Implementing frailty into clinical practice:

Transcription

1 Implementing frailty into clinical practice: Why has frailty not been operationalized? As a disease/syndrome? As a health promotion/prevention strategy? Pr Bruno Vellas M.D, Ph.D Gérontopôle UMR INSERM 1027 University of Toulouse

2 Implementing frailty into clinical practice: Strength and weakness 1. Rational for implementing frailty into clinical practice 2. Why has frailty not been operationalized? As a disease/syndrome? 3. Implementing frailty into clinical practice by the Toulouse Gérontopôle

3 Prevalence of dependency/disability: between M from 2010 to 2040 World Alzheimer Report ADI 2013

4 Older Adults Robust 50% > 65 yrs Frail and Pre-frail 40% > 65 yrs Reversible Unvoluntary weight loss, Fatigability, Muscular weakness, Slow gait speed, Low physical activity/inactivity Dependent 5-10% > 65 yrs Nursing home Dependent for basic daily activities

5 NMAPS Results: Above: (Younger transition matrix - 60 age 78 years) Below: Older Normal Speed low 1 3MSE low Both low Normal Speed low MSE low Both low 3.25 Normal Speed low MSE low Both low Normal Speed low MSE low Both low 3

6 2. Why has frailty not been operationalized? As a disease/syndrome? Was not the priority until now. Geriatric medicine was born 40 years ago with long-term care policy In the past all was built to take care of dependency, not to prevent it: nursing home payment policy By definition frail older persons are not pro-active. Same for their caregiver, if any Change habits, it is much easier for a medical practitioner to wait for patients being admitted to an emergency unit and then to the geriatric ward No drug industry Very few studies are based on clinical practice, few R.C.T but...

7 3. Implementing frailty into clinical practice by the Toulouse Gérontopôle 1. The Frailty clinic, Day Hospital 2. Frailty screening in the community with city hall 3. Frailty into family practitioner s office 4. Frailty after an emergency call (911) 5. Frailty screening with retirement plan

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9 Gérontopôle Frailty Screening Tool Frailty screening Older patients 65 yrs +, not dependent (ADL >= 5 /6) YES NO UNKNOWN Is your patient living alone? Unvoluntary weight loss in the past 3 months? Fatigability during the last 3 months? Mobility difficulties for the last 3 months? Memory complaints? Slow gait speed (+ 4s for 4 meters? ) If yes to at least one of these questions: In your own clinical opinion, do you feel that your patient is frail and at an increased risk for further disabities? YES NO If yes, kindly propose to the patient an assessment of the causes of frailty and prevention of disabilities in a day hospital.

10 Recommendations from HAS (French health authority)

11 3. Implementing frailty into clinical practice by the Toulouse Gérontopôle 1. The Frailty clinic, Day Hospital 2. Frailty screening in the community with city hall 3. Frailty into family practitioner s office 4. Frailty after an emergency call (911) 5. Frailty screening with retirement plan

12 93.6% of older adults referred to the Gérontopôle Frailty Clinic are frail or pre-frail

13 Description of 1108 older patients referred to the Gérontopôle Frailty Clinic (JNHA 2014)

14 Descriptive data of 1108 older adults referred to the Gérontopôle Frailty Clinic (JNHA 2014) Geriatric Assessment n=1108 Age (yrs), n= ,9 ± 6,1 Sex (female), n= (61,9%) BMI (kg/m²), n=698 25,9 ± 5,1 Onco-geriatric, n= (20,9%) Vit D (ng/ml), n= ,1 ± 11,3 MMSE/30, n= ,6 ± 4,9 MIS/8, n=1038 6,6 ± 1,9 ADL/6, n=1102 5,5 ± 1,0 IADL/8, n=1094 5,6 ± 2,4 SPPB/12, n=1063 CDR/3, n=1039 SPPB/12 (mean) 7,3 ± 2,9 (SPPB 10) 272 (25,6%) (7 SPPB 9) 388 (36,5%) (SPPB 6) 403 (37,9%) CDR=0 353 (34,0%) CDR=0,5 531 (51,1%) CDR=1 111 (10,7%) CDR 2 44 (4,2%) Frailty Assessment n=1108 Fried/5, n=1082 2,64 ± 1,4 Fried/5, n=1082 Robust (0 criteria) 69 (6,4%) Pre-frail (1-2 criteria) 423 (39,1%) Frail (3-5 criteria) 590 (54,5%) Unvolontary weight loss (yes), n= (32,6%) Weakness, n= (32,6%) Gait speed, n=1065 Mean (m/s) 0,78 ± 0,27 < 1m/s 814 (76,4%) <0,8m/s 547 (51,4%) Grip strength (kg), n= ,3 ± 8,2 Sedentarity (yes), n= (60,7%) Alone at home (yes), n= (42,5%) Help at home (yes), n= (69,4%) Help at home (yes), n= (52,0%) APA (yes), n= (17,2%)

15 Descriptive data of 1108 older adults referred to the Gérontopôle Frailty Clinic (JNHA 2014) Geriatric Assessment n=1108 Vision far (abnormal), n= (82,4%) Interventions: Personalized Care and Prevention Plan n=1108 Vision Vision near (abnormal), n= (22,3%) Amsler (abnormal), n= (16,7%) New medical conditions (yes), n= (54,6%) HHIE-S/40, n=1055 9,5 ± 9,8 Audition Disability (HHIE-S >21), n= (31,3%) MNA/30, n= ,2 ± 4,1 Special advice (dentistry, ORL, ophtalmo, urology) (yes), n= (48,3%) (MNA>23,5), n= (52,5%) Nutrition At risk of malnutrition (17 MNA 23,5), n= (39,5%) Change in drug prescription (yes), n= (32,8%) Urinary incontinence Undernutrition (MNA< 17), n= (8,0%) Incontinence scale/6, n=280 1,7 ± 1,4 Daily problem (score 1), n= (76,8%) Depression GDS/15, n=424 4,8 ± 3,1 History of falls n= (37,9%) Nutrition intervention (yes), n=1105 Physical activity intervention (yes), n=1101 Social intervention (yes), n= (61,8%) 624 (56,7%) 284 (25,7%)

16 Frailty clinics Most of the physicians, healthcare professionals, policy makers were not aware about frailty We had to educate them, explain the concepts in a very simple way After 2 years, we succeeded ( subjects) with some enormous efforts, and my personal involvement on a daily basis, explanation to the care payer (cost 500 Euros) How is it translatable?

17 3. Implementing frailty into clinical practice by the Toulouse Gérontopôle 1. The Frailty clinic, Day Hospital 2. Frailty screening in the community with city hall 3. Frailty into family practitioner s office 4. Frailty after an emergency call (911) 5. Frailty screening with retirement plan

18 Frail Non-Disabled (FIND) questionnaire Domain Questions Answers Score Disability A. Have you any difficulties in walking 400 meters? a. No or some difficulties b. A lot of difficulties or unable 0 1 B. Have you any difficulties in climbing up a flight of stairs? a. No or some difficulties b. A lot of difficulties or unable 0 1 Frailty C. During the last year, have you involuntarily lost more than 4.5 kg? a. No b. Yes 0 1 D. How often in the last week did you feel than everything you did was an effort or that you could not get going? a. Rarely or sometimes ( 2 times/week) b. Often or almost always ( 3 or more times per week) 0 1 E. Which is your level of physical activity? a. Regular physical activity (at least 2-4 hours per week) 0 b. None or mainly sedentary 1 If A+B 1, the individual is considered "disabled". If A+B=0 and C+D+E 1, the individual is considered frail. If A+B+C+D+E=0, the individual is considered robust. Cesari M et al. PLOS ONE 2014;9(7):e101745

19 Frailty screening in the community: City of Cugnaux: inhabitants 75 yrs +: subjects, response 44% (611) yrs: 600 subjects, response 19% (111) Frail and pre-frail: 298, 124 (42%) got complete frailty assessment and intervention program Almost 30% of the frail and pre-frail subjects Cost: Euros Extended to the Toulouse urban area, 1 million people

20 3. Implementing frailty into clinical practice by the Toulouse Gérontopôle 1. The Frailty clinic, Day Hospital 2. Frailty screening in the community with city hall 3. Frailty into family practitioner s office 4. Frailty after an emergency call (911) 5. Frailty screening with retirement plan

21 Frailty assessment in family practitioner s office

22 Study process Older patient in General Practitioner s consultation Patient with cognitive complaint or Frailty sensation 16 GP s offices around Toulouse Consultation with a nurse Medical history, comorbidities, treatments, weight, vision, audition, lifestyle, home support, Evaluation MMSE WMS-R Mini-GDS Fried criteria MNA SPPB ADL IADL Summary, propositions of recommendations and orientation proposed by the GP 22

23 Implementing frailty into family practitioner s office (N=375) Female: 62.3% Age: 81.0 ± 6.4 yrs (65-74: 15.7%, 75-84: 51.1%, 85 +: 33.2%) Comorbidities: 2.8 ± 1.6 Treatments: 3.7 ± 1.9 ADL/6: 5.8 ± 0.2, IADL/8: 6.9 ± 1.5 Fall in the last 3 months: 24% Frailty: Robust: 23.9%, Pre-frail: 45.1%, Frail: 31% MMSE/30: 25.1 ± 4.2 SPPB/12: 9. ± 2, SPPB<10: 48.1% 23

24 Family practitioner s office Not so easy 50% OK, space, not interested The process is currently undergone in 20 family physician s offices, once a month Most of these patients will not have accepted to go to the hospital Able to identify what is really the main problem for the frail older adults

25 3. Implementing frailty into clinical practice by the Toulouse Gérontopôle 1. The Frailty clinic, Day Hospital 2. Frailty screening in the community with city hall 3. Frailty into family practitioner s office 4. Frailty after an emergency call (911) 5. Frailty screening with retirement plan

26 Descriptive data Typology Cugnaux SAMU Nb Women 95 (69,9%) 56 (73,7%) Age 79,9 ± 5,4 85,8 ± 6, yrs 22 (16,2%) 5 (6,9%) yrs 85 (62,5%) 24 (33,3%) 85 yrs 29 (21,3%) 43 (59,7%) Comorbidity 3,0 ± 1,4 3,0 ± 1,4 Number of medications 4,2 ± 2,5 6,2 ± 3,0 ADL (0-6) 5,8 ± 0,5 4,6 ± 1,2 IADL (0-8) 6,9 ± 1,7 3,6 ± 2,2 Falls in the last 3 months 24 (17,6%) 62 (82,3%) Fried 1,9 ± 1,2 3,4 ± 0,9 Robust 19 (14 %) 0 (0 %) Pre-frail 74 (54,4 %) 10 (13,3 %) Frail 37 (27,2 %) 31 (41,3 %) Dependent 6 (4,4 %) 34 (45,3 %) MMSE (0-30) 25,3 ± 4,5 19,3 ± 8,5 SPPB (0-12) 8,7 ± 2,9 3,3 ± 2,5 SPPB < (50,7%) 63 (84,0%)

27 3. Implementing frailty into clinical practice by the Toulouse Gérontopôle 1. The Frailty clinic, Day Hospital 2. Frailty screening in the community with city hall 3. Frailty into family practitioner office 4. Frailty after an emergency call (911) 5. Frailty screening with the retirement insurance scheme

28 Frailty screening with the retirement insurance scheme CARSAT (National health and retirement scheme) A.P.A.(Social allowance for personalized autonomy) Set up frailty assessment and provide appropriate interventions by a trained nurse practitioner Target the population that needs help Just starting now, it took 2 years to get all the authorizations from these large public institutions

29 Implementing frailty into clinical practice: TARGETED, STRONG, SUSTAINED INTERVENTION Targeted Strong Sustained

30 Strong and sustained intervention Ability to find a cause: - 50% reported at the frailty clinic, less in home visits Direct connection with paying institutions Precision medicine for frailty and pre-frail? How to bring the frail to intervention? Not easy as few use new technologies Future for the pre-frail? P4 Medicine Pro-active Precision Participatory (wellness) Personalized (e-platform) IHU Project

31 P4 Medicine / Modern medicine P4 Medicine Pro-active, predictive Individual, precision medicine Wellness & diseases Personalized data clouds Personalized data clouds for clinical trials Modern medicine Reactive Population Only diseases Average patient population Average patient population for clinical trials

32 Our health determinants Healthcare: 10% Genetic: 30% Behavior environnment: 60%

33 Precision medicine for pre-frail and for intrinsic capacities