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 MedicineInternal Medicine Resident RotationKatherine Thompson, MD & Patricia Rush, MD
2 Objectives: SAFE Clinic Define frailty and identify frail patientsPractice and interpret:cognitive assessmentfunctional assessmentAppreciate importance of interdisciplinary care for frail patientsAppreciate relevance of geriatric assessment to your future practice
3 WHAT ELSE DO WE NEED TO KNOW? Case StudyMrs. 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 fallenReview 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 ProgressiveAt risk - adverse health outcomes, increased mortalityAssociated with chronic diseaseWorsens with advancing ageMarked by a transition from independence to dependence on caregivers
6 Measurement of Frailty Clinical features: ≥ 3 meets Criteria for FrailtyWeaknessWeight lossPoor energyLow physical activitySlownessAt risk for adverse outcomesFallsNew or worsened ADL impairmentHospitalizationDeath
7 Syndrome of Frailty Other associated features Cognitive impairment Balance/motor impairmentDepression, anxiety, lonelinessPoor quality sleepLow self-rated healthInadequate social support
8 Biologic Basis of Frailty Dysregulation across more than one of these physiological systems is associated with greater risk of frailtyDespite growing understanding of biology, diagnosis of frailty remains clinical
9 Biologic Basis of Frailty Loss of skeletal muscleDecreases in estrogen, testosterone, growth hormone, and insulin-like growth factor 1Increases in interleukin 6, C-reactive protein, tissue plasminogen activator, and D-dimerNo 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 patientsDeclines 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 specialtyfrom chemotherapy to cardiac catheterization to colon cancer screeningInability 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 illnessesDisability = 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, et.al. Frailty as a Predictor of Surgical Outcomes in Older Patients, J Am Coll Surg 2010; 210:901–908Standard 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 patientsPostoperative 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, et.al. Frailty as a Predictor of Surgical Outcomes in Older Patients, J Am Coll Surg 2010; 210:901–908STUDY 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 complicationsIntermediately frail: odds ratio [OR] 2.06Frail: OR 2.54;Increased length of stayIntermediately frail: incidence rate ratio 1.49Frail: incidence rate ratio 1.69Discharge to a skilled or assisted-living after living at homeIntermediately frail: OR 3.16Frail: OR 20.48Frailty 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 MedicineResearch – Patient Care
20 SAFE Clinic Assessment Research Informed consent obtainedDemographics (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)
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 WeaknessLow grip strengthStandardized using a dynamometerWeight 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 speedTime to walk 15 feet at usual paceSlow = ≥ 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 weekLow physical activityCalculated 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 FrailProvide individualized education, resourcesManagement strategies:Improve core manifestations of frailty: physical activity, strength, exercise tolerance, nutritionExclude modifiable precipitating factorsMinimize consequences of vulnerability
26 Patient Care: Return Visit Interdisciplinary teamAssessmentCare planningPatient follow upResults of assessmentRecommendations provided to patient & PCPPatient education materials and resourcesConsult letter dictated with recommendationsAnticipate follow up visits q6-12 months for tracking
27 SAFE: Patient Recommendations Vigorous - Not Frail:Focus on:exercisesocial supportvision/hearing screenpreventive evaluationstight control of medical conditions such as HTN, DMsmoking cessation
28 SAFE: Patient Recommendations Pre-frail – OPPORTUNITYEmphasize exercise or PT for strength and balance, fall prevention.Nutrition assessmentDriving - home safety evalSocial supportWatch for depression and cognitive changesRegular medical followup; smoking cessation.
29 SAFE: Patient Recommendations Frail: Fragile – Handle with CareFocus:Hospitalization avoidanceFall preventionReview benefits/burdens of treatmentsAdvance Care PlanningMedication management - minimize # of meds # dosesAnticipate caregiver stress
30 SAFE Clinic Team Members: FACULTY:Patricia Rush, MD MBAKatherine Thompson, MDWilliam Dale, MD PhDJoseph Shega, MDGeri Fellow: Megan Huisingh-Scheetz, MDAdv Practice Nurse: Lisa Mailliard, Geri SpecialistSocial Work:Patricia MacClarence, LCSWJeffrey Solotoroff, LCSW