Edith Haage, PT, GCS NewCourtland Senior Services 10/26/2016. NEWCOURTLAND.org
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1 Edith Haage, PT, GCS NewCourtland Senior Services 10/26/2016 NEWCOURTLAND.org
2 Edith Haage has disclosed she has no financial relationships.
3 1. Define frailty in geriatric clientele, including classification profiles, physiological changes, and biological basis. 2. Explain clinical assessment strategies and factors for consideration during evaluations for frailty. 3. Discuss interdisciplinary implications of frailty, including the risks, consequences, and costs of frailty. 4. Identify evidence-based practice interventions for pre-frail and frail participants.
4 Alas, the frailty is to blame, not we. For such as we are made of, such we be. William Shakespeare
5
6 According to the U.S Department of Health and Human Services, persons 65 years or older numbered 46.2 million in 2014 (the latest year for which data is available). Represented 14.5% of the U.S. population, about one in every seven Americans. By 2060, there will be about 98 million older persons, more than twice their number in People 65+ represented 14.5% of the population in the year 2014 but are expected to grow to be 21.7% of the population by 2040.
7 Focused on a subset of leading chronic diseases: heart disease, stroke, and diabetes. In 2006, this subset of diseases incurred estimated economic losses of $20 million in the United States. Short-term projections (to 2015) indicate that losses will nearly double The potential estimated loss in economic output for 23 nations surveyed as a whole between 2006 and 2015 totaled US$84 billion. NIH.gov
8 Average cost per hospital stay in US in 2014 was > $5,200 (Statistica.com) Average cost per SNF day in US in 2015 was > $230 (longtermcare.gov)
9 A B
10 1. Progressive physiologic decline in multiple body systems 2. Loss of function 3. Loss of physiologic reserve 4. Increased vulnerability to disease and death
11 Vulnerable to poor health outcomes Social isolation Disability Repeated hospitalization Institutionalization
12 Mobility Strength Endurance Nutrition Physical activity Some include cognitive impairment and depression
13 Studenski et al: Examined gait speed, ability to rise from a chair, and balance skills Predicted decline in function, hospitalization, and global decline in health in older patients seen in primary care Studenski S, Perera S, Wallace D, et al. Physical performance measures in the clinical setting. J Am Geriatr Soc 2003; 51:
14 5 conditions: slow walking speed, poor hand grip, exhaustion, weight loss, and low energy expenditure Statistically higher risk for falls, disability, hospitalization, and death Findings persisted after adjusting for health status, socioeconomic status, and disability at baseline Incidence of these outcomes increased in stepwise fashion from non-frail (no factors) to intermediate (one or two factors) to frail people (three or more factors)
15 Frailty index based on impairments in cognitive status, mood, motivation, communication, mobility, balance, bowel and bladder function, activities of daily living, instrumental activities of daily living, nutrition, and social resources, as well as a number of comorbidities. This index was found to be highly predictive of death or institutionalization. Originally 92 deficits, simplified to 30 items; still complex for PACE environment Rockwood K, Stadnyk K, MacKnight C, McDowell I, Hebert R, Hogan DB. A brief clinical instrument to classify frailty in elderly people. Lancet 1999; 353:
16 Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: Unintentional weight loss (10# past year) Self-reported exhaustion Weakness (grip strength) Slow walking speed Low physical activity
17 Intermediate frailty status, or Prefrail Indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3 4 years of follow-up Stay tuned: Progression vs regression
18 Frailty has been associated with being African American or Hispanic Having lower education and income Having poorer health Higher rates of comorbid chronic diseases and disability. Diabetes Depression Cognitive Decline
19
20 Robust Stable Temporal difficulties Pre-Frail Signs of dysfunction when stressed Frail At risk for poor outcomes Vulnerable to decline Poor tolerance to stressors
21 IDT Management of the Frail Participant
22 Frailty Screening: Need criteria to identify frail and pre-fail participants Comprehensive Geriatric Assessment and Treatment IDT intensive assessment to determine baselines and at risk areas Developing interventions is a critical next step in decreasing adverse health outcomes in frail older adults
23 PT OT RT CHIROPRACTIC RN RD PCP PARTICIPANT SW
24 Benefits include enhanced mobility and activities of daily living, improved gait, decreased incidence of falls, increased bone mineral density, and improvements in general well-being Exercise is likely to benefit even the frailest of older adults. Even low levels increase muscle strength.
25 NIH: 2008: minimum 150 min/week mod intensity aerobic Resistance training 2 x /week Multifactorial exercise program; mm performance, gait, endurance and power (force with speed) Gait Speed associated with survival in all studies 1.0 m/s benchmark
26 Lifestyle Modifications thedesigninspiration.com/ category/photos Thediabetesworld.com Ihealthyinfo.com
27 Proof is in the pudding Boult et al: randomized controlled intervention trial with geriatric evaluation & targeted management Intervention results: Decreased health care utilization, improved depressive symptoms, & slowed rate of functional decline. Critical importance of ensuring IDT specific recommendations are implemented.
28 Poor implementation of recommendations from the comprehensive team is the main reason management is less effective. Patient adherence to treatment plans also determines the effectiveness of comprehensive geriatric assessment. Physicians are more likely to implement the plan and patients are more likely to adhere to it if the patient and primary care physician share a collaborative relationship
29 Robust Cancer Screening / Diagnostic Testing Lifestyle Modification Smoking Cessation Strengthening Exercise Pre-frail Lifestyle Modification Comprehensive Assessment and IDT intervention Physical and Occupational Therapy for individualized dynamic program Diagnostic testing only as needed to determine interventions FRAIL Aggressive screening and diagnostics can be detrimental Modified exercise for strengthening, mobility and balance as tolerated Eventual palliative / supportive care
30 PACE: Although it is not yet clear that the PACE model offers clear monetary or health outcome advantages over traditional care, the model provides interdisciplinary team care that has proven effective in other health care models for older adults. Frailty in older adults: Insights and interventions. Espinoza, Sara; Walston, Jeremy D. Cleveland Clinic Journal of Medicine, Vol. 72, No. 12, , p
31
32 1. Espinoza, Sara; Walston, Jeremy D. Cleveland Clinic. Frailty in older adults: Insights and interventions. Journal of Medicine, Vol. 72, No. 12, , p Lally, Frank and Crome, Peter. Understanding Frailty. Postgraduate Medical Journal Jan; 83(975): Dennis T. Villareal, M.D., Suresh Chode, M.D., Nehu Parimi, M.D., David R. Sinacore, P.T., Ph.D., Tiffany Hilton, P.T., Ph.D., Reina Armamento-Villareal, M.D., Nicola Napoli, M.D., Ph.D., Clifford Qualls, Ph.D., and Krupa Shah, M.D., M.P.H. Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults. N Engl J Med 2011; 364: March 31, Fried, Linda P, Tangen, Catherine M, Walston, Jeremy, Newman, Anne B, Hirsch, Calvin, Gottdiener, J, Seeman, Teresa, Kop, Willem, Burke, Gregory and McBurnie, Mary Ann. Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontol A Biol Sci Med Sci(2001) 56 (3): M Studenski S, Perera S, Wallace D, et al. Physical performance measures in the clinical setting. J Am Geriatr Soc 2003; 51:
33 6. Rockwood K, Stadnyk K, MacKnight C, McDowell I, Hebert R, Hogan DB. A brief clinical instrument to classify frailty in elderly people. Lancet 1999; 353: Espinoza, Sara; Hazuda, Helen. Frailty Prevalence and Neighborhood Residence in Older Mexican Americans: The San Antonio Longitudinal Study of Aging. Journal of the American Geriatrics Society, Vol. 63, No. 1, , Boult C, Boult LB, Morishita L, Dowd B, Kane RL, Urdangarin CF. A randomized clinical trial of outpatient geriatric evaluation and management. J Am Geriatr Soc 2001; 49: Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993; 342: Shah PN, Maly RC, Frank JC, Hirsch SH, Reuben DB. J Managing geriatric syndromes: what geriatric assessment teams recommend, what primary care physicians implement, what patients adhere to. Am Geriatr Soc 1997; 45: Miller ME, Rejeski WJ, Reboussin BA, Ten Have TR, Ettinger WH. Physical activity, functional limitations, and disability in older adults. J Am Geriatr Soc 2000; 48:
34 The power to question is the basis of all human progress. Indira Ghandi Edith Haage, PT, GCS
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