J Nutr Health Aging. 2019;23(8):710-716 © The Author(s) A COMMUNITY PROGRAM OF INTEGRATED CARE FOR FRAIL OLDER ADULTS: +AGIL BARCELONA L.M. PÉREZ1,2, M.B. ENFEDAQUE-MONTES3, M. CESARI4,5, L. SOTO-BAGARIA1,2, N. GUAL1,2,6, M.P. BURBANO1,2, F.J. TARAZONA-SANTABALBINA7,8, R.M. CASAS9,10, F. DÍAZ11, E. MARTÍN3, A. GÓMEZ11, F. ORFILA3,12, M. INZITARI1,2,6 1. Parc Sanitari Pere Virgili, Area of Intermediate Care, Barcelona, Spain; 2. RE-FiT Barcelona research group, Vall d’Hebrón Institute of Research, Barcelona, Spain; 3. Institut Català de la Salut, Gerencia Territorial de Barcelona de Atención Primaria, Barcelona, Spain; 4. Geriatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy; 5. Department of Clinical Sciences and Community Health, Università di Milano, Milano, Italy; 6. Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; 7. Hospital Universitario de la Ribera, Valencia, Spain; 8. School of Nursing, Catholic University of Valencia San Vicente Mártir, Valencia, Spain; 9. Department of Internal Medicine, Hospital Clínic, Institut d’Investigacions August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; 10. Centro de Investigación Biomédica en Red de la Fisiopatología de la Obesidad y Nu-trición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; 11. Primary Healthcare Center Bordeta-Magòria, Institut Català de la Salut, Barcelona, Spain; 12. Institut de Recerca en Atenció Primaria Jordi Gol, Barcelona, Spain. Corresponding author: Laura Mónica Pérez Bazán, Avinguda de Vallcarca, 169-205, 08023 Barcelona, Spain, E-mail: lperez@perevirgili.cat, Telephone: +34 934 594000 / +34 600 646 967 Abstract: Objectives: To assess the 3-month impact on physical function of a program for community-dwelling frail older adults, based on the integration of primary care, geriatric medicine, and community resources, implemented in “real life”. Design: Interventional cohort study. Setting: Primary care in Barcelona, Spain. Participants: Individuals aged ≥80 years (n=134), presenting at least one sign of frailty (i.e., slow gait speed, weakness, memory complaints, involuntary weight loss, poor social support). Intervention: After frailty screening by the primary care team, candidates were referred to a geriatric team (geriatrician + physical therapist), who performed a comprehensive geriatric assessment and designed a tailored multidisciplinary intervention in the community, including a) multi-modal physical activity (PA) sessions, b) promotion of adherence to a Mediterranean diet c) health education and d) medication review. Measurements: Participants were assessed based on a comprehensive geriatric assessment including physical performance (Short Physical Performance Battery -SPPB- and gait speed), at baseline and at a three month follow-up. Results: A total of 112 (83.6%) participants (mean age=80.8 years, 67.9% women) were included in this research. Despite being independent in daily life, participants’ physical performance was impaired (SPPB=7.5, SD=2.1, gait speed=0.71, SD=0.20 m/sec). After three months, 90.2% of participants completed ≥7.5 physical activity sessions. The mean improvements were +1.47 (SD 1.64) points (p<0.001) for SPPB, +0.08 (SD 0.13) m/sec (p<0.001) for gait speed, -5.5 (SD 12.10) sec (p<0.001) for chair stand test, and 53% (p<0.001) improved their balance. Results remained substantially unchanged after stratifying the analyses according to the severity of frailty. Conclusions: Our results suggested that a “real-world” multidisciplinary intervention, integrating primary care, geriatric care, and community services may improve physical function, a marker of frailty, within 3 months. Further studies are needed to address the long-term impact and scalability of this implementation program. Key words: Frailty, integrated care, physical activity, primary care. Introduction and designed according to the results of a comprehensive geriatric assessment (CGA) when possible (5–9, 12, 13). Frailty, a dynamic state of decreased biological reserves Among other interventions, the promotion of physical activity and vulnerability to stressors, increases the risk of negative is crucial (14). Such programs may find an ideal place in health events, such as a rapid progression towards disability, primary care settings, integrating the expertise of a geriatric falls, fractures, institutionalization, and death (1). Frailty is team (15). Different studies have approached frailty in the potentially reversible (2, 3). Therefore, its early assessment, primary care or community setting (5–9, 13), but most of recognition and management represent an important component them had rigidly controlled experimental conditions of preventive strategies within healthcare systems as well as a and schemes and their submission to specific funds make challenge (4). the subsequent sustainability, implementation and scaling- Various studies have shown that interventions aimed to up of the same activities in real life, difficult (5, 7–9). detect at an early stage and manage frailty are effective (2, Under these circumstances, we recently proposed different 5–11). These interventions incorporate individualized recommendations to design and develop complex pragmatic actions aimed to reduce or slow down the progression of interventions aimed at comprehensively managing frailty (16). frailty towards disability and, consequently, to reduce and/ In agreement with these recommendations, we have designed a or eliminate the potential negative consequences on health. multifactorial person-centered intervention against frailty (16). Due to the multifactorial nature of frailty, interventions The aim of the present study is to assess a 3-month impact targeting frailty in the community should also be multifactorial, on physical function of a “real life” program for frail older Received March 8, 2019 Published online August 30, 2019, http://dx.doi.org/10.1007/s12603-019-1244-4 Accepted for publication March 25, 2019 710 J Nutr Health Aging Volume 23, Number 8, 2019 THE JOURNAL OF NUTRITION, HEALTH & AGING© adults in the community, based on the integration of primary Assessment care, geriatric medicine, and community services. The intervention follows the principles of the Frailty Intervention Trial (9), being tailored according to the problems Methods detected through a CGA conducted by the geriatrician and the physical therapist. Socio-demographic data (age, sex, The methodology of the +AGIL Barcelona program marital status, living alone), clinical characteristics (past (“Atenció primària i Geriatria Integrades amb visió medical history, Charlson comorbidity index (18), and current Longitudinal” in Catalan) is described elsewhere (16). Shortly, treatment), functional status (Barthel index for basic [0-100 it stems from a strategic alliance between the principal public points] (19) and Lawton index for instrumental activities for provider of primary care in Barcelona (Institut Català de daily living [0-8 points] (20)), nutrition (Mini Nutritional la Salut, Àmbit d’Atenció Primària de Barcelona) and the Assessment–Short Form [MNA-SF®] (21) plus a standardized major public provider of intermediate care, geriatrics and assessment of adherence to a Mediterranean diet (22)), palliative care in Catalonia (Parc Sanitari Pere Virgili). The cognition (Mini-cog® (23)), depressive symptoms (Geriatric program is conducted in the primary care center of Bordeta- Depression Scale (24)), and physical function (Short Physical Magòria (Barcelona, Spain), which provides healthcare Performance Battery [SPPB, 0-12 points] (25)) were collected. services to 32,340 citizens (20% aged ≥65 years, 6.9%≥80 Frailty status was measured using the Clinical Frailty Scale years). The protocol was approved by the Clinical Research (CFS) (26). Ethics Committee of the Institut Universitari d’Investigació en Atención Primaria, Jordi Gol. Intervention +AGIL Barcelona began in July 2016 as an additional The participant and their family or caregiver received the service and as a result, as part of the geriatric outpatient results of the CGA the same day of the evaluation. Through clinic which was transferred to the community. The geriatric a shared decision-making process, carried out on the basis team, including a geriatrician and a physical therapist, attends of motivational interviewing techniques, the geriatrician the primary care center once a week in order to assess the proposed a tailored strategy to achieve shared goals. The patients referred by the primary care team (i.e., family participants retained a copy of the agreements, set goals, and physicians, nurses, social workers). The program also fosters recommendations in plain language. Primary care staff could the subsequent maintenance of physical activity through the join geriatric visits and had access to the complete report existing community resources. Together with the nearby civic through the shared electronic health records (EHR). center we co-designed a continuation activity which initially is The multifactorial intervention, as previously described (16) performed under the supervision of a trainer and progressively included: shifts towards self-practice. The implementation includes - Physical activity. After a first individual assessment, an refinement with end-users (both professional and participants) expert physical therapist recommended an adapted exercise (16). program to be performed at home, which included strength, resistance, balance, and coordination exercises. The therapist Study population ran a supervised program including up to 10 sessions (1 h/ Primary care is in charge of identifying the potential week) of multi-modal group exercises, where group beneficiaries of the intervention. The screening strategy is socialization was also promoted. The therapist modulated the generally directed to older adults without physical disability exercises according to each participant’s capacity and needs, and/or acute clinical disease, aged ≥80 years and presenting in terms of intensity, time and type (including dual-tasking at least one sign of frailty (i.e., slow gait speed, weakness, if needed). The exercises had a functional and significant memory complaints, involuntary weight loss, or poor social character in order to increase the therapeutic adherence support). In particular, the Gerontopôle Frailty Screening Tool and make the exercises similar to the daily activity of the (GFST), an 8-item questionnaire validated for frailty screening participant. Different strategies were directed to empower the in primary care (17), was selected by a primary care team to person and to foster adherence to physical activity over support the identification of possible candidates. Being this is time, including the delegation of the participant to lead their a “real life” program, different from a rigid clinical trial, the last group session for a short time, the recommendation of referral is flexible depending on the judgment of the primary personalized exercises as “homework” and the indication of care team and eventually include individuals with a higher existing community resources to maintain physical activity degree of frailty (i.e. with some already established disability) after the 10 sessions. The Vivifrail® app or a printed chart of or “less than frail” (mostly sedentary), as previously detailed tailored exercises derived from it, is given to each participant as (16). complementary material (27), and with positive reinforcement based on motivational interviewing. - Nutrition. The intervention aimed at promoting adherence to a Mediterranean diet, following the Prevention with 711 J Nutr Health Aging Volume 23, Number 8, 2019 +AGIL BARCELONA: INTEGRATED CARE FOR FRAILTY Mediterranean diet (PREDIMED) intervention paradigm (28), (an impairment at follow-up) were imputed. and took into account the caloric and protein intake needs. Finally, changes in the CFS between baseline and three- - Health education. This included the promotion of healthy month follow-ups were analyzed by the Chi-square test. habits, reinforcing ongoing activities in the primary care center In all analyses, p-values <0.05 were regarded as statistically (e.g., smoke or alcohol control) or others (e.g., sleep hygiene, significant. The 95% confidence intervals (95%CI) were fall prevention recommendations). calculated. Analyses were performed using Stata version 14. - Adequacy of pharmacological treatment. In agreement with the family physician, the geriatrician reviewed the Results patients’ medication to increase value-based prescriptions. No standardized tool to test the medication adequacy was used From July 2016 to July 2018, 134 individuals out of 180 owing to the presence of a geriatrician with specific expertise screened (74.4 %) accepted to participate in the program (Fig on medication review and de-prescribing. The geriatrician 1). Twenty-two (16.4%) missed the follow-up (5 refused to was also remotely supported, in case of need, by the clinical undergo the follow-up visit after correctly completing ≥75% pharmacist working at the intermediate care hospital. of physical activity sessions and without any incident event, Both the therapist (on a weekly basis, when running the 14 because of an intercurrent medical event, and 3 did not group activity) and the geriatrician (in one single follow-up attend the follow-up visit despite the absence of medical visit at 3 months) monitored the intervention plan over time. complications). Finally, 112 individuals (mean [SD] age=80.8 Subsequently, the patient kept the usual follow-up with the [SD 5.8] years; 67.9% women) were included in the analysis. referent primary care professional, who continued promoting Baseline characteristics were comparable between the 112 the achievement of the initially shared goals. The geriatrician’s included participants and the 17 excluded because of events or intervention remained on demand. The coordination/interaction unknown reasons (Table 1). of the primary care and geriatric teams was facilitated by a shared EHR and formal meetings on regular basis. Figure 1 Population follow chart Outcomes The primary outcome of interest was the 3-month, pre/post intervention modification of physical performance (measured by either SPPB and/or its sub-item gait speed). As a secondary outcome, the change in the CFS was explored. Statistical analyses Baseline characteristics of the sample are presented as mean values and standard deviation (SD) for continuous variables, median values and interquartile range (IQR) for ordinal variables and percentages for categorical variables. Differences among participants included in the intervention and those who were missing, were analyzed using the Student’s t-test or the Mann–Whitney U-test and Chi-square test, as appropriated. The pre/post intervention analysis was done by a paired sample t-test for repeated samples or Wilcoxon signed-rank for continuous variables and Chi-square for categorical variables. For those participants who were unable to perform the chair stand test (n=9), the value of 61 seconds was imputed according to the reference categories previously published (25). The Analysis of variance (ANOVA) and Jonckheere-Terpstra trend test were used for continuous variables when the analyses were stratified by the frailty degree according to 3 CFS categories (“Managing well or fit”, “vulnerable”, “any degree of frailty”). PA: Physical activity. A sensitivity analysis was also performed considering the participants who did not undergo the follow-up assessment The 112 included participants were generally independent because of incident events, or for other reasons that could not for basic Activities of Daily Living (ADL, median Barthel be ascertained. In these cases, the worst change of the assessed Index=95, IQR=90-100) and instrumental ADL (IADL, median group for either SPPB (3 points loss), gait speed (0.32 m/sec Lawton’s score=6, IQR=4-8), had a relatively low comorbidity loss), chair stand test (45.6 sec increase) or balance impairment (median Charlson index=1, IQR=0-2), but presented polypharmacy (median number of drugs=7, IQR=5-9) and low 712 J Nutr Health Aging Volume 23, Number 8, 2019 THE JOURNAL OF NUTRITION, HEALTH & AGING© Table 1 Baseline characteristics of the sample Baseline characteristics Included n= 112 Missing n=17 p Age, mean (SD) 80.9 (5.8) 82.4 (4.1) 0.210 Woman, % (n) 67.9 (76) 88.2 (15) 0.086 Barthel index , median (IQR) a 95 (90-100) 95 (85-100) 0.494 Lawton index , median (IQR) b 6 (4-8) 7 (4-8) 0.617 Lives alone, % (n) 42.0 (47) 64.7 (11) 0.079 Education, % (n) Illiterate 4.5 (5) 12.5 (2) 0.131 Primary school 32.1 (36) 50.0 (8) Secondary school 49.1 (55) 37.5 (6) University degree 14.3 (16) 0 (0) Adequate physical activity , % (n) c 38.4 (43) 23.5 (4) 0.235 Falls in the last year, % (n) 34.8 (39) 41.2 (7) 0.610 Malnutrition risk , % (n) d Normal nutrition status 61.6 (69) 76.5 (13) 0.209 At risk of malnutrition 36.6 (41) 17.7 (3) Malnourished 1.8 (2) 5.8 (1) Charlson Comorbidity, median (IQR) 1 (0-2) 2 (1-4) 0.052 Previous diagnosis of cognitive impairment, % (n) 18.8 (21) 25.0 (4) 0.483 Number of drugs, median (IQR) 7 (5-9) 9 (6-10) 0.171 Gerontopôle FST positive, % (n) 94.6 (106) 100 (17) 0.328 Clinical Frail Scale - vulnerable or any frailty degree, % (n) 63.4 (71) 64.7 (11) 0.917 SPPB e, mean (SD) 7.48 (2.12) 7.18 (2.60) 0.650 Gait speed, mean (SD) 0.71 (0.20) 0.67 (0.20) 0.486 Chair stand test, mean (SD) 22.40 (13.67) 24.52 (18.20) 0.898 Balance impairment, % (n) 43.8 (49) 58.8 (10) 0.245 Physical activity sessions, mean (SD) 9.2 (1.9) 5.4 (3.1) <0.001 IQR: interquartile range, SD: standard deviation. Student’s t-test or the Mann-Whitney U-test were used for continuous variables as appropriated and Chi-square test for categorical. a. Independence for activities of daily living, range from 0-100. b. Independence for instrumental activities of daily living, range from 0-8. c. At least 30 min of physical activity 3 times/ week (based on WHO recommendation). d. Mini-Nutritional Assessment Short form score: 8-11 points. e. Short Physical Performance Battery, range from 0-14 physical performance (SPPB mean=7.5 [SD 2.1] and gait speed after stratifying the analyses by frailty degree (Table 3). mean=0.7 [SD 0.2]). However, no linear association between improvement and Regarding the intervention, physical activity was performed frailty degrees were found. Additionally, after imputing the in the whole sample, with a high adherence (90.2% attended worst observed changes in the 17 participants without the 3 ≥75% session, mean [SD]=9.2 [SD 1.9] out of 10 planned month visit because of events or for unknown reasons, we sessions), as well as health education interventions and confirmed statistically significant improvement in SPPB (+0.88 nutritional recommendations, whereas pharmacological [SD 2.16] points, p<0.001), chair stand (-10.83 [SD 17.7] sec, treatment was modified in 76 (67.9%) participants. p<0.001), balance (44.1% improved, p<0.001), and a non- Regarding the primary outcomes, after three months, the significant improvement in gait speed (+0.02 [SD 0.20] sec, SPPB and gait speed improvements were +1.47 [SD 1.64] p=0.301). points (p<0.001) and +0.08 [SD 0.13] m/sec (p<0.001) Analyzing the change of frailty degree at 3 months, respective, as is shown in Table 2. Improvement in chair stand according to the CFS, 14.3% of the participants experienced test (-5.5 [SD 12.1], p<0.001), and balance (53%, p<0.001) progression towards a higher level of frailty, 64.3% remained were also analyzed. Results remained substantially unchanged stable, and 21.43% improved of some degree (p<0.001). 713 J Nutr Health Aging Volume 23, Number 8, 2019 +AGIL BARCELONA: INTEGRATED CARE FOR FRAILTY Table 2 Effect of the Multifactorial Intervention on physical function capacity Before After Difference (95%CI) p SPPB , mean (SD) a 7.48 (2.12) 8.94 (2.03) 1.47 (1.16 – 1.78) <0.001 Gait speed (m/sec), mean (SD) 0.71 (0.20) 0.79 (0.18) 0.08 (0.05 – 0.10) <0.001 Balance impairment, % (n) 43.8 (49) 20.5 (23) 53.1 (26) <0.001 Chair stand test (sec), mean (SD) 22.40 (13.63) 17.00 (10.62) -5.50 (-7.78 – -3.22) <0.001 SD: standard deviation; a. SPPB: Short Physical Performance Battery, range from 0 to 12; 90.2% of participants attended ≥75% session, mean (SD)=9.2 (1.9) sessions; For those parti- cipants unable to perform the chair stand test (n=9), we imputed a value of 61 seconds according to the reference categories previously published (25); Paired sample t-test for repeated samples or Wilcoxon signed-rank were used for continuous variables as appropriated and chi square for categorical variables. Table 3 Effect of the Multifactorial Intervention on physical function capacity stratified by a frailty degree according to the Clinical Frailty Scale Fit, Stable, managing well (CFS 1-3), n=41 Vulnerable (CFS 4-6), n=48 Any grade of Frailty (CFS 7-9), n=23 p for trend Before After Difference p Before After Difference p Before After Difference p (95% IC) (95% IC) (95% IC) SPPB a, mean (SD) 8.43 9.68 1.25 <0.001 7.13 8.67 1.54 <0.001 6.52 8.21 1.70 <0.001 0.279 (2.05) (2.08) (0.81 – 1.69) (2.02) (1.95) (.99 – 2.09) (1.90) (1.76) (1.04 – 2.35) Gait speed (m/sec), mean (SD) 0.77 0.86 0.08 <0.001 0.71 0.78 0.07 0.005 0.60 0.69 0.09 <0.001 0.940 (0.18) (0.17) (0.05 – 0.12) (0.21) (0.17) (0.02 – 0.11) (0.14) (0.16) (0.04 – 0.13) Balance impairment, % (n) 31.7 14.6 53.8 0.001 52.1 25.0 52.0 0.009 47.8 21.7 54.5 0.043 0.540 (13) (6) (7) (25) (12) (13) (11) (5) (6) Chair stand test (sec), mean (SD) 18.28 13.97 -4.32 0.002 25.58 18.16 -7.43 <0.001 23.37 19.83 -3.55 0.235 0.352 (9.99) (4.85) (-6.89 - -1.75) (15.91) (11.91) (-11.45 - -3.41) (13.92) (13.84) (-9.56 - -2.47) SD: standard deviation; a. SPPB: Short Physical Performance Battery, range from 0 to 12; The Analysis of variance (ANOVA) and Jonckheere-Terpstra trend test were used for continuous variables as appropriated and Chi-Square for categorical variables. Discussion novelties worth noting in +AGIL Barcelona. First, it was and is still implemented in real life and did not depend on specific Our results show that +AGIL Barcelona, a multifactorial research funding. In other words, it broke the rigid structure intervention program for older community-dwellers, based of traditional research methodology concerning the inclusion/ on the integration of primary care, geriatric medicine and exclusion criteria. For example, dementia or severe frailty did community services, has a positive impact on improving frailty. not constitute reasons for being excluded from participation in The reported improvement of physical function was statistically +AGIL Barcelona (5, 7–11). In fact, the screening and referral and clinically significant, as meeting well-established criteria of +AGIL Barcelona relied much on the clinical judgment for meaningful changes in SPPB (0.3–0.8 points) (29) and gait of primary care teams, as requested by the GFST (17). It speed (at least 0.05 m/s) [30]. The benefits were consistent is believed that the complementary approach between the across different initial frailty degrees, from milder to more continuum of care offered by primary care and the time-limited advanced. specialized geriatric intervention represents an added value for Strong clinical evidence from intervention studies support the program. Second, in line with the principles of the Frailty the positive impact of multifactorial and multidisciplinary Intervention Trial described by Cameron et.al., (9) +AGIL program interventions on frailty in order to improve physical Barcelona proposed a flexible and adaptable intervention within function (5, 7–9, 11) and revert frailty (10). In this sense, our a definite range of possibilities, based on shared decision- results are in line with the available literature. Specifically, making, and far from a “one-fits-all” approach or rigid standard +AGIL Barcelona effect size at 3 months is similar to a local intervention. This might have promoted the adequacy of study that offered higher physical activity intensity (7) and the intervention and might very well reduce overtreatment greater than those reported in a systematic review that analyzes (12). The contribution of specialized professionals such as the effect of physical activity on SPPB and gait speed in older the geriatrician and the physical therapist favors the person- adults (14). centered adaptation. Third, the promotion of physical activity Despite the similarities in the multidisciplinary and mainly aimed at fostering user’s empowerment, resulted in multifactorial approach, with a common component such as the intervention becoming sustainable over the long term. the promotion of physical activity, there are differences and We speculate this might be the justification for the similar 714 J Nutr Health Aging Volume 23, Number 8, 2019 THE JOURNAL OF NUTRITION, HEALTH & AGING© 3-month impact of +AGIL Barcelona compared to existing a general perspective, our results reinforce the urgent need of literature (5, 7, 9). Despite the resemblance with the other shifting towards a change in paradigms for the management of intervention components, +AGIL Barcelona offers a relatively frailty before the establishment of the disabling process. lower frequency and duration of supervised physical activity (60-minute sessions, once a week for 10 weeks). In the aim of Ethical Standards: The protocol was approved by the Clinical Research Ethics Committee of the Institut Universitari d’Investigació en Atención Primaria, Jordi Gol and the project, the different empowerment strategies (including the comply with the current laws of Spain. motivational approach, the recommendations for self-practice Acknowledgements: We would like to thank all the +AGIL Barcelona participants and through a validated existing tool such as ViviFrail® (27), the the contribution of Ana Pomares, primary care social worker, Aracelli Abilla, primary delegation to the participant during the sessions) are meant to care physician, Lydia Fumado, primary care nurse of the Bordeta-Magòria center, Paola Mulero, head of Civic Center Casal Cívic Magòria and Heidi Schmidt for review and edit compensate the reduced frequency and duration of directed the manuscript. physical activity. It is important to remark that +AGIL Barcelona is Funding: This implementation program has been developed using internal funding from the participating institutions, Parc Sanitari Pere Virgili and Institut Català de la Salut. sustainable through a reorganization of existing resources. During the refinement phase of the program, we also requested Conflicts of interest: The authors have no financial or personal conflicts to disclose. feedback from participants about the possible lack of adherence Open Access: This article is distributed under the terms of the Creative Commons to the different interventions, including a higher weekly Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium frequency of the physical activity program. The relatively or format, as long as you give appropriate credit to the original author(s) and the source, reduced frequency, together with other factors (such as the provide a link to the Creative Commons license and indicate if changes were made. “prescription” by reference primary care and the motivational approach) might explain the high adherence to the proposed References activities compared to other programs (5, 7–9). 1. Cesari M, Prince M, Thiyagarajan JA, De Carvalho IA, Bernabei R, Chan P, et al. According to the realistic theoretical framework of the Frailty: An Emerging Public Health Priority. J Am Med Dir Assoc. 2016;17: 188–92. doi:10.1016/j.jamda.2015.12.016 reasons why frailty interventions may or may not work, recently 2. Gill TM, Gahbauer EA, Allore HG, Han L. Transitions Between Frailty States Among proposed by Gwyther et al. (12), interventions need to be Community-Living Older Persons. 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A Multicomponent Exercise Intervention that Reverses our previous methodological paper (16), and +AGIL Barcelona Frailty and Improves Cognition, Emotion, and Social Networking in the Community- Dwelling Frail Elderly: A Randomized Clinical Trial. J Am Med Dir Assoc. Elsevier seems in line with most of it. Inc.; 2016;17: 426–433. doi:10.1016/j.jamda.2016.01.019 Among the strengths of our study, +AGIL Barcelona 6. Tavassoli N, Guyonnet S, Abellan Van Kan G, Sourdet S, Krams T, Soto M-E, et al. Description of 1,108 older patients referred by their physician to the “Geriatric is a “real world” intervention program with a continuative Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability” at the implementation, and we have already highlighted the positive gerontopole. J Nutr Health Aging. 2014;18: 457–64. doi:10.1007/s12603-014-0462-z 7. Romera-Liebana L, Orfila F, Segura JM, Real J, Fabra ML, Möller M, et al. Effects of differential elements and the potential advantages compared a primary-care based multifactorial intervention on physical and cognitive function in to previous intervention studies. The relatively low number frail, elderly individuals: a randomized controlled trial. Journals Gerontol Ser A. 2018; doi:10.1093/gerona/glx259 of missing data at the follow-up is also remarkable. We also 8. Gené Huguet L, Navarro González M, Kostov B, Ortega Carmona M, Colungo acknowledge different limitations in our study: the absence Francia C, Carpallo Nieto M, et al. Pre Frail 80: Multifactorial Intervention to Prevent Progression of Pre-Frailty to Frailty in The Elderly. J Nutr Health Aging. 2018; of a control group and the lack of randomization do not doi:10.1007/s12603-018-1089-2 allow conclusive evidence on the impact of this intervention. 9. Cameron ID, Fairhall N, Langron C, Lockwood K, Monaghan N, Aggar C, et al. 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Gwyther H, Bobrowicz-Campos E, Apóstolo JLA, Marcucci M, Cano A, Holland C. is already a relevant achievement for the individual and for A realist review to understand the efficacy and outcomes of interventions designed society. to minimise, reverse or prevent the progression of frailty. Health Psychol Rev. 2018;7199: 1–23. doi:10.1080/17437199.2018.1488601 In conclusion, +AGIL Barcelona shows the implementation 13. Cesari M, Demougeot L, Boccalon H, Guyonnet S, Vellas B, Andrieu S. The Mul- and evaluation of a multifactorial, interdisciplinary, and tidomain Intervention to preveNt disability in ElDers (MINDED) project: rationale and study design of a pilot study. Contemp Clin Trials. 2014;38: 145–54. doi:10.1016/j. integrated care program for frail older adults, which is based cct.2014.04.006 on the reorganization of existing resources. This data suggests 14. Giné-Garriga M, Roqué-Fíguls M, Coll-Planas L, Sitjà-Rabert M, Salvà A. 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