Understanding and Assessing for Frailty

Transcription

1 Understanding and Assessing for Frailty Dr Gloria Yu Clinical Head of Bexley Integrated Care Consultant Physician in Elderly, General and Stroke Medicine 8 July 2015

2 Learning objectives What is frailty? Understanding the importance of identifying frailty Assessment of frailty How to manage frailty

3 Clinical Definition of Frailty Clinical Syndrome of Frailty Symptoms / Phenotype Weakness Fatigue Anorexia Under nutrition Weight Loss Signs Physiologic changes marking increased risk Decreased muscle mass Balance and gait abnormalities Severe deconditioning Adverse Outcomes of Frailty Falls Injuries Acute Illnesses Hospitalisations Disability Dependency Institutionalization Death

4 Frailty is loss of Physiological Reserve (Frailty Syndrome presenting in Crisis)Clegg, Young Rockwood, Lancet 2013 FUNCTIONAL ABILITIES Minor illness eg UTI Independent Dependent Hyper-acute Frailty syndromes: Immobility Falls Delirium Fluctuating disability Incontinence

5 Epidemiology of Frailty(1) Population estimates for frailty: = 4% = 7% = 9% = 16% Over 85 = 26% Over 90 = 56% By 2030, the number of people over the age of 80, will have doubled. In the last decade, 40% of the increase in Emergency Admissions is in the over 65s age group. The rate of Emergency Admissions has grown faster in the older age group. By 2026, 3 million people will have three long term conditions.

6 Potential Causes of Frailty (1) Decline in function of multiple organ systems (due to aging) = enhance vulnerability to stressors Hypothalamic pituitary adrenal axis failure (central regulators of homeostasis) Decrease ability to terminate the adrenocortical response to stress; decrease hippocampal glucocorticoid receptors Prolonged poststress corticosterone elevation contribute to catabolic state

7 Potential Causes of Frailty (2) Decline of growth hormone levels Contribute to decrease protein synthesis and Muscle mass Decrease bone mass Diminish immunologic state Changes in immune system may be due to T cell dysfunction Increase lymphoproliferative disorder Susceptibility to infection Autoimmune disorders

8 Stages of Frailty (Speechly and Tinnetti 1991) There may be a transitional state between vigor and frailty. Earlier stage of frailty patient should be screened and interventions instituted If lack of full recovery after an illness Then: need for aggressive Rehabilitation after acute illness and Prehabilitation when surgery is anticipated. Late stage may not be reversible failure to thrive syndrome

9 Early Clues to Impending Frailty Weight loss Tiredness Low exercise tolerance Low level of physical activity Slow walking speed Signs of cognitive impairment or depression

10 Characteristics of hospitalised individuals with failure to thrive Mean age 79 Average of six diagnoses Symptoms similar to clinical syndrome of frailty Malnourished, dehydrated, skin ulcers, falls, pain, cognitive disabilities Very limited effective intervention 16% die during hospitalisation Berkman B. et al, Gerontologist, 1989

11 Primary Care Electronic Frailty Index (efi) Survival Plots

12 Community Frailty Screening (1) FRAILTY SCALE (circle one of the nine items) (2) ABBREVIATED MENTAL TEST- AMT ( correct answer scores one) <7/10 is dementia/delirium 1. Age 6. Recognition of two persons 2. Time to the nearest hour 7. Date of birth 3. Remember 42 West Street (ask at the end) 8. Year of First World War 4. Current year 9. Name of the Monarch 5. Name of local hospital 10. Count backwards 20 to 1 TOTAL /10

13 Cumulative Deficit Model of Frailty (Primary Care Electronic Frailty Index efi) Identifies frailty based on deficits 2000 GP Read Codes 36 deficits based on signs, symptoms, diseases, disabilities, abnormal test values Maximum FI = 0.7 efi : fit = mild = moderate = severe > 0.36

14 Electronic Frailty Index (efi) LONG TERM CONDITIONS 1. Skin Ulcer 2. CVA 3. Dizziness 4. Parkinson/Tremors 5. BP 6. IHD 7. AF 8. Heart Valve Disease 9. Syncope/Low BP 10. Heart Failure 11. Peripheral Vascular Disease 12. COPD Respiratory Disease 13. Peptic Ulcer 14. Urinary Disease 15. CKD 16. Osteoporosis 17. Fragility Fracture 18. Arthritis 19. Diabetes 20. Thyroid Problems 21. Falls 22. B12/ Folate/Ferritin or Anaemia Deficiency MOBILITY & FUNCTION 23. Memory Cognitive Problems 24. Sleep Problems 25. Visual Loss 26. Hearing Loss 27. Shortness of Breath 28. Anorexia/Weight Loss 29. Urinary Incontinence 30. Foot Problems 31. Mobility & Transfer Problems DRUGS Allergies NO YES Specify Polypharmacy YES NO SOCIAL HISTORY 33. Housebound 34. Activity Limitations efi Frailty Categories 35. Social Vulnerability 36. Requirement for Care 1. Fit (efi score ) = 0 to 4 deficits out of 36 listed deficits 2. Mild Frailty (efi score ) = 5 to 8 deficits 3. Moderate Frailty (efi score ) = 9 to 13 deficits 4. Severe Frailty (efi score > 0.36) = Over 13 deficits

15 Frailty toolkit for primary care Case finding tools and advice Frailty registers and Read codes Frailty screening Mini comprehensive geriatric assessment Care coordination Care planning Medication review in older people

16 Advantages of Comprehensive Geriatric Assessment Leads to the creation of an individual treatment plan by a multidisciplinary team Improved functional outcome Improved patient survival Less likely to be institutionalised Reduction in hospital LOS Reduction in readmission rates No increase in mortality Cochrane Database 2011, Ellis et al, BMJ 2011;343:d6553

17 Prevention of Frailty (1) Important to recognise the vulnerable and frail before adverse outcomes Recognise the components which are reversible Prevent adverse outcomes e.g. falls, medication side effects, pressure areas Increase physical activity to improve muscle strength, flexibility and exercise tolerance

18 Prevention of Frailty (2) Rehabilitation to prevent decline associated with prolonged bedrest due to illness or surgery Improve the quality of acute hospital care for the frail and elderly and prevent medical complications during admission Early detection of acute illness Medical treatment where possible in the community / home Improve nutrition Voluntary Sector Support Services Public Health messages about seeking medical attention early and not to ignore abnormal symptoms

19 Prevention of Frailty (3) Comprehensive Geriatric Assessment (CGA) Better community management pathways for Long Term Conditions and chronic problems e.g. Heart Failure COPD / respiratory problems End of life / Palliative Care Pain Weight loss Incontinence

20 How do we know efi is helping? (Outcome Measures / Quality improvements) Process measures: Nos. of frontline staff trained in the recognition & management of frailty Outcome Measures (patient centred) Patient and carer experience and satisfaction Place of death being as preferred Institutionalisation rates Reduction in excess bed days/delayed transfers of care Reduction in outpatient visits/secondary care referrals Reduction in primary care consultations Staff experience and satisfaction Reduction in patient harms Reduced avoidable unplanned admissions Reduction in OOH consultations in those aged >65 years still at home 91 days post-hospital discharge

21 Value of frailty as a predictor of health, outcome, care Planning For Patients Quality of life Social and financial implications Predictor of Survival (longer term outcomes) For Secondary / Tertiary Care Complications and need for specialist management Complex care needs, long LOS, bed blocking through poor management For Community / Primary Care / Commissioners Prediction of post-discharge needs Costs of managing complexities and frailty Unpredictable changes in management and outcome

22 Conclusion (1) Frailty is a common clinical syndrome in older adults that carries an increased risk for poor health outcomes including falls, disability, hospitalisation, and mortality The importance of identifying frailty as a potentially remediable contributory factor to morbidity and mortality Importance of identifying those at risk of hospital and care home admission

23 Conclusion (2) The need to identify through careful history and examination (CGA). The presence of factors contributing to frailty including cognitive and mood problems, mobility issues and weakness, weight loss and alcohol abuse Finally to create an individualised multidisciplinary care plan aimed at treating remediable elements and providing effective support and care

24 Thank you Dr Gloria Yu Clinical Head of Bexley Integrated Care Consultant Physician in Elderly, General and Stroke Medicine