Webinar Series January 25, 2017

Transcription

1 Webinar Series January 25, 2017 Frailty Assessment of Older Canadians Using Emergency Services with Tablet Technology Jacques Lee, MD, MSc, FRCPC Sunnybrook Research Institute

2 Reminder: Q-&-A session Follows Dr. Lee s presentation Submit your Qs online during presentation We will answer as many Qs as time permits

3 Reminder: Survey & Webinar Survey will pop up on your screen after webinar Feedback on how to improve webinar series Webinar slides & video available for viewing online within 1-2 days at: cfn-nce.ca/news-and-events/webinars

4 Reminder: Upcoming Webinars Register at: Wednesday, February 1, 2017 at 12 noon ET Antidepressant guidelines for long-term care residents with advanced frailty results of CFNfunded Knowledge Synthesis Grant Laurie Mallery, Constance LeBlanc and Michael Allen, Dalhousie University Wednesday, February 15, 2017 at 12 noon ET A scoping review of evidence for measuring frailty in pre-hospital and hospital settings results of CFN-funded Implementation Grant Olga Theou, Dalhousie University Wednesday, March 1, 2017 at 12 noon ET Modeling changes in assessments to predict needs and guide care planning in home care CFNfunded Knowledge Synthesis Grant Debra Sheets and Stuart MacDonald, University of Victoria

5 Reminder: CFN Summer Student Awards Program Launching in soon! Visit:

6 Presenter Frailty Assessment of Older Canadians Using Emergency Services with Tablet Technology Emergency Services Staff Physician and Scientist at the Sunnybrook Research Institute in Toronto Director of Research for the Department of Emergency Services at the Sunnybrook Health Sciences Centre Assistant Professor, Clinician Scientist and former Director of Resident Scholarly Activities in the Department of Medicine at the University of Toronto Research focuses on improving the care of older adults who need emergency services Jacques Lee, MD, MSc, FRCPC

7 Frailty assessments of Older Canadians Using Emergency Services (FOCUS) Canadian Frailty Network Webinar Jacques S. Lee MD, MSc, FRCPC

8 Acknowledgements Canadian Frailty Network (CFN) Implementation Grant 2015 No conflicts to declare

9 Acknowledgments My Qualifications? Knows how to read Knows where the library is

10 Acknowledgements Collaborators Dr. Mary Tierney, PhD Dr. Mark Chignell, PhD Tiffany Tong, PhD (Cand.) Dr. Judah Goldstein, PhD Dr. Ken Rockwood, MD PhD Dr. Marcel Emond, MD, PhD Dr. Marie-Josee Sirois Dr. David Ryan, PhD Mike Nolan, MA Collaborators Dr. Alex Kiss, PhD Dr Gary Naglie, MD, MSc National Coordinator Joanna Yeung

11 Why?

12 Canadians 14 versus 65 Statistics Canada, censuses of population, 1921 to 2011

13 Demographics For the first time in history as of July 2015, The number of Canadians 65 and older exceeds the number of children 14 and younger 1 The doubling of older people will happen sooner in Canada than in any other G7 nation.

14 Are we ready for the Grey Tsunami? Our Ability to provide care with the CURRENT overcrowding raises grave concerns for the future

15 Assessing Frailty in the ED Sunnybrook ED - 60,000 visits / year 9 ED physicians and 30 nurses assess patients per day of those are aged 65 plus The vast majority are first time encounters no familiarity with patients history Rapid methods of assessing frailty are needed for ED staff

16 Frailty in Older Canadians The majority of older Canadians, at any age, are robust (56% of those 85) 1 But a significant minority suffer from frailty, which makes them vulnerable to adverse events 2-8 including Falls, Functional Decline, Infections DELIRIUM

17 Why is ED Delirium Important? Delirium is COMMON % in ED, Delirium is LETHAL year Mortality up to 35-40% - INDEPENDENT RISK (AHR 2.1) Delirium is NOT ALWAYS REVERSIBLE - Average 6-12 months to return to baseline 18-19, Some never recover

18 Why is Delirium in the ED Important? DELIRUM IS OFTEN UNRECOGNIZED Only recognized in 17% - 24% % - 25 % of those with delirium discharged home 20 Mortality Risk x higher if sent home with unrecognized delirium (Kakuma et al.) 22

19 Why Do We Miss Delirium? Hard to see if you aren t looking for it

20 Current Knowledge Gap The highest sensitivity reported for a predictive tool targeting the elderly is 72%, compared to sensitivities of 99 to 100% for many predictive tools targeting younger populations

21 Prediction in Older People The minimum number of variables needed to accurately identify high risk older adults exceeds the maximum number of variables that staff are willing or able to collect

22 FOCUS Study Solution: Involve the patient & family to collect a richer data set

23 FOCUS Study To test the real-world implementation of a user-friendly tablet based technology to identify high-risk older adults with Frailty or Problems with their thinking such as delirium or dementia

24 FOCUS Study Collaboration across 3 Provinces - Ontario - Quebec - Nova Scotia In English & French

25 FOCUS Study: Caveat Previous research has shown that patients with delirium do not participate in research Informed consent process systematically excludes patients at risk for delirium 28 Therefor we used delirium severity index to measure degrees of delirium

26 FOCUS Study Uses existing evidence-based questions plus Cognitive performance measures from serious game

27 FOCUS Study: Measuring Frailty ClinicalFrailty Score: CFS 29 1 to 9 point scale From Very Fit to Terminally Ill Previously validated in the community setting, in-patient settings No comparisons of patient and caregiver assessments to date

28 FOCUS: Clinical Frailty Scale

29 FOCUS Study: Serious Game

30 FOCUS Study 306 participants enrolled: Ontario: 172 (47.8%) Quebec: 100 (32.7%) Nova Scotia: 34 (11.1%) Average Age: 75.8 years Female: 146 (48.7%)

31 FOCUS Study: Usability Usability Of all ED patients 65 and older approached only 7.7% unable to use tablet (injuries, paralysis, visual acuity) An additional 1.8% with severe pain were not included

32 FOCUS Study Demographics Median, (IQR) MOCA 23 (16 26) CFS (MD) CFS (Patient) Pain (NRS) 3.4 (2-4) 3.0 (2-4) 0 (0-5)

33 FOCUS Study 306 participants enrolled Maximum of 3001 data points x 306 participants = 900,000 data points!

34 Health Needs, Adverse Outcomes 1 Month (n= 306) 911 Calls 10 (3.3%) Return to ED 28 (9.2%) Admitted 9 (2.9%) Deceased 10 (3.3%) Any Outcome 47 (14.4%) 3 Months (n= 306) 11 (3.6%) 34 (11.1%) 6 (2.0%) 14 (4.6%) 57 (17.5%)

35 Question 1 Does the CFS predict Health Needs? Compare CFS collected by MD, RA, Patient and Caregiver

36 CFS Prediction of Health Needs CFS 3 Health Needs, 1 Month Health Needs, 3 Months MD 38/47 (80%)* 44/57 (77%)* RA 35/47 (74%) 43/57(75%)* Patient 29/47(62%) 38/57 (66%) Care Giver 6/47 (13%) 6/57 (11%)

37 Delirium and Serious Game 3 enrolled patients met criteria for delirium This 1% rate is well below expected delirium rate from clinical samples (10%) Confirms previous studies demonstrating selection bias 24/306 (7.8%) had a delirium severity score 4

38 Question 2: Does the FOCUS Serious Game predict Delirium Severity?

39 Serious Game Scores & Delirium Developed a summative test performance score Delirum Index Mean Test Score (95% CI) ( ( )

40 Discussion & Conclusion Use of FOCUS tablet feasible in ED and Pre-hospital settings, across Provinces and in 2 languages Validated use of CFS in ED setting Validated use of serious game to identify patients at risk for delirium Established feasibility of automated referrals to discharge planning

41 Next Steps Validate in larger samples of patient with delirium Conduct longitudinal studies of patient during ED stay Test preventative interventions

42 Questions? Stay Calm and On!

43 References 1. Rockwood K, Howlett SE, MacKnight C, et al. Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian study of health and aging. J Gerontol A Biol Sci Med Sci. Dec 2004;59(12): Rockwood K, Fox R, Stolee P, Robertson D, Beattie B. Frailty in elderly people: an evolving concept. CMAJ. Feb ;150((4)): RGPO. Regional Geriatric Programs of Ontario Fact Sheet: The Role and Value of Specialized Geriatric Services. 2001; Accessed July 15, CDC. National Center for Health Statistics, Data Warehouse on Trends in Health and Aging. 2006; Accessed July 15, Speechley M, Tinetti M. Falls and injuries in frail and vigorous community elderly persons. J Am Geriatr Soc. Jan 1991;39(1): Madden K, Hogan D, Maxwell C. The prevalence of geriatric syndromes and their effect on the care and outcome of patients aged 75 years of age and older presenting to an emergency department. J Can Geriatric Society. 2002;5: CSHAWG. Canadian study of health and aging: study methods and prevalence of dementia. CMAJ. Mar ;150(6): Hogan DB, Fox RA. A prospective controlled trial of a geriatric consultation team in an acutecare hospital. Age Ageing. Mar 1990;19(2):

44 References 9. Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med Mar;13(2): Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and detection of delirium in elderly emergency department patients. CMAJ, 2000;163: Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med. 2003;41(5): Vasilevskis EE, Han JH, Hughes CG, Ely EW.Epidemiology and risk factors for delirium across hospital settings. Best Prac Res Clin Anaesth. 2012, 26 : Siddiqi N, House AO, Holmes J. Occurrence and outcome of delirium in medical inpatients: a systematic literature review. Age and Ageing 2006; 35: Levkoff SE, Evans DA, Liptzin B et al. Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med 1992; 152(2): Francis J, Martin D & Kapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990; 263(8):

45 References 16. McCusker J, Cole M, Abrahamowicz M,Primeau F. Delirium Predicts 12-Month Mortality. Arch Intern Med. 2002;162: Han JH, Shintani A, Eden S, Morandi A, Solberg LM, Schnelle J, Dittus RS, Storrow AB, Ely EW. Delirium in the Emergency Department: An Independent Predictor of Death Within 6 Months. Ann Emerg Med. 2010;56: Levkoff SE, Evans DA, Liptzin B, Cleary PD, Lipsitz LA. Wetle TT, Reilly CH, Pilgrim DM, Schor J, Rowe J. The Occurrence and Persistence of Symptoms Among Elderly Hospitalized Patients. Arch Intern Med. 1992;152: McCusker J, Cole M, Dendukuri N, Han L, Belzile. The course of delirium in older medical inpatients. A prospective study. J Gen Int Med, 2003:18:

46 References 20. Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med. 2003;41(5): Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and detection of delirium in elderly emergency department patients. CMAJ, 2000;163: Kakuma R, du Fort GG, Arsenault L, Perrault A, Platt RW, Monette J, MorideY, Wolfson C. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51(4): Lee JS, Schwindt G, Langevin M, Moghabghab R, Alibhai SM, Kiss A, et al. Validation of the triage risk stratification tool to identify older persons at risk for hospital admission and returning to the emergency department. J Am Geriatr Soc. 2008;56(11): Stiell IG, Laupacis A, Wells GA. Indications for computed tomography after minor head injury. Canadian CT Head and Cervical-Spine Study Group. N Engl J Med. 2000;343(21):

47 25. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26): Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269(9): Stiell IG, Greenberg GH, Wells GA, McDowell I, Cwinn AA, Smith NA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA. 1996;275(8): Adamis D, Martin FC, Treloar A, Macdonald AJ. Capacity, consent, and selection bias in a study of delirium. J Med Ethics. Mar 2005;31(3): Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. Aug ;173(5):

48 Interobserver Agreement Patient MD Care Giver R/A 0.61 ( ) Care Giver 0.56 ( ) MD 0.44 ( ) 0.55 ( ) 0.58 ( ) 0.66 ( ) - - -

49 FOCUS Study: Agreement Patients, Research Assistants and Physicians assessed baseline frailty assessment using Canadian Frailty Scale Caregivers provided CFS in a subset

50 Forming Patient Types Based on Technology Use Q1. Do you own your own computer or have one in your home? Q3. Do you own your own tablet or have one in your home? Q4. Have you ever used an Automated Banking Machine (ABM)?

51 Patient Types Based on Technology Use Type Computer Use Tablet Use ABM Use 1 (n = 95) 2 (n = 82) 3 (n = 17) 4 (n = 49) 5 (n = 33)

52 Thank you for attending!