Development of a Validated Enhanced Geriatric Assessment (ecga ) in a Primary Home-Based Interdisciplinary Practice"

Transcription

1 Development of a Validated Enhanced Geriatric Assessment (ecga ) in a Primary Home-Based Interdisciplinary Practice" Measuring Frailty in Primary Care Ted Rosenberg MD MSc FRCP (C) Fiona Manning MD MSc. FCFP (C) Clinical Assistant Professors Community Geriatrics Dept. of Family Medicine University of BC and Home Team Medical Services Victoria BC trosenberg@hometeammedical.ca fmanning@hometeammedical.ca

2 None to Declare Conflict of Interest

3 Learning Objectives Understand Frailty and ID Measures that may be used in Primary Care: Categorize level of Frailty for Elderly Patients using the CSHA Clinical Frailty Scale Be aware of other frailty Scales (Edmonton Frailty Scale, Study of Osteoporotic Fractures ) Identify and use 3 easy valid and reliable office tests to measure and track physical Frailty: Chair Transfers Grip Strength 4 meter Gait Speed Using 2 Case Examples to illustrate how measures of Frailty can be used to: To develop Goals of Care (GOC) Evaluate Patient Outcomes Learn about deployment of an enhanced frailty into a primary care home based practice: Frailty and Aging Cohort Study (Facts)

4 Case 1 Elderly Lady ( EL ) 88 year old Case Presentation Lives in Retirement home with 96 year old husband Medical Hx of Depression/anxiety, OA Lichen sclerosis Medications: Amitriptyline 50mg (1970) Oxazepam 30mg ( since Seconal taken off the market ) RFA : Slowly Brewing problems over past year, now Crisis: Severe Fatigue and unsteadiness Unable to get out of chair without husbands help Difficulty walking: slow to bathroom- incontinence Not able to get to elevator to go down for meals Difficulty bathing she and husband fell in shower Now Bird Bath at the sink Physical : Shuffling, Kyphotic, BP 164/62 sit and 122/58 stand Depressed by the prospect of having to leave Retirement home (GDS 4/5) Wt down to 91 lbs from 102, 2 years ago. BMI 19 Full labwork unremarkable : GFR 54, HGB 114, lymphocytes 0.6

5 Case Presentation Case 2 Middle Age Lad ( MAL ) 63 year old Male PMHX: OA knee- meniscal repair. Last seen in clinic 5 years ago. Habits: quit smoking Age 45, Has 2 glasses of wine per day. Occasional marijuana. 2 cups of coffee in a.m. to stay get going and stay alert Medications: RFA: Just announced Early Retirement as a teacher Exhausted and Chronically fatigued- depleted No Energy to work in evening and correct homework Sleep- Collapses at night but repeated awakenings and problems falling back to sleep in middle of night. Denies feeling depressed 1/5 on the sgds Sleeps most of Saturday problems keeping up with errands and housework Avid hiker- now finds he has trouble keeping up with wife while walking up hill in their neighbour hood Physical and Lab: BP 146/88; OA knee ; labs normal Wt slowly up 5lbs 210, BMI-31

6 4 components: Frailty Syndrome Loss of Organ Mass and Function from: Chronic diseases Injuries Ageing Causing Chronic Symptoms that may affect activities Leading to Loss of Function/ Disability Dependent IADL/ADL COPD/CHF- SOB/Fatigue- Weak Housework, walking Dementia- Cog Loss Dependant Meal Prep/Grooming Loss off Homeostatic Reserve for Acute illness and injury Eg UTI - Cystitis vs Delirium Flu Bronchitis vs. Pneumonia and CHF, Fall Fall Bruise vs. Hip # Key- VULNERABILITY

7 Prevalence of Frailty by Age 20-25% of people> % Frail Non Frail

8 Measuring Frailty CSHA Clinical Frailty Scale (CFS) Symptoms and Function 1-3- minimal symptoms 4- Symptoms 5- IADL 6-Partial ADL 7 All ADL 8- Approaching EOL Rockwood et al CMAJ ,

9 What are the CFS Scores What are the CFS Scores for: EL-? MAL-? What does their Score mean?

10 CFS Frailty Level Predicts Risk Death Institutionalization 1 point drop- 70 months 21% Mortality 23% - Institutionalization

11 Global Measure Measuring Frailty Limitations CSHA-CFS What does it tell us about individual patients? What does it tell us about individual problems Does it improve with interventions? Lacks Precision

12 Edmonton Frailty Scale 11 items, 2 performance based Predicts Surgical outcomes Rolfson, Darryl B., et al. "Validity and reliability of the Edmonton Frail Scale." Age and ageing 35.5 (2006):

13 Other Physical "Frailty Indices Study of Osteoporotic Fractures (SOF)- 3 Items Reduced energy- Do you feel full of energy - y/n Wt. Loss- 5% of body wt. (mean of 2 years) Chair Transfer 5x without arms Score for: El-? Mal-? Score: 0- robust 1- Pre-frail 2-3 -Frail Predicted: Falls Hip # Hospitalization Death Comparison of 2 Frailty Indexes for Prediction of Falls, Disability, Fractures, and Death in Older Women Kristine E. Ensrud, MD et al Arch Intern Med. 2008;168(4):

14 2 Other Frailty Measures

15 Gait Speed Measure 6 meter track in hallway/office Walk at comfortable speed Start when heel strikes over 1 meter/stop when heel strikes over 5 meter line 1 practice and then ave of 2 readings in m/s

16 Gait Speed Risk of Death Key cut point for risk: m/s Also Predicts: Hospitalization, Falls, Fracture Risk, Institutionalization and need for home supports.

17 Grip Strength (Using a Jamar Hand Dynamometer norms for Age and Gender) Leong, Darryl P., et al. "Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study." The Lancet (2015):

18 Our Patients Assessment CFS-activity, IADL, ADL SOF? Energetic most of time: y/n Wt. Loss 5% Chair transferx5 El CFS- 6 SOF-3 (Frail) Gait Speed 0.58 m/s Mal CFS- 4 SOF -1 (Prefrail) Gait Speed 1.0 m/s Measurements-5-7 minutes Grip strength- 9kg (m=20) Grip Strength 33kg (m=41) Kg

19 Frailty and Ageing Cohort Study (FACTS) N= 300 elderly people receiving home- based primary care from an interdisciplinary team in Victoria BC Add Enhanced Comprehensive Geriatric Assessment (ecga) using Standardized, Valid, Reliable Measures into usual care minutes Baseline 3 months after admission to practice Annually Goals Assist with individual Patient Assessment and Care Planning Evaluate Team Interventions Predict Risk Research about Frailty

20 Facts Health Outcomes that will be measured Deterioration in Quality of Life (QOL) Acute Health Care Utilization (hospitalization and emergency use) Nursing Home Placement Mortality Total Mortality Site of death (home, hospital, hospice, or facility) Type of death (e.g. Adv. Dementia, Frailty, Organ Failure, Metastatic Cancer, or Sudden Death) Risk Factors for: Infections (chest, urinary tract, or cellulitis) Falls and Injuries Chronic Pain Caregiver Burden

21 MMSE MOCA GDS Sleep (PSQI) <6 CFS EuroQol Wellness (DOW-6) Barthel Lawton Brody MNA>12 Gait Speed Grip Strength >30/20 BMI SBP GFR Lymphocyte Hgb Medications Hospital admissions Measuring Frailty and Health Multi Domains FACTS- Pilot Study Comparison of Patient to Population population patient X Rosenberg, Manning et al adapted AGS Posters 2016

22 El: Taper off Amitrip Start citalopram 10mg Oxazepam to 5mg Cog Behav/mindfulness for sleep Caffeine Nutrition-Boost PT/walking program Supports: AM Care Bed Rails/RTS/lift chair Our Patients Post- Interventions CFS- 6 El SOF-3 (Frail) Gait Speed 0.78 (0.54) m/s Grip strength- 14 (9) sgds- 1/5 (4/5) CFS- 4 Mal SOF -1 (Prefrail) Gait Speed 1.4 (1.0) m/s Grip Strength 39 (33) Kg sgds 0/5 (1/5) Mal: Wt loss 10lbs Kinesiologist Walking Program Cog Behav. Sleep Reduce ETOH DC Caffeine Rx Amlodipine 2.5mg QOL-?-EuroQol/SF12 Walk to Dining Room Stay in Retirement home QOL?-EuroQol/SF12 Train half Marathon

23 Conclusions Measures of Frailty in an Office Setting Frailty is a Syndrome that affects peoples QOL If someone has non specific symptoms- Fatigue, Don t feel well with negative medical/psyche work up: Simple Review of impact on Activity/ IADL/ADL- Estimate CFS If CFS >4: :Do you feel full of energy/wt loss / Chair transfers x estimate- SOF If SOF >1- Take more precise measurements that may change with interventions Gait Speed Grip Strength GDS? MOCA? QOL- SF12/EuroQol Establish Goals of Care and Health Directive

24 Comprehensive Interventions may Delay Progression of Frailty Reduce Risk Improve QOL Conclusions Interventions for Frailty Include: Medical and medication Review Nutritional Review Structured Exercise: Walking Program, Aerobic, Balance, Resistance Sleep improvement and stress reduction- CBT, mindfulness, Referrals Kinesiologist/Trainer PT OT Geriatric Team Equipment Medical Alert System Walker Lift Chair Billing- in BC. Frailty Planning Fee

25 Facts Study Stay tuned for Cross Sectional Results- Jan-Mar 2016 Annual results thereafter

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