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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

3 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

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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, et.al. 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, et.al. 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 Frailty was classified using a validated scale (0 to 5) – Frieds 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 Frailty improved predictive power (p 0.01) of each risk index (American Society of Anesthesiologists, Lee, and Eagle scores).

19 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 (Frieds 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 (Frieds 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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