PREVENTION AND MANAGEMENT OF FRAILTY. Christopher Patterson John Feightner for the Canadian Initiative on frailty and Aging 2006

Transcription

1 PREVENTION AND MANAGEMENT OF FRAILTY Christopher Patterson John Feightner for the Canadian Initiative on frailty and Aging 2006

2 Prevention & management Avoidance of definition of frailty SER of RCTs addressing non disabled seniors with outcomes of consequences SER of RCTs addressing seniors with established disabilities, same outcomes SER of exercise in community dwelling seniors Brief mention of medications Research questions

3 Healthy population Frailty Increased disability Institutionalization Acute hospital Mortality

4 Prevention and Management Systematic evidence review RCTs only; age over 60 years; community dwelling; excluded studies which targeted specific diseases 2,200 abstracts; 82 quality assessments; 28 ineligible; 5 poor quality; 27 prevention studies 18 management studies 4 systematic reviews

5 Prevention: Can interventions aimed at an older population who are not disabled prevent the consequences of frailty?

6 Prevention: Can interventions aimed at an older population who are not disabled prevent the consequences of frailty? Primary care or community sample

7 Prevention: Can interventions aimed at an older population who are not disabled prevent the consequences of frailty? Primary care or community sample Absence of disability, some risk factors

8 Prevention: Can interventions aimed at an older population who are not disabled prevent the consequences of frailty? Primary care or community sample Absence of disability, some risk factors Various interventions; home visits, CGA, PT, OT

9 Prevention: Can interventions aimed at an older population who are not disabled prevent the consequences of frailty? Primary care or community sample Absence of disability, some risk factors Various interventions: home visits, CGA, PT, OT Outcomes: function, admission to LTC, hospitalization, death

10 Prevention studies 8/27 improved function (e.g. ADL, IADL, PPT) 1/27 lower risk of institutionalization (annual home CGA for 3 years) 4/27 reduced hospital admission 4/27 statistically significant reduction in mortality (all of longer duration months; ¾ multiple home visits)

11 All studies: prevention Study Population Intervention Duration MortalityFunction Hospitalisation LTC 1002 Community based 60+; examined by MD & OT OT with follow up 9 NR NS NR NR 913 Population based 75+; screened with postal questionnaire RN comprehensive assessment; follow up 12 NS NS NR NS 1018 Primary care, US veterans, 70+ CGA by RN or PA; review with Geriatrician; telephone FU 12 NS ^ NS NS 1403 Community; retirees from Bank of America Questionnaire and computer generated suggestions; Some FU 12 NR NR NR NR 1016 HMO enrollees, 65+ Visit to RN educator, follow up addresses risk factors 12 NR ^ NR NR 1709 Primary care CGA team; short term follow up 12 NS NS NS NS 1702 Primary care, 75+ Multidimensional home visit by RN 12 NS NS NR NS 918 Primary care RN home visit reports to FMD; follow up 14 NS NS NR NS 914 Population based 70+; screened with postal questionnaire SW home visitx2; clinic visits with CNS &MD; FU 15 NS ^ NS NS 1710 Primary care, US veterans, 65+ Geriaric Medicine team clinic ; follow up 18 NS ^* NS NR 1024 Primary care, 75+ Single home visit, multidimensional assessment by RN 18 NS NS NR NR Tulloch Primary care, 65+ Home visit by RN, special visit to FMD for assessment 20 NS NS NS NS 1720 Medicare beneficiaries, 65+ MD led preventive assessment, labs, counseling; short term FU 24 v NR NR NR 1010 Primary care 70+ Annual home visit by health visitor 24 v NS NR NR 1722 Primary care, 65+ Single comprehensive functional & social assessment 24?? NS NS 1023 Primary care, living alone,75+ Home visits and folow up by lay worker 24 NS NS NR NR 1020 Population based, 75+ Quarterly home visits, non clinical 24 v NR v NS 1012 Population based, Quarterly home visits by RN 36 NS NS NS NS 1022 Primary care 75+ Stratified by questionnaire,regular visits by volunteers 36 NS NS more in treated more in treated 1021 Primary care, 65+ Postal questionnaire, health visitor makes home visits and FU 36 v NR NS NS 1397 Primary care, 65+ MD special visit for preventive health manoevres 36 NS NR NS NS 151 Population (voter registry mostly) 75+ NP performs annual CGA 36 NS ^ NS v 917 Population based, 75+ Annual visit by RN 36 NS ^ NS NS Sorensen Community, random;75+ Single home visit by SW 36 NS NS NS NS 1721 Primary care, 70+ Home visits by health visitor; follow up 36 NS NR NR NR 1434 Community based 60+; examined by MD &OT OT with follow up 48 NR NS NR NR

12 Management Can interventions aimed at those who are already frail (with functional limitations) prevent the consequences of frailty?

13 Management Can interventions aimed at those who are already frail (with functional limitations) prevent the consequences of frailty? Primary care or community sample

14 Management Can interventions aimed at those who are already frail (with functional limitations) prevent the consequences of frailty? Primary care or community sample Various interventions

15 Management Can interventions aimed at those who are already frail (with functional limitations) prevent the consequences of frailty? Primary care or community sample Various interventions Same outcomes

16 Management studies 6/18 improved function (ADL, IADL, MOS- PF10, GAS) 2/18 reduced admission to LTC 3/18 reduced acute care admissions 1/18 reduced mortality

17 All studies:management Study Population Intervention Duration MortalityFunctionHospitalisation LTC Comments 1432 Frail Adult Day Care 3 NS NS NS NS 1715 Frail Nutritional supplement 4 NR NS NS NS 1718 Frail Home care team; follow up 6 NS NS NS NS Lower hospital and LTC admission: NSS 1438 Frail Geriatric team plan; follow up 8 v NS NS NS 98 Frail Case mgr reports to specialist:follow up 10 NR NS NS NR 157 Frail Geriatric team; follow up 12 NR ^ v NS 358 Frail Physiotherapy; follow up 12 NS ^ NR NS 432 Frail Specialized team; no follow up 12 NS ^ NR NS 910 Frail Case mgr reports to team:follow up 12 NR ^ v NR 927 Frail Geriatric nurse practitioner added to FMD 12 NR ^ v NR 1000 Frail Group education; follow up 12 NR NS NS NS 1353 Frail Geriatric team clinic; follow up 12 NS NS NS NS 1717 Frail Geriatric team clinic; follow up 12 NS NS NS 1076 Frail CGA by team; follow up 15 NS ^ NR NR v restricted activity days; MOS physical function improved 1084 Frail CGA by team; follow up 16 NS NS NS NS 1085 Frail OT home visit: assistive technology 18 NR ^ v* v* *Dollar costs 2037 Frail RN visits, std management; follow up 36 NS NR NR v Deaths + LTC=v SS 1 of 17 7 of 17 4 of 17 2 of 17

18 Stuck A, Egger M, Hammer A et al. JAMA 2002;287: Study Population Number of trials Stuck 2002 Home visits to over 65s 18 Function Hospital LTC Mortality Living in community All patients.94 (.83,1.06) NR.91 (.76,1.09).91 (.81,1.01) NR Ages NR NR NR.76 (.65,.88) NR Multi dimensional assessment and follow up.76 (.64,91) NR NR NR NR More than 9 home visits NR NR.66 (.48,.92) NR NR

19 Elkan R, Kendrick D, Dewey et al. BMJ 2001;323:1-9 Study Population Number of trials Function Hospital LTC Mortality Living in community Elkan 2001 Home visits to over 65s 15 General elderly NSS NR.65 (.46,.91).76 (.64,.89) NR Frail elderly NSS NR.55 (.35,.88).72 (.54,.97) NR

20 Ploeg J, Feightner J, Hutchison B, Patterson C. Canadian Family Physician 2005;51:1244 Study Populatio n Number of trials Function Hospital LTC Mortality Living in community Ploeg 2005 Primary care outreach 19 NR NSS NS.83 (.75,.91) 1.23 (1.06,1.43)

21 Prevention: exercise For older (>60 years) community dwelling adults, who are not enrolled in or eligible for cardiac, pulmonary or rheumatologic rehabilitation programs, does enrollment in an exercise program ( of endurance, strengthening or both combined) result in diminished impairment or disability, or improved function?

22 Prevention: exercise Systematic evidence review of RCTs prepared for the CTFPHC 2005

23 Prevention: exercise Systematic evidence review of RCTs prepared for the CTFPHC 2005 Community dwelling participants over age 60

24 Prevention: exercise Systematic evidence review of RCTs prepared for the CTFPHC 2005 Community dwelling participants over age 60 True control group

25 Prevention: exercise Systematic evidence review of RCTs prepared for the CTFPHC 2005 Community dwelling participants over age 60 True control group At least 8 weeks of exercise

26 Prevention: exercise Systematic evidence review of RCTs prepared for the CTFPHC 2005 Community dwelling participants over age 60 True control group At least 8 weeks of exercise Intervention available to FMD

27 Prevention: exercise Systematic evidence review of RCTs prepared for the CTFPHC 2005 Community dwelling participants over age 60 True control group At least 8 weeks of exercise Intervention available to FMD Nagi disablement model for outcomes (impairments, functions, disabilities)

28 Prevention: exercise 3574 abstracts; 289 papers assessed for eligibility; 73 quality assessments; 32 poor; 41 good or fair 22 strengthening studies 10 endurance studies 7 combined strengthening and endurance

29 Exercise: results Impairment outcomes: e.g. strength 5/6 knee extensor (strengthening) 1/7 grip (endurance) Function outcomes: e.g. treadmill endurance 0/3 (endurance); 1/3 (strengthening); ½ (combined) Disability outcomes: e.g. physical function/ activity ¼ (endurance); 0/7 (strengthening); 0/4 (combined)

30 Medications* and frailty Epidemiological association ACE inhibitors: slower decline in muscle strength (WHAS) *Non-systematic brief review of EB references

31 Medications* and frailty Epidemiological association ACE inhibitors: slower decline in muscle strength (WHAS) Therapeutic RCTs Vitamin D (calciferol 300 ku, plus 10 wks exercise) NEG [RR injuries 3.6 (1.5,8.0)]

32 Medications* and frailty Epidemiological association ACE inhibitors: slower decline in muscle strength (WHAS) Therapeutic RCTs Vitamin D (calciferol 300 ku, plus 10 wks exercise) NEG [RR injuries 3.6 (1.5,8.0)] r-hgh (0.02 mg/kg/day plus 10 wks strengthening) NEG

33 Medications* and frailty Epidemiological association ACE inhibitors: slower decline in muscle strength (WHAS) Therapeutic RCTs Vitamin D (calciferol 300 ku, plus 10 wks exercise) NEG [RR injuries 3.6 (1.5,8.0)] r-hgh (0.02 mg/kg/day plus 10 wks strengthening) NEG Testosterone (undecanoate 80mg bid x 12 mths) increased muscle mass, NO INCREASE IN STRENGTH

34 Medications* and frailty Epidemiological association ACE inhibitors: slower decline in muscle strength (WHAS) Therapeutic RCTs Vitamin D (calciferol 300 ku, plus 10 wks exercise) NEG [RR injuries 3.6 (1.5,8.0)] r-hgh (0.02 mg/kg/day plus 10 wks strengthening) NEG Testosterone (undecanoate 80mg bid x 12 mths) increased muscle mass, NO INCREASE IN STRENGTH r-hcg (250 mcg sq 2 x weekly for 3 mths) increased muscle mass, NO INCREASE IN STRENGTH *Non-systematic brief review of EB references

35 Strengths and weaknesses of systematic reviews Choice of included studies is critical (completeness of search, relevance filter, eligibility criteria,quality assessment) In general, more rigorous studies show less impressive results Data extraction important Different conclusions from same set of studies BUT SERs are the most objective means of assessing evidence

36 Summary: For community dwelling older people with and without established functional deficits, various interventions, especially home visits, are associated with improved distal outcomes (e.g. mortality, LTC admission)

37 Summary: For community dwelling older people with and without established functional deficits, various interventions, especially home visits, are associated with improved distal outcomes (e.g. mortality, LTC admission) In primary care populations, exercise (especially progressive resistance +/- endurance) improves some impairment, but few functional or disability outcomes. Some of these (outcomes) are considered components of frailty.

38 Summary: For community dwelling older people with and without established functional deficits, various interventions, especially home visits, are associated with improved distal outcomes (e.g. mortality, LTC admission) In primary care populations, exercise (especially progressive resistance +/- endurance) improves some impairment, but few functional or disability outcomes. Some of these (outcomes) are considered components of frailty. Several drugs show promise for increasing muscle mass, but neither strength nor function.

39 Comment: Other factors that are associated with frailty (e.g. social engagement, mood, apathy, falls, delirium) and interventions to address these factors, were not reviewed. Issues of health care and social support were not adequately addresses, but are likely very important. Integrating ongoing health care and social support services (e.g.sipa) benefit vulnerable, disadvantaged elders. A pilot study (LIFE) targeting healthy people with frailty risk factors has been completed.

40 Future Directions Identify frail individuals with short, accurate (high sensitivity/specificity for adverse outcomes) tools suitable for use in primary care

41 Future Directions Identify frail individuals with short, accurate (high sensitivity/specificity for adverse outcomes) tools suitable for use in primary care Large RCTs of combinations of interventions (e.g. in screen positives: home visits; exercise; anabolic medications; cognitive behavioural techniques; caregiver support, social engagement, environmental adaptation) for screen positive individuals

42 Future Directions Identify frail individuals with short, accurate (high sensitivity/specificity for adverse outcomes) tools suitable for use in primary care Large RCTs of combinations of interventions (e.g. in screen positives: home visits; exercise; anabolic medications; cognitive behavioural techniques; caregiver support, social engagement, environmental adaptation) for screen positive individuals Large RCTs of sufficient duration (12mths) to determine optimal type and quantity of exercise to delay adverse outcomes (function & disability) in the mildly frail

43 Future Directions Identify frail individuals with short, accurate (high sensitivity/specificity for adverse outcomes) tools suitable for use in primary care Large RCTs of combinations of interventions (e.g. in screen positives: home visits; exercise; anabolic medications; cognitive behavioural techniques; caregiver support, social engagement, environmental adaptation) for screen positive individuals Large RCTs of sufficient duration (12mths) to determine optimal type and quantity of exercise to delay adverse outcomes without increasing injuries Consider broader outcome measures e.g. restricted activity days, time to end point, QOL, social engagement, incidence of delirium

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