Frailty

With age, people often develop an increasing number of health conditions that affect how they feel and their ability to remain independent. Some may struggle with decreased energy levels, low appetite, lower muscle strength and difficulty with household tasks such as shopping and cooking.

However, few health services currently exist to help. We designed the HomeHealth service in 2014-2015 in partnership with older people, carers, health and social care professionals and experts. It aims to help people aged 65+ who are starting to find everyday activities more difficult to stay independent and healthy for as long as possible. 

We are carrying out a national randomised controlled trial to test whether the HomeHealth service makes a significant difference to the people who use it, and if it proves to be good value if it were to be commissioned by the NHS. Please see our website www.ucl.ac.uk/home-health-trial for more information.

Led by PhD candidate: Jo Dawes

Supervisors: Prof Andrew Hayward, Prof Kate Walters

Dates: June 2022 - May 2026 (studying part-time)

Funder: NIHR Doctoral Research Fellowship

PhD overview:

Background

Frailty is an accumulation of physical, psychological, and social deficits, associated with vulnerability and reduced resilience against health challenges, which increase risks of adverse outcomes and health service usage. People experiencing homelessness (PEH) have poorer health than the general population. Research suggests prevalence of frailty amongst PEH is higher than amongst the general population and often presents at a younger age.

Research questions

What are the prevalence and associations with frailty amongst PEH? What life course events health behaviour and resource factors contribute to frailty in PEH? What are the perceived facilitators, barriers and potential adaptation of existing interventions and what new models of care could prevent and treat frailty amongst PEH?

 

Findings from WP1

My study included 2,288 PEH (94% aged 18–59). Frailty prevalence was 41.5%, and pre-frailty 43.8%, both significantly higher than in similarly aged adult population. Frailty was identified in 26·6% of PEH aged 18–24. Adjusted Risk Ratios (aRR) showed increased risk of frailty in older PEH (aRR=8·39, 95% CI 4·86–14·16), women (2·30, 2·59–5·73) and those not in work, education or volunteering (3·05, 1·97–4·71). Non-UK-nationals had lower risk of frailty (0·20, 0·12–0·33). Sleeping outside (0·36, 0·17–0·76), hostel-type accommodation (0·50, 0·25, 1·02) or living in insecure/ inadequate accommodation (0·49, 0·21–1·15) conferred a lower likelihood of frailty compared to recently housed, previously homeless individuals. Similar patters were observed with pre-frailty.

• WP2: Using in-depth qualitative interviews with PEH who are frail/ pre-frail, to understand what life events have contributed to decline in health.
• WP3: Qualitative workshops with PEH and staff who look after them to explore perceived facilitators, barriers and potential adaptation of existing interventions and what new models of care could prevent and treat frailty amongst PEH.

Aims

To improve understanding of the prevalence of frailty in PEH and to inform the development of interventions to prevent, identify and manage frailty in this population.

Methods

This mixed-methods research comprises three work packages (WP), informed by public and patient involvement and engagement (PPIE) with PEH and homeless healthcare providers.

WP1: A quantitative cross-sectional, secondary analysis of health needs data, collected from PEH in England using an interviewer-led survey was conducted. A Frailty Index was created for this dataset and frailty prevalence calculated. Associations between sociodemographic, health behaviour and situational factors were calculated using regression analysis.

Led by: Dr Natasha Palipane (GP ACF)

Primary supervisor: Professor Kate Walters

Project co-applicant: Dr Cini Bhanu

Co-investigators: Dr Ev Callahan (UCL); Dr Megan Armstrong (UCL); Dr Briony Hudson (UCL); Dr Caroline Shulman (Pathway); Ms Jo Dawes (UCL); Dr Rafi Rogans Watson (Pathway); Dr Julie Broderick (University College Dublin).

Dates:  May 2025 – November 2026

Funder (if applicable): NIHR School of Primary Care Research

Background:

People experiencing homelessness (PEH) have extremely poor health outcomes with mortality rates comparable to 3-6 times that of the general population. Frailty is a clinical condition characterised by increased vulnerability to changes in health and is associated with adverse outcomes including cognitive decline, reduced mobility and increased hospitalisation. Frailty presents earlier and at a higher rate amongst PEH compared to the housed population. Despite this, PEH experience poor access to health and social care. Developing targeted interventions will require an understanding of the evidence base for frailty interventions in homeless populations and an understanding of what is currently happening in clinical practice.

Aim: To understand how primary care practitioners are currently managing the frailty needs of PEH and how they can be facilitated to further support this population. 

The study consists of two work streams: 

1) Systematic review to understand the current evidence for managing frailty in PEH within the primary care context. 

2) Qualitative study with mainstream and specialist community practitioners to understand how frailty in PEH is currently being managed and how it can be optimised. 

Project Lead: Dr Danielle Nimmons

Co-applicants:  Professor Kate Walters, Dr Fiona Aspinal, Samina Begum, Katherine Barrett:

Collaborators: Professor Andy Clegg, Dr Sara Humphreys, Dr Stuart Mackay-Thomas,

Dates: April 2024 – March 2026

Funder: NIHR ARC North Thames

Background and significance of the research 

Frailty increases in prevalence with age and is associated with adverse outcomes, such as, increased risk of falls and hospitalisations. The Electronic Frailty Index (eFI) was developed to improve frailty detection and management in primary care, and is used in clinical practice. Recently a new version was created (the eFI2), aiming to improve its clinical utility. Research is needed exploring how the eFI2 can be implemented and utilised informing decision-making. Due to negative connotations, how frailty is communicated with patients in the community should be explored. Primary care clinicians manage frailty across different settings, including care homes. Research is needed exploring how the eFI2 can support care planning across settings. 

Aim

To understand how the updated eFI2 can be utilised by primary care clinicians to identify and manage frailty. 

 

Methods 

Design, Participants & Sampling: Approximately six focus groups with 6-8 participants supplemented by up to 5 semi-structured one-to-one interviews with healthcare professionals working in primary care who work with frail patients. 

Data Collection: Focus groups and interviews will be audio-recorded and transcribed verbatim.  

Analysis: Reflexive thematic analysis will be used to analyse the data.  

 Involvement of people with lived experience:  

 Two people with lived experiences are part of the advisory group for this project, contributing to: topic guides, participant information sheets, analysis and public engagement activities.  

 

Outputs

Nimmons D, Clegg A, Walters K. Using the new electronic frailty index (eFI2) to aid frailty identification and management in primary care. Br J Gen Pract. 2025 May 29;75(755):249-250. doi: 10.3399/bjgp25X742473. PMID: 40441910; PMCID: PMC12117642.