Early identification of frailty can prevent functional decline. Although multiple frailty screens exist for use in Emergency Departments (EDs), few are validated against diagnostic standards such as comprehensive geriatric assessment. To examine the diagnostic accuracy of ED screens for frailty, scientific databases were searched for prospective diagnostic accuracy test studies from January 2000 to September 2022. Studies were assessed for risk of bias using QUADAS-C. Psychometric properties were extracted and analysed using R. Six studies involving 1,663 participants describing seven frailty screening instruments (PRISMA-7, CFS, VIP, FRESH, BPQ, TRST, and ISAR), representing 13 unique data points, were included. The mean age of participants ranged from 76 to 86 years. The proportion that was female ranged from 45 to 60%. The pooled prevalence rate of frailty was high at 59%. The pooled estimate for sensitivity was 0.85 (95% CI: 0.76–0.91) versus 0.77 (95% CI: 0.62–0.88) for specificity. Pooled accuracy based on area under the ROC curve was 0.89 (95% CI: 0.86–0.90). Although few studies were found, limiting the ability to conduct a meta-analysis of individual instruments, available frailty screens can accurately diagnose frailty in older adults attending the ED. As specificity was comparatively low, additional assessment may be required to identify those requiring inpatient management or onward community referral. Further study is therefore required.

Introduction: Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study.Methods: A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August–September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors.Results: In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2–4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include.Conclusions: Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Accurate comparable prevalence proportions are required to better understand the epidemiology of frailty. Estimates in many countries are missing or incomparable. The Global Burden of Disease Frailty Index (GBD-FI) applies the deficit accumulation model to generate frailty scores from items available in the Global Burden of Disease study. To externally validate the GBD-FI. Data were obtained from the Survey of Health Ageing and Retirement in Europe (SHARE). A 20-item modified GBD-FI was compared with established frailty measures: a 70-item frailty index (FI-70), the Clinical Frailty Scale (CFS), Frailty Phenotype (FP) and SHARE-FI. Area under receiver operating characteristic curves (AUC) were fitted to examine diagnostic accuracy for frailty and predictive validity for 2-year mortality. In total, 31,624 participants aged ≥50 years from 15 countries were included. Frailty prevalence was 22% using the GBD-FI (ranging from 8% in Switzerland to 41% in Poland). The GBD-FI had good to excellent diagnostic accuracy for frailty, irrespective of approach; the AUC ranged from 0.86 (95% confidence interval: 0.85–0.87) measuring frailty using the CFS to 0.94 (0.93–0.94) with the FI-70. The GBD-FI had similar accuracy for 2-year mortality (AUC 0.71, 0.69–0.74) compared with the CFS (0.73; P = 0.186), FP (0.73; P = 0.392) and SHARE-FI (0.70; P = 0.255) but lower than the FI-70 (0.76; P < 0.001). The GBD-FI demonstrated concurrent and predictive validity, suggesting it is a valid measure of frailty. It has the potential to be an efficient, replicable and consistent approach to comparing frailty between countries and regions across time using GBD data.

Frailty is an independent age-associated predictor of morbidity and mortality. Despite this, many countries lack population estimates with large heterogeneity between studies. No population-based standardised metric for frailty is available. We applied the deficit accumulation model of frailty to create a frailty index (FI) using population-level estimates from the Global Burden of Disease (GBD) 2017 study across 195 countries to create a novel GBD frailty index (GBD-FI). Standard FI criteria were applied to all GBD categories to select GBD-FI items. Content validity was assessed by comparing the GBD-FI with a selection of established FIs. Properties including the rate of deficit accumulation with age were examined to assess construct validity. Linear regression models were created to assess if mean GBD-FI scores predicted one-year incident mortality. From all 554 GBD items, 36 were selected for the GBD-FI. Face validity against established FIs was variable. Characteristic properties of a FI—higher mean score for females and a deficit accumulation rate of approximately 0.03 per year, were observed. GBD-FI items were responsible for 19% of total Disability-Adjusted Life Years for those aged ≥70 years in 2017. Country-specific mean GBD-FI scores ranged from 0.14 (China) to 0.19 (Hungary) and were a better predictor of mortality from non-communicable diseases than age, gender, Healthcare Access and Quality Index or Socio-Demographic Index scores. The GBD-FI is a valid measure of frailty at population-level but further external validation is required.

Background: Prompt and efficient identification and stratification of patients who are frail is important, as this cohort are at high risk of adverse healthcare outcomes. Numerous frailty screening tools have been developed to support their identification across different settings, yet relatively few have emerged for use in emergency departments (EDs). This protocol provides details for a systematic review aiming to synthesize the accumulated evidence regarding the diagnostic accuracy and clinimetric properties of frailty screening instruments to identify frail older adults in EDs. Methods: Six electronic databases will be searched from January 2000 to March 2021. Eligible studies will include adults aged ≥60 years screened in EDs with any available screening instrument to identify frailty (even if not originally designed for this purpose). Studies, including case-control, longitudinal, and cohort studies, will be included, where instruments are compared to a reference standard to explore diagnostic accuracy. Predictive accuracy for a selection of outcomes, including mortality, institutionalization, and readmission, will be assessed. Clinical and methodological heterogeneity will be examined, and a random effects meta-analysis performed if appropriate. Conclusion: Understanding whether frailty screening on presentation to EDs is accurate in identifying frailty, and predicting these outcomes is important for decision-making and targeting appropriate management.

Background: Emergency Department (ED) Triage identifies patients with urgent needs. Frailty is not routinely identified and older patients presenting atypically may be inappropriately triaged as low priority. The introduction of a frailty modifier at triage is recommended in international guidelines, but is not yet widely‐adopted. Methods: A Frailty Trigger was developed following a systematic review and two‐round eDelphi. To investigate diagnostic test accuracy for frailty, we recruited consecutive adults aged ≥ 70 attending a university hospital ED between December 2021 and February 2022, comparing the Trigger to the Clinical Frailty Scale (CFS), Variable indicative of Placement (VIP), and PRISMA‐7. An independent comprehensive geriatric assessment (CGA) determined frailty status. Results: In total, 313 adults aged ≥ 70 years were available, median age 78 ± 9 years and 46% were female. Half (51%) were frail based on the CGA. The Frailty Trigger had excellent diagnostic accuracy for frailty, Area Under the Curve (AUC) of 0.822, 95% confidence interval (CI): 0.780–0.865, similar to the VIP (AUC 0.820, p = 0.937), although significantly lower than the PRISMA‐7 (AUC 0.896) and CFS (AUC 0.946). Mean administrative time was 25.5 s (SD ±10.9 s). Scoring positive on the Frailty Trigger was associated with increased length of stay (LOS), median 6.4 versus 2.3 days ( p < 0.001). After adjustment for age, sex, and co‐morbidity, a positive score was associated with reduced survival at 1 year (Hazard Ratio 2.2; 95% CI 1.15–4.33, p = 0.017). Conclusion: When applied as part of ED triage, the Frailty Trigger showed excellent diagnostic accuracy for frailty when compared to validated screens and was quick to use. It predicted LOS and mortality. Studies are required to examine feasibility and its effect on frailty pathways from triage.