Malnutrition & Frailty in Pre- & Postoperative Seniors Project Overview

Transcription

1 Malnutrition & Frailty in Pre- & Postoperative Seniors Project Overview Ava John-Baptiste, PhD Assistant Professor, Departments of Anesthesia & Perioperative Medicine, Epidemiology & Biostatistics, Interfaculty Program in Public Health Parkwood Institute, St. Joseph s Health Care London October 12, 2018

2 Goals 1. Outline the challenges associated with the perioperative care of older adults 2. Discuss frailty and malnutrition in the perioperative care of older adults 3. Provide an overview of research in development 4. Invite audience contribution

3 Geriatric Surgical Patient Optimal Preoperative Assessment 1. Cognitive/behavioral disorders 2. Cardiac evaluation 3. Pulmonary evaluation 4. Functional/performance status 5. Frailty 6. Nutritional status 7. Medication management 8. Patient counseling 9. Preoperative testing Best Practice Guidelines, American College of Surgeons National Surgical Quality Improvement Program (NSQIP)/American Geriatrics Society (AGS)

4 Why is frailty important? Frailty is a common clinical syndrome in older adults that has biological underpinnings 1 A patient health state associated with getting older; involving multiple serious health issues that increase an individual s vulnerability for extended acute care or end-of-life care 2 Frailty independently predicts adverse health outcomes falls, incident disability, hospitalization, and mortality (beyond age, sex, comorbid disease and disability) Preliminary evidence suggests interventions such as perioperative frailty assessment, multi-disciplinary care and pre-habilitation may improve outcomes 1. Xie et al. Clin Geriatr Med Feb; 27(1): Clegg et al. Lancet 2013 March:9868 (381):

5 From: Initial Manifestations of Frailty Criteria and the Development of Frailty Phenotype in the Women's Health and Aging Study II J Gerontol A Biol Sci Med Sci. 2008;63(9): doi: /gerona/ J Gerontol A Biol Sci Med Sci Copyright 2008 by The Gerontological Society of America

6 How is frailty measured? Frailty measures can be categorized into the following types: i. Multidimensional frailty indices (e.g. Fried phenotype, Edmonton Frail Scale) Dimensions: Cognition, Mobility, Nutrition, Physical performance ii. iii. iv. Single-item performance measures (e.g. Grip strength, Timed Up and Go, Chair rise) Serum/biological markers (e.g. albumin) Accumulated deficits (e.g. Canadian Study of Health and Aging Frailty Index, administrative database algorithms) v. Disability-based measures (e.g. Clinical Frailty Scale, Activities of Daily Living) vi. Comprehensive geriatric assessment

7

8 Perioperative Malnutrition Malnutrition includes both the deficiency and excess (or imbalance) of energy, protein and other nutrients 1 Undernutrition is the inadequate intake of energy, protein and nutrients, that affects body tissues, functional ability and overall health Prevalence of malnutrition in adults admitted to Canadian hospitals, who stay more than 2 days, is 45% 1 Malnourished patients stay approximately 3 days longer in hospital than nourished patients 2 In 2012 dollars longer hospital length of stay cost approximately $ $2000 per malnourished patient 2 1. Canadian Malnutrition Task Force (CMNT) Acute Care Guidelines 2. Curtis et al. Clin Nutr Oct;36(5):

9 Canadian Malnutrition Task Force (CMNT) Acute Care Guidelines

10 Nutrition Pathway Determination of a nutrition care plan by a Registered Dietitian Hospital staff (from nursing unit and food/nutrition services) provide patient-focused mealtimes; treating food as medicine National standard menu planning promoting quality, nutrient dense food meeting diverse nutritional and cultural needs Hospital administrators, physicians, nurses and allied health professionals integrate nutrition care as standard interprofessional practice Oral nutrition supplementation, enteral nutrition and parenteral nutrition are used appropriately to prevent and/or treat malnutrition Canadian Malnutrition Task Force (CMNT) Acute Care Guidelines

11 RESEARCH DEVELOPMENT

12 Projects 1. Retrospective data analysis 2. Prospective quality improvement study

13 PROJECT 1: PERIOPERATIVE STUDY OF NUTRITION AND FRAILTY IN OLDER ADULTS A RETROSPECTIVE ANALYSIS

14 Proposal Purpose: measure the prevalence of malnutrition and frailty and estimate the degree to which these factors are associated with poor outcomes Population: Cohort A: Adults age 65 plus, seen in the LHSC pre-admission clinic between November 2017 and March 2018 Cohort B: Subset who underwent elective surgery within 3 months Methods: Retrospective cohort analysis using linked administrative and health care databases Exposures: Malnutrition (CNST), Frailty (accumulated deficits) Outcomes: Composite measure of in-hospital mortality, complications, admission to ICU; Cost

15 Database Linkage Surginet Query CNST ADL Discharge Abstract Database Surgical Admission/Discharge Dates Urgent/Emergent National Ambulatory Care Database Ambulatory care visit Type Duration Consults Cerner Query Age Sex/Gender Medications English Proficiency Transfusion Laboratory Database Transfusion: RBC Fresh frozen plasma Platelets Case Cost Database Patient Level Case Cost Laboratory/Diagnostic Tests Nursing Overhead

16 PROJECT 2: QUALITY IMPROVEMENT ENHANCED SCREENING AND CARE IN THE PREOPERATIVE SETTING

17 Study Design (In Development) Purpose: enhance the identification of malnutrition and frailty in older adults scheduled to undergo elective surgical procedures; provide evidence-based interventions to improve perioperative outcomes Population: Adults age 65 plus, scheduled for elective surgeries (Type: not yet determined), seen in the LHSC pre-admission clinic Intervention: Screen for malnutrition +?Subjective Global Assessment?low levels of Vitamin B12?low iron levels Screen for frailty using a validated tool

18 Study Design (In Development) Intervention: Multidisciplinary, collaborative care involving dieticians, nursing, surgery, geriatrics, anesthesia, social work and allied health with the goal of perioperative health optimization Provide resource materials on improved nutrition, increased protein intake Prescribe a nutritional hydroxyl beta-methylbutyric (HMB) supplement Refer to family physician, community dietician or family health team dietician Provide information on community resources to enhance Outcomes: Knowledge/Behaviour, Composite in-hospital outcomes, Readmission

19 Feedback How do our research plans link to existing or planned quality improvement initiatives? How can our study design be improved? What are the opportunities for collaboration on this and related initiatives?

20 Acknowledgements Funding Sources SWAHN Contributors Academic Medical Organization of Southwestern Ontario (AMOSO)

21 SWAHN Nutrition Project Team Dr. Janet Madill, Co-Chair (SW LHIN region) Ms. Christine Wellington, Co-Chair (ESC LHIN region) Ms. Helaina Huneault Ms. Joelle Jean Ms. Julie LeBlanc Dr. Peter Lemon Ms. Michele MacDonald-Werstuck Dr. Cynthia Richard Ms. Sylvia Rinaldi Ms. Coraine Wray Ms. Catherine Joyes

22 SWAHN Nutrition Research Project Team Dr. Davy Cheng, Lead, SWAHN KGT Stream Ms. Rebecca Donnelly Dr. Suzanne Flier Ms. Dianne Gaffney Dr. Janet Martin Ms. Celine Norrington Dr. Emil Schemitsch Dr. Homer Yang Mr. Tianmin (Tommy) Zhang Ms. Emily Dawson

23