Frailty is not an inevitable consequence of ageing. Many people live to an advanced age while maintaining physical and cognitive function, functional independence and a full and active life, with ill health and disability compressed into a relatively short period before death. However, in a proportion of people, the normal gradual age-related decline in multiple body systems is accelerated, resulting in limited functional reserve, so that even a relatively minor illness or event has a substantial impact on health. This increased vulnerability is termed frailty. An increased risk of adverse health outcomes can be predicted by early identification of frailty, and adverse outcomes prevented by appropriate multidisciplinary interventions. Frailty in older people negatively impacts on their quality of life and causes ill-health and premature mortality. Older people who are frail have an increased risk of falls, disability, long-term care and death.
Frailty Estimates and Projections
Figure 10.6 and table 10.3 show population estimates for frailty and pre-frailty in the Devon population. This suggests that around 20,100 are frail (2.59% of the population) and 80,300 are pre-frail (10.36% of the population). This is much higher than England (2.59% and 10.36% respectively) due to the older age profile in the county. The highest levels were in East Devon and the lowest in Exeter.
Figure 10.6, Estimated percentage of total population who are frail or pre-frail and aged 65 and over, 2016
Source: ONS Sub-National Population Projections (2014-based) and Collard et al 2012
Table 10.3, Older People Frail Estimates, Devon, 2016
| Age Group | Reported Frailty Rate | Reported Pre-Frailty Rate | Population | Estimated Frailty | Estimated Pre-Frailty |
| 65 and over | – | 41.6% | 192,977 | 20,085 | 80,278 |
| 65 to 69 | 4.0% | – | 57,688 | 2,308 | – |
| 70 to 74 | 7.0% | – | 47,224 | 3,306 | – |
| 75 to 79 | 9.0% | – | 34,051 | 3,065 | – |
| 80 to 84 | 15.7% | – | 25,870 | 4,062 | – |
| 85 and over | 26.1% | – | 28,144 | 7,346 | – |
Source: ONS Sub-National Population Projections (2014-based) and Collard et al 2012
As these estimates focus on older people over 65 years of age with either frailty or pre-frailty, it is important to note that these are likely to be underestimates, as a proportion of the under 65 year old population will meet the criteria for frailty and pre-frailty.
Figure 10.7 reveals how the number of older people who are frail is predicted to rise over the next 25 years, increasing from 20,085 in 2016 to 33,155 in 2036.
Figure 10.7, Frailty Projections by Age Group, Devon, 2016 to 2036
Source: ONS Sub-National Population Projections (2014-based) and Collard et al 2012
As illustrated in figure 10.8, it is predicted that by 2036 there will be 33,155 older people who are frail and 113,837 who are pre-frail.
Figure 10.8, Frailty and Pre-Frailty Projections, Devon, 2016 to 2036
Source: ONS Sub-National Population Projections (2014-based) and Collard et al 2012
Detecting Frailty: the Electronic Frailty Index (EFI)
The electronic frailty index (EFI) helps identify and predict adverse outcomes for patients in primary care and is used to plan care at an individual and whole system level. The EFI uses a ‘cumulative deficit’ model, which measures frailty on the basis of the accumulation of a range of deficits, which can be clinical signs and symptoms, diseases, disabilities and abnormal test values. These are detected in primary care using a module available on the main GP practice IT systems. The score is strongly predictive of adverse outcomes and has been validated in large international studies. The EFI is presented as a score, so if nine deficits are present out of a possible total of 36 the EFI score is 0.25), with higher scores indicate increasing frailty. Higher frailty scores are associated with a greater risk of adverse outcomes such as admission to care homes and mortality.
The EFI can be used to score to the following frailty categories:
- Well / Mostly Well (EFI score 0 – 0.12) – People who have no or few long-term conditions that are usually well controlled. This group would mainly be independent in day to day living activities
- Mild or pre-frailty (EFI score 0.13 – 0.24) – People who are slowing up in older age and may need help with personal activities of daily living such as finances, shopping, transportation
- Moderate Frailty (EFI score 0.25 – 0.36) – People who have difficulties with outdoor activities and may have mobility problems or require help with activities such as washing and dressing
- Severe Frailty (EFI score > 0.36) – People who are often dependent for personal cares and have a range of long-term conditions/multi-morbidity. Some of this group may be medically stable but others can be unstable and at risk of dying within six to 12 months.
The EFI is being used for risk stratification within the Integrated Care Exeter (ICE) programme. ICE is a large scale multi-agency project in Exeter with the aim of giving residents a better experience of care, improve health and social care outcomes, and deliver care in the most cost effective way. Figure 10.9 highlights the progression of the different frailty categories over time, revealing a slow progression with great scope for intervention.
Figure 10.9, Progression of Frailty over a 10 year period, Exeter, 2005 to 2015
Source: South West Academic Health Science Network / Devon County Council, 2016
The following analyses pertain to four pilot GP practices within the ICE programme.
Figure 10.10 reveals the age-standardised percentage of persons in each frailty category by deprivation and age. This reveals higher levels of frailty in more deprived areas with relatively high levels of all frailty categories, and the greatest proportionate differences for the severe frailty category (rates in the most deprived areas are two and a half times higher than the least deprived areas). The analysis also suggests higher levels of reported frailty in females than males.
Figure 10.11 further investigates this pattern by sex by comparing the risk of different health outcomes in males compared to females. This reveals that although levels of self-reported ill health and the use of urgent care services (accident and emergency, walk-in centres and minor injury units) are slightly higher in males levels of frailty recorded through the EFI are significantly lower. However progressively higher levels of multi-morbidity, emergency admissions and premature death are seen in males. As the EFI is based on primary care data, this indicates that men are less likely to visit their GP and present signs and symptoms of frailty and disease at an early stage, making them more likely to experience a health crisis later on and have worse health outcomes. This highlights significant challenges in relation to encouraging men to the prevention of disease and overcoming their reluctance to use services, which at present means that problems for many may not be detected until they are too late to prevent or effectively control.
Figure 10.12, shows the pattern of frailty by age highlighting increasing proportions of frailty up to the age of 85 to 89, with lower levels in the oldest age category, highlighting longer life expectancy in less frail groups. Whilst frailty increases with age, it is worth noting that mild frailty in evident in a proportion of young adults, and more severe frailty can emerge in people in their 40s, 50s and 60s. The pattern is varied between different GP practices and areas, with the onset of frailty coming 10 to 15 years earlier in more deprived areas.
Figure 10.10, Age-Standardised percentage in each frailty category by deprivation and sex, Exeter, 2016
Source: South West Academic Health Science Network / Devon County Council, 2016
Figure 10.11, male vs female risk ratios for different health measures and outcomes, ordered by severity, 2016
Source: South West Academic Health Science Network / Devon County Council, 2016
Figure 10.12, Age-Standardised percentage in each frailty category by sex, Exeter, 2016
Source: South West Academic Health Science Network / Devon County Council, 2016