Frailty is an aging‐related syndrome of reduced function and physiologic reserve that increases a person's vulnerability to illness. 1 Multiple models have aimed to standardize the definition of frailty, leading to variation in the way frailty is understood and approached clinically. 2 , 3 Frailty is associated with adverse outcomes in older adults including delirium, falls, prolonged hospital stay, return emergency department (ED) visits, and mortality. 1 Early identification of frailty in the ED can help avoid undertriage, recognize care needs, implement adverse‐event prevention strategies, trigger geriatric specialist consults, and connect with community resources. 4 , 5
A comprehensive geriatric assessment (CGA) is the criterion standard for assessing frailty. 6 CGAs are lengthy and require input from multiple sources, limiting its applicability in the ED setting. As a result, numerous frailty screening tools have been validated for use in the ED, 6 , 7 such as the Clinical Frailty Scale (CFS) and Identification of Seniors at Risk (ISAR). 6 It is not known how emergency physicians screen for frailty and how frailty impacts clinical practice. Therefore, the objective of this study was to understand emergency physicians' knowledge of frailty screening, methods used to screen for frailty, and use of frailty screening in clinical decision making.
We conducted an online survey of emergency physicians working in six EDs in Ontario, Canada (University Health Network, Mount Sinai Hospital, North York General Hospital, Thunder Bay Regional Health Sciences Centre, Peterborough Regional Health Centre, and Cambridge Memorial Hospital). These sites were selected to include both academic and community hospitals, varying geography (urban, community, and northern communities), and represent diversity in a clinical setting. None of the sites had standardized frailty screening protocols. All sites had availability of geriatric emergency management nurses (GEM nurse), a province‐wide program of advanced practice nurses who conduct focused assessments of geriatric syndromes relating to the ED presentation, which may include frailty assessment, to support discharge planning. GEM nurse consultation is triggered by ED nurses or physicians. Frailty screening during GEM assessment is based on local hospital practices and is not standardized across the province. Ethics approval was obtained from the research ethics board at Sinai Health.
The initial survey was developed by geriatric emergency medicine specialists, emergency physicians, and researchers. Pilot testing was conducted with six emergency physicians from academic and community EDs to assess for comprehensibility and construct validity, with revisions made based on feedback. The final survey included two demographic questions (hospital site and years of experience) and seven study questions (see Table 1 for study questions). Respondents were asked to rate their familiarity with the syndrome of frailty, knowledge of frailty screening in the ED, and their perception of the importance of frailty screening in the ED on a 5‐point Likert scale. Respondents were also asked how frequently they screened for frailty in older patients and the methods they used to screen for frailty in the ED. Response options for the methods used to screen for frailty were based on researcher consensus and included the term “gestalt” to capture nonstandardized screening methods. Finally, physicians were asked how frailty informs their care of patients (i.e., further investigations, referrals, consult for admission) and what tools might be used to increase emergency physicians' knowledge of frailty.
TABLE 1.
Participant responses to frailty‐related survey questions, stratified by hospital type (academic vs. community).
| Total (N = 151) | Type of hospital | p‐value | |||||
|---|---|---|---|---|---|---|---|
| Academic (n = 86) | Community (n = 65) | ||||||
| Q1. How familiar are you with the syndrome of frailty in older patients in the ED? (e.g., very familiar would mean “I can define it, teach it to others, I know what tools to use to quantify it, and I include it in my assessment of older adults”) | |||||||
| Very unfamiliar | 1 | (0.7) | 1 | (1.2) | 0 | 0.48 | |
| Unfamiliar | 26 | (17.2) | 14 | (16.3) | 12 | (18.5) | |
| Neutral | 64 | (43.1) | 35 | (40.7) | 30 | (46.2) | |
| Familiar | 52 | (34.4) | 30 | (34.9) | 22 | (33.8) | |
| Very familiar | 7 | (4.6) | 6 | (7.0) | 1 | (1.5) | |
| Q2. Please rate your level of agreement with the following statement: “I know how to screen for frailty in older adults in the ED” | |||||||
| Strongly disagree | 3 | (2.0) | 2 | (2.3) | 1 | (1.5) | 0.16 |
| Disagree | 42 | (27.8) | 27 | (31.4) | 15 | (23.1) | |
| Neither agree nor disagree | 54 | (35.8) | 25 | (29.1) | 29 | (44.6) | |
| Agree | 48 | (31.8) | 28 | (32.6) | 20 | (30.8) | |
| Strongly agree | 4 | (2.7) | 4 | (4.7) | 0 | ||
| Q3. Please rate your level of agreement with the following statement: “Frailty screening is important to the management of older adults in the ED” | |||||||
| Strongly disagree | 0 | 0 | 0 | 0.76 | |||
| Disagree | 0 | 0 | 0 | ||||
| Neither agree nor disagree | 13 | (7.6) | 7 | (8.1) | 6 | (9.2) | |
| Agree | 89 | (58.9) | 49 | (57.0) | 40 | (61.5) | |
| Strongly agree | 49 | (32.5) | 30 | (34.9) | 19 | (29.2) | |
| Q4. How frequently do you screen for frailty in older patients whom you are caring for in the ED? | |||||||
| Never (0% of the time) | 12 | (8.0) | 8 | (9.3) | 4 | (6.2) | 0.69 |
| Rarely (<25% of the time) | 32 | (21.2) | 21 | (24.4) | 11 | (16.9) | |
| Sometimes (25%–49% of the time) | 40 | (26.5) | 22 | (25.6) | 18 | (27.7) | |
| Often (50%–75% of the time) | 53 | (35.1) | 27 | (31.4) | 26 | (40.0) | |
| Always (>75% of the time) | 13 | (8.6) | 7 | (8.1) | 6 | (9.2) | |
| Q5. What method(s) do you use to screen for frailty in older patients? (select all that apply) | |||||||
| CFS | 14 | (9.3) | 9 | (10.5) | 5 | (7.7) | 0.56 |
| ISAR | 3 | (2.0) | 2 | (2.3) | 1 | (1.5) | 0.73 |
| GEM nurse Specialist | 95 | (62.9) | 49 | (57.0) | 46 | (70.8) | 0.08 |
| Gestalt | 115 | (76.2) | 63 | (73.3) | 52 | (80.0) | 0.34 |
| PRISMA‐7 | 0 | 0 | 0 | — | |||
| Other | 16 | (10.6) | 6 | (7.0) | 2 | (3.1) | 0.29 |
| None | 8 | (5.3) | 12 | (14.0) | 4 | (6.2) | 0.12 |
| Q6. How do you use frailty to inform the care of your older patients? (select all that apply) | |||||||
| Workup/investigation | 88 | (58.3) | 46 | (53.5) | 42 | (64.6) | 0.17 |
| Referral to GEM nurse | 136 | (90.1) | 73 | (84.9) | 63 | (96.9) | 0.01 |
| Arrange outpatient follow‐up | 103 | (68.2) | 60 | (69.8) | 43 | (66.2) | 0.64 |
| Consult for admission | 106 | (70.2) | 62 | (72.1) | 44 | (67.7) | 0.56 |
| Home or CC referral | 118 | (78.2) | 65 | (75.6) | 53 | (81.5) | 0.38 |
| Pharmacist med review | 35 | (23.2) | 20 | (23.3) | 15 | (23.1) | 0.97 |
| Other | 8 | (5.3) | 5 | (5.8) | 3 | (4.6) | 0.74 |
| None | 5 | (3.3) | 5 | (5.8) | 0 | 0.05 | |
| Q7. What tools would be most helpful in increasing your ability to screen for frailty? (select all that apply) | |||||||
| Education modules | 86 | (57.0) | 53 | (61.6) | 33 | (50.8) | 0.18 |
| Facilitated workshops | 51 | (33.8) | 25 | (29.1) | 26 | (40.0) | 0.16 |
| Simulation | 24 | (15.9) | 17 | (19.8) | 7 | (10.8) | 0.13 |
| Interprofessional teaching | 63 | (41.7) | 39 | (45.3) | 24 | (36.9) | 0.3 |
| Reading list | 28 | (18.5) | 16 | (18.6) | 12 | (18.5) | 0.98 |
| FOAMed resources | 78 | (51.7) | 46 | (53.5) | 32 | (49.2) | 0.6 |
| Other | 13 | (18.6) | 4 | (4.7) | 9 | (13.8) | 0.05 |
Note: Data are reported as n (%).
Abbreviations: CC, community care; CFS, Clinical Frailty Scale; FOAMed, free open‐access medicine; GEM, geriatric emergency medicine; ISAR, Identification of Seniors at Risk.
The survey was electronically distributed to participating EDs between February and March 2024. A link to the survey housed on a secure web‐based survey software (Qualtrics) was sent by email to a representative at each site and was then distributed locally to all emergency physicians at that site. Two subsequent reminder emails were sent. All surveys were completed anonymously. No incentives were provided to complete the survey. Descriptive statistics with frequencies and proportions were used to analyze responses. Chi‐square tests were used to examine differences between academic and community sites. Spearman's correlations were used to assess associations between frequency of frailty screening with self‐reported familiarity of frailty tools and self‐perceived importance of frailty screening. We also compared frailty screening methods between respondents with high knowledge of frailty screening (Q2—agree, strongly agree) to those with a low knowledge (Q2—disagree, strongly disagree, and neutral). Data analysis was completed using SAS (9.3).
Table 1 summarizes the responses of the study questions by type of hospital (academic vs. community). There was a 59.5% response rate (151/253), with 57.0% of respondents practicing in an academic hospital and 50.3% with more than 10 years of ED experience. The majority (91.4%) of respondents agreed or strongly agreed that frailty screening is important in the ED; however, 61.0% reported being unfamiliar or very unfamiliar or having a neutral level of familiarity with the syndrome of frailty, and 65.6% reported a low or neutral level of knowledge about screening for frailty in the ED. There were no significant differences in responses between physicians working in academic or community EDs. With regard to frailty screening in the ED, 44.3% reported they screened for frailty more than 50% of the time. Frequency of frailty screening had a small positive correlation with increased familiarity of the syndrome of frailty (Spearman's correlation 0.27, p < 0.001) and an increased perceived importance of frailty screening (Spearman's correlation 0.32, p < 0.001).
“Gestalt” was the most common method of screening for frailty (76.2%). Consultation of a GEM nurse specialist was the second most common frailty screening method. Among the three validated screening tools specified in the survey, CFS was the most used (9.3%). Use of CFS was higher among respondents that reported a high level of knowledge for frailty screening (21.2%) compared to those who reported low knowledge (3.0%). Gestalt and GEM nurse consultation remained the most common frailty screening methods among respondents with high and low levels of reported knowledge of frailty screening. Summary of free‐text responses revealed testing gait (walk test) was also used as a frailty screening method.
Patient frailty (as recognized by respondents) was used to inform decisions on GEM nurse consultation (90.1%), referral to home and community care services (78.2%), hospital admission (70.2%), and outpatient follow‐up (68.2%). Respondents stated educational modules (57.0%), free open‐access medical education (FOAMed) resources (51.7%), and interprofessional teaching (41.7%) would improve knowledge of frailty screening in the ED.
To our knowledge, this is the largest survey of emergency physicians that describes frailty screening by physicians in the ED. The common use of gestalt or clinical judgment to screen for frailty is similar to the results of a survey of emergency nurses by Moloney et al. 8 Gestalt, widely defined among clinicians as an experience‐based “gut feel” or intuition about a clinical finding or situation, 9 is noted to poorly correlate with criterion standard CGA assessments of frailty in older adults. 10 Many of our survey respondents reported low levels of knowledge about the frailty syndrome, making the high use of gestalt as a screening method concerning. Low levels of frailty knowledge may also help explain our survey result of a surprisingly high rate of frailty screening. Contextualized with the low knowledge of frailty syndrome and frequent use of gestalt among respondents in our survey, respondent screening of frailty may represent identification of “weak and delicate” patients as opposed to the frailty syndrome.
A preference for frailty screening to be completed by nurses has been previously reported 8 and is reflected in our study, as GEM nurse consultation was the second most common frailty screening method. This may be interpreted in two ways—emergency physicians use ED geriatric services to enhance their own frailty assessments or emergency physicians defer frailty screening to other care providers. The latter approach risks not recognizing and addressing frailty in older adults for whom geriatric services referral is not initiated during ED visit. There is no singular intervention to address frailty and thus an interdisciplinary approach is typically recommended. 4 This appears to be recognized by emergency physicians, as respondents in our survey used frailty to inform specialist consultations and referral for home/community supports.
Our study has several limitations. This survey relied on self‐reported data, which are inherently subject to response biases such as overestimation of skill. Since participation was voluntary, it is subject to nonresponse bias where those who did not participate in the survey may differ in their perceived importance or familiarity with frailty. We aimed to minimize nonresponse bias by sending reminders and creating a short, user‐friendly survey that took <2 min to complete. Characteristics of physicians who did not respond were not collected, so we were unable to determine how respondents and nonrespondents differed. Our results may not be generalizable to other ED settings such as those without GEM nurse programs. We did not ask physicians to describe the information used when screening with gestalt and cannot compare it with established clinical definitions of frailty.
Overall, our study found most emergency physicians use gestalt or clinical judgment to screen for frailty and infrequently use validated frailty screening tools. Frailty screening was recognized as being important in the ED, but most respondents reported a neutral to low level of knowledge of the syndrome of frailty and available tools. This gap between perceived value and knowledge suggests a role for education on frailty screening tools and exploration of their utility in the ED.
AUTHOR CONTRIBUTIONS
Priyank Bhatnagar was involved in all parts of study process including study design, data acquisition, manuscript drafting and revisions. Shelley McLeod, Keerat Grewal, and Don Melady supported study concept and design. Don Melady, Keerat Grewal, and Alice Gray supported acquisition of study data. Cameron Thompson and Keerat Grewal supported data analysis and interpretation. All authors supported critical revisions of the manuscript.
CONFLICT OF INTEREST STATEMENT
The authors have no conflicts of interest to disclose.
Bhatnagar P, Melady D, Thompson C, McLeod S, Gray A, Grewal K. Understanding frailty screening of older adults in the emergency department: A survey of emergency physicians in Ontario. Acad Emerg Med. 2026;33:e70016. doi: 10.1111/acem.70016
Supervising Editor: Ula Hwang
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.