T ELDERLY SURGICAL PATIENT WHERE TO FROM HERE · Centre for Research in Geriatric Medicine Centre...
Transcript of T ELDERLY SURGICAL PATIENT WHERE TO FROM HERE · Centre for Research in Geriatric Medicine Centre...
Centre for Research in Geriatric Medicine
Centre for Research in Geriatric Medicine
THE ELDERLY SURGICAL PATIENT:
WHERE TO FROM HERE?
Associate Professor Ruth E. HubbardBSc, MBBS, MRCP, MSc, MD, FRACP
22nd October, 2016
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Yesterday’s Objectives
1. Describe and compare frailty measures
2. Consider frailty in relation to failure of a complex
system
3. Review importance of frailty in older surgical patients
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Objectives
1. Review a new instrument to measure frailty in routine
practice
2. Discuss limitations and potential pitfalls of frailty
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THE FRAILTY INDEX IN CLINICAL
PRACTICE
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FI in clinical practice
Comprehensive Geriatric Assessment (CGA) is used in
geriatric medicine to capture relevant information about
the health status and function of an older person
The information collected as part of CGA comprises
assessments of function, co-morbidities and cognitive/
psychological status
This data can be coded as deficits and used to derive a
Frailty Index score - the FI-CGA
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FI-CGA
Captures loss of
redundancy
As the mean value of the
FI-CGA increases, the
slope of the line in relation
to age becomes smaller
and ultimately is
indistinguishable from 0.
Rockwood, Rockwood, Mitnitski. JAGS. 2010
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FI-CGA in Hip #
FI Group
Low Intermediate High P value
≤0.25 0.25–0.4 FI >0.4
Age, yrs (SD) 74 (12) 82 (9.5) 86 (8.6) < 0.001
Length of stay,
days (SD)
21 (16.5) 36.3 (23.4) 67.8 (39.3) < 0.001
Discharged home
within 30 days
45 (80%) 24 (41.37%) 4 (6.25%) < 0.001
Inpatient mortality 0 3 (5.2%) 18 (28.1%) < 0.001
Krishnan M et al. Age and Ageing 2013
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A Frailty Index for the interRAI suite
interRAI instruments screen a large amount of info
Cross functional, cognitive, sensory, medical domains
Data can be coded as deficits
Potential to explore premorbid vulnerability vs current
health status
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FI-AC Distribution
N=1418
Mean (SD)=0.32 (0.14)
Median (IQR)=0.31 (0.22-0.41)
99th percentile= 0.69
Reference
Hubbard RE, Peel NM, Samanta M,
Gray LC, Fries BE, Mitnitski A,
Rockwood K. Derivation of a Frailty
Index from the interRAI Acute Care
Instrument. BMC Geriatr.
2015;15:27.
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Question
Which adverse outcomes are NOT associated with a
higher FI score?
a/ inpatient mortality
b/ delirium
c/ readmission to hospital
d/ all adverse outcomes are associated with frailty status
Results
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Results: FI-AC vs Discharge Destination
Discharge Destination n (%) FI-AC
Mean (SD)
Community 917 (64.7%) 0.28 (0.12)
Other inpatient care
including rehabilitation235 (16.6%) 0.39 (0.13)
Residential Aged Care 209 (14.7%) 0.41 (0.13)
Died in hospital 57 (4.0%) 0.47 (0.16)
a Comparison of mean FI-AC between groups (ANOVA) significant at p<0.001b Ordinal regression showed progressive frailty OR: 1.92 (1.76-2.10)
a
b
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FI-AC vs Adverse Outcomes a
Outcome Frequency
n (%)
Odds Ratio
(OR) b95%Confidence
Intervals
Inpatient falls 83 (5.9%) 1.29 1.10-1.50
Delirium 322 (23.1%) 2.34 2.09-2.63
Pressure ulcer incidence 42 (3.2%) 1.51 1.23-1.87
Length of stay>28 days 77 (5.4%) 1.29 1.10-1.52
Discharge to a higher level of care
(excluding deaths)294 (21.6%) 1.45 1.31-1.60
Died in hospital 57 (4.0%) 2.01 1.66-2.42
a Logistic regression models adjusted for age and genderb OR interpreted as the odds of adverse outcome for each increase of 0.1 in the FI-AC
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Delirium
OR AUC
Risk screener 8.2 (CI: 6.165, 11.071) 0.760 (CI:0.726, 0.791)
P = 0.030FI 2.3 (CI:2.075, 2.619) 0.795 (CI: 0.766, 0.825)
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Inpatient mortality
OR AUC
Risk screener n/a
FI 2.00 (CI: 1.66, 2.42) 0.78 (CI: 0.71, 0.85)
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Readmission
OR AUC
Risk screener 1.712 (CI:1.278, 2.292 0.553 (CI:0.516, 0.589)
nsFI 1.17 (CI:1.065, 1.284 0.567(CI:0.532, 0.603)
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Compare and Contrast….
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FI vs DRGs
0
5
10
15
20
25
Heartfailure
COPD UTI Syncope
Age
LoS
FI-AC
0.30
0.24
0.34
0.29
0.39
0.41
Stroke ??
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A NEW NURSE
ADMINISTERED
ASSESSMENT
INSTRUMENT
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Nurses hold the key
to assessment &
management of
functional &
psychosocial
problems
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Current nursing assessment forms
Victorian Study
11 hospitals studied
Admission assessment
– 8-27 (median 11) forms
– 150-586 (median 345) items
– 2482 data items universal
– 1283 data items selective
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The problems with current systems
Too long
Inconsistent scoring approaches
Duplication of items
Compliance patchy
Don’t interact with other systems and disciplines
Variable scientific foundations
Limited outputs
21
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The PBA
60 items
15 minutes completion (IQR 11- 20 minutes)
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PBA Base Assessment
Diagnostic
screeners
Delirium
Dementia
Depression
Malnutrition
Risk assessmentDelirium
Pressure ulcer
Falls
Severity measures
Cognition
Communication
Mood
ADL
Nutrition
Clin
ical
ob
se
rva
tio
ns
ProblemsCognition
Mood
Communication
Vision / hearing
Sleep
ADL
Medication
management
Falls
Dyspnoea
Pain
Under-nutrition
Swallowing
Traumatic injury
Pressure injury
Other skin conditions
Continence
Bowel/bladder issues
Smoking & alcohol
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Field testing (Australia)
4 hospitals
– (24 – 700 beds)
1000+ cases
Wide range of clinical
units
Patients aged 18+
iPAD data collection
Frequency
distributions
Inter-rater reliability
User satisfaction
Screener validation
24
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Selected problems
25
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cognitiveskills for
dailydecisions
Short termmemory
Mood- sad ADL-Personalhygiene
ADL-Walking
Acutechange in
ADLs
Falls(prior)
Pain Sleep
18-29
30-39
40-49
50-59
60-69
>70
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FRAILTY: LIMITATIONS
AND PITFALLS
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1. Stigmatisation
The OED defines frailty as “the condition of being weak
and delicate… weakness in character or morals”
In the minds of many older people, frailty may identify their
most feared aspects of the ageing process: wasting,
decrepitude, dependency, decline.
Being labelled by others as ‘old and frail’ might contribute
to a frailty identity …. including a loss of interest in
participating in social and physical activities, poor physical
health and increased stigmatisation.
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2. Heterogeneity of measures
Original Definition of the Fried
Phenotype by Fried et al (2)
Interpretation of Fried Phenotype (n=16)
Slowness
Gait speed
Gait speed (n=13, 81%)
Questionnaire based assessment of physical function (n=2)
Not assessed (n=1)
Weakness
Grip Strength
Dyno metre measurement of grip strength (n=10, 63%)
Questionnaire based assessment of physical function (n=3)
Timed sit-to-stand (n=2)
Self-report (n=1)
Exhaustion
Centre for epidemiological
studies depression scale
Centre for Epidemiological Studies depression scale (n=5)
Patient Self report (n=5)
Short form 36 Questionnaire (n=5)
Short form 12 Questionnaire (n=1)
Shrinkage
>10 pounds of unintentional
weight loss in 12 months
Weight loss over 12 months (n=9, 56%)
Other (BMI, appendicular lean body mass, weight loss over 6
months, investigators’ impression of cachexia) (n=5)
Not measured (n=2)
Low Physical Activity
Estimated kilocalories per week
Estimation of kilocalories (n=5)
Patient self-report (n=5)
Questionnaire based physical activities scale (n=6)
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3. Poor clinical utility
Phenotype
– Reliance on performance based tests
– Dichotomous outcomes
Frailty index
– Complex
– Time consuming
– Mathematical
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4. Conceptual fuzziness
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5. Measurement, measurement…
Libor et al. Prog
Cardiovasc Dis, 2014
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Summary
1. Review a new instrument to measure frailty in routine
practice
derivation of frailty measure from routinely collected
information
2. Discuss limitations and potential pitfalls
need to understand how frailty is being measured,
which intervention is advocated/ discouraged and
consider relevance of outcomes
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Frailty in Older Inpatients