Primary care-based management of frailty in older people

Frailty is a condition that becomes more common as people get older. Around 1 in 10 people aged 65 years and over are frail, rising to between a quarter and a half of people aged over 85.

There are currently likely to be around 85,000 frail older people currently living in the Yorkshire and Humber region, rising to around 132,000 by 2030. These frail older people are at greater risk of falls, disability and admission to hospital or a care home. They are also at higher risk of medication side effects and have poorer outcomes from surgical operations.
Frailty affects the whole body but changes to the brain, muscles, immune system and hormones are    especially important. These changes mean that frail older people are vulnerable to major changes in health with what seem like minor illnesses. For example, a frail older person who develops a minor illness like a urine infection may become immobile or fall because of weak muscles. 
They may also become delirious (more confused) because of a vulnerable brain. These sudden and major changes in health (falls, immobility, delirium) are common reasons for older people to be admitted to hospital.
Currently, the main focus for frailty is in hospitals and is reactive to these sudden changes in health. Our planned programme of work in this CLAHRC is ambitious and aims to achieve a shift to a more proactive method of frailty management that is based mainly in primary care. This will be through improved detection and management that
includes exercise programmes, improved support networks and improved communication skills. This will help address inequalities in care for older people by developing a coherent, consistent and evidence based approach to frailty.

One major current problem is that we have no way of routinely measuring how fit or frail an older person is. If we were able to do this we could provide appropriate treatments, better weigh up the risk and benefits of medications and have more informed discussions with frail older patients about risks of surgical operations. Therefore, the first phase of our work is to develop and test an electronic frailty index (eFI) using routinely collected GP health record data. To do this we are working with TPP, the company that developed SystmOne software, which is a leading computer software system used by GPs across the UK. Importantly, our partnership with TPP also means that we will be able to use the eFI in SystmOne as part of future routine GP care.
After development and testing we will use the eFI in GP practices to identify frail older people so that we can invite them to take part in a cohort study. This will form the basis for a series of investigative studies that have been designed to help develop frailty treatments, better understand resourcefulness of frail older people and their carers to improve support networks, enhance communication skills of practitioners working with frail older people and test new technology to monitor changes in frailty. This cohesive series of linked studies have collectively been designed to achieve our goal of a new primary care-based focus for frailty. We plan to work with the Evidence Based Transformation and Health Economics themes in the course of our activities, and will draw upon the collective implementation learning within our CLAHRC led by the Translating Knowledge into Action Theme.