Frailty Care Guides

1. Frailty Care Guides 4 July 2018 DrMchal Boyd Associate Professor and Nurse Practitioner Te Arai Palliative Care and End of Life Research Group

2. Place of Death in New Zealand Total Deaths, 2000-2015 The proportion of all deaths that occur in residential care has increased from 27.6% in 2000 to 36.0% in 2015. The proportion of deaths in public hospitals and other settings have declined sharply, with little change in private residence and hospice IPU. Data Source: Ministry of Health MORT data 2000-2015, extracted March 2018

3. Primary Diagnosis at Death

4. Residential Aged Care Length of Stay

5. Expected/Unexpected Deaths: % by primary diagnosis

6. Physical symptoms the last MONTH of life

7. It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change. Adaptation of Charles Darwin’s theory ‘Origin of Species’

9. Rockwood: Clinical Frailty Score

10. Rockwood: Clinical Frailty Score (cont)

11. Frailty is defined as 3 or 5 Components (Fried 2001): • unintentional weight Loss • slow walking speed • self-reported exhaustion • low energy expenditure • weakness Fried: Frailty Risk Factors Age 25 Age 63 Sarcopenia Espinoza and Fried, 2007, Clinical Geriatrics,15(6).

12. Frailty Risk Factors Medical Illness &/or Comorbidity A. Cardiovascular disease B. Diabetes C. Stroke D. Arthritis E. Chronic obstructive pulmonary disease F. Cognitive impairment/cerebral changes Physiologic A. Activated inflammation B. Immune system dysfunction C. Anaemia D. Endocrine system alteration E. Underweight or overweight F. Age Sociodemographic and Psychological A. Female gender B. Low socioeconomic status C. Race/ethnicity D. Depression Disability A. Activity of daily living disability Espinoza and Fried, 2007, Clinical Geriatrics,15(6).

13. SPICT TOOL Hospitalised Older People: Positive 48% one year mortality, negative 11% one year mortality

14. SPICT Tool

15. Worse discrimination for those with non-cancer diagnosis • Cancer: AUC 0.83 • Non-cancer: AUC 0.77 • “The surprise questions performs poorly to modestly as predictive tool for death”

16. Frailty Care Guides Medicines Care Guides for Residential Aged Care • Care Planning emerged as a major issue • Frailty Care Guides • Update RN Care Guides • More general use across the settings: • ARC • Home Care • Hospice • Acute Care

17. Topics to be Updated • EPOA • Cardiac guidelines • Advanced care planning • Gastro intestinal constipation guidelines • Delirium • Dementia • Depression • Diabetes • End of life • Falls • Fracture & contracture • Nutrition & hydration • Pain • Respiratory guidelines • Skin • Syncope and collapse • Urinary incontinence • Urinary tract infections

18. New topics to be added • Defining frailty and recognising and intervening for acute and gradual deterioration • Post fall assessment care guide • Polypharmacy and deprescribing • Challenging behaviour and mental health issues • Family support and communication • Sexuality and intimacy

19. Delirium • The following investigations are almost always indicated in patient with acute confusion in order to identify the underlying causes: • Full blood count, CRP • Calcium • Electrolytes • Liver function tests • Glucose • Urinalysis/MSU • Thyroid function tests • If possible and/or in an acute care environment: • Chest x-ray • ECG • Blood cultures • Other investigations may be indicated according to the findings from the history and examination: • CT scan e.g. if focal neurological signs, confusion developing after head iunjury or fall, raised ICP • B12 and folate • Arterial blood gases (MSU sputum) • Lumbar puncture (if meningism or headache and fever) • Causes: • Delirium may result from: • Illness – co morbidities • Infection • Medication changes and polypharmacy • Substance use/withdrawal • Pain • Immobility • Hypoxia • Constipation/dehydrationurinary retention • Environment changes • Vulnerable brain e.g. underlying cognitive impairment/stroke/traumatic brain injury/seizures • Nearing end of life

20. Nursing management considerations will include ensuring Whanau/family and carers receive an explanation of delirium and are included in management strategies where possible. • Encourage families to bring in personal items and support with care as able • Provide a low stimulus, well lit environment • Complete ABC behaviour chart • Complete falls alarm/floor line, bed • Consider regular checks or constant observer • Manage modifiable risk factors • Mobilise, sit in chair for meals • Get up, get dressed, get moving • Monitor oral intake; aim fluid intake of > 1.2L/24 hours unless otherwise indicated • Monitor bowels • Monitor pain; consider Abbey pain scale • Monitor skin integrity • Reduce catheter/line use where possible • Consider medication interactions/review • Monitor vital signs • Consider non-pharmacological strategies including: • Reorientation – clocks, calendars, newspapers • Look at natural lighting • Avoid multiple transfers within facility • Distraction – consider fiddle mitts/mats/photos/music etc • Keep communications simple – one step instruction • Consider communication barriers e.g. level of comprehension/language • Maintain restoration of sleep-wake cycle patterns • Ensure visual/hearing aids are used where possible • Monitor behaviour, include what works well and what is a trigger for escalation • Ensure all needs are met, physical, psychological and social

21. Delirium Signs and symptoms • Delirium is a common clinical syndrome characterised by: • Acute onset, hours to days, fluctuating through the course of the day • Decreased ability to maintain or shift attention • Changes in cognition or perception • Altered levels of consciousness • There is frequently more than one aetiology. Not being able to find a cause for delirium does NOT change the diagnosis. The diagnosis is a clinical one. Signs include: • Decreased ability to maintain and shift attention • Disorganised thinking and speech • Impaired memory (registration and recall) • Illusions, hallucinations (usually visual) and delusions (often persecutory) • Increased or decreased activity • Disrupted sleep/wake cycle • Disorientation in time and/or place • Changes in mood • Fluctuation is common, typically worse at night While delirium is potentially reversible, undiagnosed or severe delirium, or delirium occurring in vulnerable people can often be prolonged, leading to permanent functional and cognitive decline. Delirium is distressing for patients, families and carers but with the right care many will make a full recovery.

22. Geri-Syndrome • Multi-factorial • Intimate association with functional impairment and decline • Increased association with mortality and morbidity

23. Geriatric Syndromes • Dementia • Delirium • Urinary Incontinence • Falls • Gait disturbance • Dizziness • Syncope • Hearing impairment • Visual impairment • Osteopenia • Malnutrition • Eating and feeding problems • Pressure ulcers • Sleep problems

24. Differential Diagnoses • Traditional • Geriatric Syndrome

25. Acute Deterioration STOP AND WATCH S: Seems different than usual T: Talks or communicates less O: Overall needs more help, P: Participated less in activities A: Ate less, difficulty swallowing medications N: No bowel motion >3 days; diarrhea D: Drank less W: Weight change A: Agitated or nervous more than usual T: Tired, weak, confused, or drowsy C: Change in skin color or condition H: More help walking, transferring,toileting

26. Acute Deterioration Assessment of for reversibility Step 2: Take observations:. Warning signs that indicate sepsis: Temperature > 37.7 (low temp <36?) New Heart rate >100 bpm New Systolic BP <100 mgHg (take in account baseline obs) Step 1: Review goals of care: for hospitalisation, antibiotics or for comfort cares only?  What does the resident/family want to happen now? If comfort care only see Palliative Care Guide (pg Xx). Check CPR status, If obs are 1-3 or met Do assessment for lower respiratory tract infection/Shortness of Breath (see respiratory CG) or urinary tract infection (see urinary CG) Use SBAR form and ring GP/NP to report Need CBC, CRP, Electrolytes, CRE

27. Acute Deterioration Assessment of for reversibility Step 3: Review hydration status Has the resident orally ingested <750 ml fluids in the last 24 hours? Monitor fluid loss from vomiting or diarrhea Fever? Worsens dehydration Step 5: Review pain status Step 4: Constipation or diarrhea?  Bowels not open for 3 days or watery bowels? Assess for pain location, type and severity. Review for pain intervention (see Pain CG) Review available laxatives and clear bowels (see Bowels CG) Start input and output chart Ensure input and output equal in 24 hours  Check CRE/eGFR/Electrolytes  Offer fluids orally every 1-2 hours to increase oral fluid intake to 1000-1500/24 hours (see hydration CG). Ring NP/GP if unable to take oral fluids, consider SC NS (500 ml/12 hrs) and review diuretics Step 6: Neuro changes, increased falls, functional change and/or confusion? Delirium screen and neuro exam needed (see CG XX). Neuro assessment: Pupils, extremity Power, face and body symmetry, weakness FINAL STEP Review again after assessment goals of care: for hospitalisation, antibiotics or for comfort cares only.  What does the resident/family want to happen now? If comfort care only see Palliative Care Guide

28. SEPSISSCREENINGTOOLS Sepsisscreeningtoolsshouldevaluatethreeareas • Knownorsuspectedinfection • Systemicmanifestationsofsepsisincluding: • Acutementalstatuschange • Hyperglycemia • Hyperthermiaorhypothermia • Leukocytosisorleukopenia • Tachycardia • Tachypnea • Indicationsofneworworsenedorgandysfunctionincluding: • Coagulopathy • Elevatedlactate,creatinine,orbilirubinlevel • Hypotension • Increasing oxygen requirements • Thrombocytopenia

29. Delirium Assessments

30. Cachexia versus Starvation Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics in Geriatric Medicine. 2002; 18: 883-891

31. First line treatment • Treat contributing factors e.g. constipation • Implement basic oral nutrition support: small nutrient dense frequent meals & snacks, assistance or prompting to eat, food charts • Weekly weight for 4 weeks • Reassess: if weight loss continues move to 2nd line treatment

32. Second line treatment • Continue weekly weighs • Contact GP (may request lab tests - thyroid function, full blood count, serum transferase, albumin) • SLT referral if appropriate • Dietitian referral • Increase energy & protein intake with nutritious fluids, smoothies, complan etc • Reassess:

33. Is the resident refusing to eat? • Is cessation of eating in keeping with overall deterioration in resident’s health status? • Exclude possibility of treatable condition e.g. infection that could affect cognitive ability & appetite • May still be appropriate to offer small amounts of food & fluids, even if person is dying — always defer to resident’s cues. • Assess personal preferences and whether the resident is enjoying their meals • Discuss care plan with the family/EPOA • Palliative approach (National Health and Research Council. Guidelines for a palliative approach in residential aged care; page 59 May 2006)

34. Thank You. Michal.boyd@auckland.ac.nz