Planning for Sustainable Long Term Care

Transcription

1 Planning for Sustainable Long Term Care Gateway Geriatric Education Center Saint Louis University Division of Geriatric Medicine

2 1.Monaco Macau Japan Singapore Chad 48 8.Hong Kong Australia Spain USA China South Africa 49.0

3 The Hospital is a Place Creditor, Ann Int Med, 1993

4 HOME DayCare Alzheimer s Village ED Hospital Group Home Subacute Care (Geriatric Hospital) Nursing Home

5 Models of Care around the World Social 14 Nurse 14 DEMENTIA VILLAGE Physician 8 In 6 countries 2 models predominated

6 FRAILTY DEFINITIONS Occurs when under stressful conditions the person has diminished ability to carry out important practiced social activities of daily living.it needs to be distinguished from disability Renoir, 1915 Blonde a la rosa

7 Cognitive Reserve VO2 max Cardiac output Balance Muscle strength Frailty Threshold Age (years)

8 Frailty Cascade PSYCHOLOGICAL Depression Cognition Anxiety Fear of Falling Fatigue Health Perception SOCIAL Environment Income Support System Health Literacy Activity BIOLOGICAL Genetics Muscle Hormones Cytokines Disease Deficits FRAILTY Functional Deficit (IADLs/ADLs) Hospitalisation Nursing Home Death

9 Importance of cognitive assessment as part of the Kihon Checklist developed by the Japanese Ministry of Health, Labor and Welfare for prediction of frailty at a 2 year follow up Geriatrics & Gerontology International pages n/a-n/a, 22 NOV 2012 DOI: /j x

10 Fatigue FRAILTY (IANA) Resistance (Climb 1 flight stairs) Aerobic (Walk one block) Illnesses Loss of weight FIVE VALIDATIONS Australia(2) Hong Kong St Louis Europe

11 9-year OR of ADL deficit or Mortality in persons not lacking ADLs ADLs MORTALITY PreFra il Frail p PreFrail Frail p FRAIL SOF NS CHS Rockwood

12 Specificity of Scales in Hong Kong Study MALE MALE FEMALE FEMALE MORTALITY Physical Limit MORTALITY Physical Limit Rockwood 96.4% 98.4% 93.8% 98% CHS 99.2% 100% 99.4% 99.9% FRAIL 99.1% 99.4% 99.9% 100% Hubbard 98% 99.6% 96.1% 95.1% All had poor Sensitivity

13 SARC-F Strength: difficulty in lifting or carrying 10 lbs Assistance with walking Rise from a chair Climb stairs Falls

14 St Louis SARC-F Longitudinal

15 SARC-F in Baltimore Longitudinal Study 60+ years SARC-F Odds Ratio P-value Gait Speed <0.8 m/s 9.41( ) Mortality 3.07( ) 0.001

16 SARC-F CHENGDU hysical function as independent predictors of SARC-F 4 in multiple binary ogistic regression analysis n B S.E. P OR 95% C.I. for OR 4m walking speed TUG* completed TUG time SPPB # Grip strength

17 SARC-F: Hong Kong Sarcopenia classified using the SARC-F, EWSOP, IWGS and AWGS all increased the risk of physical limitation, and poor performance measures at follow-up in men and women. The magnitude of the relative risk were similar for all criteria involving measurements (ranging from 1.6 to 3.6) Those for the SARC-F were much higher (ranging from

18 Families and physicians fail to recognize dementia.

19 Mini-Mental Status Examination Folstein et al Educationally dependent 2. Both false positives and false negatives 3. Minimal testing of visuospatial system

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21 Sensitivity Sensitivity ROCs For SLUMS &MMSE for MCI > HS Education Area Under Curve = 94.1% Specificity Area Under Curve = 64.3% Specificity SLUMS MMSE

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24 Rapid Cognitive Screen and MCI (5 words, clock, story with country) RCS RCS vs MiniCog 2.5 minutes to complete

25 Frailty Screening in the Community Using the FRAIL Scale Elderly Centers in the New Territories East Region of Hong Kong SAR China. Jean Woo, Ruby Yu, Moses Wong, Fannie Yeung, Martin Wong, Christopher Lum

26 The prevalence of pre-frailty and frailty were 52.4% and 12.5%, respectively. The prevalence for frailty increasing with age from 5.1% for those aged years to 16.8% for those 75, being greater in women compared with men (13.9% vs 4.2%). Of those who were pre-frail or frail (n = 529), 42.5% had sarcopenia and 60.7% had mild cognitive impairment. Among those who were frail (n = 102), 63.7% had both sarcopenia and mild cognitive impairment, and only 8.8% had neither. Frailty Screening in the Community Using the FRAIL Scale

27 Fatigue Syndrome (CFS; myalgic encephalitis) Anemia (IANA) Resistance and balance Fatigue exercises And protein Resistance (Climb 1 flight stairs) Aerobic Exercise Aerobic (Walk one block) And protein Illnesses FRAILTY Treatment excess eg hypotension, chemotherapy Illnesses eg vitamin B12 deficiency, heart failure, renal failure, cancer Gulf War Syndrome (? toxin exposure) Unhappy (Depression) Endocrine (Hypothyroid, Addison s, Diabetes mellitus) Loss of weight Sleep Disorders (Sleep apnea, restless legs, insomnia) Reduce polypharmacy

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29 Causes of Weight Loss Medications Emotional (depression) Alcoholism,anorexia tardive, abuse (elder) Late life paranoia Swallowing problems Oral problems Nosocomial infections,no money (poverty) Wandering/dementia Hyperthyroidism,hypercalcemia,hypoadrenalism Enteric problems (malabsorption) Eating problems (eg. Tremor) Low salt, low cholesterol diet Shopping and meal preparation problems, Stones (cholecystitis) Morley JE, Silver AJ. Ann Intern Med 1995;123:

30 ? PsycoSocial Frailty?

31 Environment Modulates Longevity

32 After the fall of the Berlin Wall East Germans rapidly developed a survival equivalent to West Germans

33 Stressful Social Events increase Mortality in oldest-old males in Hong Kong

34 Outcomes in Nonagerians after Earthquake in Wenchuan, May

35 SOCIAL Sadness Outside activity Cognition Income adequacy Attachment to neighborhood Lethargy Univariate Analysis of Variance* Mean+Standad Deviation Variables Robust (0- Pre-Frail (2- Frail (4-6) 1) 3) P-Value ADL disabilities <.001 b,d IADL disabilities <.001 b,d Short Physical Performance Battery <.001 a,d Lower Body Functional Limitations <.001 a,d One-Leg Stand <.001 a,d Grip Strength a,d Binary Logistic Regression Odds Ratio 95% CI P-Value Mortality Robust Pre-frail Frail Ref <

36 SOCIAL overlap with FRAIL and CHS SOCIAL 47/955 (4.9%) FRAIL 106/955 (11.1%) Social 3.0% 1.9% FRAIL 9.2% SOCIAL 36/872 (4.1%) CHS 93/872 (10.7%) Social 2.8% 1.4% CHS 9.3%

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38 Effects of Exercise in the Frail Theo et al, J Aging Res 2011 Increase functional performance Increase walking speed Increase chair stand Increase stair climbing Increase balance Decrease depression Decrease fear of falling Studies mostly 3 months Need at least 45 to 60 mins 3x a week 80% of 1 repetition maximum with 3 sets of 8

39 Effects of High-Intensity Progressive Resistance Training and Targeted Multidisciplinary Treatment of Frailty on Mortality and Nursing Home Admissions after Hip Fracture: A Randomized Controlled Trial Nalin A. Singh MBBS a, Susan Quine PhD b, Lindy M. Clemson PhD c, Elodie J. Williams BApplSc d, Dominique A. Williamson BApplSc d, Theodora M. Stavrinos d, Jodie N. Grady BApplSc d, Tania J. Perry BApplScOT d, Bradley D. Lloyd MSc d, Emma U.R. Smith PhD d, Maria A. Fiatarone Singh MD e,, Comprehensive Geriatric Assessment and 12 months resistance training twice weekly Mortality OR 0.19 ( ) Nursing Home OR 0.16 ( ) ADL s p <0.02 Assistive Device p<0.01

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41 Cochrane Review 2012 Woods, Aguirre, Orrell, Spector 15 trials, 407 treatment and 311 controls participants Length of intervention varied: 1 to 24 months MMSE difference at follow up = 1.74 points (Z = 5.57, p < ) Holden Communication Scale SMD = 0.47 (Z = 3.22, p = 0.001) Wellbeing/QoL SMD = 0.38 (Z = 2.76, p = 0.006) Depression (GDS) SMD = 0.34 (Z = 1.88, p = 0.06) No benefits to ADL, behaviour, or carers measures

42 CST trial: Other results Numbers needed to treat for cognition = 6 Cost-effectiveness (Knapp et al., 2006) CST is more cost-effective than usual activities using both outcome measures: Incremental cost-effectiveness ratio: per additional point on MMSE (111 euros), per point on QoL-AD (33.2 euros) Donepezil had considerably larger cost per incremental outcome gain (AD2000, 2004)

43 Cognitive Stimulation Therapy : NHC Nursing Home SLUMS Mental Status BIMS PRE POST

44 USA Nursing Home Trends Decreased movement to nursing homes (Assisted Living, Greenhouses, Home Care) MDS 3.0 PHQ-9 Decreased Transitions Hospice (end of Life) care Increased person center care Increased dependence on technology for care Enhanced rehabilitation

45 The Cloud improving diagnosis and Sleep monitors drug monitoring Monitor for sleep apnea Monitor for hypo/hypertension Monitor for falls

46 Exoskeleton : Paraplegia

47 The Companionable project

48 Is it time for geriatricians to teach about Robo Sapiens? Paro Harry Health Assistant Robot for Rich Years Aibo

49 Are Nursebots the Future?

50 Comprehensive Geriatric Assessment GEMU 1.68 ( ) Hospital 1.49 ( ) Home assessment 1.20 ( ) LIVING AT HOME Comprehensive geriatric assessment: a meta-analysis of controlled trials Stuck et al, Lancet 342:1032, 1993

51 Sustainable Long Term Care Focus on keeping seniors at home Screen regularly for FRAILTY (Physical, Cognitive, Social) Focus on preventing disability in this group (Exercise, CST, Geriatric Assessment) FUTURE: Introduction of ROBOTIC Care?

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