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Paula Podrazik, MD University of Chicago

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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Paula Podrazik, MD University of Chicago

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  1. 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. Iatrogenic Problems—a subset of Hazards of Hospitalization Affects nearly 1 in 3 hospitalized elderly patients Adverse drug reactions are the most common form • Other complications of hospitalization: • Deconditioning • Delirium • Falls • Nosocomial Infection • Pressure ulcers • Malnutrition • Dysphagia→Aspiration Pneumonia • Polypharmacy

  6. Atypical Presentations, Multiple Causes • Functional decline, altered mental status e.g., delirium or falls due to UTI or fecal impaction • Misleading symptoms e.g., pneumonia with normal or low temperature & normal or low WBC count • Signs of one disease obscured by another e.g., Pneumonia obscured by CHF ● Inability to communicate e.g., new pressure ulcer obscured in patient post –CVA w/ aphasia or with dementia ● No presentation symptoms e.g., silent MI , painless acute abdomen

  7. Determinates of Hospitalization Outcome Baseline Frailty Hospitalization Outcome Acute illness Hazards of the Hospitalization Podrazik PM, Whelan CT. Med Clin N Am 2008

  8. 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

  9. 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.”

  10. 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.

  11. Compression of Morbidity A Public Health Blueprint for Healthy Aging. Linda P Fried MD MPH

  12. Describe the Aging Population • Heterogeneous Population • Factors that contribute to heterogeneity • Aging physiology • Collected co-morbid conditions • Functional status • Life style/environmental factors • Genetics

  13. What happens to reserves w/aging?

  14. 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

  15. 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

  16. ACOVE - A model to ID/define the at riskVulnerable Elder • Assessing the Care of the Vulnerable Elder: ACOVE Project Overview • Developed a definition of “vulnerable elders”—community dwellers, >65 & at high risk of functional decline or death using a retrospective look at Medicare data • Developed a screen to ID frail elders→the VES 13: • includes age, self-perceived health, aspects of functional status. • if screen “frail” on the VES 13 then anticipate an increased risk of morbidity & mortality • Developed set of Quality Indicators Wenger NS, Shekelle PG, et al. Ann Int Med 2001;135(8) Supplement:642-646

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

  18. 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

  19. Frailty suspected…What about prevention of hazards of hospitalization? Prevention • Delirium—Inouye model—orientation & cognitive exercises, early mobilization, prevent dehydration, hearing aides/glasses • Deconditioning—out of bed, PT/OT • Falls—bed alarms, pads • Pressure ulcers—nutrition, frequent repositioning, special mattresses • Adverse drug reactions—med review for best drug choices • Comprehensive discharge planning—recognize need @ admission w/ social work involvement Models of improved care for frail elders: HELP (Hospital Elder Life Program), GEM (Geriatric Evaluation and Management) unit, ACE ( Acute Care of the Elderly)unit models

  20. 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 delirium rate in intervention group • Decrease in functional decline (14%vs. 33%) • Decrease in cognitive decline (8%vs. 26%) Inouye S, et al JAGS 2000; 48:1697-1706 Inouye SK, et al. NEJM. 1999;340:669-676 Inouye SK , et al. Ann Intern Med. 1993;119:474-481

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

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

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

  24. 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) VALIDATION COHORTN=174 RR Low Risk (0) 1.0 Int. Risk (1-2) 2.5 High Risk (3-4) 9.2 Predicting Delirium:Predisposing Risk Factors • Cognitive Impairment (MMSE < 24); Vision Impairment > 20/70; BUN/CR > 18/1; Severe Illness= APACHE II > 16 OR CHARLSON ORDINAL CLINICAL = RATED AS SEVERE Inouye SK , et al. Ann Intern Med. 1993;119:474-481

  25. 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 • Severe acute illness

  26. What to screen? • Cognition • Function • Affect • Sensory • Social

  27. Comprehensive Geriatric Assessment Functional Ability Physical assessment Cognitive assessment Psychological assessment Social/environmental assessment

  28. New Admission—Triggers to recognize & screen for cognition 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.”

  29. New Admission—Triggers to recognize & screen for physical function 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.”

  30. 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.

  31. 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.

  32. The Hospital CGA? –a comprehensive assessment of functional status ● Screen ADLs(Activities of Daily Living) & IADLs(Instrumental Activities of Daily Living). ● Evaluate physical mobility ● Evaluate for sensory impairments—hearing & sight ● Screen for dementia ● Screen for depression ● Screen for environment/social factors

  33. Functional impairment and age as measured by ADLs

  34. Activities of Daily Living Bathing Dressing Transference Continence Feeding

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

  36. 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

  37. Gait assessment scoring to assess physical mobility • 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

  38. 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

  39. Screening for Functional Status in the Hospitalized Elderly When to screen? • Review ADLs/IADLs prior to the patient’s hospitalization • Determine new set of ADLs/IADLs after stabilization of acute illness • Readdress patient’s ADLs and IADLs prior to hospital discharge What to do? • Chart orders- walking and range of motion TID • Ambulation problem- physical therapy • Dressing/bathing/feeding- occupational therapy • Discharge planning early in hospitalization w/social work intervention

  40. 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

  41. 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

  42. Cognitive Assessment Screen with 3 item recall in 1 minute Mini-Cog Folstein Mini-Mental State Examination (MMSE) Clock-drawing test Montreal Cognitive Assessement St. Louis University Mental Status Exam

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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

  48. Depression and functional status Hospitalized elderly with higher depression scores had worse outcomes Dependent 1 ADL 3.23(1.76-5.95) Dependent >/= 3 IADL 2.67 (1.33-3.56) Not satisfied with life 3.05(1.06-8.75) Fair to poor health 3.11(1.65-5.87) *Similar results 30 and 90 days Covinsky K, Fortinsky R, Palmer R. Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Ann of Int Med. 1997;126:417-425.

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