Enabling Healthy Aging to AVOID Frailty in Community Dwelling Older Canadians

Jananee Rasiah, MN, RN1, Jeanette C. Prorok, PhD2, Rheda Adekpedjou, PhD3, Carol Barrie, CPA, CA2, Carlota Basualdo, MSc, MPH4, Rachel Burns, PhD5, Vincent De Paul, PhD6, Catherine Donnelly, PhD6, Amy Doyle, BA2, Christopher Frank, MD, CCFP, FCFP (COE, PC)7, Sarah (Gibbens) Dolsen, PhD(c)6, Anik Giguère, PhD8, Sonia Hsiung, MTSD9, Perry Kim, PhD2,6, Emily G. McDonald, MD, MSc10, Heather O’Grady, BSc11, Andrea Patey, PhD12, John Puxty, FRCP(C)7, Megan Racey, PhD13, Joyce Resin, MSW2, Joanie Sims-Gould, PhD14, Susan Stewart, MA15, Olga Theou, PhD16, Sarah Webster, MHS17, John Muscedere, MD, FRCPC2,18

1Faculty of Nursing, University of Alberta, Edmonton, AB
2Canadian Frailty Network, Kingston, ON
3Centre de Recherche du Centre Hospitalier Universitaire de Montréal, Montreal, QC
4Alberta Health Services, Edmonton, AB
5Department of Psychology, Carleton University, Ottawa, ON
6School of Rehabilitation Therapy, Queen’s University, Kingston, ON
7Department of Medicine, Queen’s University, Kingston, ON
8Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, QC
9Alliance for Healthier Communities, North York, ON
10Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, QC
11School of Rehabilitation Science, McMaster University, Hamilton, ON
12Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, ON
13McMaster Evidence Review and Synthesis Team; School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, ON
14Department of Family Practice, University of British Columbia, Vancouver, BC
15Kingston Frontenac Lennox & Addington Public Health, Kingston, ON
16Physiotherapy and Geriatric Medicine, Dalhousie University, Halifax, NS
17Centre for Studies in Aging and Health, Province Care Hospital, Toronto, ON
18Department of Critical Care Medicine, Queen’s University, Kingston, ON

DOI: https://doi.org/10.5770/cgj.25.536


The Canadian population is aging. With aging, biological and social changes occur increasing the risk of developing chronic conditions and functional loss leading to frailty. Older adults living with frailty are more vulnerable to minor stressors, take longer to recover from illness, and have difficulty participating in daily activities. The Canadian Frailty Network’s (CFN) mission is to improve the lives of older adults living with frailty. In September 2019, CFN launched the Activity & Exercise, Vaccination, Optimization of medications, Interaction & Socialization, and Diet & Nutrition (AVOID) Frailty public health campaign to promote assessing and reducing risk factors leading to the development of frailty. As part of the campaign, CFN held an Enabling Healthy Aging Symposium with 36 stakeholders from across Canada. Stakeholders identified individual and community-level opportunities and challenges for the enablement of healthy aging and frailty mitigation, as part of a focused consultative process. Stakeholders ranked the three most important challenges and opportunities at the individual and community levels for implementing AVOID Frailty recommendations. Concrete actions, further research areas, policy changes, and existing resources/programs to enhance the AVOID Frailty campaign were identified. The results will help inform future priorities and behaviour change strategies for healthy aging in Canada.

Key words: frailty, aging, activity, vaccine, optimize medications, social, diet, nutrition


Globally, population aging is on the rise, with the proportion of the population over 60 years of age projected to increase from 12% to 22% between 2015 and 2050.(1) In July 2019, Canada had 6.6 million people 65 years of age and older.(2) The increase in individual life expectancy is due to better public health, promotion of healthier lifestyles, and improved health care, including assistive and innovative medical technologies. However, living longer does not always translate to living in good health. As individuals age, they undergo biological and social changes making them at increased risk of developing multiple chronic conditions and loss of function leading to frailty. Older adults living with frailty are more vulnerable to stressors, have reduced ability to recover from minor illnesses, and experience reduced quality of life.(35) Biological changes associated with aging that predispose older adults to frailty include changes in cellular and immune function, decreased skeletal muscle, and reduced bone density.(5) Social changes associated with frailty include income or housing difficulties and increased risk of social isolation.(4,6,7)

The Canadian Frailty Network (CFN) is a pan-Canadian, non-for-profit organization funded by the Government of Canada through the Networks of Centres of Excellence Program (NCE). CFN’s mission is to improve the care of those living with frailty in Canada, and has responded in part to this need by developing a public health approach for the enablement of healthy aging. In September 2019, CFN launched a campaign called AVOID Frailty to promote identifying, assessing, and reducing risk factors that lead to the development of frailty. AVOID encompasses: Activity & Exercise, Vaccination, Optimization of medications, Interaction & Socialization, and Diet & Nutrition. For those who develop frailty, there is a need to improve its trajectory such that frailty does not progress, and this framework may help minimize progression.

The recommendations in AVOID Frailty are evidence-based (Table 1) and complement the World Health Organizations’ 2019 Integrated Care for Older People (ICOPE) approach.(8) ICOPE helps reorient health services towards a more person-centred and coordinated model of care, emphasizing functional ability and intrinsic capacity.(8) Functional ability (defined as individuals’ health-related attributes that enable them to be—and to do—what they value) relies heavily on the interaction between the environment older adults reside in and their intrinsic capacity (defined as individuals’ physical, mental, and psychological capacities).(8) Older adults with unique needs can readily participate in activities of daily living and those that they value as important when health services and social systems are better integrated.(8) Early intervention incorporating AVOID Frailty and ICOPE principles may slow or reverse biological aging and, in turn, prevent, delay, or reverse the trajectory towards frailty.(5,9,10)

TABLE 1 AVOID Frailty recommendations


To catalyze the implementation of AVOID Frailty in Canadian communities, CFN convened a meeting of stakeholders from across Canada in Toronto, Canada on February 27th, 2020 at the Enabling Healthy Aging Symposium. During this meeting, stakeholders were tasked with identifying individual and community-level opportunities and challenges to enabling healthy aging and living with frailty, as part of a focused consultative process. Herein we summarize the symposium process, plenary content, and group discussions, and suggest next steps for researchers, clinicians, decision-makers, citizen groups, and communities to consider when implementing interventions designed to enable healthy aging and mitigate frailty in older adults.


Selection of Stakeholders

Researchers, clinicians, trainees, health-care administrators, policy experts, public/community association representatives, and municipal representatives were invited to be stakeholders in the symposium (Table 2). Thirty-six stakeholders from across Canada attended the one-day meeting. Travel and accommodation were provided to stakeholders to attend the meeting in Toronto, Ontario. Stakeholders represented urban and rural communities from across Canada and provided a diverse range of perspectives. However, specific demographic data on stakeholders were not collected.

TABLE 2 Symposium attendee characteristics (n=36)


Symposium Structure and Process

The symposium was organized into three sessions. At the beginning of each session stakeholders were presented with the current state of knowledge from a relevant expert (presentation highlights summarized below), followed by large (n=36) and small group (n=8–10) discussions about individual and community level opportunities and challenges. Stakeholder voting to identify the top three opportunities and challenges was completed via an established facilitation method (dotmocracy; https://dotmocracy.org/), using colored dot stickers. Stakeholders could vote for their top three priorities and challenges, which meant they could use all three votes for one priority/challenge or spread the votes amongst the options.

Finally, in-depth discussions were held about concrete actions that could be taken now, and areas that required better evidence prior to adoption (Figure 1). Themes were summarized from small group discussions with input and confirmation from stakeholders and then shared to the large group during each session. Similar themes were grouped together, and duplicates removed for the dotmocracy voting exercises (Appendix A). All stakeholders had dedicated intervals between sessions one and two to vote for the top three opportunities and challenges at the individual and community levels, respectively.



FIGURE 1 Mortality and response team deployment


Session 1: Health Behaviour Change for the Individual

During Session 1, a plenary presentation highlighted tools and frameworks to help implement physical activity, vaccinations, medication management, healthy food intake, and social interaction within the AVOID Frailty framework. These included the Action, Actor, Context, Target, Time (AACTT) tool; the Theoretical Domains Framework (TDF); and the behaviour change technique taxonomy (BCTTv1).

0The AACTT tool can be used to identify a specific behaviour that needs to change (Action); individuals doing/could do the action that is targeted (Actor); physical location, emotional context, or social setting in which behaviours occur (Context); individuals with/whom the action is performed (Target); and time/frequency the action is performed (Time).(21) For example, the targeted behaviour change could be that health-care providers use hand sanitizer in patient rooms and hallways before and after touching patients.(21) To facilitate this behaviour change, hospital administrators have to plan for initial setup which includes identifying the individuals targeted by the proposed action, assessing the physical location to ensure ease of access, ensuring that there is constant supply of alcohol-based gel at the point of care, and ensuring this supply is maintained on a regular basis.(21) This AACTT tool can be applied to encourage behaviour change in the context of healthy aging in a similar manner, through addressing barriers and facilitating enablers to health behaviour change.

The TDF spans 14 domains, including knowledge, skills, roles, beliefs, regulation, and influence, that can help explain health-related behaviour change.(2224) TDF domains further our understanding of enablers and barriers to behaviour change in patients, public, and health-care professionals.(2224) The complementary BCTTv1 contains 16 categories based on international consensus,(25) and is a hierarchical taxonomy that includes a wide range of behaviours and steps to operationalize interventions. The BCCTv1 has been mainly applied to interventions for individual behaviour change, but has the potential to be effective for behaviour change at the organization/community level.(25,26) Therefore, a systematic approach using the TDF to screen for barriers and enablers to behaviour change and the BCTTv1 to guide intervention components for behaviour change is recommended.(2729) For example, in a study aimed to encourage behaviour change in general practitioners’ self-efficacy, risk perception and anticipated consequences were the psychological constructs associated with the prescription of antibiotics for upper respiratory infections, based on TDF.(30) Graded tasks and persuasive communication interventions were the behaviour change interventions found to be effective for affecting desirable decreases in the rate of antibiotic prescription, based on BCTTv1.(30)

In Session 2, two plenary presentations were provided about community-level strategies to enable healthy aging.

Session 2: Health Behaviour Change for the Community

Enabling Healthy Aging by Mobilizing the Community

In the five-tier Health Impact Pyramid framework for community mobilization, counselling and education interventions are at the apex of the pyramid, followed by clinical and long-lasting protective interventions, context changing interventions to make individuals’ default decisions healthy ones, and interventions targeted toward socioeconomic factors at the base.(31) Interventions closer to the apex of the pyramid are targeted toward individuals because they rely on long-lasting behaviour changes in consideration of individual circumstances that would facilitate better uptake of these changes.(31) Interventions represented closer to the base of the pyramid have greater population impact and require less individual efforts.(31) Measures implemented at every tier can maximize success of behaviour change interventions as a whole.(31)

Community involvement, an asset-based approach, is central to these interventions in order to mobilize the residents of those communities because it is strengths-based, solution-focused, and driven by local residents. As an example, the Ontario Alliance for Healthier Communities’ social prescribing intervention connects individuals within their communities to social and community supports (https://www.allianceon.org/Social-Prescribing). In this program, long-lasting protective interventions that are underway include vaccines such as influenza, pneumococcal, and shingles to maintain protection for older adults with frailty. For this program to be feasible and to better allow older adults to choose healthy options, organizers stressed the need to consult with seniors and to review the local environment/neighbourhood for barriers and co-design solutions.

Age-Friendly Communities (AFC): Ensuring Accessibility, Participation, and Wellness for All

Ensuring accessibility, participation, and wellness for all Age-Friendly Communities (AFCs) was presented as another strategy to implement community level interventions. AFCs have three primary domains to enable healthy aging:

  1. Environment (including housing, transportation, public buildings, and outdoor spaces);

  2. Social (including civic participation, employment, social inclusion, social participation needs); and

  3. Health and Wellness (including communication, information, and community support and health).(32)

In Ontario, the AFC Outreach Program was established, in conjunction with government, research, and public partners, to increase awareness in communities to of age-friendly planning principles, best-practice research and information, and connection with other AFCs, and to ensure availability of needed capacity to plan, implement, evaluate, and sustain age-friendly activities.(33) Examples of community level interventions in Ontario AFCs are provided in Table 3.

TABLE 3 Community-level interventions in Ontario AFCs


Symposium Voting Results (Sessions 1–2)

After the two sessions (as outlined in Figure 1), stakeholders from Groups 1 to 4 generated 22 individual opportunities, 28 individual challenges, 18 community opportunities, and 18 community challenges during their small group discussions (Appendix A). Stakeholders voted for their top three opportunities and challenges from the list in Appendix A. Priorities were ranked in equal importance in some of the categories (Table 4).

TABLE 4 Top three opportunities and challenges


Session 3: Next Steps and Future Research

During Session 3, questions for the groups centred around concrete actions that could be taken by CFN, areas for further research, ways to change policy, and how to direct existing resources/programs to address the top three opportunities and challenges at individual and community levels. Stakeholders agreed that raising frailty awareness, further research, knowledge translation, and policy change toward improving the quality of care for older Canadians, as well as the AVOID Frailty campaign with the public, would be useful (Figure 2). Creating a marketing campaign and using social networking tools along with public engagement methods to convey the importance of AVOID Frailty to all levels of government were suggested as concrete actions. This would be in addition to the currently developed materials, such as pamphlets, tip sheets, and posters for the AVOID Frailty campaign. Current feedback received thus far suggests that the messaging was easy to remember and the elements were perceived to be important for the prevention or the delay frailty in older adults. A further media plan for public messaging is currently being developed to enhance the spread of the AVOID Frailty campaign.



FIGURE 2 Concrete actions to enable healthy aging for individuals and communities

Expanding and strengthening the network of individuals/organizations interested in frailty research and interventions were also suggested in order to improve the reach and acquisition of fiscal resources for sustainability. Some efforts underway at this time include highlighting the impact of AVOID Frailty to key stakeholders and funders, including the government. A centralized hub for information and resources to accommodate the context-dependent nature of frailty could be another way to relay information about the AVOID Frailty campaign and to engage with a diverse range of stakeholders. The expertise of additional Canadian organizations focused on aging but not necessarily solely on frailty, such as Aging Gracefully across Environments using Technology to Support Wellness, Engagement and Long Life (AGE-WELL) NCE; Canada’s Technology in Aging, Canadian Consortium of Neurodegeneration in Aging (CDNA); and McMaster Institute for Research on Aging (MIRA), could be leveraged.

Areas for further research were proposed, such as community/civic engagement with the AVOID Frailty campaign, and evaluation of simplified messages to communicate scientific evidence on frailty. It was recommended that implementation science and knowledge translation methods should be used to better understand the implementation of interventions aligned with the AVOID Frailty framework. Economic analyses and feasibility studies for implementation could be used to inform scale and spread. Identifying core outcomes and indicators of frailty that are meaningful to all stakeholders will contribute to improvements in health and social care by allowing stakeholders to make better decisions about interventions.(34) Through these avenues of activity and engagement, policies that better enable healthy aging and delay frailty in individuals and communities can be developed.

One of the more pressing realities in the context of the Coronavirus (COVID-19) pandemic is the recognition that community dwelling older Canadians living with frailty are among the subset of the population who face the highest risk of adverse outcomes and death.(35) With public health prevention strategies, such as distancing measures, travel restrictions, avoidance of non-essential services, and limitation of contact with older adults,(35) older adults face pronounced disadvantages. The AVOID Frailty recommendations remain important (and perhaps more so) during a pandemic because maintaining activity, up-to-date vaccinations, appropriate medications,(36) as well as ensuring safe social interaction (e.g., through adapted technology) and maintaining a healthy diet, together enable healthy aging and reduce the deleterious impacts of these necessary measures on older adults. If these recommendations are implemented using appropriate individual behaviour change approaches while engaging with communities and mobilizing efforts to ensure that physical, social, and health resources are optimized, then these recommendations will serve as a protective mechanism to prevent and delay the progression of frailty.


The goal of the AVOID Frailty framework is to optimize healthy aging in older adults living with frailty or at risk of frailty. This symposium aimed to prioritize the opportunities and challenges for older adults and their communities when implementing AVOID Frailty. Stakeholders identified concrete actions that took into account existing networks and resources. Areas for further research should focus on implementation science, knowledge translation, and engagement methods.


Canadian Frailty Network (CFN) is a pan-Canadian network focused on improving the care of older people living with frailty. CFN is comprised of some of Canada’s leading academic institutions, researchers, scientists, health-care professionals, citizens, students, trainees, educators, and decision-makers. CFN supports and catalyzes original research and innovations to improve the care and quality of life of frail Canadians across all settings of care. The Network also trains the next generation of health-care professionals and scientists. CFN is funded by the Government of Canada through the Networks of Centres of Excellence (NCE) Program. Jananee Rasiah, PhD Candidate, Faculty of Nursing, University of Alberta, held and was supported by a Canadian Frailty Network Interdisciplinary Fellowship from 2019–2020. We wish to acknowledge the following individuals who contributed to the manuscript through their input in the symposium: Kerry Anderson, Julie Dunning, Samiya Abdi, Rick Bresee, Shameela Karmali, Kahir Lalji, Pascale Leon, Patrick McGowan, Deborah Sattler, and Brianna Smrke.


Dr. Megan Racey was supported by a Post-Doctoral Fellowship through the Canadian Frailty Network at the time of the Enabling Healthy Aging Symposium. Dr. Emily McDonald is co-owner of MedSafer, a medication deprescribing software. All remaining authors declare no conflicts of interest exist.


This research did not receive external funding.


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Correspondence to: John Muscedere, md, frcpc, Canadian Frailty Network, and Department of Critical Care Medicine, Queen’s University, Kingston Health Sciences Centre Watkins C, 76 Stuart St., Kingston, ON K7L 2V3 Canada, E-mail: john.muscedere@kingstonhsc.ca

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APPENDIX A. Dotmocracy Voting Options For Individual and Community Opportunities and Challenges

Individual Opportunities

Individual Challenges

Community Opportunities

Community Challenges

Canadian Geriatrics Journal, Vol. 25, No. 2, June 2022