We thank Dr. Sellinger and Dr. Carbery for their thoughtful comments 1 on our published manuscript 2. We agree that implementation of frailty into routine Inflammatory Bowel Disease (IBD) care remains a key challenge. Barriers they rightly highlight are the large number of available frailty instruments and how frailty assessment can provide the greatest value in daily practice. To answer this question and guide further clinical implementation, it may be helpful to shift the focus from asking how frailty should be assessed to first considering for what purpose we want to measure frailty and what clinical actions can or should follow once frailty is identified. Frailty assessment can serve several clinical purposes, such as predicting adverse outcomes or identifying patients who may benefit from specific interventions 3. When the primary goal is risk stratification, simple frailty screening tools, such as the G8 or Hospital Frailty Risk Score, may suffice 4, 5. In older patients with IBD, these screening tools have already been shown to be associated with adverse outcomes, similar to the results for the geriatric assessment (GA) we reported 2, 6, 7. In this setting, a frailty screening tool may be a more logical and efficient option than a GA. However, when frailty is used merely as a construct in risk prediction, it does not reveal and target underlying vulnerabilities that contribute to that risk. This is where the main strength of Comprehensive Geriatric Assessment (CGA) lies. The CGA comprises a GA, followed by developing and evaluating an integrated care plan with targeted interventions, including weighing IBD treatment decisions informed by GA findings. Therefore, when the goal of frailty assessment is to identify modifiable vulnerabilities and guide targeted interventions, such as optimizing polypharmacy or improving functional status, a (C)GA should be considered 3. Ideally, in line with standard geriatric practice, a stepped-care approach should be implemented in clinical practice consisting of three steps: an initial frailty screening, followed by a GA in patients at risk to assess functioning across domains and to identify patients who benefit from further CGA, followed by a CGA (Figure 1). The GA can be performed by the gastroenterologist or a nurse with appropriate training, using standardized assessment protocols, whereas a CGA is reserved for geriatricians. Such an approach is already recommended in other populations such as older patients with chronic kidney disease 8. For IBD practice, clinicians can either perform a frailty screening and refer to a geriatrician when frailty screening is abnormal or perform a GA themselves with a targeted GA set and establish a clear agreement with the geriatrician at their center when to refer patients for a full CGA. However, uniform implementation of this approach may not be feasible across all IBD centers because of resource constraints, including time and lack of access to multidisciplinary geriatric teams 9. In that case, a pragmatic bottom-up approach may be more realistic (Figure 1). IBD centers could start by identifying prevalent conditions associated with frailty, such as malnutrition, that can be detected using a simple screening questionnaire and addressed with relatively straightforward interventions. For example, the Fried frailty phenotype screens for a more physical frailty profile that may be targeted with physiotherapy and nutritional guidance 3. We therefore believe that the key question is not which frailty instrument is best in general, but which instrument is most appropriate for the intended clinical purpose, the available resources, and the action that should follow. Such a purpose-driven approach may help move frailty assessment in IBD from concept to implementation. A. B. Fons: conceptualization, writing – original draft, investigation. V. E. R. Asscher: writing – review and editing. S. P. Mooijaart: writing – review and editing. P. W. J. Maljaars: conceptualization, investigation, writing – original draft, supervision. The authors' declarations of personal and financial interests are unchanged from those in the original article 2. This article is linked to Fons et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70594 and https://doi.org/10.1111/apt.70621. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Fons et al. (Sat,) studied this question.
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