older patients use emergency services at higher rates , require more resources once in the emergency department ( ed ) and are more likely to experience adverse health outcomes compared with younger patients . a mechanism to identify those at higher risk for adverse outcomes may lead to improvements in care .
although older age groups use ems at disproportionately higher rates , paramedic training has changed little to meet the specific needs of this older demographic .
moreover , there has been very little alteration in how ems systems are organized , with agencies initially established to provide care for major trauma and cardiac arrest victims .
the ability of ems to cope with the influx of frail older patients may be reaching a limit , and unless changes are made in its organization , it seems inevitable that care provided to the older adult will suffer .
dichotomizing older patients as fit or frail may serve to optimize pre - hospital care .
the term  frailty  is often employed in the medical literature , including emergency medicine , and is widely recognized as a state of vulnerability or decline in physiological reserve .
a definition of frailty should integrate biological , clinical , social , psychological , and environmental components , while also reflecting the multi - system impairment that is intrinsic to this concept .
frailty is common with prevalence estimates of 40% or more in those aged 80 and older .
geriatric interventions provided in the community setting have been shown to reduce ed utilization over relatively short intervals , likely due to improved continuity of care and access .
the utility of geriatric interventions applied in the ed have demonstrated mixed results ; however , the evidence suggests benefits may be derived from targeting interventions towards high - risk clients .
although a focus on frailty might usefully inform care provision in the pre - hospital and ed settings , the concept has received little attention to date .
three approaches can be discerned : rules - based approaches such as the frailty phenotype , clinical frailty scales based on clinical judgment , and the frailty index based on deficit count .
( table 1 ) some describe frailty as a medical syndrome , while others believe that it is derived from the accumulation of age - related changes over time .
while this will be a particular challenge for defining frailty in emergency services , it is also the case that the special needs in the emergency setting  not just for reliable and valid measures , but for feasible measures that can be used rapidly  usefully will resolve some of the more esoteric considerations that are often at play in the debate about frailty measurement .
in fact , data from the medicare current beneficiary survey confirmed that the rockwood - mitnitski frailty index was a robust predictor of serious adverse events ( death , nursing home admission , hospital admission ) in the first 30 days following an older individual s visit to the emergency department .
the primary objectives of this review were : 1 ) to identify measures of frailty used by emergency medical services ; and 2 ) to describe frailty measures used in emergency medicine .
we limited our discussion to the pre - hospital and ed environments , with their unique time , resource , and system constraints .
here , we undertook a narrative review of the ems and emergency medicine literature to understand how the concept of frailty is being applied , which measures have been validated for use in this population , and what can be recommended .
the primary objectives of this review were : 1 ) to identify measures of frailty used by emergency medical services ; and 2 ) to describe frailty measures used in emergency medicine .
we limited our discussion to the pre - hospital and ed environments , with their unique time , resource , and system constraints . here
, we undertook a narrative review of the ems and emergency medicine literature to understand how the concept of frailty is being applied , which measures have been validated for use in this population , and what can be recommended .
the concept of frailty in the ems / ed literature was reviewed by identifying primary literature where measures of frailty were implemented or clinically applied . for the purposes of this review , databases ( pubmed , embase , and cinahl )
the search terms ( mesh and text ) included aged , geriatric assessment , frail elderly , frail * , health services research , outcome assessment/ screening , geriatric combined with either emergency medical services or emergency service .
this search strategy was informed by hand searches of bibliographies , review of conference abstracts , and contact with colleagues .
english language articles were included in this review if they focused on patients 60 years and older and implemented a definition of frailty or risk - screening tool in the ems / ed setting . in our desire to be liberal with inclusion criteria , 60 years and older
was chosen as this is sometimes used as the population of interest in emergency medicine literature on aging .
the risk screening tools may be proxy markers of frailty so were included in this research .
studies were excluded if they were not focused on measuring frailty in the practice setting .
the search strategy was considered up to date as of april 2009 . a single reviewer ( jg )
initiated the search strategy , screened the titles and abstracts using the inclusion/ exclusion criteria , and reviewed the full text articles .
the concept of frailty in the ems / ed literature was reviewed by identifying primary literature where measures of frailty were implemented or clinically applied . for the purposes of this review , databases ( pubmed , embase , and cinahl )
the search terms ( mesh and text ) included aged , geriatric assessment , frail elderly , frail * , health services research , outcome assessment/ screening , geriatric combined with either emergency medical services or emergency service .
this search strategy was informed by hand searches of bibliographies , review of conference abstracts , and contact with colleagues .
english language articles were included in this review if they focused on patients 60 years and older and implemented a definition of frailty or risk - screening tool in the ems / ed setting . in our desire to be liberal with inclusion criteria , 60 years and older
was chosen as this is sometimes used as the population of interest in emergency medicine literature on aging .
the risk screening tools may be proxy markers of frailty so were included in this research .
studies were excluded if they were not focused on measuring frailty in the practice setting .
the search strategy was considered up to date as of april 2009 . a single reviewer ( jg )
initiated the search strategy , screened the titles and abstracts using the inclusion/ exclusion criteria , and reviewed the full text articles .
an additional 412 records would have been located if the search strategy was not restricted by language .
no articles specifically using a measure of frailty in the prehospital setting or emergency department were identified .
the 6 original studies on risk screening tools used in the pre - hospital setting or emergency department were included in this review .
no primary research that implemented a validated measure of frailty in the ems setting was identified . because frailty is predictive of the risk for adverse outcomes , a search was also performed to identify tools that may predict risk for health deterioration or decline in functional status among older patients .
although no risk screening tools appear to be used by ems , one study described how ems services have attempted to provide more extensive care through screening , education , and referral programs for older patients in an attempt to identify unmet health care needs ( table 2 ) .
ems - based public health promotion programs are rare ; however , shah et al . determined that it is feasible for ems agencies to take on non - traditional roles in public health .
in addition , an ems specific tool is currently in the derivation phase ( peril  paramedics assessing elders at risk for independence loss ) .
this risk screening tool may represent a feasible approach for assessing older people within their own home .
no primary research that implemented a validated measure of frailty in the emergency department was identified . in the ed
setting , efforts have been made to develop tools that identify older patients at risk for functional decline , readmission to the ed , or other adverse outcomes .
although these are not conceptualized as measures of frailty , their goal is to capture those patients who might be considered to be frail in their state of vulnerability .
the first point of contact in the ed is triage , so it would be intuitive that risk assessment scales may be administered at this point .
triage scales are used in emergency departments to aid with assigning acuity levels to patients so priority can be given to those with more urgent medical problems .
a suitable risk assessment tool in this context would have to be easily obtained and embedded into the triage process .
five risk screening tools were identified that specifically targeted older adults in the ed prior to discharge ( table 2 ) . the triage risk screening tool ( trst ) , a six - item tool comprised of yes / no questions that are completed during the triage process , has been evaluated for use in older patients being discharged from the ed .
it evaluates the presence of cognitive impairment , difficulty walking or transferring , recent falls , living alone with no available caregiver , taking five or more prescription medications , ed use in previous 30 days or hospitalization in previous 90 days , and registered nurse ( assessor ) concern .
two or more risk factors or the presence of cognitive impairment leads to a designation of  high risk  .
the identification of seniors at risk ( isar ) is a self or caregiver - completed , six - item measure that is administered during the ed visit either upon early presentation or prior to discharge .
it incorporates questions pertaining to pre - morbid and acute functional dependence , recent hospitalization ( within 6 months ) , impaired memory , impaired vision , and polypharmacy ( taking more than three medications ) .
this tool has been demonstrated to be clinically relevant and to be predicative of adverse outcomes in a high - risk group of elderly patients .
the brief risk identification for geriatric health tool ( bright ) is a self- or caregiver - completed , 11-item measure .
it has been designed for use as a postal questionnaire or can be administered within the ed in order to detect older adults that might benefit from comprehensive geriatric assessment .  
the bright requests the patient or caregiver to think about the previous three months and respond with  yes  or  no  to questions related to functional problems , shortness of breath , mobility problems , cognition , falls , self - rated health , and depression .
the final two screening tools identified were the seven - item questionnaire developed by rowland et al . and an eight - item questionnaire by ruciman et al .
the seven - item screening primarily assesses function ( activities of daily living ( adl ) and instrumental activities of daily living ( iadls ) ) and mobility .
a score of four or more would identify an individual at risk for re - admission .
the tool developed by ruciman et al . included questions pertaining to function , use of diuretics , presence of soft tissue injury , memory problems , difficulties with mobility , and problems urinating .
the questions were derived from a pilot study evaluating the use of a health visitor intervention post - discharge from the emergency department .
the eight variables were identified through logistic regression and formulated based on the opinion of ed staff .
no primary research that implemented a validated measure of frailty in the ems setting was identified . because frailty is predictive of the risk for adverse outcomes , a search was also performed to identify tools that may predict risk for health deterioration or decline in functional status among older patients .
although no risk screening tools appear to be used by ems , one study described how ems services have attempted to provide more extensive care through screening , education , and referral programs for older patients in an attempt to identify unmet health care needs ( table 2 ) .
ems - based public health promotion programs are rare ; however , shah et al . determined that it is feasible for ems agencies to take on non - traditional roles in public health .
in addition , an ems specific tool is currently in the derivation phase ( peril  paramedics assessing elders at risk for independence loss ) .
this risk screening tool may represent a feasible approach for assessing older people within their own home .
no primary research that implemented a validated measure of frailty in the emergency department was identified . in the ed setting , efforts have been made to develop tools that identify older patients at risk for functional decline , readmission to the ed , or other adverse outcomes .
although these are not conceptualized as measures of frailty , their goal is to capture those patients who might be considered to be frail in their state of vulnerability .
the first point of contact in the ed is triage , so it would be intuitive that risk assessment scales may be administered at this point .
triage scales are used in emergency departments to aid with assigning acuity levels to patients so priority can be given to those with more urgent medical problems .
a suitable risk assessment tool in this context would have to be easily obtained and embedded into the triage process .
five risk screening tools were identified that specifically targeted older adults in the ed prior to discharge ( table 2 ) . the triage risk screening tool ( trst ) , a six - item tool comprised of yes / no questions that are completed during the triage process , has been evaluated for use in older patients being discharged from the ed .
it evaluates the presence of cognitive impairment , difficulty walking or transferring , recent falls , living alone with no available caregiver , taking five or more prescription medications , ed use in previous 30 days or hospitalization in previous 90 days , and registered nurse ( assessor ) concern .
two or more risk factors or the presence of cognitive impairment leads to a designation of  high risk  .
the identification of seniors at risk ( isar ) is a self or caregiver - completed , six - item measure that is administered during the ed visit either upon early presentation or prior to discharge .
it incorporates questions pertaining to pre - morbid and acute functional dependence , recent hospitalization ( within 6 months ) , impaired memory , impaired vision , and polypharmacy ( taking more than three medications ) .
this tool has been demonstrated to be clinically relevant and to be predicative of adverse outcomes in a high - risk group of elderly patients .
the brief risk identification for geriatric health tool ( bright ) is a self- or caregiver - completed , 11-item measure .
it has been designed for use as a postal questionnaire or can be administered within the ed in order to detect older adults that might benefit from comprehensive geriatric assessment .  
the bright requests the patient or caregiver to think about the previous three months and respond with  yes  or  no  to questions related to functional problems , shortness of breath , mobility problems , cognition , falls , self - rated health , and depression .
the final two screening tools identified were the seven - item questionnaire developed by rowland et al . and an eight - item questionnaire by ruciman et al .
the seven - item screening primarily assesses function ( activities of daily living ( adl ) and instrumental activities of daily living ( iadls ) ) and mobility .
a score of four or more would identify an individual at risk for re - admission .
the tool developed by ruciman et al . included questions pertaining to function , use of diuretics , presence of soft tissue injury , memory problems , difficulties with mobility , and problems urinating .
the questions were derived from a pilot study evaluating the use of a health visitor intervention post - discharge from the emergency department .
the eight variables were identified through logistic regression and formulated based on the opinion of ed staff .
further , we found limited reference to mechanisms used to identify high - risk older patients .
reasons for this may be a lack of attention paid to research focused on older patients , ems system design factors , or lack of clear understanding regarding how these tools can be applied .
in general , there appears to be a paucity of geriatric presence within the ems literature and this could be reflected in current protocols and practices .
although an operational definition of frailty has been elusive , those currently available have proven to be useful in predicting adverse outcomes .
older patients cared for by ems may not present in a typical fashion . for the frail older patient coming into the emergency department ,
the presence of geriatric syndromes has been shown to be predicative of prolonged hospital stay for patients admitted through the ed to medical units .
discerning between the fit and frail patient is critical as a first step towards identifying common geriatric problems that may have an impact on care needs and outcomes .
a measure of frailty may be useful towards identifying vulnerable older adults in the community .
pre - hospital care providers could improve care for older adults by initiating the screening process and facilitating referral or transport to the most appropriate service .
the utility of defining frailty is clear ; however , a practical method of incorporating a measure of frailty into the clinical setting is more difficult .
jones et al . demonstrated the feasibility of constructing a frailty index based on data collected from a comprehensive geriatric assessment .
of note , it is not the nature of the deficits but rather the index value that is most predictive of outcomes .
the rockwood - mitnitski frailty index is relatively simple to calculate and provides a high degree of precision . due to the broad nature of the deficits that can be included into the fi , it may be possible to create an index based upon routinely collected data from the ems environment ( e.g. , patient function ) .
paramedics are in a unique position to document the living conditions and function of an older person within their own home .
a method for capturing this important information and aggregating it in a useful format is required .
ems agencies may want to consider how the measurement of frailty can be included into current clinical practice .
a decision to incorporate a measure of frailty into the clinical assessment should be guided by the purpose .   during triage or in the pre - hospital setting , identifying whether a patient is fit or frail may be the primary concern and could lead to directing care . for this , a brief screening process such as a clinical frailty scale ( rating system ) or rules - based approach resembling the risk screening tools outlined in table 2 may be appropriate and feasible in this setting .
these tools are easily applied and may be able to stratify patients by level of frailty .
later , during the clinical evaluation , other measures of frailty ( e.g. , frailty index ) may aid with identifying changes in health status and provide prognostic value ( see table 1 ) .
this approach is thought to be more cumbersome ; however , it can be more precise in its ability to grade levels of frailty . in the pre - hospital setting
, it may be enough to know whether someone is fit or frail ; however , later in the care process when intervention options are being considered , a more precise measure may be useful in directing treatment decisions .
a persistent problem is the lack of appropriate tools designed for use or validated in the ed to aid with the assessment of the older patient .
risk - screening tools have been developed to identify patients at risk for re - admission to the ed , functional decline or death .
although these tools are not attempting to quantify frailty , their components are related to a conceptualization of frailty ( e.g. , function , mobility , cognitive impairment ) . for older patients discharged from the emergency department ,
caplan et al . advocated for the use of a simple screening tool on all people over 75 presenting to the ed .
each brief screening instrument has demonstrated a moderate ability to predict functional decline in older ed patients .
these tools are not designed to grade frailty , and may lack the necessary precision to identify which patients may benefit most from specialized geriatric services . in older patients presenting to the emergency department , functional impairment is common and is a predictor for poor short - term outcomes following discharge .
attempts have been made to quantify the under - recognition of cognitive impairment , problems with function , and other geriatric syndromes .
evaluating frailty , depending on the measure employed , may provide a more robust measure of impairment or general health status .
there is evidence that case finding with subsequent intervention can lead to improved outcomes for older people following discharge from the emergency department . it may be possible to improve the screening process through the identification and measurement of frailty in older ed patients .
although our search criteria allowed us to conduct a comprehensive review of the literature , we may have missed publications on this subject matter .
the primary objective of this review was to identify frailty tools ( table 1 ) that are currently used in the pre - hospital and emergency medicine setting .
risk - screening tools were included in this analysis , as they may identify frail older adults in the ems / ed setting ; however , this linkage has not been studied and should be the focus of further exploration .
differences in terminology between medical settings may have precluded our search criteria from identifying relevant articles in the emergency medicine literature .
it is clear that more geriatric specific research is necessary in the pre - hospital setting . to improve processes of care for older patients using pre - hospital and emergency services ,
geriatric patients should be tracked through different nodes of care ( e.g. , pre - hospital , triage , clinical assessment / treatment , and discharge ) .
a measure of frailty may mean an improved ability to include geriatric patients in interventional research , as the ability to stratify patients according to their overall health status will be possible .
the clinical utility of frailty measurement and screening requires further investigation . an older person who is fit but acutely unwell can benefit from aggressive
 usual care  . for the older person who is frail with multiple co - morbidities and acutely unwell , complex care brought by a multidisciplinary team is recommended .  
for the frail older adult , it may be ideal to intervene early through comprehensive assessment and management of issues within the community setting .
a common language of frailty is necessary to facilitate communication between health - care providers and provide a non - arbitrary way to classify relative fitness and frailty .
pre - hospital providers may be able to effectively identify those frail patients who would benefit most from specialized geriatric services .
ems providers have the advantage of interacting with patients within their own home , which provides them with a more in - depth understanding of the patient s environment , social supports , and family dynamics .
collating this information with frailty measurement may lead to improvements in processes of care , possibly through early identification and referral to geriatric services .
although our search criteria allowed us to conduct a comprehensive review of the literature , we may have missed publications on this subject matter .
the primary objective of this review was to identify frailty tools ( table 1 ) that are currently used in the pre - hospital and emergency medicine setting .
risk - screening tools were included in this analysis , as they may identify frail older adults in the ems / ed setting ; however , this linkage has not been studied and should be the focus of further exploration .
differences in terminology between medical settings may have precluded our search criteria from identifying relevant articles in the emergency medicine literature .
it is clear that more geriatric specific research is necessary in the pre - hospital setting . to improve processes of care for older patients using pre - hospital and emergency services ,
geriatric patients should be tracked through different nodes of care ( e.g. , pre - hospital , triage , clinical assessment / treatment , and discharge ) .
a measure of frailty may mean an improved ability to include geriatric patients in interventional research , as the ability to stratify patients according to their overall health status will be possible .
an older person who is fit but acutely unwell can benefit from aggressive  usual care  . for the older person who is frail with multiple co - morbidities and acutely unwell , complex care brought by a multidisciplinary team is recommended .   for the frail older adult
, it may be ideal to intervene early through comprehensive assessment and management of issues within the community setting .
a common language of frailty is necessary to facilitate communication between health - care providers and provide a non - arbitrary way to classify relative fitness and frailty .
pre - hospital providers may be able to effectively identify those frail patients who would benefit most from specialized geriatric services .
ems providers have the advantage of interacting with patients within their own home , which provides them with a more in - depth understanding of the patient s environment , social supports , and family dynamics .
collating this information with frailty measurement may lead to improvements in processes of care , possibly through early identification and referral to geriatric services .
to our knowledge , this is the first comprehensive review that aggregates research pertaining to frailty in the pre - hospital and emergency medicine literature .
there is a paucity of geriatric specific research on frailty in the pre - hospital literature .
a standardized approach to frailty assessment is warranted in order to detect and document common geriatric problems ( e.g. , cognitive impairment , functional impairment , social vulnerability , and mobility impairment ) and guide care provision in this setting .
any measure of frailty used by ems must be designed to address the challenges of clinical care encountered in this setting and must be rigorously evaluated .
it is clear , based upon our review , that little attention has been focused on this construct in the pre - hospital and emergency medicine literature .
efforts should be devoted towards developing tools to aid with discerning between fitness and frailty in older adults requiring emergency services , as their care needs will be dependent on this distinction .
 backgroundolder adults use more health - care services per capita than younger age groups and the older adult population varies greatly in its needs . 
 evidence suggests that there is a critical distinction between relative frailty and fitness in older adults . here 
 , we review how frailty is described in the pre - hospital literature and in the broader emergency medicine literature.methodspubmed was used as the primary database , but was augmented by searches of cinahl and embase . 
 articles were included if they focused on patients 60 years and older and implemented a definition of frailty or risk screening tool in the emergency medical services ( ems ) or emergency department setting.resultsin the broad clinical literature , three types of measures can be identified : frailty index measures , frailty scales , and a phenotypic definition . 
 each offers advantages and disadvantages for the ems stakeholder . 
 we identified no ems literature on frailty conceptualization or management , although some risk measures from emergency medicine use terms that overlap with the frailty literature.conclusionsthere is a paucity of research on frailty in the emergency medical services literature . 
 no research was identified that specifically addressed frailty conceptualization or management in ems patients . 
 there is a compelling need for further research in this area . 
INTRODUCTION
Objectives
METHODS
Search Strategy
RESULTS
Frailty in EMS Patients
Frailty in Emergency Department Patients
DISCUSION
Limitations
Implications to Research
Implications to Practice
CONCLUSION