Transcript Inter-Face Geriatrics and Frailty

FRAIL ELDERLY PATHWAY AND
FRAILTY IN THE ELDERLY
Dr. M. Ganeshananthan
Problem
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Increasing numbers of frail older people are
attending the Emergency Department
Frail older people have the highest ‘conversion rate’
High risk of adverse events
Long stays
High readmission rates
High rates of long term care
Solutions
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Generic interventions
 Better
access to health care systems
 Better communication
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Specific pathways for frail older people
 Based
on comprehensive geriatric assessment
 Outlined national policy documents
Frail Elderly Pathway
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Aim Integrated
pathway for frail elderly patients
 Incorporating acute hospital care, community care social
care and old age psychiatry
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Objectives
 Enhance
health of frail older people
 Reduce unnecessary emergency admissions
 Reduce the need for long term institutional care
Frail Elderly Pathway
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Maintaining independence
Choosing to admit (Enhanced rapid assessment in
ED/MAU and in the community)
Discharging to assess(Supported early discharge
for complex frail elderly patients)
Frail Elderly Pathway
The pathway is delivered by:
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Two geriatricians
IDT/OPAL
ICT in the community
Part time community psychiatrist
Day assessment centre at Milford
Rapid Response clinic
Frail Elderly Pathway
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How do we deliver this service in the acute setting?
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Comprehensive Geriatric Assessment (CGA)
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What is GCA?
CGA
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‘Multidimensional, interdisciplinary diagnostic
process to determine the medical, psychological,
and functional capabilities of a frail older person in
order to develop a coordinated and integrated
plan for treatment and long-term follow-up
CGA
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‘Multidimensional, interdisciplinary diagnostic
process to determine the medical, psychological,
and functional capabilities of a frail older person in
order to develop a coordinated and integrated
plan for treatment and long-term follow-up
CGA- Evidence
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Improves outcomes of older people in various
settings
Reduced mortality or deterioration
Improved cognition
Improved quality of life
Reduced length of stay
Reduced readmission rates
Reduced rates of long term care use
Reduced costs
CGA
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The main domains of CGA
 Medical
 Mental
health
 Functional capacity
 Social circumstances
 Environment
Frailty
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The condition of being weak and delicate: the
increasing frailty of old age
(weakness in character or morals: all drama begins
with human frailty)
Who is frail?
Frailty
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Syndrome which results from a multisystem reduction
in reserve capacity to the extent that a number of
physiological systems are close to or past the
threshold of symptomatic failure
Increased risk of disability or death from minor
external stresses
Frailty
Frailty
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Small insult results in a striking and disproportionate
change in health state
 Independent
to dependent
 Mobile to immobile
 Postural stability to proneness to falling
 Lucid to delirious
Frailty
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Distinct syndrome
Growing old is not in itself a prerequisite to
becoming frail
A disability does not lead to frailty in a robust
older person
Clinical presentations
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Non-specific
 Extreme
fatigue
 Unexplained weight loss
 Frequent infections
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Falls
 Due
to gait and balance impairment
 Hot fall
Clinical presentations
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Delirium
 Due
to reduced integrity of the brain function
 Independently associated with adverse outcome
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Fluctuating disability
 Day-to-day
instability
Pathophysiology
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Normal ageing
 Gradual
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decrease in physiological reserve
Frailty
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Accelerated
Homoeostatic mechanisms start to fail
Pathophysiology
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Cumulative decline in several physiological systems
Determined by genetic and environmental factors
Loss of physiological reserve of the brain, endocrine
system, immune system and skeletal muscle
Nutritional status
Pathophysiology
Frail Brain
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Associated with increased risk of developing
delirium and reduced survival
Associated
 Increased
cognitive impairment
 Faster rate of cognitive decline
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Independent association with dementia
Frail immune system
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Reduced stem cells
Blunting of antibody response
Reduced phagocytosis
Impaired antibody response to vaccines
Frail Immune system
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Inflammation has a major role in the
pathophysiology of frailty
 Abnormal
low-grade inflammatory response
 Hyper-responsive to stimuli
 Persists for a long period
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Inflammation leads to anorexia and catabolism
Sarcopaenia
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Frail skeletal muscle
Progressive loss of muscle mass, strength and power
Reduction in functional ability
Frailty Models
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Phenotype model
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Cumulative deficit model
Phenotype model
Phenotype model
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Detection of frailty in routine care
Difficult to translate to clinical practice
Those with cognitive impairment not included
Increased adverse outcome
Cumulative deficit model-Frailty
Index
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CSHA
92 baseline variables (health deficits)
Presence or absence of each variable as a
proportion of the total
Defined as cumulative effect of individual deficits
Clinically attractive- frailty is gradable
Strongly related to the risk of death and
institutionalisation
Prevalence
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Systematic review
Frail
9.9%
Pre-frail 42%
F>M
Steadily increased with age
 65-69
 >85
4%
26%
Outcomes
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Most frail worst outcomes
Frail more frail
Higher risk of:
 Worsening
disability
 Falls
 Admission
to hospital
 Death
 Admission
to long term care
Association between frailty,
disability and comorbidity
Assessments to identify frailty
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CGA
CGA when linked to interventions has superior
outcomes
Gold standard to assess frailty
Edmonton Frailty scale
CSHA scale
Interventions
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Inpatient CGA
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More likely to return home
Less likely to have cognitive or functional decline
Lower in-hospital mortality
Community CGA
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Continuing to live at home
Interventions
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Exercise
 Effect
sizes are small/moderate
 Intensity uncertain
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Nutritional interventions
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Scarce evidence
Interventions
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Drugs
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ACEI
Testosterone
Vitamin D
Conclusion
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Frailty is a state of vulnerability to poor resolution
of homeostasis
Cumulative decline in many physiological systems
during a life time
Minor stressor events trigger a disproportionate
changes in health status
Landmark studies have been used to develop valid
models of frailty
Association of frailty and adverse health outcomes
Conclusion
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Care is organised around single organ disease
Frailty is a practical unifying notion
Strongly associated with adverse outcome
Moving away from age to using frailty
Best evidence is for comprehensive geriatric
assessment