Beyond the Frailty threshold: from Screening to Insight
Authors:   , van Dam Carmen Sophie 
Published: October 2024

Optimizing emergency care for the aging population is a major challenge. Older adults account for a disproportionate share of 30% of all Emergency Department (ED) visits. A third of all older adults experiences adverse outcomes after an ED visit, with an increased risk in the first 3 months. This increased risk seems irrespective of their disease severity, but might be explained by frailty. Frailty is a state of decline in multiple physiological systems, faster and proportionally more than can explained by aging only.

Frailty screening can select patients who may benefit benefit from a comprehensive geriatric assessment, and targeted interventions already at the ED or during hospital admission. Second, frailty screening can guide decisions and treatment goals. Last, it creates awareness among health care professionals about the patients context. Objections to frailty screening in busy EDs are the amount of administrative workload, and the tendency of healthcare professionals to trust their own clinical judgment over formal screening tools. Frailty screening may also negatively contribute to age discrimination.

Frailty screening instruments are typically standardized multi-domain questionnaires with a hard cut-off. Discrepancies exist in derivation populations, outcome measures, and follow-up periods. We found a fair to moderate level of agreement between commonly used instruments. Prognostic accuracy was below thresholds reliable enough for clinical use in our head-to-head comparison. Calibration was poor to reasonable calibration.

Clinical judgment, polypharmacy and nonspecific complaints associated with adverse health outcomes in older adults at the ED. Although their prognostic accuracy is poor to moderate, these determinants are known for every older adult at the ED visits and should be considered as red flags.

We found only fair level of agreement between clinical judgment and a screening instrument or patient-perceived frailty. The prognostic accuracy of clinical judgment is poor to moderate. Combining clinical judgment with a validated screening instrument or patient-perceived frailty did not improve prognostication.

Polypharmacy is highly prevalent in older patients at the ED, and associated with increased 3-month mortality. Polypharmacy was also associated with readmission and self-reported falls, but not after adjustment for chronic comorbidity and frailty. This study illustrates the complexity of the observed polypharmacy–mortality association, given the confounding effects of chronic comorbidity and frailty.

26% of the ED patients present with NSC, mostly older and frail patients. NSC was associated with a twofold increased risk of functional decline and institutionalization, even after adjustment for baseline frailty, comorbidities and activities of daily live functioning. 50% received a specific diagnosis after additional analysis during ED or hospital stay.

In conclusion, frailty assessment should be part of the initial evaluation of older patients at the ED, although accurate prediction of adverse health outcomes on individual level seems almost impossible. Frailty screening can help selecting patients needing standard care (preventing undertreatment) patients who benefit from geriatric interventions, and the severe frail patients deserving palliative care (preventing overtreatment). The goal of frailty screening should shift from predicting adverse health outcomes to creating awareness among healthcare professionals about the patients context.

In the absence of an ideal frailty screening instrument, practical considerations can lead the choice of instrument to suit local implementation. Besides frailty screening with formal screening instruments, presentation with a nonspecific complaint and polypharmacy can be considered as red flags for adverse health outcomes.

Health care professionals should consider the results of frailty screening not as absolute thresholds, but rather incorporate the findings of frailty assessment in tailored cure or care, aligned with patients preferences and performances. Next, the findings of ED frailty assessment should be available for all involved healthcare professionals to streamline care processes and ensure geriatric follow-up of these patients.