Frailty in the Geriatric ED

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Main Learning Points

Dr. Kenneth Rockwood (9:25) 

Dr. Rockwood, a geriatrician at Dalhousie University, reviewed the concept of frailty and how it is intrinsically linked to aging. Then he described how the Clinical Frailty Scale broadly stratifies the degrees of frailty and can be used as a tool to screen for frailty.

Key points:

The challenge of frailty arises from the complexity of managing multiple interacting medical and social problems that begin to grow exponentially in older adults. In order to care for these patients, recognize the degrees of frailty rather than simply distinguishing between frail and not frail. When assessing frailty, consider what functions does the patient need help with? What degree of help do they require? And how high order are these functions? Also, understand how a patient was presenting two weeks before they became ill or injured, and based on this, discuss plausible goals of care. All of this information is crucial for informed decision-making and creating a care plan that includes a consideration of frailty.

Dr. Simon Conroy (22:05) 

Dr. Conroy, a geriatrician in London, England, outlined how the Acute Frailty Network has been working to improve outcomes for older people and standardize frailty screening across the National Health Service in the UK.  He emphasized the need for a cultural change in the way the care of older adults is approached.

Key points:

The protocolized approach to care that is often applied to the older adult population does not work. His main concern is that healthcare professionals are adapting their treatment, attitude, and care to the needs of older patients based on where they are in their life trajectories.  And frailty is fundamental to understanding where someone is on their life trajectory. Frailty scoring can be quick, simple, and easy to implement even at a large scale. He highlighted the different levels of impact that need to interact to standardize frailty screening from individual clinicians to service structures to national policy. It provides a common currency in the care of older people. When creating a care plan, differentiate between multifactorial frailty, an accumulation of deficits, and unifactorial frailty.

Aaron Malsch (34:53) 

Aaron Malsch, a frontline nurse clinician, discussed a different approach to the topic of frailty within Advocate Aurora. Their Geri ED program chose the Identification of Seniors At Risk (ISAR) tool to screen for frailty, which is performed on all older adults over the age of 65.

Key points:

The first two questions of the ISAR are adequate proxies to engage with frailty: Before the injury or illness did you need help on a regular basis? Since the illness or injury have you needed more help? He stressed the importance of critical thinking, not just asking questions but also considering how this information and the concept of frailty can be built into protocols. Frailty should be integrated into the workflow of physicians, nurse practitioners, and case managers who can identify post-ED services, as well as other professionals that can address frailty both in the ED and after the ED.

Event Details

Goals

1. To review the concept of frailty and various definitions and tools
2. To explore why it is an important concept in the care of older ED patients
3. To highlight some strategies for integrating frailty screening into ED processes of care

Expert Panel

Kenneth Rockwood, MD, MPA, FRCPC, FRCP
Professor of Medicine (Geriatric Medicine & Neurology)
Dalhousie University, Halifax, Canada

Simon Conroy, MB ChB, FRCP, PhD
Professor of Geriatric Medicine
University College London
Lead, Acute Frailty Network, England

Aaron Malsch, RN, MS, GCNS-BC
Senior Service Program Manager
Advocate Aurora Health
Wisconsin

Moderated By

Don Melady

MD

Bio

Dr. Don Melady is an emergency physician at Mount Sinai Hospital in Toronto, Canada and a founding member of the Geriatric Emergency Department Collaborative. He is the author of the website www.geri-EM.com – a CME accredited program for geriatric emergency medicine education – and the chair of the Geriatric EM committee of the International Federation of Emergency Medicine.

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