Using a frailty index in the Emergency Department
Dr Audrey-Anne Brousseau is the first fellow in geriatric emergency medicine in Canada. She was recently appointed as assistant professor at the Université de Sherbrooke in Quebec. Her work focuses on developing best practices for older adults in the emergency department (ED).
EDs are often the safety net of the health care system where the mission is to (rapidly) evaluate, intervene and organize transitions of care. With the aging of the population and the growing presence of older adults in EDs, this mission represents a significant challenge because older adults are complex on multiple levels.
How do we determine whether a patient is fit to go back home - or not? Needs admission - or not? Would benefit from rehabilitation, additional community services, further assessment - or not? A comprehensive geriatric assessment will provide this answer, but is rarely readily available in most EDs. Moreover, human and material resources are often limited in public health care system preventing all older adults ED patients to get a geriatric assessment and appropriate interventions.
Our team asked the question, “How can we rapidly and accurately identify older ED patients who are most likely to benefit from addition assessment and resources?” We suspected the answer would involve “frailty.”
Frailty is a core concept in geriatric medicine, an important geriatric syndrome, possibly a vital sign for older adults. However it has barely infiltrated the Emergency Medicine literature, or ED attitudes to older people. The Rockwood Frailty Index and the Fried phenotype method are two widely accepted models of frailty. However, to get ED clinicians’ attention, any tool needs to be easy, practical and fast to perform, which they are not. Since the objective is to provide the right care at the right place at the right time, EDs need rapid and effective tools to efficiently distribute resources and reduce iatrogenesis.
As documented in our article in Age and Ageing, our team developed a frailty index, built on the Rockwood model. Instead of Rockwood’s list of accumulated deficits, we used data points easily collected from a brief, electronic, “focussed geriatric assessment” tool used in many EDs throughout the world, the InterRAI ED-Contact Assessment. Instead of measuring a standard list of disease-oriented deficits, the ED-Contact Assessment evaluates a wide range of geriatric syndromes (e.g.: functional status, cognitive disorder, falls, nutrition, etc.) Using those data, gathered by a nurse or an allied health provider, we were able to establish a 24-item frailty index that performed – similarly to the original 92-item Rockwood index. We demonstrated that a patient with a higher frailty index is in greater need for further geriatric assessment and at higher risk of mortality, admission, prolonged hospital stay, and discharge to long-term care.
Now what? We know the theoretical definition of frailty. And we now have a way to identify it in real time in the ED. What is the next step? Since resources for care of older adults - human, material and financial - are often limited in EDs, we can use this new information to better prioritize access to those resources by determining which patients are most likely to benefit from them.
But a key question remains: what would be the best interventions for those older adults with frailty in the ED in order to reduce adverse outcomes and improve their quality of life? To be continued . . .