FRAILTY SCREENING & EMERGENCY DEPARTMENT: CYRILLE LAUNAY, MD, PHD DEPARTMENT OF MEDICINE UNIVERSITY HOSPITAL OF LAUSANNE MONTREAL, 2018/21/04
CONFLICTS OF INTEREST No potential conflicts of interest
HOSPITAL CARE & EDS Emergency Rooms (ERs) have become the gateway for hospital admission of patients Assimilated as acute care The Emergency Rooms (ERs) are in crisis: More and more older patients (20% of frail elderlies in ERs) Crowding, delays and diversions have increased to epidemic proportions
FRAILTY / IMPACT ON HEALTH CARE SYSTEM Emergency Rooms issues in geriatric care: Heterogeneous health & functional conditions: atypical presentation Delays in diagnosing geriatric syndroms (delirium, frailty ) 25% leave ER with no definite diagnosis Suggest the presence of non-medical problems Frailty contributes to the dynamic progression from robustness to functional decline and predisposes to: Hospitalization Slow or incomplete recovery (prolonged length of hospital stay) Institutional placement Death
FRAILTY / IMPACT ON HEALTH CARE SYSTEM Emergency Rooms issues in geriatric care: Heterogeneous health & functional conditions: atypical presentation Delays in diagnosing geriatric syndroms (delirium, frailty ) 25% leave ED with no definite diagnosis Suggest the presence of non-medical problems Frailty contributes to the dynamic progression from robustness to functional decline and predisposes to: Hospitalization Slow or incomplete recovery (prolonged length of hospital stay) Institutional placement Death MOST HEALTH CARE SYSTEMS ARE NOT PREPARED TO MEET THE ISSUES & CHALLENGES OF FRAILTY
FRAILTY / EMERGENCY ROOMS Poor accuracy of clinical judgement* to identify frailty *conclusion about a patient s needs, concerns or health problems Frailty screening is not routine in ERs Few risk assessment measures delays to provide interventions Screening tools may improve identification of previously undetected geriatric conditions by 30% in ERs
FRAILTY / EMERGENCY DEPARTMENT Poor accuracy of clinical judgement* to identify frailty *conclusion about a patient s needs, concerns or health problems Frailty screening is not routine in ERs Few risk assessment measures delays to provide interventions Screening tools may improve identification of previously undetected geriatric conditions by 30% in ERs FRAILTY SCREENING IS REQUIRED TO FACE THOSE CHALLENGES
FRAILTY / EMERGENCY DEPARTMENT Who need to be screened? Everyone because of older patients heterogeneity All geriatric patients, regardless of the presenting complaint shall be screened using a screening tool A team driven, simple to use screening tool can be powerful in helping act to prevent outcomes and improve the ER and hospital experience for the geriatric patient
FRAILTY STRATIFICATION Two-step approach: To identify older patients at risk of adverse outcomes: Frailty screening To address the needs of older hospitalized patients: Geriatric intervention based on a CGA Effects: To target patients who need the most a geriatric intervention To provide guidance on appropriate levels of treatment among older people WHICH COMPONENTS ARE RELEVANT TO IDENTIFY FRAILTY?
FRAILTY / WHICH TOOL? Choice of components is a contentious issue Depends on frailty definition: Functional decline? Disability? Cognitive function? Social factors?
FRAILTY / WHICH TOOL? Many tools
Propositions BRIEF GERIATRIC ASSESSMENT (BGA) / DEVELOPMENT Gait Impairment
FRAILTY / WHICH COMPONENTS? alidity NEED FOR A MULTIDIMENSIONNAL TOOL
FRAILTY / WHICH TOOL? Many tools many studies that examined: Diagnostic accuracy to identify frailty Validity Reliability
FRAILTY SCREENING/ WHICH TOOL? MODERATE PREDICTIVE ABILITY
FRAILTY SCREENING/ WHICH TOOL? UNBALANCE PERFORMANCE
FRAILTY SCREENING/ WHICH OUTCOME? A screening to predict which outcome?: Mortality (short or long term) 76% Functionnal decline 65% Institutionnalization 35% ED readmission/ hospitalization 18% Adverse outcomes
FRAILTY / A TOOL TO PREDICT WHICH EVENT?
FRAILTY INDEX
FRAILTY / WHICH TOOL? Many tools many studies that examined: Diagnostic accuracy to identify frailty Validity Reliability Predictive performance Few studies examined implementation in ERs
FRAILTY / WHICH TOOL? Many tools many studies that examined: Diagnostic accuracy to identify frailty Validity Reliability Predictive performance Few studies examined implementation in ERs ARE THESE TOOLS ADAPTED TO ERS?
FRAILTY / ERS CHALLENGES Crowding little time to assess patients quick decisions More and more older patients but the majority of geriatric inpatients care is provided by physicians without specific training Insufficient material resources and equipment
FRAILTY / ERS CHALLENGES Crowding little time to assess patients quick decisions More and more older patients but the majority of geriatric inpatients care is provided by physicians without specific training Insufficient material resources and equipment WHAT ABOUT FEASIBILITY?
FRAILTY SCREENING/ FEASIBILITY
FRAILTY SCREENING/ FEASIBILITY
FRAILTY SCREENING/ FEASIBILITY
FRAILTY SCREENING/ FEASIBILITY Only four studies examined feasibility Among the most common tools, only ISAR has been studied Completion rates were less than 52% Time taken range from 1 to 10 minutes Feasibility is the key point to implement a screening tool in ERs
FRAILTY SCREENING/ FEASIBILITY 60 tools examined, 56 excluded: Need more than 5 min Uni-dimensionnal Need to perform a CGA Need to assess walking speed or grip strength (not deemed feasible) Frailty index, TRST, Fried considered as not suitable to EDs
FRAILTY / MEDICAL PRACTICE
FRAILTY / MEDICAL PRACTICE Take one minute
FRAILTY / MEDICAL PRACTICE Give an important information in just one minute
FRAILTY / MEDICAL PRACTICE Good feasibility = Clinical interest in emergency department!
FRAILTY / MEDICAL PRACTICE Most tools try to identify patients at risk of functional decline during hospitalization, from 30 to 180 days after admission to EDs Hospital re-admission from 30 to 180 days One main question: Which event do we want to predict from EDs?
FRAILTY / MEDICAL PRACTICE Most tools try to identify patients at risk of functional decline during hospitalization, from 30 to 180 days after admission to Eds Hospital re-admission from 30 to 180 days One main question: Which event do we want to predict from EDs? In-hospital mortality Prolonged length of hospital stay WAY OF IMPROVEMENT?
BRIEF GERIATRIC ASSESSMENT Patients at low risk Patients at intermediate risk Patients at high risk Launay CP et al. Plos One. 2014;9: e110135
BRIEF GERIATRIC ASSESSMENT Table 1. Baseline characteristics of patients based on in-hospital mortality after an admission to the ER and risk estimates of the time to death based on multiple Cox regression models. Launay CP et al. Maturitas. 2018... And also the risk of in-hospital mortality
TAKE HOME MESSAGES Healthcare system have to face the challenges of frail inpatients Every professionals (not only geriatricians) may participate in the improvement of geriatric care It s time to increase geriatric skills, to adapt medical practices in order to provide tailored care to older patients Screening frail older inpatients is the first step of an adapted care plan The perfect tool do not exist (yet?) To be used in ERs, a screening tool need to consider: Feasibility Relevance of predicted events in Ers Screening would be nothing without recommandations
THANK YOU. Q&A? CYRILLE.LAUNAY@CHUV.CH DEPARTMENT OF MEDICINE UNIVERSITY HOSPITAL OF LAUSANNE
FRAILTY SCALE
PRISMA 7