Recognition and management of patients with frailty in the emergency department
Intended for healthcare professionals
CPD    

Recognition and management of patients with frailty in the emergency department

Joy Reid Nurse consultant, medicine of the elderly, Victoria Hospital, NHS Fife, Kirkcaldy, Scotland
Lorna Brocklesby Team lead integrated assessment team, NHS Fife, Kirkcaldy, Scotland

Why you should read this article:
  • To recognise the signs and symptoms of frailty

  • To familiarise yourself with commonly used frailty screening tools that can be used in acute and emergency care settings

  • To contribute towards revalidation as part of your 35 hours of CPD (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

In the UK, around 10% of adults aged over 65 years and around one quarter to a half of adults aged over 85 years have frailty. Early identification of frailty can improve patient outcomes, so it is vital that emergency department (ED) healthcare professionals, including nurses, understand and can recognise the signs and symptoms of this health state. This article describes frailty and outlines the relationship between common presenting complaints in older people in the ED and frailty syndromes. The article summarises some commonly used frailty screening tools that have been validated for use in acute and emergency care settings and details a frailty screening tool used in the authors’ hospital. The authors also outline some important principles of management of patients with frailty in the ED.

Emergency Nurse. doi: 10.7748/en.2022.e2136

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@JoyJcr74

Correspondence

joy.reid@nhs.scot

Conflict of interest

None declared

Reid J, Brocklesby L (2022) Recognition and management of patients with frailty in the emergency department. Emergency Nurse. doi: 10.7748/en.2022.e2136

Published online: 06 December 2022

Aims and intended learning outcomes

This aim of this article is to enhance healthcare professionals’ knowledge of frailty and frailty syndromes, as well as commonly used frailty screening tools, to support timely recognition, screening, management and referral of patients with the condition in the emergency department (ED). After reading this article and completing the time out activities you should be able to:

  • Describe frailty and recognise the potential signs and symptoms.

  • Recognise the relationship between presenting complaints of older people in the ED and frailty syndromes.

  • Discuss the negative effects of frailty on an older person’s quality of life.

  • Understand the importance of prompt screening and referral to a specialist frailty team.

  • Describe some of the validated frailty screening tools that can be used in acute and emergency settings.

  • Understand the important principles of management of a patient with frailty in the ED.

Introduction

Life expectancy in the UK is increasing, due in part to advances in medicine and in the understanding and treatment of medical conditions. According to the Office for National Statistics (2022), the number of people aged 85 years or above was estimated to be 1.7 million in 2020 (3% of the UK population), a figure that is projected to rise to around 3.1 million by 2045 (4% of the UK population). The British Geriatrics Society (2014) stated that around 10% of people in the UK aged over 65 years have frailty – a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves – rising to between one quarter and one half of those aged over 85 years.

Older people with frailty are not just cared for in older people’s settings (Conroy and Thomas 2022). It is imperative, therefore, that frailty is regarded as everyone’s responsibility and that all healthcare professionals, including those working at the ‘front door’ of the hospital – that is, admission units and emergency departments (ED) – have the knowledge and skills to effectively recognise and manage patients with this health state (Reid 2018).

In the opinion of the authors of this article, patients with frailty are often admitted to the ED for reasons that are unrelated to a specific medical condition or major deterioration in their health; instead, their admission relates to issues such as ‘reduced mobility’, ‘functional decline’, ‘falls’ or ‘not coping at home’, which are signs and symptoms of frailty.

If healthcare professionals do not appreciate the complexities associated with frailty, and are unaware of the importance of early identification and timely management, this can result in suboptimal outcomes for patients who present to the ED (Reid 2018). Furthermore, if patients with frailty are not identified at the earliest opportunity during a hospital attendance, they are at increased risk of exposure to hospital-associated harms, such as falls, delirium and malnutrition (Healthcare Improvement Scotland 2014). Lack of early identification can also mean that such patients do not benefit from a comprehensive geriatric assessment, which has been shown to improve patient outcomes through reductions in length of hospital stay and enabling people to continue to live in their own home following a hospital admission rather than requiring alternative care (Ellis et al 2017). A comprehensive geriatric assessment has been defined as a specialist, multidimensional and interdisciplinary process focused on determining an older person’s medical, psychosocial and functional capabilities to develop a coordinated and integrated plan for treatment and follow-up (Ellis and Sevdalis 2019, Quinn et al 2019).

This article discusses frailty and explores the link between older people’s presenting complaints on admission to the ED and frailty syndromes. The article also summarises some commonly used frailty screening tools that are validated for use in acute and emergency care settings and details a frailty screening tool that is used in the authors’ hospital.

Key points

  • Frailty is a clinical syndrome that relates to the vulnerability of older people and the absence of physiological resilience, which ultimately leads to functional decline

  • It is imperative that frailty is regarded as everyone’s responsibility and that all healthcare professionals, including those working at the ‘front door’ of the hospital have the knowledge and skills to effectively recognise and manage it

  • Frailty can have a significant effect on a person’s ability to manage personal and domestic activities of daily living

  • Early identification of frailty is a requirement when the patient presents to the hospital

Frailty

There are many definitions of frailty in the literature. However, one commonly accepted description is that it is a clinical syndrome that relates to the vulnerability of older people and the absence of physiological resilience, which ultimately leads to functional decline and dependency when facing an acute illness or event (Clegg et al 2013, Morley et al 2013, British Geriatrics Society 2014). As people age, the body systems gradually lose in-built reserve and individuals become more susceptible to a sudden deterioration in health status, which can include physical health and cognitive function. This deterioration can be triggered by relatively small events, such as a minor infection, change in social circumstances or change in medicine (Lyndon 2015).

Older people who do not have frailty may have the resilience to ‘bounce back’ quickly and return to their previous level of ability following a short period of functional decline due to illness or insult. However, those with frailty may experience a significant functional decline that affects their ability to perform activities of daily living and their mobility and may never return to their previous level of function (Clegg et al 2013).

There are two models of frailty described in the literature, the phenotype model and the cumulative deficit model (see Box 1).

Box 1. Two models of frailty

Phenotype model

This model describes a collection of patient characteristics – for example, unintentional weight loss, reduced muscle strength, reduced gait speed, self-reported exhaustion and low energy expenditure – which can predict suboptimal outcomes. People with three or more of these characteristics are said to have frailty (Fried et al 2001)

Cumulative deficit model

This model assumes an accumulation of ‘deficits’ – including signs and symptoms such as hearing loss, low mood, tremor or the presence of conditions such as dementia – which can occur with ageing. These deficits combine to increase the ‘frailty index’ which increases the risk of adverse outcomes. The frailty index is calculated by dividing the number of deficits an individual has by the number of possible deficits (Rockwood et al 2005)

The severity of frailty is potentially reversible if it is recognised early, while an individual’s level of frailty can change with each episode of acute illness. Therefore, it is vital that ED healthcare professionals take a careful and effective history from the patient and a collateral history from someone who knows the patient well. A physical examination alone will not provide the critical information required to ensure an effective assessment of a person with frailty and the subsequent development of a comprehensive plan. It is therefore important to gain all possible information from all available sources, with consent, to support this (Royal College of Physicians 2020).

Frailty syndromes

There are five main frailty indicators or syndromes and identification of any of these in the ED should raise suspicion that the patient may have frailty and would benefit from in-depth history taking and referral for a comprehensive geriatric assessment by a specialist frailty team (British Geriatrics Society 2014). The five frailty syndromes are listed in Table 1, alongside possible presenting complaints. If older patients are admitted to the ED with any of the ‘presenting complaints’ detailed next to each syndrome this should prompt ED professionals to consider frailty and to initiate the process for referral for a comprehensive geriatric assessment (British Geriatrics Society 2014, Turner and Clegg 2014).

Table 1.

Five frailty syndromes and possible presenting complaint

Frailty syndromePossible presenting complaint
Falls
  • Collapse

  • ‘Legs gave way’

  • Found lying on floor

Immobility
  • Sudden change in mobility

  • ‘Gone off legs’

  • ‘Stuck in toilet’

Delirium
  • ‘Acute confusion’

  • ‘Muddled’

  • Sudden deterioration of confusion (in someone with dementia or known memory loss)

Incontinence
  • Change in continence (new onset or deterioration of urinary or faecal incontinence)

Increased risk of side effects of medicines
  • Confusion with codeine phosphate

  • Hypotension with antidepressants

Time Out 1

Write a few short paragraphs outlining your understanding of frailty and share this with a colleague. Does their understanding of frailty match yours? What are the implications for patients if you interpret frailty in a different way from your colleague?

Effects of frailty

Individually and collectively, the five frailty syndromes listed in Table 1 can have a significant effect on a person’s ability to manage personal and domestic activities of daily living. Personal activities of daily living include bathing, showering, basin washing, oral hygiene including caring for dentures, hair brushing, applying make-up, toileting including the use of continence aids, nail clipping and ear and skin maintenance. Domestic activities of daily living include meal preparation, eating and drinking, housework, shopping, laundry and money management (Grey 2020).

In the authors’ experience, as people age these activities can become more challenging to perform and maintain, but the addition of one or more frailty syndromes can have a significantly negative effect on functional ability. For example, if a person is experiencing falls, this can reduce their confidence when mobilising inside and outside the house, which over time may prevent them from going food shopping, subsequently affecting food availability and the nutritional energy entering the body. This in turn has a negative effect on the person’s physical and mental state, potentially resulting in them becoming less mobile with consequent decreased muscle strength. This ‘domino’ effect can result in a collection of characteristics as described in the phenotype model of frailty in Box 1 before any of the individual issues have been recognised as risk factors. The older person may attend the ED only after months of deterioration and often with a non-related medical complaint.

This scenario demonstrates the importance of ED professionals having the knowledge and skills to identify the possibility of frailty in an older patient and to initiate a comprehensive assessment process, including referral to specialist frailty teams where appropriate. The specialist frailty team will initiate a comprehensive geriatric assessment by gathering a collateral history of the person’s functional ability, mobility, falls, medicines, continence and cognition and determine an appropriate patient pathway, which may include referral to specialist community teams.

Time Out 2

Think about a patient (or patients) you have cared for in your workplace who was assessed as having frailty. What were the presenting complaints that may have raised suspicion of frailty syndromes?

Identification of patients with frailty in the emergency department

Standards of care published in Scotland and England clearly articulate that early identification of frailty is a requirement when the patient presents to the front door of the hospital (Reid 2018).

The Healthcare Improvement Scotland (2015) Older People in Acute Care Standards state that older people should have an initial assessment on admission to hospital to identify their current health needs and any predisposing conditions that may increase the risk of healthcare-associated harm and where care and treatment can most appropriately be provided. The standards also emphasise that older people who present with frailty syndromes should have prompt access to a comprehensive geriatric assessment and management by a specialist team (Healthcare Improvement Scotland 2015). In England, the document Safe, Compassionate Care for Frail Older People Using an Integrated Care Pathway (NHS England 2014) includes similar guidelines on the importance of early identification of frailty.

Early identification of frailty in the ED through use of a validated frailty screening tool can facilitate a comprehensive geriatric assessment, which can have positive benefits for older people (O’Caoimh et al 2019). These benefits include reduced need for acute hospital admission and reduced overall length of hospital stay if the patient does require admission. Formal recognition of frailty can also support identification of appropriate patient pathways, so it is logical for the process to start at the beginning of a patient’s episode of urgent care (Elliot et al 2017, Fallon et al 2018). Different screening tools may be used in different hospitals, but the important point is that a standardised tool is used to enable staff to communicate in a shared language with other ED staff and the specialist teams that may be involved in the patient’s care and further assessment.

Some examples of commonly used frailty screening tools that are validated for use in acute and emergency care settings are described below. The authors also detail a frailty screening tool that was developed for use in NHS Fife where they are based.

Time Out 3

What is the process for referring patients with frailty for further assessment and management in your workplace? Does your hospital have a specialist frailty team? Could you request to shadow this team to enhance your understanding of frailty, the comprehensive geriatric assessment process and local patient frailty pathways?

Edmonton Frail Score

The Edmonton Frail Score (Rolfson et al 2006) is over 15 years old, but it remains well-used and is validated for use in the community and in acute care (British Geriatrics Society 2018). The scale focuses on nine elements of frailty; cognition, general health state, functional independence, social support, medicine use, nutrition, mood, continence and functional performance. The healthcare professional conducting the screening asks the patient to answer specific questions related to each of these elements, which are then scored. Functional performance is assessed by measuring the time taken to mobilise a certain distance. The total score indicates a patient’s level of frailty as follows: vulnerable (6-7); mild (8-9); moderate (10-11); or severe (12-17).

Clinical Frailty Scale

The Clinical Frailty Scale (Rockwood et al 2005) – which can be viewed at www.scfn.org.uk/clinical-frailty-scale – was originally developed as a way of summarising the overall fitness level of an older person (Geriatric Medicine Research 2022). The scale has been shown to effectively predict outcomes for older hospitalised patients in relation to mortality and other harms associated with hospital admission (Church et al 2020). The scale is now widely used as a visual judgement-based tool to screen for frailty and to roughly quantify an older person’s overall health status through evaluation of levels of function, mobility and cognition (Geriatric Medicine Research 2022). Levels range from 1 ‘very fit’ to 9 ‘terminally ill’.

The value of using the Clinical Frailty Scale in the ED is that it enables healthcare staff to visually assess the patient and to ask relevant questions to identify and summarise their level of mobility and function. This information can then be used to support decision-making regarding care and referral for further investigation and support.

Identification of Seniors at Risk

Identification of Seniors at Risk (ISAR) (McCusker et al 1999) is a six-item self-reporting questionnaire, using a ‘yes/no’ format, that considers a person’s care needs before and after an acute illness, the number of hospital admissions they have had, their vision, memory and medicine use. It is validated for use in the ED and is scored from 0 to 6 with a cut-off score of ≥2 considered high-risk (O’Caoimh et al 2019). It was originally developed as a risk-prediction tool, which may not necessarily be the same as a frailty screen but is accurate with high sensitivity in identifying patients with frailty in the ED (O’Caoimh et al 2019). The authors of an Italian study of 200 ED patients aged 65 years or over concluded that ISAR can effectively identify older people at risk of adverse outcomes following an ED admission and effectively identify high-risk patients who may benefit from specialist geriatric intervention (Salvi et al 2012). However, other authors have suggested that ISAR is not so effective at predicting specific negative healthcare outcomes in the ED setting (Galvin et al 2017).

NHS Fife frailty inpatient screen

In the authors’ hospital, the NHS Fife frailty inpatient screening tool (Table 2) was developed to support the early identification of the person with frailty at the front door as part of a larger service improvement programme. The screening tool takes the form of a yes/no questionnaire and includes a falls risk assessment (questions 5-7), which ensures compliance with the Care of Older People in Hospital Standards (Healthcare Improvement Scotland 2015), the Scottish Patient Safety Programme (2021) falls workstream (which is ongoing) and the National Institute for Health and Care Excellence (2013) guideline on falls in older people. The NHS Fife frailty inpatient screening tool also includes a cognitive screen, the validated ‘4AT’ rapid clinical test for delirium (MacLullich et al 2014), which includes the abbreviated mental test (Swain and Nightingale 1997). This negates the need for a separate cognitive impairment screen and ensures compliance with the Care of Older People in Hospital Standards (Healthcare Improvement Scotland 2015), which state that a cognitive assessment should be completed on admission.

Table 2.

NHS Fife frailty inpatient screening tool

1.Has the patient been admitted from a nursing or residential home?⁗ Yes⁗ No
2.Does the patient have new functional decline?⁗ Yes⁗ No
3.Do they have a dementia diagnosis or are there any concerns about memory and/or cognition?⁗ Yes⁗ No
4.Is the patient acutely confused, more confused than usual or more sleepy and/or drowsy than usual?⁗ Yes⁗ No
5.Has the patient fallen in the past three months or is a fall the reason for admission?⁗ Yes⁗ No
6.Does the patient attempt to walk alone although unsteady or unsafe?⁗ Yes⁗ No
7.Does the patient or their relatives have fear or anxiety regarding falling?⁗ Yes⁗ No
4AT (rapid clinical test for delirium) Score
Alertness:
This includes patients who may be markedly drowsy (for example difficult to rouse and/or obviously sleepy during assessment) or agitated and/or hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask patient to state their name and address to assist rating
  • Normal (fully alert, but not agitated throughout assessment)

0
  • Mild sleepiness for 10 seconds after waking, then normal

0
  • Clearly abnormal

4
Abbreviated mental test (AMT 4)
Ask the patient’s age, date of birth, place name (such as hospital/unit name) and current year
  • No mistakes

0
  • 1 mistake

1
  • 2 or more mistakes/untestable

2
Attention
Ask the patient: ‘Please tell me the months of the year backwards starting at December.’ You can assist them with one prompt of ‘What is the month before December?’
  • Achieves ≥7

0
  • Starts but scores <7 months or refuses to start

1
  • Untestable (cannot start because unwell, drowsy or inattentive)

2
Acute change or fluctuating course
Evidence of significant change or fluctuation in: alertness; cognition; other mental function (for example paranoia, hallucinations arising over past two weeks and evident in past 24 hours)
  • No

0
  • Yes

4
Total score
If 4AT score is 4 or above, think delirium

The NHS Fife frailty inpatient screening tool is completed by ED doctors. If the answer to any of the questions in the first section of the tool is ‘Yes’, then the patient has screened positive for frailty syndromes and is deemed ‘frailty positive’. The ED team then refers the patient to the local integrated assessment team, a specialist multi-professional team that assesses and manages patients with frailty who present to the acute hospital in Fife. The scoring from the cognitive screen is used to further inform the referral and to inform care while in the ED.

Time Out 4

What is the process in your workplace for identifying patients with frailty? Reflecting on the frailty tools described in this article, which one might be most appropriate for use in your department and why? Or would your patients benefit from a locally developed frailty screening tool?

Frailty management in the emergency department

Identification of frailty at the earliest point during admission to hospital is critical to improve patient outcomes. For a significant cohort of patients their journey will begin in the ED, therefore it is vital that ED professionals have the knowledge and skill to identify frailty in patients as quickly as possible to provide appropriate management while the patient remains in the ED and to facilitate timely referral for a comprehensive geriatric assessment.

The authors believe there are four important principles that ED professionals, including nurses, should consider when managing a patient who has been identified as having frailty:

  • If in doubt, refer to specialist teams. If you are uncertain about whether a patient has frailty, refer the patient to the specialist frailty team, particularly if the patient is not likely to be admitted to a ward. Do not assume that community support will be available. Ask for assistance from the specialist frailty team when attempting to establish what the patient will need to support them at home and the optimal way to access this support.

  • Recognise your own level of confidence and competence. This is particularly important with regards to assessing a patient’s cognitive function. If you are not confident to assess a patient’s level of frailty or cognitive function using the screening tools in your department, refer to the specialist frailty team for advice and support.

  • If relatives are present, gather additional information such as the patient’s current level of function, cognition, mobility and support as well as any recent changes in these levels. This can assist in identifying whether the patient is coping at home with their current level of support or requires further supportive interventions. It can also determine the speed of the change in the patient’s function and cognition, for example days, weeks or months. Gathering information from relatives can be helpful when the patient is unable to articulate this themselves or when you are unsure of the patient’s home situation.

  • Explain as you go. Explain to the patient and their relatives that you are using a screening tool and asking questions to identify their level of frailty to support development of a management plan that will ensure they are on the appropriate pathway for their care needs.

Issues such as falls, delirium, pressure area damage, malnutrition and adverse effects of medicines must be identified at the earliest opportunity during the person’s ED attendance to enable appropriate intervention and management. ED nurses should be aware of their local falls risk assessment and management plans and should know how to support a patient with delirium. Undertaking a falls risk assessment and supporting patients with delirium requires a multi-professional approach within the ED, including nurses, healthcare support workers and medical staff, to identify potential causes of falls and/or delirium and to rapidly initiate investigations and management (Kennedy et al 2020).

Staff should also be confident to support patients who are expressing stressed or distressed behaviours due to delirium or cognitive impairment related to dementia. Working collaboratively with local frailty teams who undertake comprehensive geriatric assessments will enable ED staff to develop their knowledge and confidence in the effective management of a patient with frailty.

Time Out 5

Review the practice in your ED with regards to managing patients with frailty. What are the main elements that should be addressed to ensure patients with frailty are provided with safe, effective and high-quality care while in the ED?

Conclusion

Frailty should be identified at the earliest opportunity when an older person presents to the ED. Healthcare professionals who work in the ED should be able to recognise the signs and symptoms of frailty and understand how certain presenting complaints are linked to frailty syndromes in older people. They should also be able to select and use – or initiate the use of – a validated screening tool to facilitate timely identification of patients with frailty and referral to specialist frailty teams for a comprehensive geriatric assessment. If healthcare professionals at the front door of hospitals can provide timely, effective, quality care for patients with frailty this may reduce the need for inpatient admission and/or reduce the hospital length of stay for those who are admitted.

Time Out 6

Identify how recognition and management of patients with frailty in the emergency department applies to your practice and the requirements of your regulatory body

Time Out 7

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account. See: rcni.com/reflective-account

References

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