Frailty

Author: Linda Dykes / Editor: Charlotte Davies / Codes: / Published: 04/06/2024

This blog was inspired by a tweet. Weve expanded on the tweet and expanded on some of the points to bring to you a frailty top ten! Some are simple, some are not.

You've got 40 minutes to cover all of frailty in EM. What learning points do you go for?

I've tried

Trauma: fall from standing is significant. Pain is different. 'Simple' rib injuries kill

Escalation of care discussion in every pt

Delirium = PINCH ME+ 4AT and not UTI + CTH

— Alex Nevard (@AlexNevard) January 24, 2024

1.Frailty

Think frailty in all patients >65, but remember, age does not mean a patient is frail. Do a frailty score, a cognitive assessment (using 4AT or AMTS) and ask about home situation. Remember not all elderly patients are frail – one study suggested a maximum of 35% are!¹

2. Falls Kill

Assess all falls, even those from standing carefully. Look at the intrinsic and extrinsic causes of the fall with a proper lying and standing BP at one and three minutes.

3. Ban the Dipstick

Run through PINCH ME for alternative causes of delirium – its not a UTI because they smell of a UTI or because the dipstick is positive – itss a UTI because they have signs of infection and no alternative cause, or urinary symptoms.

4. Medication Review

Sick day rules⁸ – stop diuretics, ACEI, ARBs, flozins and metformin if patient not eating/drinking properly or has good going diarrhoea with dehydration risk.

Calculate the anticholinergic burden, and lower it as much as possible to reduce the risk of adverse events. Unless you live in an area flush with GPs, Id do it yourself, rather than asking for a GP medication review.

5. Investigate Sensibly

• Ditch the dipstick
• Check Mg if weak, diarrhoea, on PPIs or diuretics, or if alcohol excess.
• Do a PR in confused older people. Diagnostic yield claimed to be higher than head CT (no ref found though). To paraphrase @ffolliet constipation isnt the poo you do see, its the poo you dont.
• Did we mention dont dip the wee?

6. Communicate!

• Get a social history
• If someone phones up and knows where the house key is/what the carer agency is/ contact details for family members WRITE IT IN THE NOTES!

7. Dont over-treat hypertension

• Lowest mortality *overall* in frail elderly is systolic 160-180mmHg. It only takes one paramedic, triage nurse or ED doctor to go oh, your BP is a bit high to undermine a GPs carefully laid plan.

8. PD meds – make them paranoid about it, promote OPTIMAL

9. Set ceilings of care

Start to think about what is best for your patient. Would they really benefit from a catheter or are you ticking the measure urine output box. Is their social circumstance ever going to be ideal. How will we ever get the patient with dementia to start drinking fluid again?

And, just because we can start NIV – should we?

Have the DNA CPR discussion.⁹

10. Get patients home if at all possible

Patients generally do better at home than we expect. Ambulatory options can be arranged. Confusion is much better in the home environment. If its safe to do so – get the patient home.

References

1. Kojima G, Iliffe S, Taniguchi Y, et al. Prevalence of frailty in Japan: A systematic review and meta-analysis. J Epidemiol. 2017 Aug;27(8):347-353.
2. Frailty – Top Tips to help you use the Clinical Frailty Scale. Dr Lynda Dykes Medical Education Resources.
3. Bali T. Falls. RCEMLearning, 2020.
4. Wallace J, Raven D. Silver Trauma. RCEMLearning, 2018.
5. Measurement of lying and standing blood pressure: A brief guide for clinical staff. Royal College of Physicians, 2023.
6. Diagnosis of urinary tract infections. Quick reference tool for primary care for consultation and local adaptation. Public Health England, 2020.
7. Fordham S. Delirium in the Elderly. RCEMLearning, 2023.
8. Effective Prescribing and Therapeutics. Sick Day Rules. NHS Scotland.
9. Davies C. DNA CPR in the ED. RCEMLearning, 2021.