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Age is not an accurate indicator of the health of older adults. It also doesn’t tell us much about an individual’s healthcare needs. How do we identify those at greatest risk of adverse health outcomes? We invited Aisling O’Halloran and Roman Romero-Ortuno, of Trinity College Dublin, Ireland, to discuss their study on frailty published in the TILDA Gateway. Read on to find out how these researchers used TILDA data to find potentially fairer ways of allocating health and social care in Ireland.

First things first: what is frailty?

Frailty occurs when many body systems have lost their inbuilt reserves. Regardless of age, frailty is more likely in adults who live with multiple medical conditions (multimorbidity), or chronic physical or cognitive disabilities. This can make older adults more vulnerable to infections like COVID-19, or lead to a rapid decline in their health from relatively minor illnesses.

Depending on the cause of the decline, many people living with frailty may recover their independence through a temporary support network. Yet, others may not return to their baseline health level and need long-term support.

Frailty is a dynamic condition, with frequent transitions in states over time. It may slow down or even reverse with early and appropriate interventions that improve resilience, including:

· Specific medical interventions

· Multidisciplinary rehabilitation programmes

· Nutritional optimisation

· Regular medication reviews

· Engagement in meaningful social activities

Health and social care

Availability of comprehensive medical assessment and multidisciplinary rehabilitation services is limited. This can mean long waiting lists. Similarly, community care teams can operate under pressure with a limited number of carers. A fair system would prioritise frailer older adults for quicker access to services, compared to people the same age who are healthier.

When it comes to social care, many services are currently allocated based on a one-off assessment of care needs. This does not reflect the significant fluctuations in those needs that could change over time. If an individual improves, can previously allocated care be reallocated to someone else who needs it more? Or the opposite – can they get worse and previously allocated care becomes insufficient? What care could be provided to avoid premature institutionalisation?

Introducing the Clinical Frailty Scale

The Clinical Frailty Scale (CFS) measures multiple important aspects of age-related declines in health.

The CFS was developed as a tool to assess the presence and severity of frailty among adults aged 65 and over.

Healthcare professionals will give a score from 1-9:

· 1-3 indicates reducing levels of fitness

· 4 indicates vulnerability (or very mild frailty)

· 5 or more indicates increasing frailty severity

What can we learn from a CFS score?

Increasing frailty severity (higher CFS scores) have previously been shown to predict higher use of health and social care services in studies of older adults in Canada and Europe. We used data collected from the TILDA study in 2018, to group TILDA participants by CFS score. We measured how often each group used a range of health and social care services in the previous year. This allowed us to estimate allocation of resources for people aged 65 and over in Ireland.

We found that use of all services increased with increasing CFS scores. This includes GP, community, hospital, and social and home care support services. Even among those who were living with frailty, service use increased with frailty severity. We also found that the number of hours of unpaid informal care, provided by family and friends, increased with frailty severity.

The TILDA cohort – the benefit of using eight years of data

The TILDA cohort is a nationally representative sample of over 8,000 adults living in the community aged 50 years and older. A vast array of data on the health, economic, and social circumstances are gathered on the same individuals every two years. This includes information on the use of a range of health and social care services, and the data needed to assess frailty status using the CFS.

The TILDA study is the only one in Ireland to provide this level of detailed information on the lives and circumstances of older adults. This allowed us to estimate allocation of health service resources for people aged 65 and over in Ireland. We also tracked changes in frailty status over eight years from 2010-2018 using the five waves of data collection, demonstrating that frailty is indeed very dynamic over time. This shows the great benefit of TILDA being a long-term longitudinal population-based study.

Providing the right care for individuals

We made two key findings. Firstly, CFS is significantly correlated with use of medical and social services and therefore could improve allocation of those services based on the greatest need rather than based on age.

Secondly, we showed that frailty status is dynamic. The health and care needs of older adults change over time, but unfortunately a one-off assessment doesn’t factor this in. Of those who are living with frailty, half may still be frail in two years but almost one quarter will no longer be classified as living with frailty.

What next?

Incorporating frailty assessments could improve allocation of health and social care services, better tailor services to individual needs, and help provide quicker access to those who need it more.  

Routine CFS scoring (or other validated frailty identification tools) could be implemented by integrated care teams with relative ease and the appropriate training. The National Frailty Education Programme is already well placed to provide all health professionals with the knowledge they require to carry out frailty assessments in the community. Given that frailty is so dynamic, it should be assessed among community-dwelling adults aged 65+ at least every two years, if not more often.

Influencing new health policies

We are keen for this research to reach as wide and inclusive an audience as possible, including health policy makers and health service planners. HRB Open Research allows our research to be accessed free of charge enabling our study findings to be shared and viewed as widely as possible by anyone with an interest in improving health service provision in Ireland and even internationally.

We are passionate that this type of research should be free to all regardless of means. After all, we will all be older adults one day, so it is an investment in our future selves!

You can read the Research Article and its peer review reports on HRB Open Research here: Informing patterns of health and social care utilisation in Irish older people according to the Clinical Frailty Scale

Browse through the TILDA Gateway to read more impactful studies by TILDA researchers and interesting projects based on analysis of TILDA data.