Digital and Remote Enhancements for the Assessment and Management of older people living with frailty (DREAM)


A Comprehensive Geriatric Assessment (CGA) is a process involving older people (usually aged 65 years and over), their families and health and social care staff, which seeks to identify and help manage their problems and prevent new ones arising. This process can mean that people are less likely to need hospitalisation or to go into a care home.

Starting in January 2022, the aim of the project is to develop a model of enhanced Comprehensive Geriatric Assessment for use in non-hospital settings. The research aims to develop a process of remote assessment and care called enhanced Comprehensive Geriatric Assessment (eCGA). The research will be completed in collaboration with a stakeholder group of older people, their family members, and health and care professionals.

Anticipated outputs:

  • The outcomes of this development work will include a detailed plan of eCGA, developed with stakeholders, and a proposal for a future programme of work.
  • Development of a learning system to optimise anticholinergic medication prescribing for older people living with frailty

The NHS needs to improve support for GPs to optimise the medications prescribed to frail older people to avoid harmful effects. This project focuses on anticholinergic medications (ACs) used to treat bladder, bowel and mood problems which can cause confusion and falls in older people. This project aims to develop a tool to help doctors and pharmacists review a patient’s medical history to assist appropriate prescribing of ACs. This will help reduce the risk of harmful side effects in older people which can lead to hospital admissions.

This project will develop the Anticholinergic Medication Index (ACMI) tool to calculate AC medication burden for older people. The tool will be tested using anonymised routine data from the Connected Bradford dataset to see how the score predicts being admitted to hospital with confusion or a fall.


To improve quality of life and clinical outcomes and save NHS and social care costs.

Cross-ARC expansion of CARE75+ cohort study

The Community Ageing Research (CARE75+) Study is a longitudinal cohort study that recruits older people (≥ 75 years) via General Practices across England. The study is hosted at Bradford Teaching Hospitals NHS Foundation Trust and uses the support of the Clinical Research Networks in the Northeast & Cumbria, North-West Coast, West Midlands, Thames Valley & South Midlands, and the South-West Peninsula to assist with recruitment. CARE75+ collects an extensive range of data on health, social circumstances, wellbeing, and frailty outcomes, with data available from over 1800 participants. Furthermore, CARE75+ provides an efficient research recruitment platform for other studies that need to access older adults for research. To date, CARE75+ has provided participants for multiple studies on topics including pain, quality of life measures, cognitive frailty, and independence.

Next step

Recruitment is on-going, with current expansion of the CARE75+ Remote pathway.



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