Additional research is needed to refine criteria for screening frail older persons, identify objective measures of disability that are reliable and valid in frail older persons, and improve the inform

The gap

Consensus across the literature

Supporting evidence — 5 representative gaps

• Prevalence and associated factors of oral frailty in elderly patients undergoing elective surgery: a secondary analysis of a cross-sectional study (2026) · doi

  This study has several limitations. First, as the data were derived from a cross-sectional survey, causal relationships between potential risk factors and oral frailty cannot be established. Second, the sample was limited to elderly patients undergoing elective surgery at a single tertiary hospital in Shijiazhuang, Hebei Province, over a specific period, which may restrict the generalizability of the findings. Third, data were primarily self-reported, without objective validation, potentially introducing recall and social desirability biases, which could affect accuracy and reliability.

  Keywords: several limitations first derived cross sectional survey causal relationships potential risk factors oral frailty cannot
• Risk of falls and syncope across frailty levels in hypertensive older adults: a longitudinal study (2026) · doi

  Some limitations should be acknowledged. First, our sample included exclusively hypertensive out- patients ≥ 75  years, limiting generalizability to com- munity-dwelling individuals from other clinical set- tings, where frailty and motor impairment may be less prevalent. Accordingly, the specific geriatric set- ting may have contributed to the high rates of both frailty and falls. On the other hand, the specific study setting may limit the applicability of our results to older individuals with more severe motor and func- tional impairment, who are less likely to access out- patient services. Although follow-up data collection included a review of electronic clinical records, we cannot exclude the possibility of misclassification of outcome events—potentially related to unblinded adjudication—as well as underreporting or inaccura- cies in event timing due to recall bias from patients or caregivers. Moreover, mortality may have led to early censoring, preventing the occurrence of falls or syncope events and thereby potentially underestimat- ing the true risk in the most vulnerable individuals. Finally, detailed information on the characteristics and aetiology of syncopal episodes was not available, nor was it possible to determine whether patients had undergone diagnostic evaluations for syncope or falls. Author contribution Study concept and design: Giulia Rivasi, Marco Capacci, Alessandro Mengozzi, Andrea Ungar. Acquisition of data: all authors. Analysis and interpretation of data: Giulia Rivasi, Marco Capacci, Alessandro Mengozzi, Enrico Mossello, Agostino Virdis, Andrea Ungar. Drafting of the manuscript: Giulia Rivasi, Marco Capacci, Alessandro Mengozzi, Andrea Ungar. Critical revision of the manuscript for important intellectual content: all authors. Final approval of version to be published: all authors. Agreement to be account- able for all aspects of the work: all authors. Funding Open access funding provided by Università degli Studi di Firenze within the CRUI-CARE Agreement. The study was supported by Fondazione Cassa di Risparmio di Firenze. We acknowledge co-funding from the European Union - Next Generation EU, in the context of the National Recovery and Resilience Plan, Investment PE8—Project Age-It: “Ageing Well in an Ageing Society”. This resource was co-financed by the Next Generation EU [DM 1557 11.10.2022]. Views and opinions expressed are however those of the authors only and do not necessarily reflect those of the European Union or the European Commission. Neither the European Union nor the European Commission can be held responsible for them. The sponsors did not influence the study design, conduct or reporting. Data availability The data that support the findings of this study are available from the corresponding author upon reason- able request.

  Keywords: authors european patients individuals falls giulia rivasi marco capacci alessandro mengozzi andrea ungar funding union
• Impact of frailty on perioperative and oncologic outcomes after robotic radical prostatectomy: a multicenter study with competing risk analysis (2026) · doi

  This study has several strengths, including its multicenter design, focus on a high-risk elderly population, and applica- tion of advanced statistical methods (competing risk anal- ysis, non-linear modeling). However, several limitations should be acknowledged. First, the retrospective design introduces potential selec- tion bias. Second, frailty was assessed using a single screen- ing instrument (G8) rather than a full multidimensional geriatric assessment. Although G8 is widely validated in oncogeriatric populations, the categorical thresholds (mild, moderate, severe) were exploratory and cohort-specific, limiting comparability with other frailty frameworks. Third, unmeasured variables such as functional status, sarcopenia, and social support may influence outcomes. Fourth, the cohort represented a highly selected elderly surgical popu- lation (79.9% ASA ≥ 3), limiting generalizability to younger or healthier patients. Fifth, surgeon experience, learning curve status, and center volume were not captured—estab- lished determinants of RARP outcomes [13]. The observed 30-day mortality (2.0%) and conversion-to-open rate (4.9%) substantially exceed benchmarks for high-volume centers 1 3Journal of Robotic Surgery (2026) 20:529 (mortality < 0.2%, conversion 1–2%). This discrepancy reflects: (a) the high-risk frail population; (b) inter-center heterogeneity; and (c) possible inclusion of early learning curve cases. In a post-hoc sensitivity analysis comparing high-volume (≥ 50 RARP/year, n = 312) vs. lower-volume centers (n = 275), major complications (11.5% vs. 18.5%, p = 0.02) and 30-day mortality (1.0% vs. 3.3%, p = 0.048) differed significantly, confirming center-level heterogeneity. Thus, our findings should not be generalized to high-volume experienced centers without independent validation. Sixth, detailed adjudication of mortality causes was not uniformly available, limiting interpretation of procedure-related versus competing medical mortality. Seventh, the predictive model requires external validation before clinical implementation. Eighth, the low number of cancer-specific events limits sta- tistical power for cancer-specific survival analysis; longer follow-up is needed. Ninth, postoperative renal outcomes (AKI/AKD) were not assessed; a recent series identified preoperative eGFR as the primary predictor of renal com- plications after RARP, and frailty may interact with baseline renal function [32]. Future studies should incorporate renal outcomes. Despite these limitations, our study provides a nuanced understanding of frailty in elderly patients undergoing RARP and highlights the importance of competing risk methodology in this population.

  Keywords: high volume mortality risk frailty outcomes rarp renal elderly population competing specific limiting center centers
• Designing Randomized, Controlled Trials Aimed at Preventing or Delaying Functional Decline and Disability in Frail, Older Persons: A Consensus Report (2004) · doi

  Additional research is needed to refine criteria for screening frail older persons, identify objective measures of disability that are reliable and valid in frail older persons, and improve the informed consent process for high-risk participants, recognizing that research in this subgroup is essential to improving their health outcomes.

  Keywords: frail older persons additional needed refine criteria screening identify objective measures disability reliable valid improve
• Impact of biopsychosocial frailty trends on survival and quality of life of older adults: a secondary analysis of data from a community-based active monitoring program (2026) · doi

  6 Conclusion This work has several limitations. This study is based on a secondary analysis of programmatic data, meaning participants were not randomly selected and received tailored interventions within the program. Therefore, while we observed improvements in frailty status and associated outcomes, these findings may not be solely attributable to the intervention. However, the correlation between frailty reduction and fewer adverse events is consistent with broader literature, suggesting that lowering frailty—regardless of the mechanism - remains a critical objective in community-based elder care. Another important limitation regards the empirical process for detecting negative events such as death, hospitalisation and institutionalisation: information is collected from participants or their relatives. In some cases, it was not possible to receive information on people who suddenly disappeared, which may have led us to underestimate the frequency of negative events. However, this was possible for both groups (improved/stable and worsened) so as not to influence the analysis. The second limitation is that the presented data are the result of a secondary analysis of the information collected during the day-to-day running of the program, which means that important elements may have been missed. In fact, the frequency of telephone monitoring varies by level of frailty, from one call every 3 months for the “Robust” to one every week or even more for the “Very Frail”; again, this should not affect the analysis because the comparison was made within the same level of frailty among individuals who were offered the same protocols. An additional methodological consideration concerns the temporal relationship between frailty trajectory classification and outcome occurrence. Frailty trajectories were defined using the first and last available SFGE assessments, while mortality outcomes were recorded throughout follow-up. This may introduce a potential survivor or immortal time bias, as participants needed to survive long enough to undergo repeated assessments. However, within the LLE program, participants were routinely monitored through scheduled contacts approximately every 6 months, and mortality information was continuously updated during follow-up. Furthermore, comparisons were performed within baseline frailty strata, partially limiting heterogeneity in follow-up intensity and risk profile. A further limitation of this study is the lack of clinical data that, of course, affect the trends we described. Furthermore, the classification of frailty change into three categories (improved, stable, worsened) does not capture the magnitude of transitions: a change from Robust to Pre-frail and from Robust to Very frail is both classified as “worsened.” This approach, while more reliable given the category-level validation of the SFGE, necessarily reduces the granularity of the information on individual trajectories. The program-based nature of the sample represents an additional source of potential selection bias: participants were not randomly selected from the general population but were identified through municipal registries and voluntarily enrolled. Individuals

  Keywords: frailty participants information within program based events limitation worsened level every robust frail follow secondary