The Elusive Frailty Formula: Shining the geriatric light on the 1-5% Dr John Puxty

Transcription

1 The Elusive Frailty Formula: Shining the geriatric light on the 1-5% Dr John Puxty

2 Health Care use is not uniform by Seniors

3 How common is Frailty? Approximately10% of all individuals 65 years or older in the community might be considered frail (Collard et al 2012) Some of the factors which increase likelihood of being frail include: increasing age: 4% of individuals years old 7% of year olds 26% of 85 years and older gender: women are twice as likely to be frail as men social vulnerability seems to increase risk presence of multiple chronic diseases (co-morbidites) (Andrew et al 2012) Majority of older adults categorized as ALC requiring LTC or in LTC are frail elderly! 3

4 Contributory factors to Frailty Vulnerability to adverse outcomes resulting from an interaction of : Physical Extreme age Weight loss Fatigue/Inactivity/Poor grip strength Slow gait Socio-economic Isolation Caregiver gaps Poverty: gender and immigration status Co-morbidity factors Impaired cognition/mood Polypharmacy especially sedative use Multiple chronic diseases 4

5 Targeting High-risk vulnerable frail elderly: High risk ER/acute care users Repeat attendance at ER/acute care in previous 90 days AUA 4-6 scores within ER within the last 90 days 5

6 6 Assessment Urgency Algorithm (AUA)

7 Merits of AUA as High-risk ER Screening Tool Ontario derived tool validated nationally and internationally Simple to apply taking usually only few minutes Linked to impaired self-reliance (issues with ambulation, bathing, dressing lower body and personal hygiene) which negatively impact on caregiver coping and/or affected individuals mood Predicts risk of 30 day ER re-attendance, 90 day readmission, increased LOS and ALC likelihood Reduced false positives relative TRST/ISAR Implicit link to CCAC InterRAI Assessment Form Paper and electronic format (PDA) versions are available 7

8 Targeting High-risk vulnerable frail elderly: High risk ER/acute care users Repeat attendance at ER/acute care in previous 90 days AUA 4-6 scores within ER within the last 90 days Presence of multiple chronic diseases 8

9 Health Care Visits by Seniors with Chronic Conditions (rate per 1000 seniors) Number of Chronic Disease more important than Age in determining health care visit numbers (Source CIHI Jan 2011)

10 Targeting High-risk vulnerable frail elderly: High risk ER/acute care users Repeat attendance at ER/acute care in previous 90 days AUA 4-6 scores within ER within the last 90 days Presence of multiple chronic diseases Clinical Frailty Scale (5-7) 10

11 The Clinical Frailty Scale

12 Targeting High-risk vulnerable frail elderly: High risk ER/acute care users Repeat attendance at ER/acute care in previous 90 days AUA 4-6 scores within ER within the last 90 days Presence of multiple chronic diseases Clinical Frailty Scale (5-7) Presence of Geriatric Syndromes (Falls, Confusion, Incontinence, Social Crisis) Frailty independently associated with falls and fractures in both older women and men (Ensrud KE et al J Am Geriatr Soc Mar;57(3):492-8) Pre-operative frailty predictive of post-operative delirium (Leung JM et al Anesth Analg 2011) 12

13 Recognition of Presence of Frailty is Important Because Presence impacts on outcomes during hospitalization Post-Surgery Independent marker for worse outcomes following surgery, including postoperative complications, mortality, length of stay and discharge to care facilities (Brown NA, and Zenilman ME: Adv Surg 2010, 44: ;. Makary MA, et al J Am Coll Surg 2010, 210: ; Robinson TN, et al: Ann Surg 2009, 250: ). Relationship between increased frailty and costs, not just at the time of hospitalization for surgery, but at six months post discharge (Robinson et al Am J Surg 2011, 202: ). 13

14 Recognition of Presence of Frailty is Important Because Presence impacts on outcomes during hospitalization Post-Surgery Cardiac disease Frailty and confers increased mortality risk from cardiovascular disease (Afilalo J, et al. Am J Cardiol 2009, 103: ). Pulignano and colleagues identified that moderately frail patients with heart failure benefited from a targeted intervention with improved clinical outcomes and improved healthcare costs (Pulignano G, J Cardiovasc Med 2010, 11: ). Singh and colleagues explicitly call for early identification of frailty amongst patients with cardiac disease to help tailor decision making, optimization of other co-morbidities and frame discussions about prognosis and goals of care with patients and their families (Singh M, et al Mayo Clin Proc 2008, 83: ). 14

15 Recognition of Presence of Frailty is Important Because Presence impacts on outcomes during hospitalization Post-Surgery Cardiac diagnoses It is predictive of long term outcomes including risk of future use of Institutionalization and mortality 15

16 Canadian Study of Aging & Health: Frailty in Canada 2,305 individuals 70 yrs or older were studied over 5 yrs 41.4% were felt to be well 15.2% were considered vulnerable with some evidence of slowing up in their normal activities 13.3 were mildly frail needing some help with IADL s such as finances, driving, managing medication or cooking were moderately or severely frail requiring help with ADL s such as bathing, dressing, toileting and walking Rockwood K, et al CMAJ 2005;173(5):489-95

17 Recognition of Presence of Frailty is Important Because It is predictive of long term outcomes including risk of future use of Institutionalization and mortality. Well Vulnerable Mild Frailty Moderate to severe Frailty 17

18 Recognition of Presence of Frailty is Important Because It is predictive of long term outcomes including risk of future use of Institutionalization and mortality. Well Vulnerable Mild Frailty Moderate to severe Frailty 18

19 Recognition of Presence of Frailty is Important Because Presence impacts on outcomes during hospitalization Post-Surgery Cardiac diagnoses It is predictive of long term outcomes including risk of future use of Institutionalization and mortality Outcomes are modifiable 19

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