Functional Decline in Community Dwelling Older Adults

Transcription

1 Functional Decline in Community Dwelling Older Adults An Update from the Frail Senior/Medically Complex Task Group Rehabilitative Care Alliance Dr. Jo-Anne Clarke Geriatrician North East Specialized Geriatric Services

2 Disclosure Faculty: Jo-Anne Clarke Relationships with commercial interests: No Grants/Research Support Speakers Bureau/Honoraria: Pfizer, less than $5000 in unrestricted educational grants/speakers fees in 2012 Merck, less than $5000 in unrestricted educational grants/speakers fees in 2014 Consulting Fees: None Other: None Disclosure of commercial support This program has not received any financial or in-kind support. Potential for conflict of interest: There is no conflict of interest

3 Courtesy Dr. S. Sinha, with permission

4 1) Steep Downward Slant Trajectory Health Wellness Heart Attack / Car Accident Few of us will die in this manner Illness Death Function Diagnosis Death Time Courtesy, Dr. J McElhaney

5 2) Gradual Slant Trajectory Health Wellness MS / ALS Illness Death Function Diagnosis Time Death Courtesy, Dr. J McElhaney

6 3) Peaks and Valleys Trajectory Health Wellness Chronic Heart and Lung Failure Function Illness Death Diagnosis Time Death Courtesy, Dr. J McElhaney

7 4) Gradual Descending Plateaus Trajectory Health Wellness Function Illness Death Diagnosis Time Frailty and Dementia Dwindling Over Time Death

8 Honest doc, if I d known I was going to live this long, I would have taken better care of myself

9 Chronic disease burden Rapoport et al, 1999; National Population Health Survey, Chronic Dis Canda 2004 Older persons accumulate chronic illness as they age Age Number of chronic conditions % 30% 14% 12% % 25% 25% 30% % 24% 22% 41% Heckman, With Permission

10 Disability Gilmour & Park, Suppl Health Reports, Stats Can Canadian Community Health Survey adults > 65, are women Age Basic ADL Instrumental ADL Men Women Men Women % 4% 9% 18% % 9% 21% 36% % 23% 46% 65% Heckman, With Permission

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12 Frailty A medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual s vulnerability for developing increased dependency and/or death 1 Is a result of deficit accumulation Is a predictor of poor outcomes Functional decline Falls Health service utilization Caregiver fatigue and stress Death Institutionalization Morley et al JAMDA 14 (2013)

13 Inouye, 2007 Frailty and Functional Decline are geriatric syndromes

14 HRS Study - Association btw disease, geriatric syndromes, and disability Condition Number of geriatric conditions Stroke Diabetes Heart disease Cancer RR of disability Ann Intern Med 2007;147: Heckman, With Permission

15 Geriatric syndromes As prevalent as chronic disease In the HRS, 50 % of people > 65 had 1 or more geriatric conditions Commonly co-occur with chronic disease more than 25% of older adults with chronic disease have at least one geriatric syndrome Strongly associated with functional decline and disability More likely than stroke to cause disaility Top 3 predictors of why cannot go home from hospital (mobility, incontinence, cognitive impairment) Incontinence Pressure ulcers Falls Frailty Delirium Cognitive impairment.

16 Frailty: Is a changeable state Frailty is dynamic, characterized by frequent transitions between frailty states over time However, transition to states of greater frailty (up to 43.3%) was more common than states of lesser frailty (23.0%). Gill et al. Arch Intern Med 2006;166:

17 Disability can occur insidiously Not physically frail Physical frailty was the only factor that was associated significantly with the development of insidious disability, Physically frail OR 2.1 (95%CI: 1.2 to 3.8) Gill. Am J Med. 2004;117:484

18 Disabled patients recover 80% recover But it can be short lasting Type of Disability Recovery 2 mo Recovery 6 mo Any 79% 57% Persistent 64% 40% Even with chronic disability (> 3months) > 60% recovered Chronic 57% 33% Hardy et al JAMA 2004

19 Hospitalizations and illnesses leading to restricted activity are important sources of disability Factors associated to development of disability Factor COPD 1.09 Depression 1.32 Cognitive impairment 1.23 CHF 1.66 Stroke 1.66 Frailty 2.09 New Intervening event Hospitalization 59.8 Restricted activity 5.11 Hazard Ratio Most common reason for disability post hospitalization was cardiac, but: Injurious falls most POTENT, conferring the highest risk of disability 79.4% of admissions for a fallrelated injury led to any disability, 45.2% to persistent disability, 58.8% to disability with nursing home admission. Gill T et al JAMA 2004, JAMA 2010

20 Risk factors for functional decline community dwelling (Stuck 1999 soc sci med.) Risk Factors Syndrome Intervention Cognitive impairment Depression High Disease burden High and low BMI LE functional limitation Low frequency of social contacts Low level of physical activity Polypharmacy Poor self perceived health Smoking Vision impairment FUNCTIONAL DECLINE Modify reversible factors Asses and treat Co-manage Healthy diet, exercise Exercise and physio Social engagement Exercise and physio Medication review? Smoking cessation Assess and treat

21 Risk factors for functional decline community dwelling (Stuck 1999 soc sci Risk Factors Syndrome Intervention Cognitive impairment Depression High Disease burden High and low BMI LE functional limitation Low frequency of social contacts Low level of physical activity Polypharmacy Poor self perceived health Smoking Vision impairment med.) FUNCTIONAL DECLINE Modify reversible factors Asses and treat Co-manage Healthy diet, exercise Exercise and physio Social engagement Exercise and physio Medication review? Smoking cessation Assess and treat

22 Interventions work to reduce functional decline in frail older adults Exercise works in the frail 1-2, even in LTC 3, in the cognitively impaired 4-5 and in those with geriatric syndromes 6 to reduce functional decline and falls Home OT with exercise improves function and reduced mortality 7 Medication Review improves function, reduces falls and mortality 8-9 Comprehensive Geriatric Assessment Leads to better prescribing, better function, improved cognition, less institutionalization, less hospitalization, lower mortality Gill NEJM 2002;347: Pahor J Gerontol A biol Sci Med Sci 2006: Fiaterone N Engl J Med 1994; Vreugdenhil Scand J Caring Sci ;26:12 5. Pitkala. JAMA Intern Med. 2013;173: Kim, Arch Gerontol Geriatr :99 7. Gitlin et al. JAGS 2009;57: Garfinkel et al Isr Med Assoc2007;9:430-4, 9. Hill et al. Drugs Aging 2012;29: Stuck, Lancet NZHTA Report 2004, 12. Schmader Am J Med Beswick Lancet 2008, 14. Challis 2004.

23 Comprehensive assessment An individualized approach to Risk Factor Modification Medication Review Optimize Communication (vision, hearing) Dehydration/Orthostatic BP Mood Cognition Function Balance Gait Aids, Environmental modification Formal and informal supports Interdisciplinary With timely access and open communication with home care /community support services

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25 Heterogeneity is the new normal This population is by definition complex, and heterogeneous One approach will not fit all older adults Cannot use a simple tool, simple model No guideline exists for the management of complexity Approach with most likelihood of success tends to be multi-dimentional / mutli-disciplinary/ multiorganizational in approach Mantra of geriatrics it depends Dementia -- is it a predictor of poor outcome for rehab?

26 Predicting restorative potential is complicated Patterns of Functional Decline at the end of life is highly variable Frail patients 8x more likely than elders who have sudden death to be ADL dependent at end of life; organ failure patients 3x more likely 1 Determining expected trajectory is challenging easier to predict if acute or subacute change Approach should be determined by the comprehensive clinical assessment What components have led or are contributing to the functional decline, and what is reversible/modifiable. Need to ask the question why 1. Lunney JAMA 2003;2387

27 Strategic Directive The Rehabilitative Care Alliance is a province-wide collaborative established by the LHINs for the purpose of effecting positive changes for rehabilitative care across Ontario. Through the development of standardized frameworks, toolkits, and processes, the Alliance is working to promote best practice to enhance outcomes for people receiving rehabilitative care. Priority Initiatives Rehabilitative Care Definitions Framework Frail Senior/ Medically Complex Outpatient/ Ambulatory Capacity Planning & System Evaluation Planning Considerations for Rehab/CCC Bed Re- Classification Term April 2013 March

28 Mandate of the Frail Senior/Medically Complex Task Group Develop a rehabilitative care approach for Frail Senior/Medically Complex populations to support operationalization of priority elements of the Essential Elements of Assess and Restore Framework 1 1 Living Longer, Living well. Highlights and Key Recommendations from the Report Submitted to the Minister of Health and Long-Term Care and the Minister Responsible for Seniors on recommendations to inform a Seniors Strategy for Ontario (December, 2012) 28

29 Key Elements of an Assess and Restore Approach to Care 1. Screening of at-risk seniors in community, primary care, and hospital settings 2. Assessment to determine whether a person is at high risk for loss of independence, has restorative potential, and requires facility-based care 3. Navigation & Placement to the appropriate provider, setting, and type of care 4. Facility-Based A&R interventions based on best practices in care delivery 5. Transitions home with linkages to primary care and other community supports 29

30 Target Population i.e. High Risk Community-dwelling adult with restorative potential who have experienced potentially reversible functional loss/decline for whom home-and/or ambulatory-based rehabilitative care is either not a safe, effective or available option, and who are at risk of institutionalization (acute care or LTC) if nothing is done. RCA Frail Senior/Medically Complex Task Group (2014) 30

31 Step #1 Screening/Early Identification 31

32 Step #1 Early Identification/ Screening Where Community ED Who CCAC CSS Primary Care GEMS or Delegate When How Referral for ADL/IADL support A change in functional status Part of 90 day re-ax A change in functional status At time of check-up Assessment Urgency Algorithm (AUA)/CLINICAL IMPRESSION Upon presentation with functional impairment(s) If the screen identifies the patient as being high risk ii, an urgent comprehensive assessment may be required if clinically appropriate and/or not recently completed. Refer the patient to the Lead Provider (as identified in collaboration with LHIN partners) who will lead/navigate Steps #2 & #3. The assessment in Step #2 is to be completed collaboratively with Primary Care, SGS i &other involved community providers * Denotes potential Lead Provider. LHINs may identify another organization/group to lead Steps #2 & #3 based on local resources i As per definition provided in Specialized Geriatric Services - Review Template (July 7, 2014). Ministry of Health and Long-Term Care (MOHLTC) Ii As per Rehabilitative Care Alliance definition of High Risk. An AUA Score of 5 or 6 reflects High Risk iii 32 As per Rehabilitative Care Alliance definition of Restorative Potential iv As per Rehabilitative Care Alliance Definitions Framework

33 Step #1 - Screening Screening Tool Assessment Urgency Algorithm (AUA) has been endorsed as the screening tool to support the identification of high risk adults This screening tool enables risk stratification supporting the development of referral pathways based on risk level and local resources Takes 45 seconds to complete The Task Group acknowledges that no single tool can capture all issues that may contribute to risk. Therefore the group endorses additional clinical considerations and the use of clinical judgement to inform a final decision about risk and development of an appropriate clinical plan. 33

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35 Step #2 Assessment to Determine Need for Bedded Rehabilitative Care 35

36 Step #1 Early Identification/ Screening Where Community ED Who CCAC CSS Primary Care GEMS or Delegate When How Referral for ADL/IADL support A change in functional status Part of 90 day re-ax A change in functional status At time of check-up Assessment Urgency Algorithm (AUA)/CLINICAL IMPRESSION Upon presentation with functional impairment(s) If the screen identifies the patient as being high risk ii, an urgent comprehensive assessment may be required if clinically appropriate and/or not recently completed. Refer the patient to the Lead Provider (as identified in collaboration with LHIN partners) who will lead/navigate Steps #2 & #3. The assessment in Step #2 is to be completed collaboratively with Primary Care, SGS i &other involved community providers Step #2 Assessment to Determine Need for Bedded Rehabilitative Care Note: Where already involved, consider consulting members of the community allied ID team to support assessment Lead Provider* CCAC Specialized Geriatric Services i Primary Care Provider(s) What Arrange for Completion of a Comprehensive Clinical Assessment by a Healthcare Provider(s) with Geriatric Expertise that Considers the Geriatric Syndromes and Baseline and Current Functional Status including: A. Confirmation that Patient is High Risk ii Recent ADL/functional decline Risk of needing ED, hospital or LTC if nothing is done B. Confirmation of Restorative Potential iii C. Ruling Out an Acute Medical Cause of Functional Decline w 1 Care/ED Practitioner * Denotes potential Lead Provider. LHINs may identify another organization/group to lead Steps #2 & #3 based on local resources i As per definition provided in Specialized Geriatric Services - Review Template (July 7, 2014). Ministry of Health and Long-Term Care (MOHLTC) Ii As per Rehabilitative Care Alliance definition of High Risk. An AUA Score of 5 or 6 reflects High Risk iii 36 As per Rehabilitative Care Alliance definition of Restorative Potential iv As per Rehabilitative Care Alliance Definitions Framework

37 Step #2 Arrange for Completion of a Comprehensive Clinical Assessment by a Healthcare Provider(s) with Geriatric Expertise that Considers the Geriatric Syndromes and Baseline and Current Functional Status, including: Confirmation that Patient is High Risk ii Confirmation of Restorative Potential iii Ruling Out an Acute Medical Cause of Functional Decline w 1 Care/ED Practitioner ii As per Rehabilitative Care Alliance definition of High Risk. An AUA Score of 5 or 6 reflects High Risk iii As per Rehabilitative Care Alliance definition of Restorative Potential 37

38 Step #3 Streamlined Referral 38

39 Step #1 Early Identification/ Screening Where Community ED Who CCAC CSS Primary Care GEMS or Delegate When How Referral for ADL/IADL support A change in functional status Part of 90 day re-ax A change in functional status At time of check-up Assessment Urgency Algorithm (AUA)/CLINICAL IMPRESSION Upon presentation with functional impairment(s) If the screen identifies the patient as being high risk ii, an urgent comprehensive assessment may be required if clinically appropriate and/or not recently completed. Refer the patient to the Lead Provider (as identified in collaboration with LHIN partners) who will lead/navigate Steps #2 & #3. The assessment in Step #2 is to be completed collaboratively with Primary Care, SGS i &other involved community providers Step #2 Assessment to Determine Need for Bedded Rehabilitative Care Note: Where already involved, consider consulting members of the community allied ID team to support assessment Lead Provider* CCAC Specialized Geriatric Services i Primary Care Provider(s) What Arrange for Completion of a Comprehensive Clinical Assessment by a Healthcare Provider(s) with Geriatric Expertise that Considers the Geriatric Syndromes and Baseline and Current Functional Status including: A. Confirmation that Patient is High Risk ii Recent ADL/functional decline Risk of needing ED, hospital or LTC if nothing is done B. Confirmation of Restorative Potential iii C. Ruling Out an Acute Medical Cause of Functional Decline w 1 Care/ED Practitioner Step #3 Streamlined Referral Lead Provider* CCAC Specialized Geriatric Services i Primary Care Provider(s) What A. Confirm patient is eligible for bedded level of Rehabilitative Care iv B. Determine most appropriate level of bedded Rehabilitative Care iv C. In consideration of suggested process timelines, complete referral to most appropriate level of bedded rehabilitative care. NOTE: Expedited priority access may be considered for patients who present to ED or are anticipated to imminently require institutionalization * Denotes potential Lead Provider. LHINs may identify another organization/group to lead Steps #2 & #3 based on local resources i As per definition provided in Specialized Geriatric Services - Review Template (July 7, 2014). Ministry of Health and Long-Term Care (MOHLTC) Ii As per Rehabilitative Care Alliance definition of High Risk. An AUA Score of 5 or 6 reflects High Risk iii 39 As per Rehabilitative Care Alliance definition of Restorative Potential iv As per Rehabilitative Care Alliance Definitions Framework

40 Step #3 Referral to a Bedded Level of Rehabilitative Care* Confirm Eligibility for Bedded Level of Rehabilitative Care* Determine most appropriate type level of bedded Rehabilitative Care i Complete referral to most appropriate level of bedded Rehabilitative Care I * Where community options are not a safe, effective or available option. i As per Rehabilitative Care Alliance Definitions Framework (see Appendix) 40

41 DRAFT Process Timelines to Support Timely Access to a Bedded Level of Rehabilitative Care from the Community in Order to Avoid an Acute/ED Admission. Expedited priority access may be considered for patients who present to ED or who are anticipated to imminently require institutionalization. The Lead Provider will monitor the patient s status regularly while awaiting admission and communicate urgency for admission accordingly. Within 8 hours for patients from the ED Note: If admission to a rehabilitative care bed cannot be facilitated within 8 hours, arrange for intensive in-home services to support the patient at home while awaiting admission Note: Local targets should be adjusted to align with HSAAs, as appropriate. Step #1 Early Identification/ Screening Step #2 Standardized Assessment to Determine Need for Bedded Rehabilitative Care Step #3 Referral Admission to a Bedded Level of Rehabilitative Care Within 2 weeks for patients from the community If required, arrange for intensive in-home services to support the patient at home while awaiting admission 41

42 Appendix - Definitions Framework for Bedded Levels of Rehabilitative Care DEFINITIONS FRAMEWORK FOR BEDDED LEVELS OF REHABILITATIVE CARE (FINAL DRAFT) The definitions for the bedded levels of rehabilitative care reflect the understanding that the focus of rehabilitative care across the 4 levels may vary from where it is a primary focus in some levels (e.g. Rehabilitation and Activation/Restoration) to a more secondary focus in others where the medical complexity of the patient is higher than in other levels (e.g. Short and Long Term Complex Medical Management). Note: The framework is not inclusive of all beds within CCC or Acute Care. Palliative Care, Respite, Behavioural programs as well as programs where patients are waiting for an alternate level of care (e.g. ALC and LTC) are beyond the scope of this rehabilitative care framework as their focus is not rehabilitative care. However, there is recognition that patients within these programs may receive some rehabilitative care for maintenance during their admission. Bedded Levels of Rehabilitative Care (i.e. Hospital-based designated inpatient rehab beds and complex continuing care beds as well as convalescent care/restorative care Patient Characteristics beds within LTCH) Rehabilitation Activation / Restoration Functional Trajectory Progression Progression Level of Care - Goal Target Population Functional Characteristics Estimated Average LOS Discharge Indicator Short Term Complex Medical Management Stabilization & Progression Long Term Complex Medical Management Maintenance Medical/Allied Health Resources Medical Care Nursing Care Therapy Care Intensity of Therapy Reporting Tools 42

43 43 CASES Functional decline in community dwelling elders -- the importance of CGA within an assess restore framework

44 Case Study #1 Community Comprehensive Assessment 84 yr male, functional decline PMHx: ischemic CM (EF <20%) Mod-Severe dementia Osteoporosis Main concern: lives with his wife, primary caregiver Nocturia 4-6x/night Wanders at times out of house Severe caregiver burden (placement imminent) Meds: Furosemide 40mg AM Ramipril 5mg OD Donepezil 10mg daily Alendronate 70mg weekly Rosuvastatin 10mg daily Lorazepam 0.5mg BID PRN Exam: BP:85/45 lying, 70/40 standing (unsteady) JVP flat, chest clear, CVS N, no edema, not delirious. Heckman, 2014, with permission 44

45 Case Study #1 Community Comprehensive Assessment Issues: HF, cogntion, caregiver stress, polyuria, sleeplessness, multiple meds? Plan not focused on comfort care AUA: 6, Frailty scale:6. Focus: relieve Caregiver stress, manage sleep and nocturia Review: ACE benefits (muscle, heart function) Statin prefer to stop Diuretic reduce as volum depleted Donepezil: modest impact, may be contributing to frequency Alendronate: has been on for five years? Day program Heckman, 2014, with

46 Case Study #1 Community Comprehensive Assessment Medication changes: Diuretic reduced by half Taken at lunch Weaned donepezil in half Lorazepam couldn t win that one. Day program: Started going more respite, interaction, physical exercise component Outcome Attending day program 2x/week Brighter, more cheerful and interactive Nocturia: once/night Wife: more rested, improved outlook Institutionalization averted Died: CHF exacerbation 18 months later Heckman, 2014, with

47 Case #2 Community to CGA and Outpatient Rehab 79 yr man, functional decline and Parkinson s HPI: PD x 3 year, levodopa since. Rigidity and mobility. Gradually more rigid, more impaired mobility. Has had multiple falls. Depressed. Has had active suicidal thoughts in past, not now, although very lonely, frustrated at his limitations, would be fine with him if he didn t wake up one day. Nothing brings him joy. Low appetite. Spent most of assessment in tears.(has had hx depression in past) Function: 4 ww, impaired mobility. CCAC PSW 30 min BID personal care Friend helps groceries, transportation --? Financial abuse Cognition good does own income taxes, bills, etc. Never married, sister POA and collateral today. PMHX: PD, macular degeneration, depression MEDS: Levodopa/carbidopa (IR, plus CR at HS), entacapone, vitalux, vitamin D. senokot

48 Case #2 Community to CGA and Outpatient Rehab EXAM Appeared sad, with reduce expression. Moderate rigidity, unsteady, shuffling gait, multistep pivot turn. TUG 28 sec. hypophonia, sialorhea. BP 135/78, No postural drop CVS, Resp, GI, Neuro Normal, MOCA 23/30, GDS 12/15 IMPRESSION: Depression PD, suboptimally treated Social stressors AUA 6, CSHA 5-6 PLAN Needs multidisciplinary intensive approach Social work RE: friend, transportation, supports Outpatient Physio: falls, balance, functional mobility Medication optimization for PD, depression Assess fracture risk: BMD SLP: voice, swallowing

49 Case #2 Community to CGA and Outpatient Rehab Follow up 4 months Completed physiotherapy (1:1 over 8 weeks Now participating in Parkinson s Exercise Program at older adults centre Had SLP voice training (16 in 4 wks) Had several RN/SW home visits Helped with transportation (no more friend) and SMH following Medication changes: Pramipexole (0.25 mg TID), Citalopram started and titrated to 20mg with RN assist, Risedronate added for low BMD Outcome: Feels much better no more tearfulness, not depressed. Enjoys his social outings Mobility: most improved. More fluid, no freezing, no shuffle, 3 point pivot, face more expressive TUG 16 sec, with walker. MOCA: 23/30 Outpatient reassessment 6 months

50 Case Study #3 Community to Rehabilitative Care Bed 75 year old female who has been followed since 2009 for depression, Parkinson's disease, rheumatoid arthritis, pain, functional decline. Housebound since 2009, coming out very rarely for doctor s appointments. Very private and resistant to care, services, any home visits. Over the years, refused to have senior mental health involved, refused the arthritis society or their exercises. Has gradually come to accept our team. Our visits have focussed on getting her RA under control (had previously refused speciality care, we referred her to a specialist who was able to get her very active RA under control since 2011 with methotrexate, plaquenil). Her tremor predominant Parkinson s has been reasonably controlled on sinemet 100/25 ½ TID (we had titrated up slightly in , which resulted in mild diskinesias, and so had to come back down). Very depressed off and on has seemed to improved with mirtazapine, albeit not completely. She lives with her son who had taken over many IADLs (secondary to pain and depression). 50

51 Case Study #3 Community to Rehabilitative Care Bed Home visit September 2013 Patient continues to spend most of her days in bed. She is not interested in additional physiotherapy, or support with CCAC. Her son is providing her B12 and methotrexate injections weekly, as he has been trained to administer these. Her pain reasonably good today. She did not have any pain in her hands and shoulders and was able to move reasonably well through the assessment, with the exception of significant pain at the right hip. She reports that she is now mobilizing with a walker and at times a 1- person assistance because of this pain. There have been no falls or cognitive changes. She is independent with her commode at the bedside and also for mobilizing to the bathroom. She is independent with eating, but her son prepares her meals. She gets assistance with bathing and some assistance with dressing. She is independent with using the phone. She gets assistance with meal preparation, laundry and housekeeping, all due to limited mobility. She manages her own medications, which were at the bedside today, as well as finances.

52 52 Case Study #3 Community to Rehabilitative Care Bed Home visit June 2014 Patient bedbound, in tears. Discontinued her RA meds in December (thinks it was making her stomach symptoms worse). Many prescribed therapies and medications not on her list. Wishing she could die. Pain is worse that it has ever been. Refused her long acting narcotics. Very clear she wants help. Desperate to improve and be in less pain. No longer leaves her bed. Son has not been working (had to take a leave of absence for 4 months). She has not mobilized independently since April. Has lost 10lbs since last assessment (no interest in eating), often vomiting. Tremor is worse, Parkinson s worse, having a bowel movement q 7-11 days. Incontinence developing (urinary). Son has to make a decision within the next 2 weeks as to whether he has to return to work. Meds - Coversyl plus 5/2.5mg day, ASA, Percocet, Levodopa/Carbidopa ½ TAB TID, Mirtazapine 45mg OD, (She had stopped laxative, plaquenil, metyhotrexate, B12) Assessment - Active RA (leading to pain), Active Parkinson s (leading to worsening tremor, constipation, nausea), Constipation (leading to nausea, weight loss, urinary incontinence), Depression (secondary to pain and immobilty, leading to medication non-compliance), Immobility, Deconditioning, Frailty, High Caregiver Burden. AUA 6, CSHA 7

53 Case Study #3 Community to Rehabilitative Care Bed Needs re-institution of RA medications, optimization of pain, titration of PD meds (to 1 tab TID), treat constipation, physiotherapy, caregiver respite. Needs urgent admission to rehab, or will be in LTC, hospital within days to weeks All of the above has historically been treatable, and responded to therapy, mobility was independent less than 3 months ago, (therefore, restorative potential present). Notes from Rehab June 2014: Was very motivated to participate in rehab. Did seated morning exercise classes, stair training, worked with 2 WW. Worked with OTA to become independent with ADLs at discharge. Counselling with social work on not having her son doing all ADLs, IADLs. Used more information for MOW, private agencies. Parkinson s optimized (Increased sinemet to TID) Constipation optimized (lax-a-day, improved PD treatment) Medications switched to hydromorph contin 3mg BID with breakthrough 1mg PRN Celebrex added Re-referred to Rheumatology and Orthopedic program

54 Case Study #3 Community to Rehabilitative Care Bed Home Visit September 2014 Upon my arrival she was sitting at the kitchen table eating soup with her son. She smiles and tells me she is doing much better. No longer bed bound, depressed. Pain under better control. She has continued to exercise (no small miracle). She has accepted CCAC services once weekly for personal care and some housekeeping services. Rheumatology involved, methotrexate restarted. Her son has returned to work after a lengthy caregiver leave. Meds At Discharge: Celebrex 200 mg daily ASA 81 mg daily Ferrous gluconate 300 BID Hydromorphone contin CR 3mg BID Hydromorphone 1mg PRN Lax a Day once daily Sinemet 100/25 TID Mirtazapine 45 mg OD Pantoprazole 40mg Daily The effect has been transformative 54

55 5 Elements of Assess and Restore Comprehensive Geriatric Assessment PLUS Intervention

56 An Effective Assess and Restore Strategy Will Appreciate the complexity and heterogeneity of this population Understand that functional decline is a geriatric syndrome, which is a complicated clinical problem requiring specialty care Emphasize the need for timely and effective geriatric assessment that includes a multidisciplinary approach, specialized services, and intervention Minimize red tape and multiple assessments as barriers to timely and effective intervention Creates capacity in the system to support a pre-hab, rehab and post- hab approach

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