1. Why Frail Seniors are Important? A Presentation to the NL Public Sector Pensioners’ Association Oct 7 th 2015 Capital Hotel Dr. Roger Butler Associate Professor of Family Medicine MUN

2. My Mom

4. Objectives 1.The attendee will be introduced to a model of frailty taking into account the entire population of seniors. 2. The attendee will be introduced to the evidence supporting diet and exercise vs drug therapy for the senior age group. 3.The attendee will be introduced to some of the demographic challenges facing the frail seniors in our province. 4.The attendee will be introduced to some of the important determinants of health in this age group.

5. Frailty Frailty is a clinical state in which there is an increase in an individual’s vulnerability for developing increased dependency and /or mortality when exposed to a stressor. JAMA Vol 14,issue 6, June 2013 pages 392-397

7. Frailty develops as a consequence of age-related decline in many physiological systems. Between a quarter and half of people older than 85 years are estimated to be frail, and these people have a substantially increased risk of falls, disability, long-term care, and death.

8. Prevalence and co-occurrence of the three frailty phenotypes. Josep Garre-Olmo et al. Age Ageing 2013;42:46-51 ©

9. Robust VS Frail older adults Frailty Phenotype ≥3 of unintentional weight loss, exhaustion,weakness, slow walking, low physical activity and accumulation of medical, functional or social deficits Robust mobile and functionally independent Robust patients have a medication focus on prevention, treatment,and to alleviate symptoms and delay functional decline and mortality. Frail patients who are approaching end of life need to take a more palliative approach and often one can stop preventative therapies.

12. Average Life Expectancy tables USA 1997 (Walters) MalesFemale

13. Managing Aggressive Behavior in Dementia Dr. Roger Butler

14. Risks of Medicines in Frail Older Adults 1.ADR’s 2.Hospitalisation 3.Functional impairment 4.Geriatic syndromes 5.Impaired hepatic and/or renal function 6.Drugs with anticholinergic and sedative properties 7.Antiplatelet,anticoagulants and hypoglycemic agents.

15. Can we reverse frailty? Physical frailty can potentially be prevented or treated with specific modalities: 1. Exercise 2. Protein calorie supplementation 3. Vit D 4. Reduction of Polypharmacy Jama vol 14, issue 6,June 2013,pages 392-397

16. Fact or Fiction Seniors are costing the health care system too much money?

17. Do diet and exercise trump medications in the elderly? It depends….. 1.Combined Impact of Health Behaviours and Mortality in Men and Women : The EPIC –Norfolk Prospective Population Study Jan 2008 Kay –Tee Shaw et al www.plos medicine.orgwww.plos 2.Comparative effectiveness of exercise and drug interventions on mortality outcomes :metaepidemiological study 2013 BMJ Huseyin Naci, John PA loannidis director ( London School of Economics)

18. Combined Impact of Health Behaviours and Mortality in Men and Women : The EPIC –Norfolk Prospective Population Study 20,244 men and women aged 45-79 No cardiovascular or cancer at baseline 1993-1997 Followed until 2006 Scored 1 point for each of 4 health behaviours: Current non smoking = 1 point Moderate Alcohol intake = 1 point Fruit and vegetable 5 servings per day = 1 point Not physically inactive = 1 point

19. Results If you have all 4 behaviours you have a 4 fold difference in total mortality in men and women Equivalent to 14 years chronological age Trends strongest for cardiovascular causes.

20. Comparative effectiveness of exercise and drug interventions on mortality outcomes : metaepidemiolgical study 16 meta-analyses 305 randomized controlled trials 339274 participants…..14716 exercise group remainer drug trials Four disease processes examined: 1.Effectiveness of exercise on the secondary prevention of coronary heart disease 2.Rehabilitation of stroke 3.Treatment of heart failure 4.Prevention of diabetes

21. Results No statistically detectable differences were evident between exercise and drug interventions in the secondary prevention of coronary artery disease and prediabetes. Physical activity interventions were more effective than drug treatment among patients with stroke ( exercise more effective than antiplatelets and exercise more effective than anticoagulants.) Diuretics were more effective then exercise in heart failure. Physical inactivity has been ranked as the fifth leading cause of disease burden in Western Europe

22. United Kingdom 14% of adults exercise regularly with only 1/3 meeting recommended levels of physical activity Utilization rates for prescription drugs continue to rise : 2000 – 11.2 perscriptions for every person 2010-17.7 perscriptions for every person

23. Newfoundland and Labrador Senior Demographics Total population 2015 = 527,756 Population >65=97,269 % >65=18.4% >85=9442 Males >85 =3221 Females >85=6221 Conservative frailty estimate >85 =2500 to 5000 >85= I/3 are demented = 3000 Stats Canada 2015

26. 1978-Present NL Staffing reallocation in Nursing Homes (80% of budget salaries…. MDS) 2005 -2007 Have status with have not infrastructure(10 year) Rising Tide Report Alzheimer’s Canada 2010 Alzheimer’s International 2012 Public Health Priority 2014 avg NH age 86 /Dementia # 1 diagnosis/90% DVA 2017 ….oldest proportion over 65 in Canada 2030 …oldest proportion over 65 in the world

27. Challenges Develop a provincial strategy not just for well but for frail elderly Develop a consistent home first approach Develop age friendly communities Develop standards for training of home support workers to meet the needs of todays clients Develop standards of care for personal care homes Develop sustainability of community support organizations

28. Challenges Poverty/Housing Nutrition Income support Transportation Allied health support Medical home model Palliative Care Advance Care Directives