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Emergency Medicine

Introduction

The prevalence of frailty among older adults presenting to emergency departments (ED) appears to be significantly enriched compared to background rate estimates (of around 10%)found in studies of community dwelling older adults in high-income countries. A study in Dublin of almost 200 consecutive patients older than 70 reported that 47% were classified as frail using a deficit accumulation index (DAI) frailty assessment (Fallon et al., 2018). Among a sample of U.S. older adults discharged home after their ED visit, 20% were found to be frail using the physical frailty phenotype (Stiffler et al., 2013). 

Impact of Frailty on Emergency Medicine 

Frail older adults in the ED present significant challenges to emergency medicine providers. The first occurs at the beginning of every interaction--with triage--because the differences in response to illness and injury in older adults may result in a lower severity score than is warranted by the condition.  

Under-diagnosis at triage has been documented in studies of older adults presenting to EDs across the United States (Platts-Mills et al., 2010; Kodadek et al., 2015). The failure to accurately triage acute illness in older adults results, in part, from the blunted responses to illness in this population, arising from changes in the immune system and reaction to both endogenous and exogenous pyrogens (see Research Topics). This can lead to less dramatic clinical findings on exam--lack of fever and other inappropriately normal vital signs and more subtle laboratory value abnormalities than in younger patients with similar disease (Katz and Carpenter; Heffernan et al., 2010).  In addition, medication side effects and communication challenges, including vision and hearing deficits, can create further barriers for emergency medicine providers evaluating older adults for serious illness or traumatic injury.  

Frailty also increases the risk of poor outcomes following an ED visit. Hospital admission, death, and nursing home admission among older adults within 30 days of ED discharge have all been linked to a higher DAI. After adjusting for demographics, insurance status and previous health service use, only repeat ED visits were not significantly associated with an elevated DAI (Hastings et al, 2008).Functional decline has even been noted in study of vulnerable older adults who were seen in the ED for what were thought to be minor injuries (Sirois et al., 2017). 

Deliriumis a second risk factor which complicates the ability to provide rapid disease identification and stabilization, as well as significantly delaying disposition, lengthening ED stays and triggering hospitalization. Importantly, these two risk factors are not fully independent as frailty measured by DAI has been linked to risk of delirium in the ED (Giroux et al., 2018). 

Applying Knowledge of Frailty in the Emergency Department 

Practical limitations to assessing frailty in the ED are significant. In particular, while the biology of physical frailty is likely to play a key role in the under-diagnosis and triage of older adults in the ED, current physical frailty assessment is not practical in the ED. Even if testing could be administered, grip strength and walking speed cannot be easily interpreted in those with acute illnesses which effect functional capacity. This is easily appreciated to be true for common presentations such as asthma or pneumonia. Some have started to look at using components of physical frailty measured in those being discharged from the ED as individual markers of outcomes(Afilalo et al., 2020), but research on frailty in the ED has generally used deficit accumulation scoring systems to categorize patients. Wider recognition of and screening for frailty among older adults prior to an ED visit, when these patients are well, may be of higher value than evaluating for frailty at the point of an ED visit. These pre-ED visit frailty results could be shared with the emergency medicine provider during an acute event, like allergy warnings or difficult airway alerts to help identify higher risk patients.Furthermore, such a flag could allow for the appropriate adjustment interpreting vital signs at triage, for example. 

Appreciating that the vulnerability impacts not just the acute care but also the success of the disposition should direct the types of interventions studied to reduce the impact of frailty. Ancillary services that can facilitate communication beyond the ED visit, such as pharmacy consultation for medication reconciliation, social work or case management resources to support transitions in care, may allow emergency medicine providers to improve the long-term health of vulnerable adults who pass through their care.The foundations of emergency medicine, identification of time sensitive disease and injury as well as efficient and timely care of these patients, are unlikely to change. However, being able to identify vulnerable older adults who are at high risk of poor outcomes, should be recognized as equally as important. Innovative approaches in caring for these vulnerable older adults is likely to lead to changes that improve care for this population.  

The research to date has been done on descriptive cohort studies and the field is ready for randomized clinical trials comparing the use of DAI screening, or pre-determined physical frailty, to improve outcomes during and following ED visits (Jorgenson and Braband, 2017). 

References: 

  • Fallon et al, Screening for frailty in older emergency department patients: the utility of the Survey of Health, Ageing and Retirement in Europe Frailty Instrument. QJM, 2018; 111(3):151 
  • Stiffler et al 2013 Frailty assessment in the Emergency Department J Emerg Med 45(2): 291 
  • Platts-Mills TF, Travers D, Biese K, et al. Accuracy of the emergency severity index triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention.  AcadEmerg Med. 2010;17(3):238-243. doi:10.1111/j.1553-2712.2010.00670.x
  • Kodadek LM, Selvarajah S, Velopulos CG, Haut ER, Haider AH.  Undertriage of older trauma patients: Is this a national phenomenon? J Surg Res 2015. doi:10.1016/j.jss.2015.05.017
  • Katz ED, Carpenter CR. Fever and immune function in the elderly. In: Geriatric Emergency Medicine.  Meldon SW, Ma OJ, Woolard R (eds), McGraw-Hill, 55-69 
  • Heffernan DS, Thakkar RK, Monaghan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma - Inj Infect Crit Care. 2010;69(4):813-818. doi:10.1097/TA.0b013e3181f41af8 
  • Hastings SN, Purser JL, Johnson KS, Sloane RJ, Whitson HE. Frailty predicts some but not all adverse outcomes in older adults discharged from the emergency department.  J Am Geriatr Soc. 2008;56(9):1651-1657. doi:10.1111/j.1532-5415.2008.01840.x 
  • Giroux M, Sirois MJ, Boucher V, et al. Frailty Assessment to Help Predict Patients at Risk of Delirium When Consulting the Emergency Department. J Emerg Med. 2018;55(2):157-164. doi:10.1016/j.jemermed.2018.02.032 
  • Sirois MJ, Griffith L, Perry J, et al. Measuring frailty can help emergency departments identify independent seniors at risk of functional decline after minor injuries.  J Gerontol - Ser A Biol Sci Med Sci. 2017;72(1):68-74. doi:10.1093/gerona/glv152 
  • Afilalo et al, 2020 Frailty and adverse outcomes in older adults being discharged from the emergency department: A prospective cohort study. CJEM. 2020 Jan;22(1):65-73 
  • Jørgensen R, Brabrand M. Screening of the frail patient in the emergency department: A systematic review. Eur J Intern Med. 2017. doi:10.1016/j.ejim.2017.09.036