FRAILTY: irremediable dependence for activities of daily living SUNSHINERS: WHAT S WRONG. What s a SUNSHINER?
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1 SUNSHINERS: WHAT S WRONG With Health Care of Older People? Dr. John Sloan Clinical Professor Division of Community Geriatrics Department of Family Practice University of British Columbia,Vancouver, BC FRAILTY: irremediable dependence for activities of daily living What s a SUNSHINER? FRAIL, plus: I don t want to be a burden on the people I love. I care more about being comfortable than I do about living longer. I don t want to take medication (unless I really need it). I don t want to go to the hospital (unless I really need to). SUNSHINERS are frail elderly who have made a critical decision about their future. The SYSTEM S PRIORITIES 1. Prevention 2. Rescue 1
2 First, Are PREVENTION and RESCUE what frail Sunshiners want and need? LET S REVIEW THEM Prevention Doesn t Work if you re Frail FOUR GOOD REASONS WHY NOT EVERYBODY S DIFFERENT example: kidney function 1. No prediction in the unpredictable Creatinine clearance age DIFFERENCE UNPREDICTABILITY YOU CANT PREDICT for someone who is UNPREDICTABLE 2
3 FOUR GOOD REASONS WHY NOT MULTIPLE PATHOLOGY 2. NO FRAIL IN TRIALS illness AGE The QUORUM EPIPHANY Clinical trial exclusion criteria are unbelievably comprehensive Trials have EXCLUSION CRITERIA You CAN T DO studies to support prevention in frailty FOUR GOOD REASONS WHY NOT 3. LIMITED CHANCE OF BENEFIT 4. OFFSETTING DANGER Bottom Line: FRAILTY lives in an EVIDENCE-FREE ZONE 3
4 WHAT ABOUT RESCUE? What about RESCUE? FRAILTY DYNAMICS The Slippery Slope capability illness FRAILTY DYNAMICS The Slippery Slope FRAILTY DYNAMICS Natural History capability function illness time FRAILTY DYNAMICS REAL Natural History function CRISIS in FRAILTY Small change in health, big change in function She can t get down for meals, so we just can t cope. time The crisis is a crisis of FUNCTION 4
5 How does the system RESPOND to that kind of crisis? ATTEMPT RESCUE! 911 Typical Hospital Course (a true story) ( the only light on at 3 am) Admitted to medicine Treated with antibiotics Confused and noisy day 3 Diarrhea day 4 Climbs over side rail, breaks arm day 5 Hospital Course (cont d) SPECIALISTS (cardiology, infectious disease, wound nurse, swallowing-evaluation OT, geriatric psychiatry, rheumatology, alternate-care-level manager) 11 medications day 15 Low blood pressure and not speaking day 18 Family declines ICU dies day 21 PREVENTION = DRUGS RESCUE = HOSPITAL 5
6 AND Predictors of Hospitalization Previous admission Morbidity ( health needs ) Depression Alcohol Eating problems, weight loss Walking, Timed Manual Performance Cognitive impairment Caregiver dissatisfaction Distance from the hospital Reducers of Hospitalization DOES HOSPITAL HELP? Multidisciplinary program Rapid access to home-based service GP hospitals (Norway) Access to home psychiatric services MD visits Randomized trial home versus hospital: no difference. Caplan G et al. Hospital in the home: a randomised controlled trial. MJA 1999;170: Tell me something I don t know 1. Frailer: likelier to have a crisis and go to hospital, less likely to get out. 2. More support: less likely to have a crisis and go to hospital. 3. Hospital doesn t improve outcome. A LITTLE HOME- GROWN EVIDENCE Home VIVE program Vancouver Three physicians, one nurse About 250 patients Average age 85 All homebound 6
7 Emergency Admissions When we ask, 131 patients compared before and after Total Visits Prevented: 74 SOURCE: Dr. Reva Adler, Program Director What does a sunshiner want? WHAT SHE FEARS WHAT SHE WANTS INTOLERABLE SYMPTOMS BEING A BURDEN TERRIFYING FUTILE HOSPITAL EXPERIENCE 1. Keep me comfortable 2. Keep me functioning 3. Don t abandon me 4. Let me make the DECISIONS OKAY, WHAT SHOULD WE DO? 1. IDENTIFY THE FRAIL (AND THE SUNSHINERS) How do you feel about MEDICATION? HOSPITAL? BEING A BURDEN? 7
8 2. HAVE the tough conversations ADVANCE DIRECTIVES Advance directives Caregiving contract KISS ADVANCE DIRECTIVES 2 ADVANCE DIRECTIVES 3 Just Two Questions: ARE YOU A SUNSHINER? comfort and function priority want to stay home not keen on medication Comfort versus prolonging life? Substitute decision-maker? 3. Do Their Care at HOME not office PRIMARY care A Team, not just a nurse or a doctor 24/7 Flexible caregiver Support THE DOCTOR AND HOME CRISIS 1. You CAN assure comfort 2. SUPPORT FUNCTION 3. Your chance of curing major event is SMALL but about equal to hospital s 4. Share these expectations 5. ALLEVIATE the burden of treatment 8
9 4. Integrate Services for Frailty BUT FIRST CHANGE THE MINDSET About hospital default in crisis About preventive meds About primary care at home About integration and responsibility sunshiners.ca 9
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