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Mini-CHAMP Improving Hospital Systems of Care: Making the Case for Identifying and Assessing the Frail Elderly

Mini-CHAMP Improving Hospital Systems of Care: Making the Case for Identifying and Assessing the Frail Elderly. Paula Podrazik, MD University of Chicago. New Admission. Mrs.G 80 y/o BF DM type II, htn, s/p CVA, OA, OP admitted for wt. loss, confusion, falls. Recently

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Mini-CHAMP Improving Hospital Systems of Care: Making the Case for Identifying and Assessing the Frail Elderly

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  1. Mini-CHAMPImproving Hospital Systems of Care:Making the Case for Identifying and Assessing the Frail Elderly Paula Podrazik, MD University of Chicago

  2. New Admission Mrs.G 80 y/o BF DM type II, htn, s/p CVA, OA, OP admitted for wt. loss, confusion, falls. Recently hospitalized at an outside institution. Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax q week Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84 RR 16 Lungs clear, Cor RRR, Neuro non-focal ER evaluation—unremarkable blood work, CT head— no bleed Intern reports patient is at baseline per daughter and comments patient is just a “FTT.”

  3. Questions raised: • How do you recognize frailty ? • How do you define frailty? • What is the importance of identifying frailty in the hospital setting? • What do you need to screen in the suspected frail patient during hospitalization? • Can you prevent hospitalization-associated decline?

  4. Overview: Inpatient Setting Important for the Elderly • Crucial step in the health care continuum • High rates of hospitalization • Account for 47% of all inpatient days (but represent only 13% of the population) • Age 85 and over, twice hospitalization risk • High rates of readmission • 25% of hospital admissions represent readmission of older adults • Cost—outcomes Fethke CC, Smith IM, Johnson N. Risk factors affecting readmission to the health care system. Medical Care. 1986;24:429-437 Graves EJ, Gillum BS. National Hospital Discharge Survey: annual summary, 1994. Vital Health Stat. 1997;13:128

  5. Worse Outcomes for Hospitalized Older Adults Delirium Iatrogenic Complications—3-5x > rate Functional decline—effects 35% of hosp. elderly Nursing home placement Caregiver stress Mortality

  6. Determinates of Hospitalization Outcome Baseline Frailty Hospitalization Outcome Acute illness Hazards of the Hospitalization

  7. Words that trigger the need to ID & teach about frailty Failure to thrive Dwindles Declining A/O x 1 or 2 Confused Poor historian Malodorous Recent discharge Unkempt Nursing home Weight loss Age 75 or over Non-compliant Needs assistance/ has caregiver Falls

  8. New Admission—Triggers to TeachID/discuss frailty Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OP admitted for wt. loss, confusion, falls. Recently hospitalized at an outside institution. Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax q week Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84 RR 16 Lungs clear, Cor RRR, Neuro non-focal Intern reports patient is at baseline per daughter and comments patient is just a “FTT.”

  9. Geriatricians ID frailty features At least 50% of Geriatricians cited each of the following characteristics associated w/frailty • Under nutrition • Functional dependence • Prolonged bedrest • Pressure sores • Generalized weakness • Aged >90 • Wt loss • Anorexia • Fear of falling • Dementia • Hip fracture • Delirium • Confusion • Going outdoors infrequently • Polypharmacy Fried LP, Walston J. Principles of Geriatric Medicine & Gerontology 5th ed. 2003:1487-1502.

  10. What happens to reserves w/aging?

  11. Functional Reserve of Older Adults • Vision loss: 27% those over age 85 • Cognitive impairment: 50% over age 85 • Assistance w/ADL: > 50% over age 85 • Functional reserve losses impact on an acute illness: • Presentation • Treatment • Morbidity & Survival • Recovery

  12. What is frailty? • Definition must include: • Association with aging • Multi-system impairment • Instability • Change over time • Allowance for heterogeneity within the population • Association with an increased risk of adverse outcomes • Can include co-morbidities • Can include a disability Rockwood K, et al. Drugs & Aging 2000 Oct 17(4):295-302 Fried LP, et al. J Gerontol Med Sci.2001 56A;M146-M156

  13. ACOVE–a model to ID/define the at risk Vulnerable Elder • Assessing the Care of the Vulnerable Elder: ACOVE Project Overview • Develop a definition of “vulnerable elders”—community dwellers, >65 & at high risk of functional decline or death • Develop system to ID • ID medical conditions for which effective methods of prevention& management exist • Develop set of Quality Indicators Wenger NS, Shekelle PG, et al. Ann Int Med 2001;135(8) Supplement:642-646

  14. Frailty Suspected:Why screen? • Impact on Outcomes • Prevention

  15. Risk of rehospitalization—one outcomes look at frailty • Age over 80 • Inadequate social support • Multiple active chronic health problems • History of depression • Moderate-severe functional impairment • Multiple hospitalizations past 6 months • Hospitalization past 30 days • Fair or poor health self rating • History of non-adherence to medical regimen Naylor M, Brooten D, Campbell, et al. JAMA. 1999;17:613-620

  16. Hospital Elder Life Program:A program of prevention • Yale hospital system, ≥ age 70, admitted to acute care hospital • Screened for cognitive impairment, sleep deprivation, immobility, dehydration, vision or hearing impairment • Targeted interventions • Outcomes • Decrease in functional decline (14%vs. 33%) • Decrease in cognitive decline (8%vs. 26%) Inouye S, et al JAGS 2000; 48:1697-1706

  17. Triggers to Recognize & Screen for Frailty • Advanced age (>70, > 75, > 80???) • Suspected functional impairments • Suspected cognitive impairment • Consider if /and • Multiple co-morbidities • Psychosocial issues • Sensory impairments

  18. What to screen? • Cognition • Function • Affect • Other • Sensory • Social

  19. What to prevent? • Delirium—Inouye model • Deconditioning—out of bed, PT/OT • Falls • Pressure ulcers • Adverse drug reactions—med review • Comprehensive discharge planning—recognize need @ admission

  20. DEVELOPMENT COHORT N=107 RR 1.  Vision 3.5(1.2-10.7) 2. Severe Illness 3.5(1.5-8.2) 3.  Cognition 2.8(1.2-6.7) 4. BUN/Cr > 182.0 (1.1-4.6) ROC = 0.74 (0.63, 0.85) VALIDATION COHORTN=174 RR Low Risk (0) 1.0 Int. Risk (1-2) 2.5 High Risk (3-4) 9.2 ROC = 0.66 (0.55-0.77) (SEE Pocket Card) Predicting Delirium:PreDisposing Risk Factors • NOTE: COG. IMPAIRMENT (MMSE < 24); VISION IMPAIRMENT > 20/70; BUN/CR > 18/1; SEVERE ILLNESS= APACHE II > 16 OR CHARLSON ORDINAL CLINICAL = RATED AS SEVERE • ROC= 0.74 (0.63-0.85) Inouye SK , et al. Ann Intern Med. 1993;119:474-481

  21. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Adult Patients. NEJM. 1999. • Design: Prospective, Matched, 852 patients, Medicine Service • Inclusion: Age > 70, Not delirious at admit, Intermed. or High Risk • Intervention --Focused on 6 risk factors for delirium: Cognitive Impairment, Sleep Deprivation, Immobility, Visual impairment, Hearing impairment, Dehydration • 1o End Point = Incident Delirium  Assessed daily until discharge Inouye SK, et al. NEJM. 1999;340:669-676

  22. Targeted Interventions Cognitive Impairment Sleep Deprivation Immobility Orientation/ Activities Early Mobilization Non-drug; sleep enhancement

  23. Targeted Interventions Visual Impairment Hearing Impairment Dehydration Visual Aids, Devices Hearing devices, Remove earwax Early recognition & po repletion

  24. Prevention Protocols Inouye SK, et al. NEJM. 1999;340:669-676 SEE CHALK

  25. Management: Non-Pharmacologic • Cognition: orientation board (carry pen!) & open drapes during day • Sleep: minimize deprivation (no 2am labs, no o/n BS/vitals if able, give meds when awake) • Mobility: OOBchair asap, PT/OT, no foley/restraints • Vision: glasses • HOH: get aids; adapt environment; stethoscope trick • Dehydration: po fluids; observe at mealtime; avoid “Boost at nightstand” • Observation: Involve family (rotate members) or get sitter; move pt to room close to RN station

  26. Results • USUAL CARE = 15.0% • PREVENTION GROUP = 9.9% • OR 0.60 (CI 0.39- 0.92) • RRR= 40% ARR= 5.1% • NNT = 20 • NO BENEFIT ONCE DELIRIUM OCCURED Inouye SK, et al. NEJM. 1999;340:669-676.

  27. New Admission—Triggers to recognize & docognitive screening Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OP admitted for wt. loss, confusion, falls. Recently hospitalized at an outside institution. Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax q week Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84 RR 16 Lungs clear, Cor RRR, Neuro non-focal Intern reports patient is at baseline per daughter and comments patient is just a “FTT.”

  28. How common is dementia? • Age strongest risk factor for dementia • At age 65, prevalence 8-12% • At age 85, prevalence 50% • Persons with dementia in US- 4 million • Projected number by 2040- 14 million • 25% of older hospitalized adults admitted to medicine have impaired cognition

  29. Dementia and Delirium • MMSE <24/30→ Delirium risk 2.82(1.19-6.65) • Delirium associated with worse outcomes • Orientation board and cognitive stimulation decreased confusion 8% vs. 26%. * Confusion = loss of 2 points on MMSE Inouye SK, et al Ann Intern Med 1992;119:474-481

  30. Screening Cognitive Impairment • Patient measure: • Mini Mental Status Exam (MMSE) • Mini-cog • Proxy measure

  31. Folstein MMSE • 30 point screening test • Screens multiple cognitive domains • Not a direct screen of executive function • Studies usually use cut off 24 for positive • Reliability of results dependent on age & education Folstein M, Folstein S, McHugh P. J Psychiatr Res. 1975;12:189-198

  32. Troubleshooting the MMSE • Validation done under rigorous technique • Serial 7’s vs. spelling WORLD backwards • 8th grade education or < → WORLD • >8th grade education→ serial 7’s • Administer in quiet, non-threatening environment • Correct sensory deficits as much as possible

  33. Reminders about MMSE • Screening test for cognitive impairment • Can help to risk stratify— delirium, functional decline, iatrogenic injury, pressure ulcers • Useful as a baseline to monitor change • Not a determination of decision-making capacity

  34. Screening Tools: Mini-cog • Step 1:Remember & repeat three unrelated words • Step 2: Clock-drawing test (CDT)—distracter • Step 3: Repeat 3 previously presented words • Step 4: Scoring:1 pnt. for each recalled word • Score=0; + screen for dementia • Score=1-2 with abnl CDT; + screen for dementia • Score=1-2 with nl CDT; neg. screen for dementia • Score=3; neg. screen for dementia Borson S, et al. Int J Geriatr Psychiatry2000;15:1021-1027

  35. Screening Tests for Cognition:Summary Teaching Points • Mini-cog—quick bedside tool • MMSE—screening tool only • If patient screens positive: • Use orientation board • Early mobilization • Discharge plan—unique D/C needs • Screen for functional, sensory impairments

  36. New Admission—Triggers to recognize & dophysical function screening Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OP admitted for wt. loss, confusion, falls. Recently hospitalized at an outside institution. Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax q week Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84 RR 16 Lungs clear, Cor RRR, Neuro non-focal Intern reports patient is at baseline per daughter and comments patient is just a “FTT.”

  37. Functional impairment and age

  38. ID patients at significant risk for functional decline while hospitalized Independent Risk Factors 1) Pressure ulcer? 2) Baseline cognitive deficits? 3) Baseline functional impairments? 4) Baseline low social activity level? Score risk for functional decline: no =8%risk; yes to 1-2 questions =28% risk; yes to > 2 questions=63% risk Inouye SK, et al.J Gen Intern Med1993;8(12):645-52.

  39. Functional decline occurs in the hospital • Functional limitations increase with age. • Functional decline occurs in approx. 34-50% hospitalized older pts. • Higher mortality—twice the risk • Higher rates of institutionalization • Prolonged hospital stay • Interventions can decrease functional decline (Hospital Elder Life Program). • Functional status determines D/C plan.

  40. How does one assess functional status? Report Self-report Proxy report Direct observation Level of support Independent Needs assistance Dependent

  41. Activities of Daily Living Bathing Dressing Transference Continence Feeding

  42. Instrumental Activities of Daily Living Using the phone Traveling Shopping Preparing meals Housework Taking medicine Managing money

  43. Gait-timed get up and go • Quantitative evaluation of general functional mobility • Timed command w/rise from chair; walk 10 feet; turn around; walk back and sit in chair. Wall JC, Bell C, Campbell S, et al J Rehabil Res Dev 200 37(1):109-113

  44. Gait assessment scoring • Usual time to completion 10 seconds • Frail elder usually < 20 seconds • > 20 seconds needs PT evaluation • Performance on test associated with: ADL/IADL performance Falls risk Risk of nursing home placement

  45. Trigger to Recognize & Teach:Who to screen for functional impairment? Who to screen? • Patients @ advanced age (>70, >75, >80 ???) • Patient who is re-admitted in past month • Person with at least 1 risk factor • Cognitive impairment • Functional impairment • Pressure ulcer • Low social activity score

  46. Screen for function, cont. When to screen? • Review ADLs/IADLs prior to hospitalization • After stabilization of acute illness • Prior to hospital discharge What to do? • Chart orders- walking and range of motion TID • Ambulation problem- physical therapy • Dressing/bathing/feeding- occupational therapy

  47. Frailty & the Hospital: A Final Word • Frail elders occupy approx. 25% medicine beds. • Frail elders @ high risk for worse outcomes. • Screen for cognition, functional status, psychosocial, sensory impairments. • Screen based on advanced age (>70) & suspected functional impairments. • Take measures to prevent delirium, falls and functional decline. • Recognizing frailty begs for a comprehensive D/C plan and Med Review.

  48. Mini-CHAMP: Geriatrics Topics • Theme #1: Identification of the Frail /Vulnerable Elder • • Identify and assess the vulnerable hospitalized older patient • • Dementia in hospitalized older medical patients: Recognizing and screening for dementia, • assessing medical decision making capacity, implications for the treatment of non-dementia • illness, pain assessment, improving the post-hospitalization transition of care • Theme #2: Recognize and Avoid Hazards of Hospitalization • • Delirium: Diagnosis, treatment, risk stratification and prevention • • Falls: Assessment and prevention • • Foley Catheters: Scope of the problem, appropriate indications and management • • Deconditioning: Scope of the problem, prevention • • Adverse Drug Reactions and Medication Errors: Principles of drug review • • Pressure Ulcers: Assessment, treatment and prevention • • Depression: Assessment and treatment • Theme #3: Palliate and Address End-of-Life Issues • • Pain Control: General principles and use of opiates • • Symptom Management in Advanced Disease: Nausea • • Difficult Conversations and Advanced Directives • • Hospice and Palliative Care and Changing Goals of Care • Theme #4: Improve Transitions of Care • • The Ideal Hospital Discharge: Core components and determining destination • • Destinations of Post-Hospital Care: Nursing homes for skilled rehabilitation and long-term care

  49. Mini-CHAMP: Teaching on Today’s Wards Analyzing the process of teaching • Goal setting • Process mapping tool • Barriers to teaching & topic selection • Individual & team dynamic • Emphasis on teaching ACGME competencies of communication & professionalism Systems-Based Practice • Intro. to QI on the wards Practice-Based Learning and Improvement • Case audit • Census audit

  50. How to teach on the wards? • Teach at bedside • Trigger to teach • Summary teaching points • Teaching Aides • Website materials • Tools—D/C work sheet, delirium/opiate conversion cards • Methods—audits, mapping

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