implementing frailty into clinical practice

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

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

Prevalence of dependency/disability: between 350-600M from 2010 to 2040

World Alzheimer Report 2013. ADI 2013

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

NMAPS Results: Above: (Younger transition matrix - 60 ≤ age ≤ 78 years) Below: Older 78 +

.32

Speed low

1

Both low

3

3MSE low

2

Normal 0

.01

.10

.06 .06

.07

.86

.08

.25

Speed low

1

Both low

3

3MSE low

2

Normal 0

.20

.28

.18 .64

.50

.34

.05

.48

Speed low

1

Both low

3

3MSE low

2

Normal 0

.06

.18

.22 .08

.14

.72

.07

.44

Speed low

1

Both low

3

3MSE low

2

Normal 0

.11

.19

.19 .24

.27 .51

.10

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...

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

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.

Gérontopôle Frailty Screening Tool

Recommendations from HAS (French health authority)

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

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

Geriatric Assessment n=1108

Age (yrs), n=1108 82,9 ± 6,1

Sex (female), n=1108 686 (61,9%)

BMI (kg/m²), n=698 25,9 ± 5,1

Onco-geriatric, n=1103 230 (20,9%)

Vit D (ng/ml), n=1065 18,1 ± 11,3

MMSE/30, n=1071 24,6 ± 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

SPPB/12 (mean) 7,3 ± 2,9

(SPPB≥10) 272 (25,6%)

(7≤SPPB≤9) 388 (36,5%)

(SPPB ≤6) 403 (37,9%)

CDR/3, n=1039

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=1098 358 (32,6%)

Weakness, n=1083 353 (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= 1083 20,3 ± 8,2

Sedentarity (yes), n=1096 665 (60,7%)

Alone at home (yes), n=1083 460 (42,5%)

Help at home (yes), n=1105 767 (69,4%)

Help at home (yes), n=1105 575 (52,0%)

APA (yes), n=1105 190 (17,2%)

Descriptive data of 1108 older adults referred to the Gérontopôle Frailty Clinic (JNHA 2014)

Geriatric Assessment n=1108

Vision

Vision far (abnormal), n=1019 840 (82,4%)

Vision near (abnormal), n=1039 232 (22,3%)

Amsler (abnormal), n=1060 177 (16,7%)

Audition

HHIE-S/40, n=1055 9,5 ± 9,8

Disability (HHIE-S >21), n=1055 330 (31,3%)

Nutrition

MNA/30, n=1048 23,2 ± 4,1

(MNA>23,5), n=1048 550 (52,5%)

At risk of malnutrition (17≤MNA≤ 23,5), n=1048

414 (39,5%)

Undernutrition (MNA< 17), n=1048 84 (8,0%)

Urinary incontinence

Incontinence scale/6, n=280 1,7 ± 1,4

Daily problem (score≥ 1), n=280 215 (76,8%)

Depression GDS/15, n=424 4,8 ± 3,1

History of falls n=285 108 (37,9%)

Interventions: Personalized Care and

Prevention Plan

n=1108

New medical conditions (yes), n=1104

603 (54,6%)

Special advice (dentistry, ORL, ophtalmo, urology) (yes), n=1101

532 (48,3%)

Change in drug prescription (yes), n=1102

362 (32,8%)

Nutrition intervention (yes), n=1105

683 (61,8%)

Physical activity intervention (yes), n=1101

624 (56,7%)

Social intervention (yes), n=1106

284 (25,7%)

Descriptive data of 1108 older adults referred to the Gérontopôle Frailty Clinic (JNHA 2014)

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 (+ 3500 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 ?

Cesari M et al. PLOS ONE 2014;9(7):e101745

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)

b. None or mainly sedentary

0

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”.

Frail Non-Disabled (FIND) questionnaire

Frailty screening in the community:

• City of Cugnaux: 16 314 inhabitants

• 75 yrs +: 1 403 subjects, response 44% (611)

• 70 - 74 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: 50 000 Euros

• Extended to the Toulouse urban area, 1 million people

Frailty assessment in family practitioner’s office

22

Study process

Patient with cognitive complaint

Medical history, comorbidities, treatments, weight, vision, audition, lifestyle, home support, …

Consultation with a nurse

Frailty sensation

Older patient in General Practitioner’s consultation

or

16 GP’s offices around Toulouse

Evaluation • MMSE • WMS-R • Mini-GDS • Fried criteria • MNA • SPPB • ADL • IADL

Summary, propositions of recommendations and orientation proposed by the GP

Implementing frailty into family practitioner’s office (N=375)

23

• 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%

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

Descriptive data Typology Cugnaux SAMU

Nb 136 75

Women 95 (69,9%) 56 (73,7%)

Age 79,9 ± 5,4 85,8 ± 6,7

65-74 yrs 22 (16,2%) 5 (6,9%)

75-84 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 < 10 69 (50,7%) 63 (84,0%)




• 3. Frailty into family practitioner office


• 5. Frailty screening with the retirement insurance scheme

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

Targeted

Strong

Implementing frailty into clinical practice: TARGETED, STRONG, SUSTAINED INTERVENTION

Sustained

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

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

Our health determinants

•Healthcare: 10%

•Genetic: 30%

•Behavior environnment: 60%

•Precision medicine for pre-frail and for intrinsic capacities

implementing frailty into clinical practice

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