Recognising older frail patients near the end of life: What next?

EJINME-03683; No of Pages 7 European Journal of Internal Medicine xxx (2017) xxx–xxx

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European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim

Narrative Review

Recognising older frail patients near the end of life: What next? Magnolia Cardona-Morrell a,⁎, Ebony Lewis a, Sanjay Suman b, Cilla Haywood c, Marcella Williams d, Audrey-Anne Brousseau e, Sally Greenaway f, Ken Hillman a,g, Elsa Dent h,i a South Western Sydney Clinical School, The Simpson Centre for Health Services Research, The University of New South Wales, Level 3, Ingham Institute Building, 1 Campbell Street, Liverpool, NSW 2170, Sydney, Australia b Medway NHS Foundation Trust, Elderly Care Service, Medway Maritime Hospital, Windmill Rd, Gillingham, Kent ME7 5NY, England, UK c Austin Hospital and Department of Medicine, University of Melbourne, 145 Studley Rd, Heidelberg, VIC 3084 Melbourne, Australia d School of Nursing, Lansing Community College & Sparrow Hospice House, HHS Building 204.5 411 North Grand Avenue, Lansing, MI 48933, USA e Schwartz-Reisman Emergency Medicine Institute, Mount Sinai Hospital, 600 University Ave, Toronto, ON M5G 1X5, Canada f Sydney West Area Palliative Care Service, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW 2145 Sydney, Australia g Intensive Care Unit, Liverpool Hospital and South Western Sydney Clinical School, The University of New South Wales, Level 2, Intensive Care Unit, Liverpool Hospital, Elizabeth Street, Liverpool, NSW 2170, Sydney, Australia h Torrens University Australia, 220 Victoria Square, Adelaide, SA 5000, Australia i Baker Heart and Diabetes Institute, Level 4, 99 Commercial Road, Melbourne, VIC, 3004, Australia

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Article history: Received 31 August 2017 Received in revised form 19 September 2017 Accepted 23 September 2017 Available online xxxx Keywords: Frail Elderly Geriatric Assessment/methods Terminal Care Advanced Care Planning End-of-life Review

a b s t r a c t Frailty is a state of vulnerability resulting from cumulative decline in many physiological systems during a lifetime. It is progressive and considered largely irreversible, but its progression may be controlled and can be slowed down and its precursor –pre-frailty- can be treated with multidisciplinary intervention. The aim of this narrative review is to provide an overview of the different ways of measuring frailty in community settings, hospital, emergency, general practice and residential aged care; suggest occupational groups who can assess frailty in various services; discuss the feasibility of comprehensive geriatric assessments; and summarise current evidence of its management guidelines. We also suggest practical recommendations to recognise frail patients near the end of life, so discussions on goals of care, advance care directives, and shared decision-making including early referrals to palliative and supportive care can take place before an emergency arises. We acknowledge the barriers to systematically assess frailty and the absence of consensus on best instruments for different settings. Nevertheless, given its potential consequences including prolonged suffering, disability and death, we recommend identification of frailty levels should be universally attempted in older people at any health service, to facilitate care coordination, and honest discussions on preferences for advance care with patients and their caregivers. Crown Copyright © 2017 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine. All rights reserved.

1. Introduction As the population survives longer thanks to technological advances and improvements in public health infrastructure, it is projected that by 2050 one in five people will be aged 60 and over [1]. Frailty is an age-related syndrome associated with multiple organ failure and declines in physiological reserve that makes older people susceptible to adverse health outcomes [2] such as falls [3], functional dependency [4–6], institutionalisation [3] and death [3,5,6]. Frailty has already become a global public health priority [7] and specialised geriatric services ⁎ Corresponding author at: The Simpson Centre for Health Services Research, The University of New South Wales, PO Box 6087 UNSW, Sydney, NSW 1466, Australia. E-mail addresses: [email protected] (M. Cardona-Morrell), [email protected] (S. Suman), [email protected] (C. Haywood), [email protected] (M. Williams), [email protected] (A.-A. Brousseau), [email protected] (S. Greenaway), [email protected] (K. Hillman), [email protected] (E. Dent).

worldwide are under pressure to meet the complex management needs of frail adults with chronic illness [8]. Recognising frail patients who are approaching the end of life is complex and often delayed due to clinical uncertainty [9] and public perception that the end of life is a point in time rather than a process that can take days, weeks, or years [10]. In fact, the end of life journey can commence years earlier with frailty being one of its salient features. The coexistence of frailty and cognitive impairment and dementia indicates that the dying trajectory has commenced [11]. Delays in diagnosing worsening frailty as a terminal process (i.e. end of life) [9] often lead to aggressive and non-beneficial treatments [12] that can impair quality of remaining life and increase suffering, foster false hope [13] and preclude healthy grieving for both patients and their families. According to guidelines, a comprehensive frailty assessment in all older adults is recommended across the continuum of care because it is known that frailty status has a strong association with poor outcomes [14]. However, it is not routinely measured in some settings, for

https://doi.org/10.1016/j.ejim.2017.09.026 0953-6205/Crown Copyright © 2017 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine. All rights reserved.

Please cite this article as: Cardona-Morrell M, et al, Recognising older frail patients near the end of life: What next?, Eur J Intern Med (2017), https://doi.org/10.1016/j.ejim.2017.09.026

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example in the emergency department (ED), perhaps due to the perceived duration of the assessment in an already busy environment [15]. Reasons for overlooking frailty in the clinical setting is the slowly progressing clinical presentation or attribution of frailty to normal ageing process rather than a disease [16]. Other factors are: the clinicians focus on a specific organ system based model [17] to which frailty– being a multisystem disease–does not conform; lack of geriatric training by non-geriatric clinicians [18]; or lack of awareness of frailty tools available to examine older adults [19]. All of this leads to a delay in recognising frailty especially in the early stages where targeted interventions to delay or slow-down the progression would be of benefit [20]. This review aims to present an overview of the importance and feasibility of timely recognition of frailty, and discuss the how, where and so what of identifying older frail people. Recommendations for practice across all settings are also presented. 2. Why identify frail people near the end of life Frailty is progressive and the transition from pre-frailty to frailty is far more common than the reverse [21]. Inexorable decline in function despite treatment of the underlying medical conditions, is a marker of impending mortality [22]. Preventing prolonged suffering and facilitating the transition from active treatment to comfort care are the goals of identification of serious life-threatening illness [23] i.e. people nearing the end of life. Identifying seniors at risk in emergency departments has been attempted with mixed results and modest predictive accuracy [24]. Frailty is understood to be the best predictor of mortality in community dwelling older people, surpassing the predictive ability of co-morbidity and biological age [25]. Regardless of how frailty is measured, the rates of functional decline and mortality are higher among the frail than in non-frail persons [26]. For frail older adults the dying journey is often prolonged into years and it is at the point when there is a significant decline or a significant stressful event -such as a hip fracture or a pneumonia episode- that recognising a person has commenced the dying trajectory is essential to guide the transition from active curative treatment to palliation and holistic supportive care [27]. 3. How to identify frailty and how accurate assessments really are Despite a ‘call for action’ [28] and the availability of instruments, there is still no consensus on an operational definition [29] of frailty and how to measure it [30]. However, it is well accepted that a comprehensive geriatric assessment (CGA) is the gold standard to identify frailty in community settings, and when conducted on the ward after an emergency admission and followed by a care plan is associated with higher likelihood of patient discharge to their own home and longer survival [31]. However, it is time-consuming (takes at least 1 h) and resource-intensive; requires specialist skill and physical measurement of anthropometric components which may be impractical to undertake in the ED setting where space is scarce and patients are immobilised, or limited by cardiac monitoring technology. As an added complicating factor frailty scales rely on comprehensive documentation which may be burdensome for non-specialist staff [32] or are not feasible in general practice due to time constraints, nor in residential aged care facilities which do not have access to electronic health records [33]. A wide variety of frailty and functional decline indices have been used on different patient sub-populations over the past two decades and they include clinician-measured, observed, and self-reported functional status assessments. Frailty can be identified using either the Frailty Index (FI) [34] and its electronic version (eFI) [35], Fried’s frailty phenotype [36], the Clinical Frailty Scale (CFS) [37], the Fatigue Resistance Ambulation Illness Loss of weight (FRAIL) scale [38], PRISMA-7 [39], and the Groningen Frailty Indicator (GFI) [40]. The SHARE75+ is a combination of observed and self-reported parameters

and has acceptable predictive validity of 2-year mortality and 4-year disability [41]. The evaluation of a brief questionnaire EASYcare-TOS found that it is feasible to identify frailty in a time-pressured, nonspecialist environment of a general practice setting [42]. However this instrument has not been prospectively validated in terms of the ability of the scores to predict disability or mortality. The constructs of the instruments above vary as some are limited to physical performance domains and others also incorporate associated comorbidities (some examples are shown in Table 1). Their validity and reliability also vary as some are objectively measured and others are self-reported or observed [43]. The strength of their associations with adverse outcomes also differ, as does the instrument requirements for equipment and expertise of the assessor which can be a limitation for clinical settings. Others such as the Edmonton Frailty Scale (EFS) do not require a geriatrics-trained staff for administration [44] but involve demonstration of functional status not always possible to undertake in acute settings. The most widely used approach to measure frailty is the phenotypic approach which is strongly based around or the sarcopenia hypothesis of frailty, i.e. physical markers [3], and the cumulative deficit approach which encompasses not only the physical aspect but cognition and functional decline, falls, comorbidities, continence, etc. [34]. Many of these instruments have been applied to the community setting [45]. Others such as the Identification of Seniors at Risk (ISAR) tool are used in older emergency department patients and have a poor-to-fair ability to predict adverse follow-up composite outcomes (AUROC 60–70%) [46]. In residential aged care facilities where there may be more time to exhaustively assess patients, the FRAIL-NH scale has been viewed as a simple and practical method to screen for frailty [47]. Studies focusing on ward patients have yielded better predictive results for poor hospital outcomes: using the Clinical Frailty scale (CFS), in-patient mortality was statistically significantly associated with frailty and CFS had a predictive ability N 70%. Both the CFS [32,48] and Fried scale [49] have been associated with longer length of stay and admission to aged–care wards [48]. Frailty is also associated with increased mortality at several time points (one month, three months and one year) in older surgical patients postoperatively [50]; in older medical patients one-month mortality using the SUHB scale [51]; and six month mortality using the Fried scale [52]. Evidence from a systematic review indicates that when comparing several frailty scales to predict composite outcomes (either death, nursing home admission or a change in low to high level care) only the Frailty Index of Accumulative Deficits had adequate predictive power (AUROC N 70%) at both time points [53]. In sum, the frailty concept is generally associated with adverse outcomes but the choice of instrument depends on the setting to be used, the time available for assessment, the skill level required for administration and the environment where the patient can demonstrate functional ability. 4. Who should identify frailty and a person approaching end of life The CGA covering medical, nutritional, functional and psychological domains needs to be conducted by a multidisciplinary team, whether in hospitals or the community. But many occupations can contribute to identification and management of older people at risk. Nurses and allied health professionals such as occupational therapists can play a key role in the identification and management of frailty [54] in healthcare facilities and in the community, and in supporting informal caregivers to reduce their burden [55]. Physiotherapists can assist in the many objective measures current frailty items require such as mobility and walking speed and dietetics can help inform nutritional status, weight loss and management [56]. Instruments to identify the dying trajectory earlier than at crisis point can be based on combinations of objective parameters and subjective clinical judgment such as RADboud indicators for PAlliative Care needs (RADPAC) for general practitioners [57]; or combinations

Please cite this article as: Cardona-Morrell M, et al, Recognising older frail patients near the end of life: What next?, Eur J Intern Med (2017), https://doi.org/10.1016/j.ejim.2017.09.026

✓ ✓

of signs of chronic illness and symptoms of acute deterioration for hospital staff such as the SPICT tool [58] which requires specialist knowledge; or the Simple Clinical Score [59], the CriSTAL tool [60], and the Rothman Index [61] which can all be determined by nonspecialists and non-medical staff. Others rely on laboratory or other sophisticated testing interpreted by specialists such as APACHE [62] and SAPS [63] for intensive care settings.

✓ ✓ ✓ ✓ ✓

✓

✓

✓

✓ ✓

✓ ✓ ✓

✓

✓ ✓ ✓

✓ ✓ ✓ ✓ ✓ ✓

✓

✓

✓

✓

✓ ✓ ✓ ✓

GFI can be administered by clinician or self-report (there are two versions) this example is the self-report version. a

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✓ ✓ ✓

65+ y.o 65+ y.o 75+ y.o 50+ y.o 75+ y.o 65+ y.o 65+ y.o Not specified 65+ y.o 70+ y.o 49–60 y.o Afro-American USA 2002 USA 2001 UK 2015 Europe 2010 Canada 2008 Netherlands 2012 Italy 2012 Ireland 2014 Canada 2005 Belgium 2006 USA 2012 CGA [108] Fried [36] CFS [48,67,109] SHARE-FI [110] PRISMA-7 [39] GFIa [111] ISAR [68,112] SUHB [51] FI-CGA [113] SHERPA [114] FRAIL Scale [38]

✓

✓

✓

Outpatient Emergency Hospital ward

✓ ✓ ✓ ✓

✓ ✓

Observed/clinician judgment Measured Activities of daily living Community

Target age group Country & publication year Instrument name

Table 1 Characteristics of some frailty indices used in different settings since 2001.

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5. Where is the best setting to identify frailty and end of life

Nursing home

Domains Study setting

Co-morbidity/illness severity

Administration mode

Self-report

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Previous research on frailty and its associated outcomes has been largely focused in the community setting [3,64] where CGAs can also be performed if resources permit [65]. Frailty measurement tools are often applied in the primary care setting, and are a proactive way to identify older adults who may need palliative care services rather than hospital transfers for acute care; or in residential aged care facilities, where mean prevalence of frailty ranges widely from 19.0 to 75.6% [66]. However, the routine introduction of a 66-item instrument may not be realistically incorporated in clinical screening or care where time and resources are scarce to cater for the needs of a complex and highly dependent clientele. The briefer CFS has also been used in aged care facilities and found to be highly correlated with malnutrition and mortality [67]. In the emergency department, the best described screening questionnaire is the ISAR which can be self-reported. Score on the ISAR has been shown to be modestly predictive of functional decline, representation to hospital, and mortality [68]. It can be used to identify older adults at higher risk of adverse outcomes and orient them to a more comprehensive geriatric assessment in the community or by a Geriatric Emergency Management nurse. Identifying frailty on general ward patients may avoid invasive, nonbeneficial and harmful treatments [25] and can help clinicians identify the level of care warranted such as a palliative approach [69]. The literature consistently reveals that patients who receive palliative care support or advanced care planning have fewer ICU admissions and reduced length of stay in ICU [70]. Such advanced care planning is particularly critical in the elderly and those living in long term care facilities since end-of-life decisions should be an integral part of their care. Early integration of palliative care in the management of frail elderly in the community could support advanced care planning but a lack of training for general practitioners to improve early recognition of palliative care patients or discuss the patients’ goals of care remains a barrier [57,71]. Even in hospitals, identification of older patients with palliative care needs continues to be delayed until after patients deteriorate and referrals occur as late as around the time of rapid response call attendances [72]. Finally, older people often visit general practitioners, presenting an opportunity to identify frailty in primary care to facilitate care coordination. A web-based tool called the “Frailty Portal’ is currently being tested in primary care for feasibility and effectiveness in increasing awareness and helping access to services [73]. A meta-analysis indicated that mean score and range results derived from the Frailty Index using routine primary care data might be different from those reported from research datasets, [74] casting doubts on its reliability and construct validity. 6. What to do next: practical recommendations for action Is frailty a reversible process? It has been recently suggested that pre-frailty and physical frailty can be treated to maintain independence and function within the limitations of old age [28]. Identifying prefrailty or vulnerable state is just as important as diagnosing frailty. They are both part of a continuum. Since pre-frailty carries a fourfold increase risk of a person becoming frail [3] interventions targeting the pre-frail state [75] are warranted, as are open discussions about the poorer prognosis of well-established frailty. Dying well is as important

Please cite this article as: Cardona-Morrell M, et al, Recognising older frail patients near the end of life: What next?, Eur J Intern Med (2017), https://doi.org/10.1016/j.ejim.2017.09.026

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as living well [76,77]; so where return to independence cannot realistically be achieved, provision of services to the patients carers can help the patient remain at home. Alternatively, detection of significant frailty with functional dependence may herald a requirement for residential care. The British guidelines for the management of frailty [78] recommend frailty assessment at all encounters with older people in community settings using the widely adopted comprehensive geriatric assessment; diagnosing chronic illness to optimise treatment; deprescribing; and honest discussion − including consideration of inappropriateness of hospitalisation − [79] followed by an individualised care and support plan that covers maintenance and terms of escalation. Likewise the Asia-Pacific guidelines [80] support the comprehensive geriatric assessment for measuring frailty in outpatient settings, addressing polypharmacy, and propose referral of frail adults to a progressive, individualised physical activity program that includes multimodal exercise (resistance training, balance and flexibility exercises and aerobic exercise such as walking) to reduce major mobility disability in older adults and prevent hospitalisation or nursing home admission. In addition, the latter guidelines propose investigation of reversible causes of fatigue such as sleep apnoea and depression, and managing reversible causes of weight loss and fatigue with protein and caloric supplementation. Interventions for frailty that improve the quality of life of aged care facility residents are also a potential benefit even if the nursing home status does not change. Evidence from a recent systematic review indicates that physical activity programs of at least 6 months duration including 3 or more sessions of 60 min each per week can delay the onset of frailty [81]. In order to control the progression of frailty, in another study pre-frail patients attending their general practitioners received a range of nutritional and physical activity intervention components. Independently they were associated with a reduction in frailty status amongst pre-frail and frail older adults, and when the interventions were combined results showed a five-fold reduction in physical limitations [82]. An earlier study also found that a 3-month physical training in prefrail older adults improved functional performance [83]. There is currently no international consensus regarding guidelines for emergency management of older adults with frailty. We suggest that rapid identification of frailty using a validated screening tool be combined with a patient’s acute illness severity (AIS). This frailty identification can be performed using a synthesis frailty measurement tool which combines a visual chart of frailty severity with written text and clinical judgement. The CFS is one such example [37]. The combination of CFS and patient AIS recently showed to predict mortality well in older patients in the ED [84]. However, the feasibility of undertaking a CGA in the ED is dependent upon the available resources of the different health systems; CGAs can be costly and time-consuming. The inter RAI group offers a brief electronic and useful tool for older adults assessment of functional deficits in the ED [85]. As frailty is often not clinically recognised in older adults unless it is specifically screened for [78], the Geriatric Emergency Department Guidelines recommend that in the ED setting, all older adults be screened for frailty [86]. If a patient is identified as frail, it is imperative that there be a rapid response implemented to manage the condition [87]. The exact rapid response to be elicited is not yet clear in the literature, although the concept of frailty emergency teams to avoid unnecessary hospitalisations has been proposed and successfully tried in some settings [88]. If resources permit, a consultant geriatrician-led CGA is suggested for use in the ED as an effective measure to prevent hospitalisations. Whether this approach also prevents readmissions or long lengths of stay may depend on the availability of local community support services [89] and the natural aged-related rate of deterioration. For very old adults identified as severely frail who may not be suitable for physical training programs, end-of-life interventions are most appropriate [90]. Familiarising with recognisable dying trajectories in emergency departments [91] can facilitate early goals of care

discussions and palliative care referrals [92]. Long considered the “gold standard” by the American Society of Medical Oncology for individuals with advanced cancer, early palliative care focuses on improving quality of life by optimising symptom management [71] for other advanced, incurable chronic illnesses such as terminal pulmonary, heart and kidney disorders. The terminal illness associated with advanced frailty also requires a different construct concentrating on supportive care and the social needs of the elderly. The integration of early palliative care for those facing life-limiting illness has received increasing attention worldwide, as the perception of patient abandonment changes [93] and the choice of comfort rather than life-prolonging treatments is favoured [94]. Palliative care can help prevent frequent hospitalisations, reduce symptom burden, and improve quality of life for individuals facing chronic illness. Additional advantages include: improved health related quality of life, increased health care utilisation, enhanced treatment decision making and advanced care planning, improved mood, better patient satisfaction with care, and improved end-of-life care [95]. There is good evidence to show that if an unwell person and their family are aware that the patient is dying, they will make treatment choices that ensure a higher quality of death [96]. There is a preference for dignity and independence over longevity. Thus informed, patients and families are much less likely to opt for intensive care admission and other high burden nonbeneficial treatment options. People who are being made aware of their poor prognosis also state the importance of being able to have some control over the dying process, choose their place of care and, if possible, place of death [97]. All of this reflects the concept of a good death [98,99]. By giving patients and families the opportunity to follow care pathways that reduce consumption of acute resources, others with true prospects of recovery will benefit in health care systems with limited resources. This also reduces stress and job dissatisfaction for the medical teams who would otherwise be inflicting therapy on dying patients that they realise is futile [100]. Finally, reducing the burden of unnecessary hospital admissions and transfers from residential aged care facilities is a key advantage to advance care planning. The emergency room could serve as the gatekeeper for an acute care hospital as well as the first point of care for many patients and informal caregivers with distressing symptoms. Therefore, training emergency care providers to assess patients’ care goals and boldly discuss disease trajectory, prognosis, and evidence-based prognostic indicators is essential [101]. 7. Unresolved issues for future research Identifying frailty to guide decisions on interventions to slow its progression and early referrals to community and palliative care may be seen as a cost-saving exercise by some. While triaging frail dying people to other services may lead to reduction in acute care costs, in practice, a sense of equity in healthcare and a duty to be honest about poor prognosis are the ethical responses to the escalating problem of high and unrealistic demand for services to prolong life in the absence of benefit. Despite numerous frailty instruments developed [45] and testing in multiple settings, only half the eligible people are screened with them [69], and there still remains no agreed upon instrument to diagnose frailty. Perhaps one size does not fit all, but there appears to be consensus on the concept of frailty as a reduction of physiological function in the presence or absence of chronic disease that increases vulnerability to adverse outcomes [29]. Deciding which frailty instrument is most accurate and easily administered in a specific setting can be challenging. The phenotypic approach has been validated in community settings [3,102] but implementation in the acute clinical setting may prove difficult. Objectively measuring the phenotypic criteria in older adults admitted to the hospital is complex as their acute illness may not reflect their true frailty status before admission; and busy emergency departments lack access to handheld dynameters, space to assess mobility and instructions are not understood by patients with cognitive impairment [103]. On the other hand the

Please cite this article as: Cardona-Morrell M, et al, Recognising older frail patients near the end of life: What next?, Eur J Intern Med (2017), https://doi.org/10.1016/j.ejim.2017.09.026

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Frailty Index has been found by others to be predictive of poor outcomes [53] but can be time-consuming and access to all measurable items at the time of assessment may not always be possible. Of concern, many frailty measurement tools used in clinical practice today have not been tested adequately for validity and reliability [104] and they appear to measure different concepts. A lack of cross-cultural validation is also common [104]. In addition, many tools which were originally designed for use in the community are now used in hospital settings without additional validation. However, real-life clinical care calls for pragmatic approaches including the use of self-reported frailty as it is also known to be associated with falls and fractures [105]. Other self-reported instruments such as the Barthel-20 Index assess aspects of physical performance that may differ from motor or performance scales such as the TUG test [106]. We therefore support the recommendation that, when possible, health practitioners supplement self-reported frailty with the use of a frailty measurement tool that has been validated for their specific clinical field and for the population groups served; but we acknowledge that adaptation from objective measurements to observed or self-reported parameters may have to be a compromise for real-life settings. It is reassuring that another study using selfreport did not yield significantly different frailty profiles from those based on objective measures in older populations [107]. 8. Conclusions Regardless of the lack of agreement in defining and measuring frailty and the nature of its trajectory including pre-frailty, early screening for risk of death and frailty levels before hospital admission still remains an important step in holistic assessments of older people. Frailty measurement in either the hospital ED, community or in aged care facilities lends itself well to the identification of patients who need a response appropriate to their needs, including advance care planning and should be integral to assessment at all settings. Recognising frailty and functional decline can have a significant impact on clinical decision regarding management. The purpose of detecting and managing frailty early in older patients is to attempt to maintain physical performance for as long as possible while at the same time creating an appropriated environment where the frail person can survive safely. There is evidence of physical training strategies to slow its progression and minimise the complications of frailty such as poor functional outcomes and death. Multidisciplinary teams can play a part in providing active or comfort care based on need. When frailty becomes more advanced palliative care can help facilitate a good death involving attention to the physical, psychosocial, and spiritual aspects of patient care aligned with patient’s informed goals of care. It is the responsibility of all clinicians both in the community and hospital settings to screen for frailty and associated risk of death among older patients. There needs to be systems of care, especially in the community setting so once frailty is identified, practitioners consult older patients on their personal values, guide the establishment of realistic goals, and refer them to the most appropriate care pathway. Declarations of interests All authors disclose no actual or potential conflict of interest including any financial, personal or other relationships with commercial or organisations that could inappropriately influence, or be perceived to influence, their work. This work was supported by a program grant from the National Health and Medical Research Council of Australia [NHMRC grant # 1054146] which paid the salaries of MCM and EL. An NHMRC Fellowship supported ED. A Fellowship from Schwartz/Reisman Emergency Center, Sinai health System, Canada, supported AAB. The funding bodies had no role in the choice of topic, interpretation of data or decision to submit for publication.

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