Synopsis
Recognise acute disease when frailty blunts classic symptoms, separate reversible illness from baseline vulnerability, and provide proportionate emergency treatment, comprehensive geriatric assessment and rehabilitation that prevents avoidable dependency.
- Frailty is vulnerability to stress, not a diagnosis explaining acute deterioration; new confusion or mobility loss should trigger a medical assessment.
- First-line assessment combines ABCDE, glucose, NEWS2, pain and injury review with collateral about cognition, mobility, ADLs, intake and medicines before illness.
- Classic symptoms may be absent: pneumonia can present as delirium, myocardial infarction as weakness, and urinary retention as agitation.
- Use 4AT for possible delirium and investigate hypoxia, infection, pain, retention, constipation, dehydration, medicines and environmental triggers.
- Reconcile time-critical treatment, anticoagulants, insulin, opioids, anticholinergics and renally cleared medicines immediately after arrival.
- Investigations follow the syndrome and red flags; indiscriminate testing does not replace examination, trend review and diagnostic ownership.
- Begin comprehensive geriatric assessment early, covering medical disease, function, cognition, mood, nutrition, continence, sensory needs, medicines, carers and goals.
- Prevent deconditioning from the first safe day through normal clothing, chair meals, toilet walking, repeated mobilisation and prompt removal of unnecessary tethers.
- Discuss escalation and resuscitation proportionately using the acute diagnosis, likely reversibility, baseline, values and treatment burden rather than age alone.
- A safe transition names owners for pending results, medicine changes, rehabilitation, equipment, nutrition and early community follow-up.
Key red flags
New oxygen requirement, respiratory distress, hypotension, mottling, reduced urine or altered consciousness requires emergency physiological support.
Sudden focal deficit, new inability to stand, speech change or persistent ataxia requires acute stroke assessment.
Fall with head impact, anticoagulation, focal bony pain or inability to weight bear requires urgent injury imaging.
Acute abdominal pain, distension, vomiting, gastrointestinal bleeding or peritonism requires surgical and resuscitation assessment.
Abrupt delirium, missed time-critical medicines, hypoglycaemia, retention or faecal loading requires rapid reversible-cause treatment.
Unexplained injury, neglect, carer conflict or absence of essential food, heating or medicines raises a safeguarding concern.
Symptoms follow missed time-critical treatment, new sedation, hypoglycaemia, hypotension or impaired clearance.
Hypoxia, hypotension, reduced urine, mottling or reduced consciousness requires immediate emergency treatment.
Investigation priorities
Identify physiological danger before atypical symptoms mislead.
Management branches
Frailty is accompanied by new cognitive, physiological or functional deterioration.
- Use ABCDE, glucose, NEWS2 and focused injury, neurological, chest, abdominal, bladder and bowel assessment.
- Obtain collateral and reconcile medicines while treating time-critical disease and correcting immediate precipitants.
- Start CGA, delirium prevention and function-preserving care in parallel rather than waiting for diagnostic completion.