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SAFE Clinic Successful Aging & Frailty Evaluation University of Chicago – Geriatrics and Palliative Medicine Internal Medicine Resident Rotation Katherine.

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Presentation on theme: "SAFE Clinic Successful Aging & Frailty Evaluation University of Chicago – Geriatrics and Palliative Medicine Internal Medicine Resident Rotation Katherine."— Presentation transcript:

1 SAFE Clinic Successful Aging & Frailty Evaluation University of Chicago – Geriatrics and Palliative Medicine Internal Medicine Resident Rotation Katherine Thompson, MD & Patricia Rush, MD

2 Objectives: SAFE Clinic
Define frailty and identify frail patients Practice and interpret: cognitive assessment functional assessment Appreciate importance of interdisciplinary care for frail patients Appreciate relevance of geriatric assessment to your future practice

Case Study Mrs. Thomas (82 y/o woman) comes to Clinic with her son. Son is concerned that Mrs. Thomas is not doing well. On exam, patient is pleasant, quiet, cooperative. BP 154/70, HR 70 regular, RR 16. Weight 154 lb. Exam is generally unremarkable. HEENT, Cardiac, Lungs, Abdomen all negative. Has 1+ edema over ankles. Has good sitting balance, but uses arms to arise from chair and stumbles on her way to the exam table. Labs: CBC, BMP, TSH from 3 months ago were basically normal. Hgb GFR 50. WHAT ELSE DO WE NEED TO KNOW?

4 Case Study BACKGROUND: Mrs. Thomas is a widow. Husband died 6 yr ago
Mrs. Thomas lives alone. Sons brings her groceries once a week. Pt administers her own medication. Son feels mother is depressed - does not attend family events. Son states patient is slow to answer phone when he calls and seems sort of confused. Last week, she thought he was his father (deceased 6 yr ago) Son suspects mother has fallen because he sees bruises. Mrs. Thomas denies she has fallen Review of chart shows patient has lost 7 lb in past 2 years. WHAT IS GOING ON ??

5 Definition of Frailty Diminished capacity to withstand stress
Progressive At risk - adverse health outcomes, increased mortality Associated with chronic disease Worsens with advancing age Marked by a transition from independence to dependence on caregivers

6 Measurement of Frailty
Clinical features: ≥ 3 meets Criteria for Frailty Weakness Weight loss Poor energy Low physical activity Slowness At risk for adverse outcomes Falls New or worsened ADL impairment Hospitalization Death

7 Syndrome of Frailty Other associated features Cognitive impairment
Balance/motor impairment Depression, anxiety, loneliness Poor quality sleep Low self-rated health Inadequate social support

8 Biologic Basis of Frailty
Dysregulation across more than one of these physiological systems is associated with greater risk of frailty Despite growing understanding of biology, diagnosis of frailty remains clinical

9 Biologic Basis of Frailty
Loss of skeletal muscle Decreases in estrogen, testosterone, growth hormone, and insulin-like growth factor 1 Increases in interleukin 6, C-reactive protein, tissue plasminogen activator, and D-dimer No diagnostic laboratory test is available


11 Under-recognition of Frailty by Clinicians
Frailty does not fit into classic organ-specific models of disease. Subtle decline may not be evident to clinicians, family members, or patients Declines in strength, endurance, and nutrition may not cause patients to seek medical attention and may hinder their doing so

12 Why should I care? Frail patients are internal medicine patients (increasing numbers every year) Ability to identify frailty will affect your medical decision-making and treatments regardless of specialty from chemotherapy to cardiac catheterization to colon cancer screening Inability to identify frailty will result in bad outcomes for you and your patients

13 Frailty Assessment as a Prognostic Tool: Survival by Frailty Stratification

14 How does Frailty compare with CoMorbidity and Disability?
CoMorbidity = presence of 2 or more significant chronic illnesses Disability = inability to perform 1 or more Activities of Daily Living (ADL) Ambulating, Toileting, Showering, Dressing, Eating

15 Frailty: distinct entity
Fried, LP et al. Journal of Gerontology, 56A: M , 2001

16 Clinical Application of Frailty Assessment Preoperative Surgical Risk Makary, Martin, Frailty as a Predictor of Surgical Outcomes in Older Patients, J Am Coll Surg 2010; 210:901–908 Standard indications for medical or surgical interventions might not be generalizable to older patients because physiologic changes from aging can alter the risk-to-benefit analysis. Goal: reduce postoperative complications in older patients Postoperative complications in patients aged 80 and older increase 30-day mortality by 26%

17 Johns Hopkins Dept of Surgery – 2010 Frailty as Risk for Surgical Outcomes Makary, Martin, Frailty as a Predictor of Surgical Outcomes in Older Patients, J Am Coll Surg 2010; 210:901–908 STUDY DESIGN: Prospectively measured Frailty in 594 patients (age 65 years or older) presenting to a university hospital for elective major surgery between July 2005 and July 2006. Frailty was classified using a validated scale (0 to 5) – Fried’s Criteria - weakness, weight loss, exhaustion, low physical activity, and slowed walking speed. Main outcomes measures: 30-day surgical complications Length of stay Discharge disposition.

18 RESULTS: Frailty and Surgical Outcomes
Preoperative frailty was associated with an increased risk for postoperative complications Intermediately frail: odds ratio [OR] 2.06 Frail: OR 2.54; Increased length of stay Intermediately frail: incidence rate ratio 1.49 Frail: incidence rate ratio 1.69 Discharge to a skilled or assisted-living after living at home Intermediately frail: OR 3.16 Frail: OR 20.48 Frailty improved predictive power (p 0.01) of each risk index (American Society of Anesthesiologists, Lee, and Eagle scores).

19 Research – Patient Care
SAFE Clinic Successful Aging & Frailty Evaluation University of Chicago – Geriatrics and Palliative Medicine Research – Patient Care

20 SAFE Clinic Assessment Research
Informed consent obtained Demographics (age, race, education, income, living situation, height, weight, BMI) EPIC data (problem list, meds) MD Progress note (acute issues, sensory impairment, assist devices-cane or wheelchair, recent hospitalizations, other pertinent)

21 SAFE – Initial Assessment
Vulnerable Elder Survey (VES-13) Self-rated health & functional status Comorbidities (Charlson comorbidity index) Falls (AGS falls questions) Sleep (Pittsburgh Sleep Index) Depression (PHQ-2) Pain (Pain map & pain thermometer) Stress Caregiver strain

22 SAFE – Initial Assessment
Cognition (MOCA +/- MMSE) Physical function (Short physical performance battery) 1) Stands (side-by-side, semi-tandem, tandem, hold for 10 seconds) 2) Chair stands (5 stands from chair, without using arms) 3) Measured walks (2 timed 4-meter walks, take faster time, goal = less than 8.7 sec)

23 Frailty (Fried’s Frailty Criteria) ≥ 3 meets Frailty Criteria
Weakness Low grip strength Standardized using a dynamometer Weight loss > 5% weight loss, or 10 lbs in 1 year “In the last year, did you lose 10 lbs or more, not on purpose?” Slowed gait speed Time to walk 15 feet at usual pace Slow = ≥ 6 or 7 sec. depending on gender, height

24 Frailty (Fried’s Frailty Criteria) ≥ 3 meets Frailty Criteria
Fatigue/low energy “How often in the last week did you feel that everything you did was an effort?” and “How often would you say you could not get going?” Significant response = “moderately often” or more on ≥ 3 days in the last week Low physical activity Calculated Kcal expenditure based on standardized instrument (Minnesota leisure time activities questionnaire)

25 SAFE Clinic: Patient Care
Identify patients: Not Frail Pre-frail or intermediate, or Frail Provide individualized education, resources Management strategies: Improve core manifestations of frailty: physical activity, strength, exercise tolerance, nutrition Exclude modifiable precipitating factors Minimize consequences of vulnerability

26 Patient Care: Return Visit
Interdisciplinary team Assessment Care planning Patient follow up Results of assessment Recommendations provided to patient & PCP Patient education materials and resources Consult letter dictated with recommendations Anticipate follow up visits q6-12 months for tracking

27 SAFE: Patient Recommendations
Vigorous - Not Frail: Focus on: exercise social support vision/hearing screen preventive evaluations tight control of medical conditions such as HTN, DM smoking cessation

28 SAFE: Patient Recommendations
Pre-frail – OPPORTUNITY Emphasize exercise or PT for strength and balance, fall prevention. Nutrition assessment Driving - home safety eval Social support Watch for depression and cognitive changes Regular medical followup; smoking cessation.

29 SAFE: Patient Recommendations
Frail: Fragile – Handle with Care Focus: Hospitalization avoidance Fall prevention Review benefits/burdens of treatments Advance Care Planning Medication management - minimize # of meds # doses Anticipate caregiver stress

30 SAFE Clinic Team Members:
FACULTY: Patricia Rush, MD MBA Katherine Thompson, MD William Dale, MD PhD Joseph Shega, MD Geri Fellow: Megan Huisingh-Scheetz, MD Adv Practice Nurse: Lisa Mailliard, Geri Specialist Social Work: Patricia MacClarence, LCSW Jeffrey Solotoroff, LCSW

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