Define frailty Recognise the consequences of frailty Know why CGA important and what are the main components of a CGA that can be done in an initial

Transcription

1 Dr Kyra Neubauer

2 Define frailty Recognise the consequences of frailty Know why CGA important and what are the main components of a CGA that can be done in an initial assessment Understand what are potential reversible causes of frailty Understand medicine rationalisation in frailty

3 Between % of patients on the acute take are frail older adults 10% >65s frail 25-50% of>85s (women>men) 35-75% frail older adults are in patients within an acute trust at any one time Over 80 s take 31% of all bed days in hospital LOS goes up with increasing age and increasing frailty 30% of >65s who are admitted to hospital are dead within 12 months

4 >2.2 million 60+s emergency admissions 2012/13 cost 3,4 billion 47% admissions >65 Average spending on older peoples services in Trusts/LHBs 3.6% (1-7%) of total Geriatricians 3.6 % of workforce

5 Definition of frailty The core feature of frailty is increased vulnerability to stressors due to impairments in multiple, interrelated systems that lead to decline in homeostatic reserve and resiliency The main consequence is an increased risk for multiple adverse health-related outcomes (progression of disease, falls, disability, and premature death). Around 10% of >65s are frail, 25-50% of >85s

6 Phenotype model unintentional weight loss, reduced muscle strength, reduced gait speed, self-reported exhaustion and low energy expenditure Cumulative deficit model Rockwood, Canada -accumulation of deficits; symptoms e.g. loss of hearing or low mood and signs such as tremor, through to various diseases such as dementia, which can occur with ageing, which combine to increase the frailty index

7 Inability to perform one or more basic ADL in the three days A stroke in the past 3/12 Depression and Dementia A history of falls or difficulty mobilising One or more unplanned admissions to hospital in the past 3/12 Malnutrition and unexplained weight loss Incontinence In receipt of a POC or in care home Multiple co-morbidities Reduced walking speed sarcopenia

8 Falls/ collapse Immobility/ sudden change in mobility Delirium/ sudden worsening of confusion in someone with previous dementia or known memory loss). Incontinence and new onset or worsening of urine or faecal incontinence). Susceptibility to side effects of medication e.g. confusion with codeine, hypotension with antidepressants

9 It is a marker for physical and cognitive decline It is a predictor for death It enables better long term planning for patients It allows for appropriate treatment, which includes the avoidance of over-treatment Recognition allows possible reversible causes to be addressed

10 Electronic frailty index- cumulative deficit model (36 in total) Rockwood clinical frailty index PRISMA 7 Questionnaire - which is a seven item questionnaire to identify disability A score of > 3 is considered to identify frailty. Gait speed)- usually over 4m Timed up and go test the time taken in seconds to stand up from a standard chair, walk a distance of 3 metres, turn, walk back to the chair and sit down. Self-Reported Health 'How would you rate your health on a scale of 0-10'. A cut-off of < 6 was used to identify frailty. GP assessment - clinical assessment. Polypharmacy - frailty is if the person takes five or more medications.

11 Electronic Frailty Index Five-year Kaplan Meier survival curve for the outcome of mortality for categories of fit, mild frailty, moderate frailty and severe frailty (internal validation cohort).e Andrew Clegg et al. Age Ageing 2016;ageing.afw039 The Author Published by Oxford University Press on behalf of the British Geriatrics Society.

12 Evidence for Comprehensive geriatric assessment in combination with MDT management on COTE wards early coordinated discharge planning and integrated multidisciplinary care to support community reablement integration of services with multi-agency management across primary, secondary care, health and social care Emergency departments delivering services for older people by aligning Emergency Physicians with Geriatricians and multidisciplinary teams

13 Components Medical Assessment Assessment of functioning Psychological assessment Social assessment Environmental assessment Elements Problem list Co-morbid conditions and disease severity Medication review Nutritional status Basic activities of daily living Instrumental activities of daily living Activity / exercise status Gait and balance Mental status (cognitive) testing Mood / depression testing Informal support needs and assets Care resource eligibility / financial assessment Home safety Transportation and tele-health

14 Twenty-two trials evaluating 10,315 participants who underwent CGA in six countries were identified. more likely to be alive and in their own homes at up to six months P = and at the end of scheduled follow up (median 12 months) P = when compared to general medical care. Were less likely to be institutionalised P < less likely to suffer death or deterioration P = more likely to experience improved cognition in the CGA group P = Less likely to be readmitted NNT for patients to be alive and in their own home at 1 year =33.

15 Ask about Falls/ mobility Continence Cognition/ mood Medicine reconciliation including concordance Social support Check walking speed/tugt Observation/examination for signs of neglect/ weight loss/sarcopenia Clock test

16 Consider physical activity-resistance/balance exercises Increase protein/total calories. Vit D supplements. Weight loss Pain management Look for treatable causes and management of continence Investigation, advice and support around cognition and mood STOP/START. Alcohol advice Personalised shared care and support plan, Advanced care planning

17 Polypharmacy increasing about 21% patients in Scotland medications EQUIP prescribing error rate 9% in hospitals and 1.7 million serious errors /year in General Practice % of patients take new medication as prescribed, have no SEs and adequate info. 10/7 after starting medication 1/3 rd patients non-adherent High levels of inappropriate prescribing Risks of prescribing errors increase 16%/each new medication NSAIDs, antiplatlets and anticoagulants and diuretics commonest Potentially serious drug-drug interactions in 13% patients ADR 6.5% of hospital admissions

18 STOP START Beers criteria Pragmatism and real life evidence Risk/ benefits Knowledge of physiology of ageing Patient choice and patient circumstances

19 Hypoglycemic medication Antihypertensives Statins Biphosphonates Diuretics Quinine-limited benefit/ fatalities Anticholinergics be aware of ACB scale PPIs Drugs for vertigo Antidepressants Analgesia Hypnotics

20 Cholesterol treatment Trialists meta-analysis =reduction in cardiovascular events >75 Cochrane review of primary prevention of ASCVD= safe and effective in >75 Prospective study of Pravastatin in elderly at risk RCT in Benefits NNT 45 over 2-3 yrs NNT 10 over 10 yrs Risks Increases diabetes for every 134 vasc. Events/deaths prevented 54 new DM 10-25% incidence of myalgia and weakness Memory impairment?

21 NNT for secondary prevention NNT for hip fractures100, NNT wrist fractures between better for vertebral fractures although trials included asymptomatic fractures. Risks atypical fractures, GI side effects and osteonecrosis of the jaw

22 1 point Haloperidol Quetiapine Mirtazapine Paroxetine Trazodone Ranitidine Furosemide 2 points Clozapine Nortriptyline Baclofen Cetirizine Loratadine Cimetidine Loperamide Prochlorperazine 3 points Chlorpromazine Amitriptyline Imipramine Chlorpheniramine Hydroxyzine Oxybutynin

23 Lives alone. Visited by niece weekly no formal POC. Neighbour supports. Neighbour requests visit as she has fallen 3x in last two weeks. On last occasion she was unable to rise unaided. She has hypertension, angina and osteoporosis She is on Bendroflumethazide, Digoxin, Ramipril, Simvastatin, Nicorandil, Bisoprolol, Codeine, Alendronic acid and colecalciferol. She is confused and disorientated

24 What else do you need to know? What do you want to do? What do you need to consider for the future?

25 Lives in sheltered housing. Presenting with signs of a lobar pneumonia Family give history decline in mobility and cognition over last 12/12 Several falls in last 4/52 Has been admitted to hospital 3 times in last 6/12 Family report intermittent choking on food and fluids and weight loss of 1 stone in 3/12

26 What are the issues? What do you want to do? What do you tell the family?

27 Frailty is important prognostic marker Addressing frailty allows for improved QOL, avoidance of inappropriate treatment and better joint planning Rationalisation of medicine reduces ADR, improves outcomes and reduces unnecessary costs ANY QUESTIONS?