Title: Identifying trajectories of progression of frailty in elderly individuals
Funder: Department of Health and Social Care

Abstract: The aim of the work is to better identify those elderly individuals in the community whose level of frailty is increasing, and for whom, it would be appropriate to target potentially resource intensive interventions such as nutritional and exercise advise, with other guidance and support. The goal would be to reduce the risks of unplanned admissions to nursing homes and acute admissions to hospital. Our research aim is that elderly individuals can be grouped into those with different time courses (or trajectories ) of becoming increasingly frail with sufficient precision to be achieve the targeting goal above. The methodological background is the recent development, and introduction into primary care, of a frailty score based, the electronic frailty index, eFI, derived from counting deficits ascertained from the accumulated health record from primary care. We believe that by taking a longitudinal approach to determining frailty would offer a robust but practical approach to identifying those most at risk. We aim to test three specific hypotheses: That there are specific clusters of trajectories of development of frailty over five years based on the changes in eFI score. That these clusters are associated with differences in the one and three-year adverse outcomes of mortality, unplanned hospitalisation and admission to care home. That these clusters add more prognostic value of adverse outcome than the current use of eFI We plan a retrospective cohort study using up to eight-year routinely collected data from two large primary care databases which link to subsequent health and social outcomes. The work comprises 3 phases: Anonymised primary care electronic health record data from the ResearchOne database of 249,000 participants with available data from January 1 2009, aged 65+ will be analysed to calculate the cumulative crude number of deficit variables based on the eFI rules. In each of the successive four years, the cumulative number of the deficits will be increased based on the new recording of any previously unrecorded variable and hence 5-year trajectories derived. As part of the analysis, to address the impact of variability in consultation behaviour on deficit recording, Age UK will lead on establishing a PPI working group to derive a consensus view on the real-life consultation patterns for the individual deficits and agree about the cut off period of the time to last mention. A patient s crude and modified frailty trajectories hence comprise the counts of both crude and modified deficits for five years, respectively. The trajectories will be tested in a second primary care database to examine their reproducibility and the fit of individual patient profiles to these We will explore the association between distinct frailty trajectories and adverse outcomes of mortality, unplanned hospitalization and care home admission using both cohorts over the next three years of follow-up. The starting time for follow up will either be the end of the fifth year or the year of the first outcome, whichever occurs first.

Lay abstract: Frailty is a condition of increased tendency (or 'vulnerability') to major changes in health because of seemingly small problems, such as an infection or new medication. It is common in older age, affecting around 10% of people aged over 65, and develops because as we get older our bodies change and can lose their inbuilt reserves, for example we lose muscle strength. People with frailty are at increased risk of falls, disability, loneliness, and therefore hospitalisation and nursing home admission. These problems can reduce quality of life and are costly for the NHS and social care. There is evidence that providing expert help on diet, physical acivity, together with other more specific treatments can minimise frailty and increase independence for older people with frailty. Recently a calculator called the electronic frailty index (eFI) score has been made available in the NHS to help GPs find older people living with frailty so that better treatments can be provided. The GP can use the exisitng primary care record to calcuate the eFI score, based on the different disorders and conditions a patient has consulted with over the recent past. The eFI score changes over time, and our study will try to find out if we can identify different groups of older people with frailty based on how quickly or slowly their score changes. For example, if an eFI score is changing very quickly, this might suggest that a person s health is deteriorating, and they may need extra support from the NHS or social care services. We will use two very large GP databases for our study. This will enable us to see how diverse groups of people with frailty can be identified, and whether they are at higher risk of hospital admission, nursing home admission, and death. If successful, the study will give us the opportunity to further help GPs identify older people with frailty who are at higher risk of worsening health, and people whose health is more stable. This information will help GPs develop new, more appropriate services for older people living with frailty.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE