Frailty trajectories to identify end of life: alongitudinal population-based study
Daniel Stow, Fiona E. Matthews and Barbara Hanratty
Background:Timely recognition of the end of life allows patients to discuss preferences and make advance plans,and clinicians to introduce appropriate care. We examined changes in frailty over 1 year, with the aim of identifyingtrajectories that could indicate where an individual is at increased risk of all-cause mortality and may requirepalliative care.Methods:Electronic health records from 13,149 adults (cases) age 75 and over who died during a 1-year period(1 January 2015 to 1 January 2016) were age, sex and general practice matched to 13,149 individuals with no recordof death over the same period (controls). Monthly frailty scores were obtained for 1 year prior to death for cases, andfrom 1 January 2015 to 1 January 2016 for controls using the electronic frailty index (eFI; a cumulative deficit measureof frailty, available in most English primary care electronic health records, and ranging in value from 0 to 1). Latentgrowth mixture models were used to investigate longitudinal patterns of change and associated impact on mortality.Cases were reweighted to the population level for tests of diagnostic accuracy.Results:Three distinct frailty trajectories were identified. Rapidly rising frailty (initial increase of 0.022 eFI per monthbefore slowing from a baseline eFI of 0.21) was associated with a 180% increase in mortality (OR 2.84, 95% CI 2.34–3.45)for 2.2% of the sample. Moderately increasing frailty (eFI increase of 0.007 per month, with baseline of 0.26) wasassociated with a 65% increase in mortality (OR 1.65, 95% CI 1.54–1.76) for 21.2% of the sample. The largest (76.6%)class was stable frailty (eFI increase of 0.001 from a baseline of 0.26). When cases were reweighted to population level,rapidly rising frailty had 99.1% specificity and 3.2% sensitivity (positive predictive value 19.8%, negative predictive value93.3%) for predicting individual risk of mortality.Conclusions:People aged over 75 with frailty who are at highest risk of death have a distinctive frailty trajectory in thelast 12 months of life, with a rapid initial rise from a low baseline, followed by a plateau. Routine measurement of frailtycan be useful to support clinicians to identify people with frailty who are potential candidates for palliative care, andallow time for intervention.