The Concept of Vulnerability: Clinical Versus Policy Perspectives

  • Agar Brugiavini
  • Ludovico Carrino
  • Cristina Elisa Orso
  • Giacomo Pasini


In Chap.  2, we address the substantial differences existing among the Western European LTC legislations (namely, Austria, Belgium, the Czech Republic, England, France, Germany, Italy and Spain), both between and within countries, on defining the target population in need of long-term care (LTC). Although the majority of programmes cover functional (mostly Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [iADL]) and cognitive limitations, the assessment process appears in most countries as a patchwork of different rules and practices. These differences can give rise also to differential measurement criteria: the health outcomes may attract different weights within an assessment scale; some limitations are given more importance than others in determining eligibility; and there are legislations that characterize some deficit as necessary and/or sufficient for eligibility.


Needs assessment process Access to care Target older population ADL/iADL limitations Cognitive limitations 


  1. Bakx, P., Meijer, C., Schut, F., & Doorslaer, E. (2014). Going formal or informal, who cares? The influence of public long-term care insurance. Health Economics, 24, 631–643. CrossRefGoogle Scholar
  2. Brock, D. W. (1989). Quality of life measures in health care and medical ethics. Working Paper No. 66, World Institute for Development Economics Research of the United Nations University.Google Scholar
  3. Clegg, A., Young, J., Iliffe, S., Rikkert, M. O., & Rockwood, K. (2013). Frailty in elderly people. The Lancet, 381(9868), 752–762.CrossRefGoogle Scholar
  4. Colombo, F., & Mercier, J. (2012). Help wanted? Fair and sustainable financing of long-term care services. Applied Economic Perspectives and Policy, 34(2), 316–332.CrossRefGoogle Scholar
  5. Comas-Herrera, A., Costa-i-Font, J., Gori, C., di Maio, A., Patxot, C., Pickard, L., … Wittenberg, R. (2003). European study of long-term care expenditure: Investigating the sensitivity of projections of future long-term care expenditure in Germany, Spain, Italy and the United Kingdom to changes in assumptions about demography, dependency, informal care, formal care and unit costs. Report to the European Commission, Employment & Social Affairs DG. PSSRU Discussion Paper 1840.Google Scholar
  6. Conroy, S. (2009). Defining frailty—The holy grail of geriatric medicine. The Journal of Nutrition, Health & Aging, 13(4), 389–389.CrossRefGoogle Scholar
  7. Da Roit, B., & Le Bihan, B. (2010). Similar and yet so different: Cash-for-care in six European countries’ long-term care policies. Milbank Quarterly, 88(3), 286–309.CrossRefGoogle Scholar
  8. De Vries, N., Staal, J., Van Ravensberg, C., Hobbelen, J., Olde Rikkert, M., & Nijhuis-Van der Sanden, M. (2011). Outcome instruments to measure frailty: A systematic review. Ageing Research Reviews, 10(1), 104–114.CrossRefGoogle Scholar
  9. Eleftheriades, C., & Wittenberg, R. (2013). A critical review of international practice on assessment and eligibility in adult social care: Lessons for England. Oxford: Centre for Health Service Economics & Organisation (CHSEO).Google Scholar
  10. European Commission. (2015). The 2015 Ageing Report. Luxembourg: Publications Office of the European Union.Google Scholar
  11. Fried, L. P., Ferrucci, L., Darer, J., Williamson, J. D., & Anderson, G. (2004). Untangling the concepts of disability, frailty, and comorbidity: Implications for improved targeting and care. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 59(3), M255–M263.CrossRefGoogle Scholar
  12. Fulop, T., Larbi, A., Witkowski, J. M., McElhaney, J., Loeb, M., Mitnitski, A., & Pawelec, G. (2010). Aging, frailty and age-related diseases. Biogerontology, 11(5), 547–563.CrossRefGoogle Scholar
  13. Gallagher, A., Li, S., Wainwright, P., Jones, I. R., & Lee, D. (2008). Dignity in the care of older people—A review of the theoretical and empirical literature. BMC Nursing, 7(1), 11.CrossRefGoogle Scholar
  14. Gori, C. (2012). Home care in Italy: A system on the move, in the opposite direction to what we expect. Health & Social Care in the Community, 20(3), 255–264.CrossRefGoogle Scholar
  15. Gori, C., & Fernandez, J.-L. (2015). Long-term care reforms in OECD countries. Bristol: Policy Press.CrossRefGoogle Scholar
  16. Jiménez-Martín, S., & Prieto, C. V. (2010). A double sample selection model for unmet needs, formal care and informal caregiving hours of dependent people in Spain. Documento de Trabajo, 2010, 25.Google Scholar
  17. Katz, S., Downs, T. D., Cash, H. R., & Grotz, R. C. (1970). Progress in development of the index of ADL. The Gerontologist, 10(1 Part 1), 20–30. CrossRefGoogle Scholar
  18. Kempen, G. I. J. M., Myers, A. M., & Powell, L. E. (1995). Hierarchical structure in ADL and IADL: Analytical assumptions and applications for clinicians and researchers. Journal of Clinical Epidemiology, 48(11), 1299–1305. CrossRefGoogle Scholar
  19. LaPlante, M. P. (2010). The classic measure of disability in activities of daily living is biased by age but an expanded IADL/ADL measure is not. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 65(6), 720–732. CrossRefGoogle Scholar
  20. Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9(3), 179–186.CrossRefGoogle Scholar
  21. Maarse, J. A. M., & Jeurissen, P. P. (2016). The policy and politics of the 2015 long-term care reform in the Netherlands. Health Policy, 120(3), 241–245. CrossRefGoogle Scholar
  22. Mahoney, F., & Barthel, D. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 61.Google Scholar
  23. Markle-Reid, M., & Browne, G. (2003). Conceptualizations of frailty in relation to older adults. Journal of Advanced Nursing, 44(1), 58–68.CrossRefGoogle Scholar
  24. Mitnitski, A. B., Mogilner, A. J., & Rockwood, K. (2001). Accumulation of deficits as a proxy measure of aging. The Scientific World Journal, 1, 323–336.CrossRefGoogle Scholar
  25. Mot, E., & Aouragh, A. (2010). The Dutch system of long-term care. ENEPRI.Google Scholar
  26. Nordenfelt, L. (2004). The varieties of dignity. Health Care Analysis, 12(2), 69–81. CrossRefGoogle Scholar
  27. Nussbaum, M., & Sen, A. (1993). The quality of life. Oxford University Press.Google Scholar
  28. OECD. (2013). A good life in old age? Paris: OECD Publishing.CrossRefGoogle Scholar
  29. Pel-Littel, R., Schuurmans, M., Emmelot-Vonk, M., & Verhaar, H. (2009). Frailty: Defining and measuring of a concept. JNHA—The Journal of Nutrition, Health and Aging, 13(4), 390–394.CrossRefGoogle Scholar
  30. Pialoux, T., Goyard, J., & Lesourd, B. (2012). Screening tools for frailty in primary health care: A systematic review. Geriatrics & Gerontology International, 12(2), 189–197.CrossRefGoogle Scholar
  31. Pilotto, A., & Ferrucci, L. (2011). Verso una definizione clinica della fragilità: utilità dell’approccio multidimensionale. Giornale di Gerontologia, 59, 125–129.Google Scholar
  32. Pilotto, A., Gallina, P., Fontana, A., Sancarlo, D., Bazzano, S., Copetti, M., … Pellegrini, F. (2013). Development and validation of a Multidimensional Prognostic Index for mortality based on a standardized multidimensional assessment schedule (MPI-SVaMA) in community-dwelling older subjects. Journal of the American Medical Directors Association, 14(4), 287–292.CrossRefGoogle Scholar
  33. Rockwood, K., & Mitnitski, A. (2007). Frailty in relation to the accumulation of deficits. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 62(7), 722–727.CrossRefGoogle Scholar
  34. Rodríguez-Mañas, L., Féart, C., Mann, G., Viña, J., Chatterji, S., Chodzko-Zajko, W., … Nicholson, C. (2013). Searching for an operational definition of frailty: A delphi method based consensus statement. The frailty operative definition-consensus conference project. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 68(1), 62–67.CrossRefGoogle Scholar
  35. Schulz, E. (2010). The long-term care system in Denmark. ENEPRI Research Report No. 73, 28 May.Google Scholar
  36. Socialstyrelsen. (2009). Care of older people in Sweden 2008. Socialstyrelsen—National Board of Health and Welfare.Google Scholar
  37. Sourial, N., Wolfson, C., Bergman, H., Zhu, B., Karunananthan, S., Quail, J., … Béland, F. (2010). A correspondence analysis revealed frailty deficits aggregate and are multidimensional. Journal of Clinical Epidemiology, 63(6), 647–654.CrossRefGoogle Scholar
  38. Thomas, V. S., Rockwood, K., & McDowell, I. (1998). Multidimensionality in instrumental and basic activities of daily living. Journal of Clinical Epidemiology, 51(4), 315–321.CrossRefGoogle Scholar
  39. WHO. (2002). Towards a common language for functioning, disability and health. Geneva: World Health Organization. Retrieved from
  40. Wiener, J. M., Hanley, R. J., Clark, R., & Van Nostrand, J. F. (1990). Measuring the activities of daily living: Comparisons across national surveys. Journal of Gerontology, 45(6), S229–S237.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2017

Authors and Affiliations

  • Agar Brugiavini
    • 1
  • Ludovico Carrino
    • 2
  • Cristina Elisa Orso
    • 1
  • Giacomo Pasini
    • 1
  1. 1.Department of EconomicsCa’ Foscari UniversityVeniceItaly
  2. 2.Department of Global Health & Social MedicineKing’s CollegeLondonUK

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