Transcript SAFE Clinic: Successful Aging & Frailty Evaluation

SAFE Clinic
Successful Aging & Frailty Evaluation
University of Chicago – Geriatrics and Palliative Medicine
Internal Medicine Resident Rotation
Katherine Thompson, MD & Patricia Rush, MD
Objectives: SAFE Clinic
• Define frailty and identify frail patients
• Practice and interpret:
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cognitive assessment
• functional assessment
• Appreciate importance of interdisciplinary care
for frail patients
• Appreciate relevance of geriatric assessment to your
future practice
Case Study
Mrs. Thomas (82 y/o woman) comes to Clinic with her son.
Son is concerned that Mrs. Thomas is not doing well.
On exam, patient is pleasant, quiet, cooperative.
BP 154/70, HR 70 regular, RR 16. Weight 154 lb.
Exam is generally unremarkable. HEENT, Cardiac, Lungs, Abdomen
all negative. Has 1+ edema over ankles. Has good sitting balance,
but uses arms to arise from chair and stumbles on her way to the
exam table.
Labs: CBC, BMP, TSH from 3 months ago were basically normal.
Hgb 11.2. GFR 50.
WHAT ELSE DO WE NEED TO KNOW?
Case Study
BACKGROUND:
• Mrs. Thomas is a widow. Husband died 6 yr ago
• Mrs. Thomas lives alone. Sons brings her groceries once a week.
Pt administers her own medication.
• Son feels mother is depressed - does not attend family events.
• Son states patient is slow to answer phone when he calls and
seems sort of confused. Last week, she thought he was his father
(deceased 6 yr ago)
• Son suspects mother has fallen because he sees bruises.
Mrs. Thomas denies she has fallen
• Review of chart shows patient has lost 7 lb in past 2 years.
WHAT IS GOING ON ??
Definition of Frailty
• Diminished capacity to withstand stress
• Progressive
• At risk - adverse health outcomes,
increased mortality
• Associated with chronic disease
• Worsens with advancing age
• Marked by a transition from
independence to dependence
on caregivers
Measurement of Frailty
• Clinical features: ≥ 3 meets Criteria for Frailty
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Weakness
Weight loss
Poor energy
Low physical activity
Slowness
• At risk for adverse outcomes
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Falls
New or worsened ADL impairment
Hospitalization
Death
Syndrome of Frailty
• Other associated features
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Cognitive impairment
Balance/motor impairment
Depression, anxiety, loneliness
Poor quality sleep
Low self-rated health
Inadequate social support
Biologic Basis of Frailty
• Dysregulation across more than one of these
physiological systems is associated with greater
risk of frailty
• Despite growing understanding of biology,
diagnosis of frailty remains clinical
Biologic Basis of Frailty
• Loss of skeletal muscle
• Decreases in estrogen, testosterone, growth
hormone, and insulin-like growth factor 1
• Increases in interleukin 6, C-reactive protein,
tissue plasminogen activator, and D-dimer
• No diagnostic laboratory test is available
Under-recognition of Frailty
by Clinicians
• Frailty does not fit into classic organ-specific
models of disease.
• Subtle decline may not be evident to clinicians,
family members, or patients
• Declines in strength, endurance, and nutrition
may not cause patients to seek medical attention
and may hinder their doing so
Why should I care?
• Frail patients are internal medicine
patients (increasing numbers
every year)
• Ability to identify frailty will affect
your medical decision-making and
treatments regardless of specialty
– from chemotherapy to cardiac
catheterization to colon cancer screening
• Inability to identify frailty will result in bad outcomes
for you and your patients
Frailty Assessment as a Prognostic Tool:
Survival by Frailty Stratification
How does Frailty compare
with CoMorbidity and Disability?
CoMorbidity = presence of 2 or more
significant chronic illnesses
Disability = inability to perform 1 or more
Activities of Daily Living (ADL)
Ambulating, Toileting, Showering, Dressing, Eating
Frailty: distinct entity
Fried, LP et al. Journal of Gerontology, 56A: M146-156, 2001
Clinical Application of Frailty Assessment
Preoperative Surgical Risk
Makary, Martin, et.al. Frailty as a Predictor of Surgical Outcomes in Older Patients,
J Am Coll Surg 2010; 210:901–908
• Standard indications for medical or
surgical interventions might not be
generalizable to older patients because
physiologic changes from aging can
alter the risk-to-benefit analysis.
• Goal: reduce postoperative
complications in older patients
• Postoperative complications in patients
aged 80 and older increase
30-day mortality by 26%
Johns Hopkins Dept of Surgery – 2010
Frailty as Risk for Surgical Outcomes
Makary, Martin, et.al. Frailty as a Predictor of Surgical Outcomes in Older Patients,
J Am Coll Surg 2010; 210:901–908
STUDY DESIGN:
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Prospectively measured Frailty in 594 patients (age 65 years or older)
presenting to a university hospital for elective major surgery
between July 2005 and July 2006.
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Frailty was classified using a validated scale (0 to 5) – Fried’s Criteria
- weakness, weight loss, exhaustion, low physical activity, and slowed
walking speed.
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Main outcomes measures:
30-day surgical complications
Length of stay
Discharge disposition.
RESULTS: Frailty and Surgical Outcomes
• Preoperative frailty was associated with an increased risk for
postoperative complications
– Intermediately frail: odds ratio [OR] 2.06
– Frail: OR 2.54;
• Increased length of stay
– Intermediately frail: incidence rate ratio 1.49
– Frail: incidence rate ratio 1.69
• Discharge to a skilled or assisted-living after living at home
– Intermediately frail: OR 3.16
– Frail: OR 20.48
• Frailty improved predictive power (p 0.01) of each risk index
(American Society of Anesthesiologists, Lee, and Eagle scores).
SAFE Clinic
Successful Aging & Frailty Evaluation
University of Chicago – Geriatrics and Palliative Medicine
Research – Patient Care
SAFE Clinic Assessment
Research
• Informed consent obtained
• Demographics (age, race,
education, income, living
situation, height, weight, BMI)
• EPIC data (problem list, meds)
• MD Progress note (acute issues,
sensory impairment,
assist devices-cane or wheelchair,
recent hospitalizations, other pertinent)
SAFE – Initial Assessment
• Vulnerable Elder Survey
(VES-13) Self-rated health
& functional status
• Comorbidities
(Charlson comorbidity index)
• Falls (AGS falls questions)
• Sleep (Pittsburgh Sleep Index)
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Depression (PHQ-2)
Pain (Pain map & pain thermometer)
Stress
Caregiver strain
SAFE – Initial Assessment
• Cognition (MOCA +/- MMSE)
• Physical function (Short
physical performance battery)
1) Stands (side-by-side,
semi-tandem, tandem,
hold for 10 seconds)
2) Chair stands (5 stands from chair,
without using arms)
3) Measured walks (2 timed 4-meter walks,
take faster time, goal = less than 8.7 sec)
Frailty
(Fried’s Frailty Criteria)
≥ 3 meets Frailty Criteria
• Weakness
– Low grip strength
– Standardized using a dynamometer
• Weight loss
– > 5% weight loss, or 10 lbs in 1 year
– “In the last year, did you lose 10 lbs or more,
not on purpose?”
• Slowed gait speed
– Time to walk 15 feet at usual pace
– Slow = ≥ 6 or 7 sec. depending on gender, height
Frailty
(Fried’s Frailty Criteria)
≥ 3 meets Frailty Criteria
• Fatigue/low energy
– “How often in the last week did you feel that everything you did
was an effort?”
and
“How often would you say you could not get going?”
– Significant response = “moderately often” or more on ≥ 3 days in
the last week
• Low physical activity
– Calculated Kcal expenditure based on standardized instrument
(Minnesota leisure time activities questionnaire)
SAFE Clinic: Patient Care
• Identify patients:
Not Frail
Pre-frail or intermediate, or
Frail
• Provide individualized education, resources
• Management strategies:
– Improve core manifestations of frailty: physical
activity, strength, exercise tolerance, nutrition
– Exclude modifiable precipitating factors
– Minimize consequences of vulnerability
Patient Care: Return Visit
• Interdisciplinary team
– Assessment
– Care planning
• Patient follow up
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Results of assessment
Recommendations provided to patient & PCP
Patient education materials and resources
Consult letter dictated with recommendations
• Anticipate follow up visits q6-12 months for
tracking
SAFE: Patient Recommendations
Vigorous - Not Frail:
Focus on:
• exercise
• social support
• vision/hearing screen
• preventive evaluations
• tight control of medical
conditions such as HTN, DM
• smoking cessation
SAFE: Patient Recommendations
Pre-frail – OPPORTUNITY
• Emphasize exercise or PT
for strength and balance,
fall prevention.
• Nutrition assessment
• Driving - home safety eval
• Social support
• Watch for depression and
cognitive changes
• Regular medical followup;
smoking cessation.
SAFE: Patient Recommendations
Frail: Fragile – Handle with Care
Focus:
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Hospitalization avoidance
Fall prevention
Review benefits/burdens of treatments
Advance Care Planning
Medication management
- minimize # of meds # doses
• Anticipate caregiver stress
SAFE Clinic Team Members:
• FACULTY:
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Patricia Rush, MD MBA
Katherine Thompson, MD
William Dale, MD PhD
Joseph Shega, MD
• Geri Fellow:
• Adv Practice Nurse:
• Social Work:
Megan Huisingh-Scheetz, MD
Lisa Mailliard, Geri Specialist
– Patricia MacClarence, LCSW
– Jeffrey Solotoroff, LCSW