Introductory Webinar Better Care, Better Health, Better Value A - - PowerPoint PPT Presentation

Better Care, Better Health, Better Value A Better Rehabilitative Care System

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 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%

Rockwood et al CMAJ 2005

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

Rockwood et al CMAJ 2005

CSHA Clinical Frailty Scale

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

Rockwood et al CMAJ 2005

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

• rder 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

Courtesy A. Costa, J. Hirdes

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 Courtesy A. Costa, J. Hirdes

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

Courtesy A. Costa, J. Hirdes

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

Courtesy A. Costa, J. Hirdes

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