The Holistic Approach to Frailty Syndrome in Older Adults: Multidimensional Assessment and Integrated Care—A Narrative Review

Frailty is a dynamic state of reduced reserve whose expression reflects clinical, functional, cognitive, psychological, social, and environmental factors. This structured narrative review examines its conceptual models, determinants, consequences, multidimensional assessment, holistic interventions, and coordination across hospital, community, and home care. The literature search was conducted in PubMed/MEDLINE, Scopus, Web of Science, and Embase up to September 2026, supplemented by World Health Organization (WHO) documents, Google Scholar, and citation tracking. Physical phenotype, deficit-accumulation, multidimensional, judgement-based, and electronic approaches address different clinical questions and should not be treated as interchangeable. Brief case finding is most useful when it leads to assessment of modifiable contributors and a care plan aligned with the older person’s goals. Evidence most consistently supports progressive multicomponent exercise; nutritional support, medication review, falls prevention, and cognitive or social interventions should target identified needs. Hospital geriatric care, structured discharge, community follow-up, and home-based services require coordination, shared information, and reassessment, although evidence for particular models remains heterogeneous. Under-recognition, fragmented services, limited multidisciplinary capacity, caregiver burden, and unequal access constrain implementation. Frailty care is best understood as a longitudinal, person-centred process. Future research should test clinically meaningful outcomes, reproducible pathways, and equity in digital and non-digital delivery.