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Transitioning to a Regional Rehabilitative Care Program in Waterloo Wellington LHIN

Frail Senior Care Pathway – Introductory Webinar

What will we cover today?

• Cases

• Frailty, complexity and risk

• Overview of pathway

• Back to the cases

• Questions/discussion

Case 1: The acute care “veteran”

94 year old man: Second world war veteran

• Dementia: probably mild Alzheimer’s disease

• Heart failure: ischemic, ejection fraction 45% – History of hypertension, diabetes (diet controlled)

– Mild renal insufficiency

– Optimal heart failure medications and doses

• Yet, 3 ED visits with 1 admission for recurrent heart failure in 2 months, and referred to HF clinic

Case 2: Meet Mrs. Jones

87-year-old woman with generalized weakness

• Last year: gradual functional decline, fatigue, poor energy

• Last 2 months: unintentional 15 pound loss (now 80 lbs)

• Last 2-3 weeks: – most of day in bed sleeping – diarrhea 3-4 times per day – decline in cognition: requires cuing to eat and drink, help

dressing / bathing / transfers – Family stressed

FRAILTY, COMPLEXITY AND RISK

Patterns of aging

• Successful aging:

– avoidance of disease and disability

– maintenance of physical and cognitive function

– sustained engagement in social, productive activities

• Clearly, not all people achieve this

– at progressively higher risk of poor outcomes

– They are “FRAIL”

Rowe & Kahn, The Gerontologist (1997) 37 (4): 433-440.

What is frailty? Bergman et al. J Gerontol 2007;62A:7;731-7

• Vulnerability to stressors resulting from the age-related accumulation of impairments in multiple systems

• Stressor

– illness

– iatrogenic

– environmental (e.g. roadside curb)

• Predisposes to

– Functional impairment / disability

– Caregiver burden and ill-health

– Falls

– Homecare utilization

– Institutionalization

– Hospitalization

– Death

Deconstructing frailty

• Is the problem

– Multimorbidity?

– Disability?

– Geriatric syndromes?

– All of the above?

Multimorbidity burden Rapoport et al, 1999; National Population Health Survey, Chronic Dis Canda 2004

Age Number of chronic

conditions

0 1 2 3+

40-59 44% 30% 14% 12%

60-79 20% 25% 25% 30%

80+ 12% 24% 22% 41%

Source : CIHI Jan 2011

Rockwood et al CMAJ 2005

Not all seniors with multimorbidity are frail Bergman et al 2007

Is it disability? Gilmour & Park, Suppl Health Reports, Stats Can 2005

• 2003 Canadian Community Health Survey of 28617 adults > 65 (17205 women)

Age Basic ADL Instrumental ADL

Men Women Men Women

65-74 4% 4% 9% 18%

75-84 8% 9% 21% 36%

85+ 20% 23% 46% 65%


Not all frail seniors are disabled ... Bergman et al 2007

• Health and Retirement Study

– 11093 Americans 65 years and over

– Community and nursing homes

• Assess association between disability and

– Chronic diseases (active or severe)

– Geriatric “conditions”

What about “geriatric syndromes”? Ann Intern Med 2007;147:156-64

HRS Geriatric conditions and age

Number of

geriatric

conditions

65-74 75-84 85+

1 or more 40% 56% 76%

2+ 12% 23% 44%

3+ 4% 10% 32%

Geriatric

Condition

Prevalence

Hearing

impaired

25.7%

Dizzy 13.4%

Incontinence 12.7%

Injurious

fall

9.6%

Vision

impaired

8%

Cognitive

impairment

7.3%

Low BMI 2.9%

Chronic

Disease

Prevalence

Musculo-

skeletal

29.7%

Diabetes 13.2%

Heart disease 9.2%

Psychiatric

disorder

7.1%

Lung disease 5.8%

Stroke 5.4%

Cancer 4.8%

HRS: Disability Condition Risk ratio of

disability

Number of geriatric conditions

1

2

3+

2.1

3.6

6.6

Stroke

Diabetes

Heart disease

Cancer

3.0

1.3

1.2

1.0

Concurrence of ...

• comorbidities

• disabilities

• geriatric syndromes

• gaps in social support

• interacting with one another leading to a downward spiral ...

• How is this recognized ?

“Eyeball test”

• Can you tell frailty just by looking

at it?

• Experts can … to a point

• Non-experts prone to bias

• Need something better…

FREID Frailty Phenotype Fried et al 2001

Fried predicts outcomes?

Frailty and deficit accumulation Rockwood & Mitnitski J Gerontol Med Sci 2007; Mitnitski et al BMC Geriatrics 2002

• Concept: The more things wrong with you, the more frail you are

• Secondary analysis from Canadian Study on Health and Aging – Random sampling of 10267 persons 65 years+ – 2914 underwent structured clinical assessment at baseline – 1338 survivors assessed 5 years later – 64% women, age 82.0 (SD 7.4)

• Developed Frailty Index of 70 deficits associated with cognitive and functional decline

65% is bad, regardless of how you get there

Data from the Canadian National Population Health Study Song et al J Am Geriatr Soc 2010

What do you see? • Dose response relationship • Predicts mortality


CSHA Clinical Frailty Scale

Correlates well with Frailty Index Predicts frailty outcomes Key indicator: “slowed up”


Institutionalization risk

PERFORMANCE MEASURES

Can we assess frailty more quickly?

• Gait velocity

• Grip strength

Studenski et al JAMA 2011

Grip Strength Ling et al CMAJ 2010

FEATURES OF FRAILTY: GERIATRIC SYNDROMES

Geriatric syndromes share risk factors Tinetti et al, JAMA 1995

• Prospective cohort study of 927 community-dwelling seniors, aged 72 or higher, with Baseline and 1 year follow-up

Frailty is important

• Multiple ways to recognize – Various length to complete – Each has its own strengths and drawbacks – Each predicts outcomes in a graded, dose-

response relationship • Over the medium to long-term

• Persons with frailty are at risk of multiple geriatric syndromes – Inter-related via shared risk factors – Therefore, opportunity to intervene at multiple

levels at once

Fundamental “Equations” of geriatrics

• Frailty = Vulnerability

• Frailty x Stressor = Bad outcome

• From patient/system perspective the issue is RISK

Managing frail seniors

• Stressor Management: HELP program

• Frailty: Comprehensive Geriatric Assessment

Comprehensive Geriatric Assessment Abellan 2010

Multidimensional interdisciplinary process focused on determining a frail older persons’ medical, psychological and functional capacity in order to develop a coordinated and integrated plan for treatment and long-term follow-up

• Identify and understand individual’s deficits, problems and strengths – Medical and psychiatric health, medications – Function, Mood, Memory – Resources, including $, supports, caregiver

• Understand the person’s level of frailty

• Develop a proper multidisciplinary plan of management tailored to the level of frailty

The process: Comprehensive Geriatric Assessment

Socio-demographic Living situation and means of transportation Informal Caregiver and other social supports, Elder abuse Advance directives

Cognition Overall performance Behavioural issues and psychosis

Psychiatric Mood and Anxiety Function Basic and Instrumental Activities of Daily Living (BADLs, IADLs) Mobility Gait problems and gait aids, Falls Senses Vision and Hearing Elimination Bladder and bowel function

Health indicators

Nutrition Pain Cardiorespiratory Skin integrity Substance abuse

Medical Primary prevention (e.g. immunization) Secondary and tertiary (optimal chronic illness management) Polypharmacy / medication review

Geriatric Assessment works Stuck, Lancet 1993; Day, NZHTA Report 2004; Schmader Am J Med 2004; Beswick Lancet 2008; Challis 2004

• CGA leads to

– More optimal prescribing

– Better function, cognition

– Less institutionalization

– Less hospitalization

– Lower mortality

• NEED TO TARGET THE RIGHT PATIENT

• DEGREE OF RISK DETERMINES WHO AND WHEN

Overview of process

September 2013 – April 2014

Assessment Urgency Algorithm Development Study (Ontario, Canada)

• Focus group with GEM nurses and ED physicians – Predict: referral to special geriatric services or home care, admission, long-stay/ALC

• Created an ED assessment based on items from: – Community intake version assessment

– Items clinicians felt important for ED patients

• Assessed ED patients age 75 + – Mean Age: 83 (SD: 5.2)

– 60% Female

– Triage Acuity (CTAS):

• Resuscitation: 0%

• Emergent: 21%

• Urgent: 48%

• Less Urgent: 24%

• Non-Urgent: 7%

41

# Hospitals Number of ED

assessments

(N=860)

1 Cambridge Memorial Hospital 119

2 Grand River Hospital 44

3 Grey Bruce Health Services 126

4 Haliburton Highlands Health Services 34

5 Peterborough Regional Health Centre 175

6 St. Joseph’s Health Centre 120

7 St. Mary’s Hospital 225

8 Trillium Health Centre 20

Courtesy A. Costa, J. Hirdes

42 Courtesy A. Costa, J. Hirdes

MOPED Study

43

Royal Jubilee & Nanaimo Regional General Hospitals VIHA, British Columbia

Grace Hospital Winnipeg, WRHA, Manitoba

Royal Victoria Hospital Barrie, Ontario

Queen Elizabeth II Health Sciences Centre Halifax, Capital District Health Authority, Nova Scotia

Saskatoon City, Royal University, & St. Paul’s Hospitals SktnHR, Saskatchewan

Regina General & Pasqua Hospital RQHR, Saskatchewan

N= 2,101


Assessment Urgency Distribution by Discharge Destination, MOPED

20%

11%

17%

26%

10%

17%

6% 4%

14%

30%

16%

32%

0%

10%

20%

30%

40%

50%

1 - Low 2 3 4 5 6 - High

Community Acute Care


AUA Distribution by Discharge Destination, Multinational Sample

17%

12% 16%

18%

13%

24%

6% 6% 10%

16%

26%

37%

0%

10%

20%

30%

40%

50%

1 - Low 2 3 4 5 6 - High

Community Acute Care

45 Courtesy A. Costa, J. Hirdes

Cumulative Percentage of Geriatric Syndromes, MOPED

interRAI Assessment Urgency

0%

20%

40%

60%

80%

100%

LOW MED. HIGH

3+ items

2 items

1 item

0 items

Triage Acuity (CTAS)

0%

20%

40%

60%

80%

100%

Low (4-5) High (1-3)

46

Items: Signs of Depression ADL Impairment Cognitive Impairment Signs of Caregiver Distress Behaviours


Proportion Designated “ALC” among Patients Admitted by Assessment Urgency & CTAS, MOPED (N=936)

LOW

MED.

HIGH

0%

5%

10%

15%

20%

25%

30%

35%

LOW (4-5)HIGH (1-3)

N/A 5%

N/A 17%

32%

22%

47

Overall Prevalence: 18% TRIAGE

AUA


AUA Clinical Profile

AUA Score and Features

Level 1 Self-reliant in ADLs / IADLs Health is excellent or good No unstable health conditions

Level 4 Unable to complete ADLs /IADLs Family reports not overwhelmed Reports mood as not sad, depressed, or hopeless No support required in hygiene ADLs

Level 2 Self-reliant in ADLs / IADLs Health is fair or poor No unstable health conditions

Level 5 Unable to complete ADLs / IADLs Family reports not overwhelmed Reports mood as not sad, depressed, or hopeless Support required in hygiene ADLs

Level 3 Self-reliant in ADLs / IADLs Health is excellent or good OR fair or poor Has unstable health condition(s)

Level 6 Unable to complete ADLs or IADLs Family reports not overwhelmed Reports mood is sad, depressed, or hopeless

OR Unable to complete ADLs or IADLs Family reports being overwhelmed

Case 1: Our veteran’s CGA

• Medical issues described above – Relatively mild conditions that are easily address EXCEPT THAT….

• Social frailty: Lives with daughter – Single mom, sandwich generation – Very stressed, little time to cook, weigh father – Eat out a lot: high sodium diet

• Intervention: – ++ support, CCAC, Community Support Services – Ultimately admitted to Assisted Living – Doing well

Under FEMC Pathway

• First ED visit: – AUA = 6

• CGA would have been conducted at that time

• Recurrent ED visits likely averted – Better and more timely care

• Now in Supportive living - stable

Case 2: CGA key features

• Function: 18 months ago was cycling 40 km, downhill skiing

• ADLs, IADLs: independent 3 months ago

• Cognition previously intact, now fluctuates, impaired

• Mood: depressed over last 3 weeks

• Widow, lives in house with son, CCAC for ADLs x 3 months; needs walker + assistance with transfers

Medical

• HF with severe LV dysfunction (idiopathic)

• Microscopic hematuria NYD • Hysterectomy • Right cataract extraction with

failed corneal transplant and a redo 3 years ago, subsequent wound dehiscence and a dislocation last year

• Internal hemorrhoids • Atrophic gastritis

• Rabeprazole 20 mg p.o. once daily

• Lisinopril 5 mg p.o. once daily • Digoxin 0.125 mg p.o. once daily • Spironolactone 25 mg p.o. once

daily • Furosemide 40 mg p.o. once daily • ASA 81 mg p.o. once daily • Bisoprolol 1.25 mg p.o. once daily • Calcium Carbonate 500 mg p.o.

b.i.d. • Vitamin D3 1000 IU p.o. b.i.d. • Vitamin B100 one tablet p.o. once

daily

What are her problems? She is medically unwell • Possible digoxin toxicity, dehydration (r/o renal failure,

electrolyte abnormalities, other medical) • Cardiomyopathy: not optimized • Polypharmacy • Malnutrition • Deconditioning • Delirium

– Possibly also depressed

• Visual impairment • Others?

– Incontinence? Caregiver stress?

Summary • Pathway takes a proactive approach to identifying frail

seniors AT RISK with AUA

• CGA identifies issues: medical, psychosocial, disability

• Early identification promotes earlier intervention and prevention

• Facilitates HR planning

• All providers participate in CGA – education

eLearning Series: Frailty Modules Frail Elderly/Medically Complex Stream of Care

CGA

Amputations

CGA

Early Identification

Standard Assessment

Timely Navigation

Person-Centred Care

Coordinated transitions

Capacity Building – Staff learning needs

Frailty

Falls

Medication Review

Pain Incontinence

Mobility Cognition

Developed based on the content from the GiiC Toolkits – Regional Geriatric Program of Toronto

Frailty x Stressor = Bad outcome

Questions?

FRAILTY IS

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