Digital Frailty in Ageing Societies: Introducing a Digital Health Vulnerability Index (Preprint)

UNSTRUCTURED Digital health is now embedded in routine care through patient portals, teleconsultations, remote monitoring, digital triage, and other hybrid service models. While these changes can improve access and efficiency, they may also create new barriers for older adults who have limited cognitive, sensory, functional, or social capacity to engage with digitally mediated care. Current constructs such as digital literacy, digital exclusion, and conventional frailty only partly explain this problem because they do not fully capture the mismatch between the digital demands of healthcare systems and the real world capabilities and supports available to patients. This Viewpoint introduces digital frailty as a clinically relevant, multidimensional state of vulnerability that arises when a person’s intrinsic capacity and available support are insufficient to meet the digital requirements of healthcare. We argue that digital frailty should be understood not as a synonym for age, disability, or low digital confidence, but as a relational and potentially modifiable mismatch between individuals and care environments. Framing the issue in this way shifts attention from blaming patients to designing safer and more equitable systems. To operationalize this concept, we propose a Digital Health Vulnerability Index as a pragmatic framework for identifying patients at risk of digitally mediated care failure. The framework focuses on four proximal domains of vulnerability, namely access, skills, confidence or trust, and support, and is paired with brief consideration of hearing, vision, and cognition to improve clinical interpretability. Rather than functioning as a static label, the index is intended as a routable mechanism to trigger proportionate responses such as assisted digital support, proxy enabled access, simplified workflows, and analogue alternatives for safety critical steps. We further propose proportionate universalism as the most appropriate implementation principle, so that digital support is universal in reach but calibrated in intensity according to need. This approach has implications beyond individual assessment and extends to pathway design, procurement, governance, reimbursement, and digital inclusion policy. In ageing societies, digital vulnerability should be recognized as a determinant of functional access to care. A digitally inclusive health system therefore requires not only better technology, but also better identification, adaptation, and accountability for the patients most at risk of being left behind.