Post on 25-Jul-2020
Frailty in Aging
Elizabeth Phung, DO Medical Director – Beacham Center for Geriatric Medicine, Johns Hopkins Bayview Medical Center Faculty, Division of Geriatric Medicine and Gerontology Johns Hopkins University School of Medicine
• No financial disclosures
2
Disclosures
3
Defining Frailty
Defining Frailty
• Picture someone you know who you might describe as frail
Defining Frailty
• Picture someone you know who you might describe as frail
• What makes frail the right word?
Defining Frailty
• Picture someone you know who you might describe as frail
• What makes frail the right word? • Is there a difference between frail
and vulnerable?
8 https://www.theatlantic.com/health/archive/2014/12/the-challenge-of-treating-frailty/383327/
10
The Case of Mrs. C
Defining Frailty
Two Frameworks: • Physical Frailty (aka Frailty Phenotype) • Accumulation of Deficits Frailty
Defining Frailty: Physical Frailty
Physiologic (Physical)
Frailty
Physical Activity
Muscle Strength
Weight Loss
Energy Level
Walking Speed
Robinson TN et al 2016
Biologic Aging
Chronic Disease - Depression - Cognitive Decline - Cancer - Cardiovascular - Diabetes/Obesity
Dependence Disability Chronic Disease Early Mortality
Genes Environment Diet Activity
Stress Response Systems
Energy Metabolism
Weakness
Fatigue
Slowness
Weight loss
Causes of Physical Frailty
Walston J, 2018
PhysiologyTriggers Symptoms Outcomes
FRAILTY
14
Xue, Qian-Li & Bandeen-Roche, Karen & Varadhan, Ravi & Zhou, Jing & Fried, Linda. (2008). Initial Manifestations of Frailty Criteria and the Development of Frailty Phenotype in the Women's Health and Aging Study II.
Defining Frailty: Physical Frailty
• Weight loss • Weakness • Exhaustion • Slowed walking speed • Low activity
Fried, LP et al 2001
* Frail if 3 of 5 are present
Defining Frailty: Deficit Accumulation
Deficit Accumulation
Frailty
Social Vulnerability
Nutrition
Cognition
Function Decline
Medical Conditions
Robinson TN et al 2016
Causes of Deficit Accumulation Frailty
https://www.flickr.com/photos/michpics17/7019477251
Defining Frailty
Deficit Accumulation
Frailty
Social Vulnerability
Nutrition
Cognition
Function Decline
Medical Conditions
Physiologic (Physical)
Frailty
Physical Activity
Muscle Strength
Weight Loss
Energy Level
Walking Speed
Robinson TN et al 2016
Modal Pathway- 2017 Outcomes
Falls
Disability
Dependency
Death
Syndrome
Weakness
Weight loss
Slowed performance
Exhaustion
Low activity
Molecular & Genetic
Mitochondria
Epigenetics
Senescence
Autophagy
Disease Varadhan ,et al, J Gerontology, 2014 Kalyani R, et al Lancet 2014 Leng, et al., Aging 2004 Walston, J et al Archives IM 2002
↑ IL-6, CRP, WBC ↑ Clotting
Glucose intolerance ↓IGF-1, DHEA-S
Physiology
↑ Cortisol
↑ Angiotensin
Consequences of Physical Frailty CHS WHAS
Incident Fall 1.29 (1.00 – 1.68) No Change Worsening Mobility
1.50 (1.23, 1.82) 10.44 (3.51, 31.00)
Worsening ADL Disability
1.98 (1.54 – 2.55) 15.79 (5.83, 42.78)
First Hospitalizations
1.29 (1.09,1.54) No Change
Death 2.24 (1.51,3.33) 6.03 (3.00, 12.08)
Fried LP et al 2001 Bandeen-Roche K et al 2006
Hazard Ratios Estimated Over 3 Years, covariate adjusted, p>0.01
How Do We Assess Frailty?
21
Proliferation of Frailty Tools •Frailty is the wild west of geriatrics • ~75 assessment tools and rapidly growing • Due to a lack of biological understanding and lack of specificity (how is frailty distinct from aging or chronic diseases?) • There is no agreement on how to best measure it (Manas 2012)
Physical Frailty Phenotype (PFP)
22
¬ Weight loss (more than 10lbs) ¬ Weakness (grip strength) ¬ Exhaustion (self-report) ¬ Walking Speed (15 feet) ¬ Physical Activity (Kcals/week) Scoring: • Not Frail: 0 • Intermediate: 1-2 • Frail: ≥3
(Fried at al 2001)
Frail Scale
23
Rockwood Clinical Frailty Scale
24
How Are Frailty Tools Being Used?
10/6/19 25
Buta BJ, Walston JD, Godino JG, et al. Frailty assessment instruments: Systematic characterization of the uses and contexts of highly-cited instruments. Ageing Res Rev. 2016;26:53–61. doi:10.1016/j.arr.2015.12.003
Common problems in frailty to reduce the severity and improve outcomes
26
Falls Cognitive impairment Continence Mobility Weight loss and poor nutrition Polypharmacy Physical inactivity
Low mood Alcohol excess Smoking Vision Problems Social isolation and loneliness
Treating Frailty
• Exercise • Increase protein in diet • Vitamin D supplementation (only if low) • Focus medications (weigh risk/benefit) • Plan carefully for surgery = Outcomes show improvement in functional outcome and patient survival, reduction in hospital days and readmission rates. No increase in mortality Morley 2013
28
The Case of Mrs. C
Would these patients benefit from the same perioperative care plan?
29
LOS 5.3 days 1 in 3 patients will suffer complication 1 out of 5 patients will be readmitted
LOS 2.5 days 1 in 20 patients will suffer a complication 1 in 20 patients will be readmitted
Premier data JHBMC 2017
History of the Geriatric Pilot at JHBMC
30 Verification process through ACS goes live in 2019
31
Tinetti, Molnar and Huang, JAGS 2017; Slide by Andrea Schwartz MD MPH
The Geriatric 5Ms
• 11 item screening validated tool • Takes 3 minutes to complete • Does not require geriatric expertise • Incorporates a cognitive screen and psychosocial
determinants • Implemented in general, vascular, urology, and
gynecology services in February 2018 for ≥ 65 yrs. • Successful screened 492 patients (42%) • Identified 175 patients (36%) with a high frailty score (≥
6)
33
Edmonton Frail Scale
10/6/19 34
Benefits of the Edmonton Cognition Screen
• During the past 4 months, 21 patients have been identified as having cognitive impairment (Clock Draw = 2) with NO previous history
• 17/21 patients (80%) were on more than 5 prescription medications
• 6/21 patients (29%) often forgot to take prescribed medications
35
Using the Edmonton to Improve Care Coordination
36
Category Edmonton Screen Intervention
Cognitive Impairment Clock Draw, Remembering Medication Regional Anesthesia/ Avoid Narcotics Delirium Prevention/Screening Aspiration Precautions Fall Precautions Geriatric Resource Nurse Co-Management with Geriatric Medicine
Functional Impairment Get up and Go, Functional dependence Referral to PT/OT Fall Precautions Co-Management with Geriatric Medicine
Lack of Social Support Social Support Social work consult/SNF placement Alert case manager
Depression
Depression Social work consult Case manager Communication with Caregiver Geriatric Resource Nurse Co-Management with Geriatric Medicine
Malnutrition Weight loss Nutrition Consult, Nutritional Supplements
37
The Case of Mrs. C
Weekly Preoperative Multidisciplinary Call
• Representation from Anesthesia, Geriatric Medicine, Surgery, Nursing, Case Management, Rehabilitation Medicine, Chaplaincy
• Review average of 3 high risk patients per week
38
39
Outcomes from Multidisciplinary Call – First 3 months (EFS ≥ 6, Age ≥ 85)
• 34 patients identified (30% of our IP surgery population) – mean age 77 – mean Edmonton 7.4
• Most highly scoring EFS variables: polypharmacy, multiple admissions, functional impairment
• No ACP in 12/34 (35%) of patients
39
40
• 8/34 (24%) cases were cancelled • Geriatric co-management: 10/26 (38%)
– 60% seen on POD #1 – 40% seen range POD #2 - 16
• PT/OT consultation: 18/26 (70%) – 76% seen POD #1 – 24% seen range POD #2 – 8
• 8/26 (31%) discharged to SNF
40
Outcomes from Multidisciplinary Call – First 3 months (EFS ≥ 6, Age ≥ 85)
Outcomes from the Geriatric Surgery Pilot March 2018 – July 2018, JHBMC General Surgery patients ≥ 75 (pilot cohort) compared to March 2017 –
July 2017 (pre-pilot cohort)
41 Data from Premier
Outcome Pre-Pilot (n = 98)
Obs. Exp. O/E Pilot (n = 96)
Obs. Exp. O/E
LOS (median) 4.69 4.89 0.96 3.82 4.55 0.84 Complications 28.6% 30.2% 0.95 15.6% 27.5% 0.57 Readmissions 21% 12.6% 1.67 8.79% 12.97% 0.68 Mortality 0% 6.5% 0 5.2% 5.8% 0.9 Cost $23,094 $16,252 1.42 $17,133 $14,393 1.19
Next steps:
• Identify high risk patient who will benefit from improved care coordination/resource allocation
• Develop and sustain a value driven protocol for high risk patients that would benefit the health system
• Recognition for our care of the older surgical patient by organizations nationwide
42
10/6/19 43
• Susan Gearhart, M.D, Jeremy Walston, M.D. & Dianne Bettick, MSN, RN for slide contribution and mentorship
• Heather Agee, M.D., John Anderson, M.D., & Beacham Center Staff for their continued mentorship in my career development
• My parents, husband and son for their never-ending support
44
Many thanks to:
Questions?
45