What type of study is this?

This is a Cohort Study study (also classified as: Pre-Registered Trial).

December 1, 2025Open Access

Community Specialist Teams for Older Persons at risk of, or living with frailty in Ireland: a prospective cohort study

Key Points

Older adults receiving comprehensive geriatric assessment maintained health-related quality of life after 6 months, and mortality remained low.
At 30 days, incidence of functional decline was 26.4%, highlighting the intervention's impact on older adults' health status.
Prospective cohort study recruited 303 older adults screened for frailty, with follow-up assessments at 30- and 180-days conducted via telephone.
Community-based interventions may reduce avoidable hospitalizations and ED presentations, emphasizing the need for early frailty identification.

Abstract

Abstract Background This study explored the clinical and process outcomes of older adults at risk of or living with frailty who received an interdisciplinary Comprehensive Geriatric Assessment (CGA) in the community. Methods This prospective cohort study recruited older adults aged ≥75 who were screened for frailty and referred to one of three Community Specialist Teams for Older Persons (CST-OP) hubs in the Mid-West of Ireland by their General Practitioner (GP). Follow-up assessments were conducted via telephone by an independent assessor at 30- and-180-days. The primary outcome was functional status. Secondary outcomes included primary healthcare use, secondary healthcare use, nursing home admission, health-related quality of life (HRQoL), patient satisfaction and mortality. The study protocol was prospectively registered on Clinicaltrials.gov (NCT05527223). Results A total of 303 participants (mean age=83.2 years) were recruited. Incidence of 30-and 180-day functional decline was 26.4% and 33.7% respectively. The majority of older adults who availed of community-based CGA maintained functional independence up to 6-months post index visit. At 30-days, the mortality rate was 1.0%, Emergency Department (ED) presentation 6.9%, hospitalisation 6.6% and nursing home admission 4.0%. HRQoL significantly improved at 30-and-180-days. There was a significant improvement in HRQoL, F(2,542) = 13.8, p0.001, η2=0.5. The presence of frailty was a significant predictor of adverse outcomes. Conclusion Community-based CGA results in favorable health outcomes including HRQoL among community-dwelling older adults. Community-based CGA may also mitigate against potentially avoidable ED presentations and hospitalisations. Use of the Clinical Frailty Scale is recommended to predict the risk of functional decline, increased rates of mortality, NH admission, hospitalisation or ED presentation at 30- and 180-days among community-dwelling older adults.

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