the frailty field but do have a role within the multidisciplinary team and the care process of people living with frailty.

SLPs’ understanding of frailty can influence their perception of their role and interventions when working with people with frailty. SLPs who have a comprehensive understanding of frailty may be better equipped to assess and treat communication and swallowing disorders commonly associated with frailty. For example, by proactively addressing dysphagia they can reduce the risk of malnutrition, aspiration pneumonia, and other adverse health outcomes (Carrión et al., 2015). Additionally, SLPs who are aware of the cognitive and psychological aspects of frailty can effectively address communication difficulties in frail individuals, including cognitive-communication disorders, aphasia, voice disorders, and dysarthria (Cichero, 2018). In comparison, SLPs who view frailty primarily as a physical condition may focus more on addressing the physical aspects of communication and swallowing disorders, such as muscle weakness and coordination deficits (Machida et al., 2017). SLPs with a comprehensive understanding of frailty are more likely to collaborate with other healthcare professionals, such as physiotherapists and occupational therapists, to provide comprehensive care that addresses the complex needs of people with frailty (Cameron & Kurrle, 2015).

This study’s findings highlight the need for targeted frailty education among SLPs as well as the wider multidisciplinary team (Warren et al., 2022; Windhaber et al., 2018). Although there is increasing attention on frailty in clinical practice, research has found that many healthcare professionals are still largely unaware of the condition of frailty and do not routinely focus on frailty in their clinical practice (Ambagtsheer et al., 2019; Papadopoulou et al., 2021). Studies involving a range of healthcare professional groups demonstrate difficulties defining frailty, as well as displaying limited awareness of frailty screening tools (D’Avanzo et al., 2017). Misconceptions, such as believing that frailty is a natural part of ageing or is non-modifiable, are common among healthcare professionals and people with frailty (Archibald et al., 2020), and these findings were replicated in this study. As a result, assessment and management of frailty is often neglected in clinical care, suggesting that healthcare providers require further training related to frailty (Warren et al., 2022). A limited number of studies have focused on frailty training programs for healthcare professionals. These studies found significant improvements in frailty knowledge (Donoghue et al., 2022), self-perceived competence in frailty assessment (Arakawa Martins et al., 2020), and completion of standardised frailty assessments and consideration of frailty-related issues during routine care (Kotsani et al., 2021). Common features of successful programs included having multidisciplinary participants and/or facilitators, delivering a tailored program, and utilising flexible teaching modalities (Warren et al., 2022).

Frailty education programs for SLPs should involve developing the knowledge and skills necessary to address the distinct needs of individuals with frailty. They should also emphasise the importance of individualised, person-centred, and integrated care (Kime et al., 2022). Key areas that could be incorporated into such training include definitions of frailty (e.g. what it is, how it is diagnosed, and factors contributing to its development), communication strategies for older adults with frailty, dysphagia management, cognitive-communication interventions, and collaborating with multidisciplinary teams. Training in collaboration with multidisciplinary teams should focus on coordinating care with other healthcare providers, such as specialist physicians (e.g. geriatricians), GPs, nurses, physiotherapists, and occupational therapists. Frailty education for SLPs could be implemented in various ways that cater to different needs and contexts. Examples include embedding frailty education into courses/curricula during formal training, continuing education and professional development, interprofessional education, simulation training, mentoring, and supervision to inform SLPs of best practices and evidence-based interventions (Warren et al., 2022).

Beyond education programs, the findings also suggest there is a lack of clinical practice guidelines for SLPs specific to frailty. Speech Pathology Australia dedicates a webpage and position paper to Ageing and Aged Care, providing information to members for navigating the aged care system and reference to the Professional Standards and Ethics Code of Practice (Speech Pathology Australia, 2023). Despite the large amount of valuable information on these pages being useful in guiding SLPs’ practice with older people in general, there is a lack of information specific to frailty.

Limitations and future directions

The main limitation of the current study is its small sample size. Despite two invitations across Australia and the use of snowball sampling, recruitment was restricted to only seven SLPs. The research team were satisfied that the data collected were adequate with respect to the exploratory aims of the research (Hennink & Kaiser, 2022), but findings may not be generalisable to the wider population of SLPs that provide care for people living with frailty and it is not yet plausible to provide specific recommendations to SLPs regarding their role in the frail population.

Using this study as a basis, future research in consultation with SLPs may generate consensus on the management of frailty, including recognition of potential risk factors and preventative measures, as well as developing educational programs to improve frailty knowledge at the clinical frontline (Cameron & Kurrle, 2015; Windhaber et al., 2018).

Conclusion

This study provides insight into the perceptions of practicing SLPs regarding frailty care and management. It highlights the need for increased frailty education and awareness among SLPs and within the multidisciplinary team, to improve service provision and quality of care. Together with previous research, this study’s findings could be used to inform targeted strategies to improve knowledge and awareness of frailty among health professionals, ultimately leading to better health outcomes and quality of life for individuals living with frailty.

Declaration of interest

No potential conflict of interest was reported by the authors.