Mrs. Vivianne Dubois is an 84-year-old female presenting to your Emergency Department with her daughter. She tells you that she is here because she has been feeling weak and has had a fall. You speak to her daughter and find out that in the past year since her husband’s death, Vivienne has been struggling to take care of herself, requiring assistance with bathing and cooking. Recently, she has had several falls, and her daughter is concerned one of these falls may result in serious injury. Is this patient frail, and if so, how can one quantify this degree of frailty?
In Canada, the population of Canadians aged 85 and older will triple in the next 25 years.1 With increased length times in the Emergency Department (ED) leading to increased adverse events and mortality in the elderly population,2 it is imperative that we identify ways to optimize care of our older patients. It is important to identify when elderly patients are frail. We can identify frailty when they present to the ED, although it is optimal for this assessment to be done when the patient is at their baseline so we can then compare their level of functional change. Frailty is the state of heightened level of risk in comparison to other individuals of the same age.3
The Clinical Frailty Scale (CFS)
In this article, we will briefly review a very useful, Canadian-created tool to measure frailty: the Clinical Frailty Scale (CFS).4 Figure 1 shows the CFS. It is a helpful summary of an older person’s overall health status as identified in a clinical encounter. Although it may not be intuitive at first glance, with consistent use, the CFS can become a shared language for healthcare providers. Here are some key points:
- It is a validated scale for adults aged 65 or older with multiple comorbidities.
- It is used to determine the general level of fitness of the individual and score it from 0 (very fit) to 9 (terminally ill). This scale uses a variety of elements including Activities of daily living (ADLs)*, and instrumental activities of daily living (IADLs)**. These scores assess for functionality and the ability to live independently.
*ADLs are basic activities fundamental to independent living, such as walking, feeding, bathing, dressing, toileting, and transferring.
**IADLs are activities that are considered more complex and although still contributory to quality of life, can easily be delegated: managing finances, shopping, house maintenance, medication management, transportation and communication management.
Pro Tips when using the Clinical Frailty Scale
- Introduce the CFS tool and the individual’s ADLs/IADLs with an open question such as “Can you tell me about how you or your spouse/parent has been doing at home in the past two weeks?” Further inquiry can dive deeper into specifics of function and cognition. With this, we must identify where their functional baseline lies and how that may be different when they are being seen in the ED. This can help with clear communication and safe discharge planning including community supports.
- There is both a written and a visual component to assist you in determining the patient’s frailty score, although it is important that the description be consistent with the patient’s presentation rather than the image independently.
Most people will fit one specific score criteria, but about 20% will find themselves with overlap. In this scenario, it is an area of controversy, but some experts recommend erring on the side of the more severe frailty score.5
To assist with navigating the CFS for novice providers or perhaps for seasoned clinicians who are inexperienced with the CFS, there is a classification tree (Figure 2).6 You can also find this resource online at https://gmrtoolkit.ca/. Additionally, you can find the “Clinical Frailty Score (CFS)” app on the app store if you feel this may be a helpful reminder.
Case Conclusion
Returning back to our case. Mrs. Dubois requires substantial assistance with her IADLs, but in reviewing her ADLs, she only requires assistance for bathing. Based on this assessment, she would be scored as a 6 on the CFS, living with moderate frailty. This will be used to track her frailty progression and her potential for requiring increased community supports as she becomes more frail. For safe discharge, we investigated for causes of falling (such as delirium, electrolyte abnormalities, cardiac conduction abnormalities, etc.) and we spoke to the family about comfort with discharge home. Her daughter will stay at home with her until they can arrange for Mrs. Dubois to move in with her and her family full-time. In the meantime, we will also send a request for community support with bathing/general household assistance to assist the family and decrease the risk of caregiver burnout.
This post was copyedited by Sydney Terry.
- 1.Hallman S, LeVasseur S, Bérard-Chagnon J, Martel L. A portrait of Canada’s growing population aged 85 and older from the 2021 Census. Statistics Canada. Published April 27, 2022. Accessed August 3, 2023. https://www12.statcan.gc.ca/census-recensement/2021/as-sa/98-200-X/2021004/98-200-X2021004-eng.cfm
- 2.Guttmann A, Schull M, Vermeulen M, Stukel T. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 2011;342:d2983. doi:10.1136/bmj.d2983
- 3.Rockwood K, Howlett S. Age-related deficit accumulation and the diseases of ageing. Mech Ageing Dev. 2019;180:107-116. doi:10.1016/j.mad.2019.04.005
- 4.Theou O, Squires E, Mallery K, et al. What do we know about frailty in the acute care setting? A scoping review. BMC Geriatrics. 2018;18(1). doi:10.1186/s12877-018-0823-2
- 5.Rockwood K, Theou O. Using the Clinical Frailty Scale in Allocating Scarce Health Care Resources. Can Geriatr J. 2020;23(3):210-215. doi:10.5770/cgj.23.463
- 6.Theou O, Pérez-Zepeda M, van der, Searle S, Howlett S, Rockwood K. A classification tree to assist with routine scoring of the Clinical Frailty Scale. Age Ageing. 2021;50(4):1406-1411. doi:10.1093/ageing/afab006
Reviewing with the Staff
Geriatric Emergency Medicine is an emerging topic of clinical and academic interest in Emergency Medicine, particularly in Canada. As the proportion of older adults in our population grows, we must become proficient at identifying and managing frailty, as frailty is associated with adverse outcomes such as worsening disability, high rates of prolonged hospitalization, and increased mortality.7 The case provided is a common one, and an excellent scenario in which we can use the CFS to inform clinical decision making.
As Emergency Physicians, we pride ourselves on our ability to provide high-quality, compassionate care to all comers. The emergency department is often the last bastion of hope for the most vulnerable people in our society, including frail older adults. Considering a patient\'s frailty enhances our ability to provide patient-centered emergency care that is appropriate for their stage of illness and overall goals of care.
Karyssa Hamann