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What is frailty? Iden1fica1on and management
Lelly Oboh Consultant Pharmacist, Care of older people
8th November 2016
Frailty in the spotlight
• Watch Mrs Andrews' Story – what went wrong? hMps://youtu.be/I0TVbhHdg4A
What is frailty? • Age-‐associated decline in physiologic reserve and
func3on across mul3-‐organ systems leading to increased vulnerability for adverse health outcomes (Fried et al 2001)
• A dis1nct health state where a minor event can trigger major changes in health from which the pa1ent may fail to return to their previous level of health (Bri1sh Geriatric Society)
• Progressive Long term condi1on, with episodic deteriora1ons
Typical frail older person • Female, over 85 years • Mul1ple diseases, òmobility, ñdependence, weight loss, fa1gue
• Present clinically with frailty syndromes such as falls, confusion, incon1nence, delirium, adverse drug effects ðFrequent and long hospital admissions
For more informa+on on frailty read BGS Fit for Frailty 1&2 h7p://www.bgs.org.uk/index.php/fit-‐for-‐frailty
Reduced func1onal reserve in frailty
Frailty, Morbidity and Disability (Fried et al 2004)
Fried LP et al. Untangling the Concepts of Disability, Frailty, and Comorbidity: Implica1ons for Improved Targe1ng and Care. J Gerontol A Biol Sci Med Sci (2004) 59 (3): M255-‐M263.doi: 10.1093/gerona/59.3.M255
5.7%
26.6%
46.2%
21.5%
Phenotype model of frailty • Relates to what they look like and how they feel • 3 or more of…
• Unintended Weight Loss • Slow Gait Speed • Low Energy Expenditure • Self Reported Exhaus1on • Poor Grip Strength ( sarcopenia)
• Fried LP et al. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-‐56.
hMps://www.ncbi.nlm.nih.gov/pubmed/11253156
Survival curves of frailty (phenotype model) Fried JP et al. Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology 2001: Vol 56A, No. 3, M146–M156
Deficit model
• Accumula1on of deficits-‐ increasing frailty index-‐ increase risk of adverse outcomes
• Relates to the number of deficits i.e symptoms, signs and disease e.g. poor eyesight, social vulnerability
• Frailty Index is a % of total of deficits
Rockwood CFS 2004 Rockwood K et al CMAJ. 2005 Aug 30; 173(5): 489–495. hMps://
www.ncbi.nlm.nih.gov/pmc/ar1cles/PMC1188185/
Survival curves using Culmula1ve Deficit model Rockwood et al. 2005,
E-‐Frailty index
• eFI uses rou1ne 10 care data to iden1fy older people with mild, moderate and severe frailty
• Robust predic1ve validity for outcomes of mortality, hospitalisa1on and nursing home admission.
• Rou1ne implementa1on of t eFI could enable delivery of evidence-‐based interven1ons to improve outcomes
Andrew Clegg, et al. : Development and valida1on of an electronic frailty index using rou1ne primary care electronic health record data. Age Ageing (2016) 45 (3): 353-‐360 doi:10.1093/ageing/afw039l.
Five-year Kaplan–Meier survival curve for the outcome of mortality for categories of fit, mild frailty, moderate frailty and severe frailty (internal validation cohort).
Andrew Clegg et al. Age Ageing 2016;ageing.afw039
© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.
Iden1fy frailty using tests..
– Walking speed (gait speed) -‐ Gait speed is usually measured in m/s and recorded recorded over a 4m distance. Speed < 0.8 m/s or >5s to walk 4m.
– Timed up and go test -‐ The TUGT measures, in seconds, the 1me taken to stand up from a standard chair, walk a distance of 3 metres, turn, walk back to the chair and sit down. TUGT >10secs
– PRISMA 7 Ques3onnaire – A 7-‐ item ques1onnaire to iden1fy disability. Score of > 3 is considered to iden1fy frailty
Iden1fying frailty clinical prac1ce
Frailty syndromes – Falls – Reduced mobility – Delirium – Incon1nence -‐ urgency – Heightened Sensi1vity to drug effects – UTI – ACOPIA and ‘Social admission’, bed blockers, frequent flyers
Fit for Frailty 1 2014 • Guidance to support health and social care professionals in the community, outpa1ent clinics, community hospitals and other intermediate care sepngs and in older people's own homes
• Advice about ac1ons to prevent the adverse outcomes associated with frailty and help people live as well as possible with frailty.
• Many older people with frailty in crisis will manage beMer at home of there are the right support systems For more informa+on on frailty read BGS Fit for Frailty 1&2h7p://www.bgs.org.uk/index.php/fit-‐for-‐frailty
Fit for Frailty 2 2014 Premises underpinning frailty services 1. Interven1ons across health and social care aimed
at improving physical, mental and social func1oning to avoid adverse events like hospitalisa1on vs strictly disease-‐ orientated biomedical approach
2. Individualised treatment and interven1ons 3. Sustained support over a long 1me that con1nues
even through intervening crises and adverse events.
4. Interven1on plan that enables par3cipa3on of the older person.
5. Engagement with the family and/ or carers
NICE (NG56) Mul3morbidity: Clinical assessment and management. 2016 • To op1mise care for adults with mul1morbidity by reducing treatment burden (polypharmacy and mul1ple appointments) and unplanned care.
• To improve QoL by promo1ng shared decisions based on what is important to each person (treatments, health priori1es, lifestyle & goals) – Who will benefit from this approach – How to iden1fy them (incl. frailty) – What the care involves
Managing Frailty Can we stop or reverse frailty? • Evidence for exercise train programmes to address sarcopenia
• Mul1 faceted approach to target the specific characteris1cs (Cameron et al 2013)
How do we manage the effects? • Comprehensive Geriatric Assessment • Meta analysis of controlled trials of CGA in acute hospitals on emergency pa1ents (Ellis et al 2011).
• Less likely to die • More Likely to end up living at home, with cost reduc1on
Comprehensive Geriatric assessment
• A mul1dimensional, interdisciplinary diagnos1c process focused on determining a frail older person’s medical, psychological and func1onal capability, in order to develop a coordinated and integrated plan for treatment and long-‐term follow-‐up
The Comprehensive Geriatric Assessment
Care plan • Named co-‐ordinator • Main & Current Issues • Management/Maintenance Plan – With goals and solu1ons, Who is responsible for carrying out? , 1mescales, review
• Escala3on Plan – What to look out for, What to do / Who to contact?
• Urgent care Plan-‐ for crisis • Overall aim is Comfort – for pallia1ve treatment only, even in life threatening situa1ons
• Advanced care plan /End of Life Plan agreed / just in case medicines
What principles can be applied to medicines op1misa1on?
• iden1fica1on during pharmacy interven1on e.g medicines review so we don’t cause harm by intervening
• Conduct evidence-‐based medica1on reviews for older people with frailty (e.g. STOPP START criteria).
• Use clinical judgment and personalised goals when deciding how to apply disease-‐based clinical guidelines to the management of older people with frailty.
• Generate a personalised shared care and support plan (CSP) outlining treatment goals, interven1ons, follow up review, crisis plan
Frailty Polypharmacy and Medicines Op1misa1on
Nina BarneM and Lelly Oboh Consultant Pharmacists, Care of older people
November 2016
Medicines Op3misa3on Outcome focused approach to safe and effec3ve use of medicines that takes into account the pa3ent’s values, percep3on and experience of
taking their medicines
hMp://www.rpharms.com/promo1ng-‐pharmacy-‐pdfs/helping-‐pa1ents-‐make-‐the-‐most-‐of-‐their-‐medicines.pdf
Important Outcomes for adults • Improved quality of life • Making a posi1ve contribu1on • Improved health and emo1onal
wellbeing • Personal Dignity • Control and choice • Economic wellbeing • Freedom from discrimina1on
Frailty, polypharmacy and mortality 2350 French older people • Independent and combined effects of polypharmacy and frailty on mortality risk
• 6x increased risk of death in frailty vs. robust and non polypharmacy (>5 drugs)
• 3x more likely to be on 5 drugs • 6x more likely to be on 10 drugs • High risk prescribing (polypharmacy, an1cholinergic) can contribute to frailty (Gnjidic D et al 2012)
Herr M et al 2015 Pharmacoepidemiol Drug Saf. 2015 Jun;24(6):637-‐46
Implica1ons for medicines op1misa1on
Evidence: Pharmacist led interven3ons reducing hospital admissions
• No evidence of impact of medica1on reviews on hospital bed use (Philp I et al IJIC 2013)
• Systema1c reviews and Meta analysis (Thomas R Age and Ageing 2014) – Interven1ons led by hospital pharmacists reduce unplanned hospital
admissions in older pa1ents with heart failure (3RCTs) – Interven1ons led by hospital or community pharmacists for the general
older popula1on do not reduce unplanned admissions (16 trials)
• Many interven1ons that might be expected to avoid admissions, including home based medica1on reviews do not (Kings Fund 2010)
• BoMom line…… No robust evidence that pharmacist led interven1ons reduce hospital admissions in older people
Moving towards medicines op3misa3on
Pa3ent iden3fica3on • From drug related to pa1ent centred, real need vs poten1al need • Most frail elderly have high risk factors! Find them, find the drugs! Assessments and reviews-‐ approach and scope • From drug reviews to holis1c and pa1ent-‐centred incl. social
vulnerability, func1onal status as well as drugs and disease • Including evidence base, then individualising drug therapy
according clinical judgement and pa1ent narra1ve Interven3ons • General fixed solu1ons to individualised jointly agreed solu1ons • Working in silo to collabora1ve and MDT/integrated working • Pharmacist to pharmacist referrals • Care coordina1on-‐led by pharmacist as expert in use of medicines 1. Heather Smith et al 2013. Integrated Medicines oP1misA1on on Care Transfer (IMPACT) project
2. Nina BarneM et al 2016. Impact of an integrated medicines management service on preventable medicines-‐related readmission to hospital: a descrip1ve study. Eur J Hosp Pharm doi:10.1136/ejhpharm-‐2016-‐000984
3. Blagburn J et al 2015. Pa1ent-‐centred pharmaceu1cal care to reduce avoidable drug related readmission. Eur J Hosp Pharm 2016;23:80-‐85 doi:10.1136/ejhpharm-‐2015-‐000736
4. Oboh L, Qadir MS. Deprescribing and managing polypharmacy in frail older people: a pa1ent-‐centred approach in the real world. Eur J Hosp Pharm 2016; doi:10.1136/ejhpharm-‐2016-‐001008Heather Smith et al 2013. Integrated Medicines oP1misA1on on Care Transfer (IMPACT) project
How should we be different?
• Leading medicines op1misa1on (over and above reviewing medicines lists)
• Care co-‐ordinators • Enablers • Pa1ent Advocates • Safety and Governance leads
Improved Consulta3ons
• Clinical pharmacists and pa1ents encounters moved from giving informa1on to pa1ent led conversa1ons, with shared agenda, shared treatment decisions and joint solu1ons to problems iden1fied
Structuring a consulta1on
Managing short consulta3ons The Four E’s – EXPLORE – EDUCATE – EMPOWER – ENABLE Requires a prac%%oner engagement and empathy with the pa3ent
BarneM 2011
A patient-centred approach to managing polypharmacy
© N BarneM L Oboh K Smith NHS Specialist Pharmacy Service 2015
Iden1fy or receive referral for frail older
person
Thank you