Background

Frailty is a condition that is common in older age. It develops because as we get older our bodies change, and can lose their inbuilt reserves. These changes mean that older people with frailty can experience sudden, dramatic changes in their health when they have an illness or injury. For example, an apparently minor illness such as an infection, or an injury such as a fracture, can cause an older person with frailty to become less mobile and unable to carry out day-to-day tasks. This can often result in admission to hospital, and a further period of immobility. This is a major problem because, in frailty, even short periods of immobility can cause muscles that are already weak to become even weaker, preventing movements such as getting out of a chair, getting out of bed, getting on and off the toilet and climbing stairs.

Older people with frailty are therefore likely to need a period of rehabilitation to improve overall muscle strength and ability to carry out day-to-day tasks before returning home from hospital. In the NHS, around a third of older people with frailty are likely to return home after a brief period of rehabilitation on a hospital ward. A further third will need a period of rehabilitation in ‘intermediate care’, which is a range of community rehabilitation services provided either in a setting such as a community hospital, or at home. However, current guidelines recommend that intermediate care should be for a relatively short period of between 2 to 6 weeks. A large national audit shows that people discharged from intermediate care often do not feel ready to leave the service and research suggests that the initial improvement from this short period of rehabilitation may not be sustained in the longer-term.

An important part of rehabilitation is progressive physical exercise. We have developed the Homebased Older People’s Exercise (HOPE) programme, which is a home-based exercise intervention for older people with frailty. Participants follow an exercise manual that contains exercises to strengthen the important muscles required for movements such as getting out of a chair, getting out of bed, and climbing stairs, under the guidance of a physiotherapist. The HOPE programme was developed with considerable input from older people with frailty, including the design of the exercise manual, to make sure that it is meaningful and acceptable to users. We have tested the HOPE programme with frail older people in a pilot clinical trial and the results show that the HOPE programme is feasible and safe, with potential to improve mobility.

Our proposal is to study the HOPE programme as extended rehabilitation for older people with frailty who have been discharged home from hospital or from intermediate care after illness or injury. Our earlier pilot trial recruited frail older people from the community, so in this study we first plan to test recruitment from hospital and intermediate care. We also plan to test if it is possible to collect follow-up data using postal questionnaires. If we are able to successfully recruit and follow up enough participants we will continue the study and recruit a much larger number so that we can find out with more certainty if the HOPE programme can improve quality of life for older people with frailty. We will also test whether the HOPE programme provides value for money, and study how it is provided in practice so that we can roll it out across the NHS if it is successful.

Aims & Objectives

Primary: To establish whether a home-based exercise intervention plus usual care as extended rehabilitation for older people with frailty improves health-related quality of life.

Secondary:

  • To establish whether the intervention improves mental health.
  • To establish whether the intervention improves activities of daily living.
  • To establish whether the intervention reduces hospitalisation rates, care home admission rates, falls and overall health and social care resource use.
  • To establish whether the intervention is cost-effective.
  • To understand how the intervention is experienced and understood by providers and recipients, and explore the organisational implications of embedding and sustaining the intervention in preparation for wider NHS roll-out.

Methods

Pragmatic multi-centre randomised controlled trial, including internal pilot with progression criteria and an embedded process evaluation and parallel cost-effectiveness analysis.

Population: Older people (aged >65) with frailty admitted to hospital following acute illness or injury then discharged home directly from hospital or from intermediate care services.

Intervention: 24 week home based exercise intervention (HOPE Programme).

The Hope Programme

The Home-based Older People’s Exercise (HOPE) programme is a home-based exercise intervention for older people with frailty. It is a 12 week graded, progressive exercise intervention aimed at improving strength, endurance and balance that is presented to participants in an exercise manual and delivered by community-based physiotherapists and therapy assistants. Participants will receive weekly support through five face-to-face home visits and seven telephone sessions. The programme will be extended with weekly telephone calls for a further 12 weeks to ensure that participants are well-positioned for ongoing self-management following completion of the intervention.

Outputs

Prescott M, Lilley-Kelly A.  Cundill B, Clarke D, Drake S, Farrin AJ, Forster A, Goodwin M, Goodwin VA, Hall AJ, Hartley S, Holland M, Hulme C, Nikolova S, Parker C, Wright P, Ziegler F, Clegg A. Home-based Extended Rehabilitation for Older people (HERO): study protocol for an individually randomised controlled multi-centre trial to determine the clinical and cost-effectiveness of a home-based exercise intervention for older people with frailty as extended rehabilitation following acute illness or injury  including embedded process evaluation. Trials 2021;22( 783). https://doi.org/10.1186/s13063-021-05778-5

Clegg A, Barber S, Young G, Iliffe S, Forster A. The Home-based Older People’s Exercise (HOPE) trial: a pilot randomised controlled trial of a home-based exercise intervention for older people with frailty. Age and Aging 2014; 43: 687-695.  (PDF)

Partners & Collaborators

Investigators

Dr Andrew Clegg, Dr David Clarke, Bonnie Cundill, Professor Amanda Farrin, Professor Anne Forster, Dr Vicki Goodwin, Suzanne Hartley, Professor Claire Hulme, Phil Wright, Professor John Young

Collaborators

Academic Unit of Elderly Care and Rehabilitation, University of Leeds.
Bradford Institute of Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust
Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds.
Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds.
University of Exeter Medical School.

Timescales

01/03/2017 – 31/05/2023

Funding agency

National Institute for Health and Care Research (NIHR)

Further information

For further information please contact Project Lead Professor Andrew Clegg or Trial Manager Matthew Prescott Tel: 01274 383424

This summary presents independent research funded by the National Institute for Health and Care Research Health Technology Assessment Programme (NIHR HTA)  (Grant Reference Number: 15/43/07). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Ethical Approval:

Yorkshire & The Humber – Bradford Leeds Research Ethics Committee (REC Reference 17/YH/0097).

Trial Registry:

ISRCTN Registry: 13927531 https://doi.org/10.1186/ISRCTN13927531