Interprofessional Care for Elders through 48/5

Interprofessional Care for Elders through 48/5 Janet E. McElhaney, MD, FRCPC, FACP HSN Volunteer Association Chair in Geriatric Research Professor of Medicine, Northern Ontario School of Medicine Health Sciences North and Advanced Medical Research Institute of Canada Sudbury, ON

Objectives Goal responsive acute care for elders Transforming seniors care - five key clinical issues addressed within 48 hours of admission Recognize dynamic frailty as the margin for improvement and goals of care in acute illness - Mobility is the 5 th vital sign Understand the importance of interprofessional collaboration

Dorothy s Story 65+ population are hospitalized 3X more often than younger adults; 37% of discharges, 50% of inpatient days, and 60% of expenditures 65+ population 80% have one chronic disease; 50% have two At discharge, 33% are more disabled and one half never recover 5% die in hospital, 20-30% die in the year after hospitalization

Determinants of Health Competence Confidence Connection

Clinical Frailty Scale: 1. Very fit robust, active, energetic, well motivated and fit; exercise regularly, are in the most fit group for their age 2. Well without active disease, less fit than people in category 1 3. Well, with treated comorbid disease symptoms are well controlled compared to those in category 4 4. Apparently vulnerable not frankly dependent, but commonly complain of being slowed up or have disease symptoms 5. Mildly frail limited dependence on others for instrumental activities of daily living 6. Moderately frail help is needed with both instrumental and basic activities of daily living (e.g. climbing stairs and bathing) 7. Severely frail mostly dependent on others for the activities of daily living 8. Very severely frail completely dependent on others for the activities of daily living 9. Terminally ill Rockwood et al; CMAJ; 173:489-495, 2005

Risks Associated with Hospitalization 65+ population are hospitalized 3X more often than younger adults; 36% of hospitalizations and 50% of hospital expenditures 65+ population 80% have one chronic disease; 50% have two At discharge, 33% are more disabled and one half never recover 5% die in hospital, 20-30% die in the year after hospitalization Elixhauser A et al; AHRQ Pub. No. 00-0031, HCUP Fact Book No. 1, 2000 Covinksy KE et al; J Am Geriatr Soc; 51:451, 2003 US data: 1993-1997

Ferrucci et al. JAMA 277:728, 1997 Barker et al. Arch Int Med 158:645, 1998 Falsey et al. N Engl J Med. 2005;352:1749 Catastrophic Disability Defined as a loss of independence in 3 ADL 72% who experience catastrophic disability have been hospitalized Leading causes of catastrophic disability Strokes CHF Pneumonia and influenza Ischemic heart disease Cancer Hip fracture

Vitality vs. Independence 1 2 3 4 When reserve capacity is decreased to a crucial level, adaptive mechanisms to stressors can no longer be mobilized, leading to a breakdown of homeostasis and crossing the threshold to clinically manifested frailty syndrome. 5 6 7 8 9

Mrs. M 94 year old woman living at home: Brought to ED by ambulance after a fall confused and # of pelvic ramus Multiple previous falls all preceded by dizziness and legs giving way Receives weekly home care for IADL support and manages her finances and meds (blister packed) daughters are her POA PMH: CHF, Afib, HT, chronic back pain, MCI (MMSE 26/30 Aug 09), hypthyroid, previous cataract surgery Meds: metoprolol 25 mg bid, warfarin 3 mg daily, furosemide 60 mg daily, Ca/Vit D, levothyroxine 100 mg daily What are the diagnoses?

Hierarchical Assessment of Balance and Mobility (HABAM) Hierarchical Assessment of Balance and Mobility scores for two patients admitted after a fall: patient, a 79-year-old woman who had not been able to get up for several hours but recovered, and patient, an 81- year-old woman who died on the fourth hospital day. Rockwood et al., J Am Geriatr Soc, 2008;56:1213-1217,

The Care Pathway: 48/5 Starts within 48 hours and focuses on evidenceinformed decisions about: Appropriate medications Delirium / Cognition Nutrition / Hydration Bowel / Bladder Functional mobility Every day is an activation day Interprofessional collaborative practice Mobility is the fifth vital sign

Mrs. Z 87 year old woman with advanced dementia admitted with urosepsis and barely rousable on admission Supported at home by her daughter for bathing and climbing stairs. Had a fall without injury in the day preceding hospital admission No recent hospital admission On admission, patient could not move off pressure points in bed

Hierarchical Assessment of Balance and Mobility (HABAM) Hierarchical Assessment of Balance and Mobility scores for two patients admitted after a fall Rockwood et al., J Am Geriatr Soc, 2008;56:1213-1217,

GRACE: Goal Responsive Acute Care for Elders Cardiovascular Disease Diabetes Osteoporosis Chronic Lung Disease Cognitive Impairment Usual Aging Dynamic Frailty IADL Frailty ADL Frailty 80 80 80 80 80 Age

Summary Goal responsive acute care for elders Patient-centred means goals of care established to return to previous level of independence 48/5 focuses interprofessional collaborative practice on the goals of care Recognize dynamic frailty and use mobility as the fifth vital sign