Managing frailty in the emergency department
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Managing frailty in the emergency department

Adrian O’Dowd Health journalist

Nurses can use screening tools to identify frailty and improve patient outcomes with early detection

Frailty is a common issue in the emergency department (ED) and handling it well is crucial to good patient care. For many people, their journey with frailty begins in the ED. Emergency nurses have the opportunity to promptly identify frailty and make referrals, improving outcomes for people living with frailty.

Emergency Nurse. 32, 1, 10-11. doi: 10.7748/en.32.1.10.s4

Published: 02 January 2024

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Picture credit: iStock

What is frailty and how common is it?

Frailty is a state of health where a person lacks the physiological reserve to deal with a minor illness or injury. People living with frailty have higher vulnerability to illness, poorer quality of life and poorer health outcomes, and do not recover as quickly after a minor illness or injury.

Data collected before the COVID-19 pandemic suggested that 5-10% of people attending EDs and 30% of patients in acute medical units were older and living with frailty. NHS England estimates there are more than 4,000 daily admissions of people with frailty across England, caused by falls, minor infections and reactions to medications, while over 75s with frailty occupy about 20% of all bed days.

Somerset NHS Foundation Trust consultant nurse in community urgent care services Mike Paynter believes the estimates should be higher: ‘We know that older people living with frailty attending an ED will have, by definition of their age, significant comorbidities – primarily cardiovascular and respiratory.

‘Older patients are also likely to have mobility issues, slower reflexes, deteriorating eyesight and be at risk of falls. Osteoarthritis and osteoporosis put older people at a greater risk of fragility fractures.’

What are the signs and symptoms of frailty?

According to NHS Fife nurse consultant in medicine of the elderly and frailty Joy Reid, typical signs and symptoms of frailty can include falls, immobility, functional decline, incontinence, delirium, cognitive impairment and dementia.

Symptoms can also include weakness, weight loss and a decreased ability to cope with illness and adapt to life challenges.

In moderate to severe cases of frailty, people may have weak muscles and other conditions such as arthritis or problems with their sight, hearing or memory. People with frailty will walk slowly, get tired easily and find certain movements difficult, such as going upstairs or getting out of a chair.

Who typically experiences frailty and can younger people have frailty?

Frailty is often associated with older people, but younger people can also be affected as a result of chronic health conditions and living in areas of deprivation.

Mr Paynter says: ‘There is a small percentage of younger people that I would consider frail due to other physical long-term conditions such as cystic fibrosis, likewise people with learning difficulties have poorer health outcomes.

‘Fragility or frailty is a broad term and within that there will be some patients who share the common features of lack of mobility, lack of cognition or lack of eyesight. These patients often manage on their own at home for quite long periods, but it can take only a small event or incident – such as a trip on the stairs – to scupper their health and well-being.’

Why should emergency nurses have the knowledge and skills to recognise and manage frailty?

The NHS Long Term Plan, which was published in 2019, states that healthcare professionals should support people to age well and, as the population increasingly lives longer, frailty will become a more prevalent condition.

The plan also says that all hospitals with a 24-hour ED should provide an acute frailty service for at least 70 hours a week, with the aim to complete a clinical frailty assessment within 30 minutes of a patient’s arrival in the ED or same-day emergency care unit.

In addition, the most recent NHS Commissioning for Quality and Innovation framework includes a requirement relating to identifying and responding to frailty in the ED. It recommends that patients in EDs with grades of six or above on the Clinical Frailty Scale should receive a comprehensive geriatric assessment and referral or follow-up where needed.

Types of frailty screening tools available

Screening tools are available to help emergency department nurses assess whether or not patients are displaying signs of frailty. These include:

  • » Rockwood Frailty Scale – this scores frailty in people ranging from ‘1 very fit’ to ‘9 terminally ill’. It is also known as the Clinical Frailty Scale and is recommended by NHS England

  • » Edmonton Frail Scale – this is an index used to measure alterations related to frailty. It assesses nine subscales: cognition, general health status, functional independence, social support, medication use, nutrition, mood, continence and functional performance

  • » NHS RightCare Frailty Toolkit – this was developed to support the delivery of the NHS Long Term Plan for frailty, the toolkit suggests systems to understand the priorities in frailty care and what actions to take

Why is early detection of frailty so important?

Early detection helps patients as quickly as possible and helps to prevent other consequent problems. Ms Reid explains: ‘Outcomes for patients who are identified at the front door of the hospital as having frailty can significantly improve. Their length of stay will be reduced and patients may be able to be supported with alternative specialist teams in a different environment rather than staying in the acute hospital, for example at home with Hospital at Home service.’

What questions should nurses ask relatives about patients living with frailty?

Ms Reid recommends speaking to the patient themselves initially to gather information about their usual health, function, mobility, and presenting complaint, but she adds: ‘Gathering information from relatives can be helpful when the patient is unable to articulate this information for themselves.

‘If relatives are present and the patient consents, gather 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 help to determine whether the patient is coping at home with their current level of support or if they require further supportive interventions.’

Find out more

Age UK (2020) Understanding Frailty.

British Geriatrics Society (2014) Identifying Frailty and Its Outcomes.

British Geriatrics Society (2018) Frailty: What’s it All About?

NHS England (2023) Commissioning for Quality and Innovation (CQUIN): 2023/24.

NHS England and NHS Improvement (2019) Same-day Acute Frailty Services.

This is an abridged version of an article at rcni.com/managing-frailty-ed

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