RCEM BPG: Frailty and Geriatric Syndromes in Urgent Care: A Clinical Briefing

 

Frailty and Geriatric Syndromes in Urgent Care: A Clinical Briefing

• ‘The Silver Book II’: Quality Care for Older People with Urgent and Emergency Care Needs (Intercollegiate, February 2021)

Executive Summary

As the demographic shift continues, older people living with frailty have become the primary user group of NHS Emergency Departments (ED). Frailty is a state of vulnerability resulting from a loss of biological reserves and physiological failure, leading to a high risk of adverse outcomes including functional decline, institutionalisation, and death [5-7]. Current urgent care systems often exhibit a mismatch between population needs and clinical capability, particularly regarding "Non-Specific Complaints" (NSCs) and "Silver Trauma" [141, 196].

The gold standard for management is Comprehensive Geriatric Assessment (CGA), a multidimensional, interdisciplinary process that identifies urgent medical, social, and functional needs to create an integrated care plan [44]. Key priorities for the ED clinician include:

• Early Identification: Using the Clinical Frailty Scale (CFS) to establish a baseline (2 weeks prior to presentation) [26].
• Syndrome Recognition: Actively screening for delirium, falls, and polypharmacy rather than focusing on a single "chief complaint."
• Shared Decision-Making: Balancing clinical risk with "what matters most" to the patient, acknowledging that many prefer living at risk over losing autonomy [38, 39].
• Mitigating Iatrogenic Harm: Preventing pressure injuries and delirium caused by ED "tethers" (catheters, IV lines, and immobilisation) [159, 250].

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Definition and Classification

Frailty

Frailty is defined as a condition characterised by the failure of physiological mechanisms and loss of biological reserves [5-7]. It is operationalised through two primary models:

1. Phenotype Model: Identifies frailty based on five variables: unintentional weight loss, self-reported exhaustion, low energy expenditure, slow gait speed, and weak grip strength [11].
   • Robust: 0 factors.
   • Pre-frail: 1–2 factors.
   • Frail: \ge3 factors.
2. Cumulative Deficit Model: Identifies frailty as the life-course accumulation of 'deficits' (symptoms, signs, diseases, and lab values) [12]. The Frailty Index (FI) is the proportion of deficits present (e.g., 9/36 deficits = 0.25 FI).

Classification in Urgent Care

The Clinical Frailty Scale (CFS) is the recommended tool for NHS providers to grade frailty from 1 (Very Fit) to 9 (Terminally Ill) [26, 45]. It provides a gradation of vulnerability rather than a binary present/absent classification.

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Epidemiology & Aetiology

• Incidence: In community-based studies of those over 65, approximately 7% are frail and 47% are pre-frail [11]. In the ED, falls (a primary frailty syndrome) account for 17% of all presentations in older people [189].
• Age/Sex: Frailty increases with chronological age, but is distinct from it. "Low energy transfer" trauma (falls from standing) is more common in older females [194].
• Aetiology: Frailty results from the cumulative effect of individual deficits that reduce redundant physiological capacity [16].
• Predisposing Factors: Poverty, dental problems, social isolation, and chronic medical conditions contribute to syndromes like malnutrition [244].
• Pathology: Characterised by immunosenescence (leading to atypical infection presentations) and altered pharmacokinetics [222].
• Prognosis: Frailty is a powerful predictor of mortality, increased length of stay (LOS), and institutionalisation. Older patients with "Non-Specific Complaints" have a three-fold increased risk of in-hospital death compared to those with specific complaints [145].

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Clinically Relevant Anatomy

Assessment must account for age-related anatomical and physiological changes:

• Neurological: Reduced brain volume and increased bridging vein fragility increase subdural haematoma risk in "minor" head trauma [195].
• Integumentary: Thinning dermis and reduced subcutaneous fat increase susceptibility to pressure injuries, which can begin within 30 to 120 minutes on hard ED surfaces [250, 252].
• Musculoskeletal: Sarcopenia and osteoporosis (affecting 1 in 3 women over 50) lead to "Silver Trauma" where severe internal injuries (e.g., rib fractures, occult hip fractures) occur from low-energy mechanisms [104, 196].
• Physiological: Altered autonomic responses mean that "normal" vital signs may mask critical illness (e.g., a SBP of 110 mmHg may represent profound shock in a normally hypertensive patient) [146].

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Clinical Assessment: The ABCD(E) Approach

Traditional triage often fails older adults. Clinicians should use an adapted assessment style:

Airway & Breathing

• Atypical Presentation: Pneumonia may present without cough (20%), fever (50%), or tachycardia (60%) [144].
• Silver Trauma: "Stealth trauma" in the chest is common. Have a low threshold for CT imaging for any chest discomfort following a fall [196].

Circulation

• Sepsis: Older patients are frequently under-resuscitated due to unfounded fears of fluid overload [222].
• Vital Signs: Interpret in light of baseline. SBP >100 mmHg is not helpful for risk stratification without comparison to patient norms [146].

Disability (Neurological)

• Delirium (Acute Brain Failure): Affects 8–17% of older ED patients but is missed in 67% of cases [154, 158].
  • Hypoactive Delirium: Most common, worst prognosis, most likely to be missed [159].
  • Assessment Tools: 4AT, bCAM, or the "Months of the Year Backwards" task [160, 162, 163].
• Dementia: Establish baseline cognition from collateral history (family/caregivers) [151].

Exposure & Environment

• Skin Check: Full-body exam required within 2 hours of arrival. Inspect sacrum and heels [250].
• The Geriatric 5Ms: A framework for holistic assessment [151]:
  1. Mind: Mentation, delirium, dementia, depression.
  2. Mobility: Gait, balance, fall history.
  3. Medication: Polypharmacy, high-risk drugs (anticholinergics, sedatives).
  4. Multicomplexity: Multiple chronic conditions and social factors.
  5. Matters Most: Patient goals and advance directives.

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Key Investigations & Interpretation

Investigation	Interpretation for Older/Frail Adults
Urine Dipstick	Do not rely on this. Asymptomatic bacteriuria is present in 25-50% of nursing home residents; dipsticks do not differentiate this from UTI [165, 234].
Vital Signs	Tachypnoea and altered mental status are more sensitive markers of sepsis than fever or SBP [223].
ECG	Essential for syncope/falls; look for silent ischaemia or conduction delays.
Imaging	Low threshold for CT in Silver Trauma. Occult fractures and "stealth" head/chest injuries are common [196].
Blood Tests	Lactate is critical for sepsis risk; CRP/WCC lack sensitivity/specificity in this cohort [230, 231].

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Treatment and Summary of Evidence

• Comprehensive Geriatric Assessment (CGA): Strong evidence that inpatient CGA increases the likelihood of a patient being alive and in their own home at follow-up [41].
• Sepsis: Treat with broad-spectrum antibiotics and isotonic crystalloids. Source control is vital [222].
• Pain Management: Under-treatment is common. Paracetamol is first-line. Avoid NSAIDs due to renal/GI risks. Use Oxycodone or Hydromorphone in renal impairment instead of Morphine [210, 217].
• Parkinsonism: Never omit Parkinson’s medications. If NBM, use Rotigotine patches. Avoid dopamine antagonists (Haloperidol, Metoclopramide) [254].
• Deprescribing: Use STOPP/START criteria to identify potentially inappropriate medications (PIMs) [218].

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Complications and Management

Complication	Timeframe	Management
Pressure Injury	Immediate (30-120 mins)	Move from trolley to hospital bed/specialist mattress <2 hours. 2-hourly turns [250].
Delirium (Iatrogenic)	Immediate/Delayed	Remove "tethers" (catheters, IV lines). Ensure sleep, hydration, and hearing aids/glasses [159].
Functional Decline	Delayed (Days)	Early mobilisation and OT/PT involvement in the ED [261, 263].
Neuroleptic Malignant Syndrome	Immediate	Caused by withdrawal of Parkinson’s meds. Requires urgent specialist input [254].

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Learning Aids: The "S.I.L.V.E.R." Mnemonic for Trauma

• Stealth Trauma: Assume internal injury even in low-energy falls.
• Identify Frailty: Use the Clinical Frailty Scale (CFS).
• Low threshold for CT: Especially head and chest.
• Vital signs: Compare to baseline; "normal" may be abnormal.
• Environment: Mattress, food, water, and hearing aids.
• Review Medications: Watch for anticoagulants and polypharmacy.

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References

1. British Geriatrics Society. Silver Book II: Urgent Care for Older People. 2021.
2. Rockwood K, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005.
3. Conroy S, et al. Comprehensive geriatric assessment for frail older people in acute settings. Age Ageing. 2011.
4. Fried LP, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001.
5. Han JH, et al. Delirium in the emergency department: an independent predictor of mortality in older adults. Ann Emerg Med. 2010.
6. Nickel CH, et al. Non-specific complaints in the emergency department. Swiss Med Wkly. 2016.
7. Coats TJ, et al. Silver Trauma: the changing face of major trauma. RCEM Learning. 2018.

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Example EPIC EHR Documentation Structure

Geriatric Urgent Care Assessment

[ ] Baseline Clinical Frailty Scale (CFS) (2 weeks prior): ( ) 1. Very Fit ( ) 2. Well ( ) 3. Managing Well ( ) 4. Vulnerable ( ) 5. Mildly Frail ( ) 6. Moderately Frail ( ) 7. Severely Frail ( ) 8. Very Severely Frail ( ) 9. Terminally Ill

[ ] Cognition/Delirium Screen: ( ) 4AT Performed? [Yes/No] ( ) Result: [Normal/Suggests Delirium/Suggests Cognitive Impairment] ( ) Collateral history obtained? [Yes/No] From: ______________

[ ] Fall Risk/Silver Trauma Assessment: ( ) Mechanism: [Low energy/Standing Fall/High energy] ( ) Anticoagulation/Antiplatelets? [Yes/No] ( ) Secondary trauma survey completed (Shake, Rock, Rattle, Roll & Stroll)? [Yes/No] ( ) Low threshold CT indicated? [Yes/No]

[ ] Medication Review: ( ) Polypharmacy (>5 meds)? [Yes/No] ( ) High-risk meds identified (Anticholinergics/Benzos/NSAIDs)? [Yes/No] ( ) Parkinson's meds given on time? [Yes/N/A]

[ ] Nursing/Safety Bundle: ( ) Skin check completed <2 hours? [Yes/No] ( ) Pressure ulcer present? [Yes/No] Stage: _____ ( ) Moved to specialist mattress <2 hours? [Yes/No] ( ) Toileting/Hydration/Nutrition addressed? [Yes/No]

Medical Decision-Making (MDM) Section

• Impression: [e.g., Sepsis secondary to UTI vs. Delirium triggered by polypharmacy].
• Risk Stratification: Patient is CFS [X] with a background of [list comorbidities]. High risk for iatrogenic decline.
• Shared Goals of Care: Discussion held with [Patient/LPA]. Goals are [Cure/Recovery/Palliative].
• Plan: CGA-attuned management. Avoided catheter to reduce delirium risk. Referred to [Acute Frailty Team/HaH]. Outpatient Fracture Liaison Service referral for secondary prevention.

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