The Public Safety Group Blog

It’s 05:45 hours. You and your partner are in the ambulance bay at the station, getting an update from the outgoing crew about last night’s shift and the status of the ambulance. They had a guy who woke up with pulmonary edema, a bad opiate OD, a young girl in labor, a bar fight with three guys and a bunch of soft tissue injuries, a rollover car wreck off the expressway, and a couple of routine calls. You also hear that they spent a lot of time on the wall at the ED with a patient who was very frail. Everything they used was restocked, and we actually caught up on the paperwork.

What is Frailty? 

We have all taken care of “frail” patients during our EMS careers. What does the term “frail” conjure up in your mind? Perhaps terms like: fragile, feeble, slight, or infirm?

Frailty is characterized by a decline in functioning across multiple physiologic systems accompanied by increased vulnerability to stressors (falls, infection, or comorbidities) leading to increased morbidity/mortality. This “syndrome” is primarily found in geriatric patients, but it is not restricted to the elderly. Typically, the tools used to assist in diagnosis are focused on the older adult group. 

Some have argued that if physicians routinely tested younger adults (18-59 years) with age-appropriate validated assessment tools, frailty would be a more common diagnosis. Frailty as a geriatric syndrome has been shown to affect 5% to 17% of older adults. It is more common in woman than men, possibly because woman tend to live longer, increasing their likelihood of becoming frail.

A physician can diagnose frailty with a physical exam and using frailty scales/scoring systems. These tools help determine if the patient is non-frail, prefrail, or frail so that a treatment plan can be developed. There are more than a dozen scales/scoring systems in common use around the world. There’s also little consensus on which tool is the best. The most common criteria found on the scales/scoring systems include: 

• Weight loss (unintentional) in the past 12 months (at least 10 pounds (4.5 kg).

• Grip strength (measured by dynamometer) that is weaker compared to others with similar body characteristics and sex.

• Low energy or poor endurance (feeling fatigued or exhausted often).

• Gait speed (slow movement or walking speed).

• Low physical activity level.

Since measuring physical strength (i.e., grip strength) is often used to determine frailty, that’s one reason for the common misconception that frailty is similar to physical weakness. 

In 2019, the International Conference on Frailty and Sarcopenia Research (ICFSR) developed the first edition of clinical practice guidelines for the identification and management of frailty. Sarcopenia is a progressive age-related loss of muscle mass and strength. There have been multiple updates to the guidelines. Updates are based on research in a similar manner that ILCOR issues consensus on science and treatment recommendations on emergency cardiac care. 

Symptoms of Frailty 

The patient with frailty may describe symptoms such as:  

• Frequently feeling fatigued or exhausted.

• Muscle weakness or reduction in strength.

• Moving slowly or having other trouble moving around (due to decreased strength and/or flexibility).

• Having difficulty with balance and stability.

• Accidental urinary or bowel incontinence.

• Avoiding spending time out in public or with loved ones (social isolation).

• Depression.

• Needing help with activities of daily living (i.e., eating, dressing or bathing).

• Losing weight without trying. 

Many of the above symptoms fit with other prehospital presenting problems, but it is helpful to be aware of frailty symptoms and how they may contribute to the patient’s overall health and well-being. 

Causes of Frailty

Frailty occurs when the body is not healthy enough to recover from illness or injury. This can be due to comorbidities (i.e., diabetes, polypharmacy), having a limited diet without proper nutrition, and a sedentary (non-active) lifestyle. Things that can contribute to frailty include: 

• Short-term illnesses: influenza or food poisoning.

• Minor injuries: muscle sprains, strains, and stress fractures.

• Chronic conditions: stroke, congenital heart disease.

• Severe injuries: a broken hip, head trauma.

Understanding the Risks of Developing Frailty

The following factors have been shown to increase the risk of developing frailty: 

• Age: about 1 in 10 people over 65 have frailty. That number climbs to 1 in 4 among people 85 and older.

• Severe illnesses or injury: the more severe a condition is, the more it raises the risk of frailty.

• Treatments for severe illnesses or injury: may strain overall health, but providers still recommend them when the pros outweigh the cons (i.e., cancer chemotherapy or radiation therapy, or transplant surgery for organ failure).

• Congenital conditions: congenital heart disease is a common cause of frailty in children. Other congenital conditions may increase frailty risk after childhood.

• Support network (family, friends, other loved ones): providers often consider if the patient has a support network in determining frailty. Not having a support network may make frailty more likely since it can make it harder to get food, medical care, and join in physical and social activities.

How EMS Providers Can Care for Frail Patients

Discussion about frail patients is not typically found in the original EMS training programs. When teaching providers about the frail patient, after reviewing the information provided in this blog, it may be helpful to review a few cases. Consider discussing potential clues found on the scene that might indicate a frail patient. Also consider how this knowledge might impact your assessment, management, and transport decisions. Always follow the assessment plan you have been taught to use for responsive patients but also consider the info that is sometimes right in front of you! Here are three cases you could start with: 

EMS Training Case #1 

• You are dispatched to a private residence for a 65-year-old male with breathing difficulty. On arrival his wife meets you at the door and states, “after 50 years of chain smoking, with all these breathing medicines he takes, he still will not quit.” As you enter the kitchen you observe he is sitting leaning forward in the tripod position struggling to breathe. He looks about 110 lbs and has a tissue in his hand since he is coughing up green sputum.

• Assessment: you know so far – age, COPD, underweight, heavy smoker, takes lots of meds, may have chest infection.

• Considerations: You may have to get most of the history from his wife, inquire about other comorbidities, get the med list, how does today’s distress compare to prior incidents?

• Treatment/Transport: treat per your protocols (oxygen, bronchodilator), keep him warm. Don’t let him walk to the ambulance, don’t lay him down, transport to the most appropriate ED, and monitor/reassess closely.

EMS Training Case #2 

• You are dispatched to the home of a 5-year-old boy who is having chest pain. On arrival his mother meets you at the door and takes you to his room. She explains that he has been doing so good lately. She says he has had many surgeries because he was born with heart valve problems. Today he was playing with the dog and suddenly turned blue and complained of pain in his chest. He looks underweight and very anxious to you. Mom says he needs to go to the cardiac unit at Northside Hospital and he is being treated by Dr. Fogel’s team. She will bring his binder with meds and treatment history.

• Assessment: you know so far – age, congenital heart condition, multiple surgeries, lots of meds, cyanosis and chest pain came on suddenly while playing, mom is very helpful, get the patient on the monitor and vital right away!

• Considerations: Mom has 5 years of history in her head and the binder…keep her nearby! Ask how this compares to prior incidents and how her son was treated in those cases.

• Treatment/Transport: treat per pediatric protocols (oxygen, call med control as needed, may be helpful to alert Dr. Fogel’s team you are on the way to the ED). Of course keep the child as calm as possible by talking with him. 

EMS Training Case #3 

•  You respond to the local park where you see a familiar face on the patient who is a 14-year-old female complaining of “another broken wrist.” She states she was watching the other kid play on their skate boards and took a try but fell on her right arm. You have treated her previously and know that she is very skinny and has a bone disease and history of many prior fractures. Her father has been called and is on the way. She is very helpful with history and states this is probably her 20th fracture.

• Assessment: you know so far – age, bone disease with many prior fractures, very skinny child, dad is on the way.

• Considerations: although she is an “young pro” at fractures… be sure to give her a complete head to toe physical exam as she is very prone to fractures! She may also have a high pain threshold so be sure to palpate and check those distal pulses and motor sensation.

• Treatment/Transport: treat per pediatric protocols (splinting, cold pack) and transport to ED where she is normally managed once dad arrives.  

Additional EMS Training Cases 

When teaching EMS students how to work with frail patients, develop your own cases to review based on your experiences! Be sure to include some of the potential frail patient history and discuss its relevance to the presenting problem. Remember to emphasize that if a patient has frailty the EMS provider should consider that this can lead to complications such as: 

• Lower immunity: frailty can leave the patient vulnerable to new illnesses and slow down recovery from illnesses they already have.

• Increase vulnerability to injury: frailty can make the patient prone to and slow to recover from injury.

• Make other conditions more severe: even minor conditions can turn into dangerous or fatal complications.

• Limited treatment options: patients with frailty may not be able to safely undergo certain procedures or surgeries.

• Cause of disability: frailty can cause the patient to develop a disability.

• Take away independence: patients with frailty may not be able to live alone and in their own homes.

• Shortened life expectancy: accumulating and worsening health issues, combined with frailty can turn life-threatening. 

In Summary 

• If frailty is suspected, it can impact, in a negative way, the presenting problem that you were called for.

• Assessment and management may take a little longer, involve more “tender” care on moving the patient with frailty, and perhaps a destination where they have been previously managed would be appropriate.

• Sometimes your observations of the living conditions and lack of assistance may be helpful to the ED in considering the patient is frail.

• As the population gets older, more EMS calls are likely to involve a patient who is frail, so learn about this condition and watch out for it in the field.

• Don’t forget that this is not just a syndrome exclusive to the elderly!

• As always be careful out there!