Frailty: Tailoring Care to Need & Vulnerability John Muscedere, - PowerPoint PPT Presentation

Frailty: Tailoring Care to Need & Vulnerability John Muscedere, Scientific Director & CEO Canadian Frailty Network

Disclosure • Scientific Director for the Canadian Frailty Network • Funded by the Government of Canada through the Networks of Centers of Excellence • Partner with other NGOs, governments and industry • Conduct industry sponsored clinical trials in the ICU • N8 pharma, Shionogi, Polyphor

Outline • Aging in Canada • Overview of frailty • Why we should care about frailty • Tailoring care based on frailty assessment – Examples of frailty care innovations

Canadian Frailty Network (CFN) Who are we? • Not-for-profit pan-Canadian network since 2012 • Funded by the federal government through Networks of Centres of Excellence • Multi-disciplinary network which includes investigators, stakeholders, trainees, partners, citizens, and caregivers What do we do? • We aim to improve care for older adults living with frailty and to support their family and friend caregivers through practice and policy change 4

Our Conceptual Framework

Aging in Canada • Number and proportions of seniors over age of 65 are increasing rapidly • Older segments of population growing most rapidly • Number of working adults for every senior is dropping Source: Government of Canada — Action for Seniors report, 2014. Data from Stats Canada and Office of the Superintendent of Financial Institutions.

Volume of Health Services by Age • ~216 million physician services Per-capita services by patient age and gender, 2015-16 delivered in 8 provinces surveyed. • >70 million (1/3 rd ) services to patients aged 65+. • Service utilization rates increase steadily with age. • Data: 2015-2016; 8 provinces surveyed • Slade, S., Shrichand, A., & DiMillo, S. 2019. Health Care for an Aging Population: A Study of how Physicians Care for Seniors in Canada. Ottawa, Ontario. The Royal College of Physicians and Surgeons of Canada. • Original Data Source: Canadian Institute for Health Information, National Physician Database, 2015-16

Healthcare consumption

Evolution of Aging… Healthy Function Aging Age 9

Frailty Health State • Frailty is defined as a state of increased vulnerability resulting from reduced physiological reserve and loss of function across multiple systems reducing the ability to cope with normal or minor stressors. • ‘Minor’ events trigger major changes in health status • Associated with increased risk of physical, cognitive and functional decline, adverse health outcomes and mortality Source: e: Xue e Q, The e Frai ailty Syndr drom ome: : Defi fini nition n and d Na Natur ural Hist stor ory. Clin n Ge Geriat atr Me Med 2012. 12. Clegg egg A, The e frai ailty synd ndrom ome. Clin n Me Med d 2011. 11. 10 Walston Wa on J, Rese sear arch h Age gend nda a for or Frai ailty in Olde der Adul ults. s. J Am Ge Geriatr Soc 2006. 06.

Common Features of Frailty

Frailty…Impact and Determinants • Frail patients have functional loss, many require caregivers, are at higher risk of institutionalization and are frequent users of healthcare services • Vast majority of long term care residents are frail • Majority of elderly patients who are hospitalized are frail • Frail patients often have worse outcomes when they receive medical interventions • Determinants of frailty include public health aspects: – Social isolation/loneliness, nutrition, vaccination, inactivity, polypharmacy, community organization

Frailty in Canadians ( > 65 y.o.) Sources: 1. statcan.gc.ca/pub/82-003-x/2013009/article/11864-eng.htm 2. Kehler et al, BMC Geriatrics 2017

Prevalence of frailty is high and growing in Canada That’s approximately 1,500,000 Canadians Expected to be 2,000,000 by end of next decade statcan.gc.ca/pub/82-003-x/2013009/article/11864-eng.htm

Older Adults: Frailty prevalence increase with age Kehler et al, BMC Geriatrics 2017

Sex: Prevalence of frailty higher in women Systematic review of seven international studies showed that women have higher frailty scores than men at any age. Mitnitski et al. JAGS 53:2184 – 2189, 2005 Gordon et al. Sex differences in frailty: a systematic review and meta-analysis. Exp Gerontol 2017;89:30-40.

Socioeconomic Status: Prevalence of frailty Predicted frailty index by wealth and neighborhood deprivation, both split by quintiles, in fully adjusted models 0.2 0.18 0.16 0.14 Frailty Index Least deprived 0.12 2 0.1 3 4 0.08 Most deprived 0.06 0.04 0.02 0 Wealthiest 2 3 4 Least wealthy Level of wealth Lang et al. Socioeconomic status, neighborhood deprivation, and frailty in older adults. JAGS 2009

First Nations People and Frailty 20% 30% 50% 50% 50% 50% Figure A – Frailty patterns over age groups in general Figure B – Frailty categories across age groups in Canadian population . Canadian Community Health First Nations people living on-reserve and in Survey, as published by Hoover et al. (2013) northern First Nations communities Walker (2017) Canadian Journal on Aging, 1-12. Hoover et al. (2013) Health Reports, 24(9): 10 – 17.

How is Frailty measured? • Over 60 frailty assessment instruments have been described – Reliability, validity poorly studied for many of them – Variable agreement between scales – Variable data collection burden • Two conceptual models: Phenotype or as an accumulation of deficits • Common (and best studied) assessment instruments: – Frailty phenotype model – Deficit Accumulation (Frailty Index) – Clinical Frailty Scale Buta et al. 2016, Ageing Res Rev. 26: 53 – 61. Viña et al, 2016, Molecular Aspects of Medicine 50; 88 – 108

Frailty – Accumulation of Deficits Frailty Index = e.g. in a dataset with 50 health measures, Number of deficits in an individual a person with 10 things wrong (10 deficits) Total number of potential deficits measured has a frailty index of 10/50 = 0.20. Source: Rockwood et al, CMAJ 2011. DOI:10.1503/cmaj.101271

Frailty associated with worsened outcomes, hospitalization and mortality Rockwood et al, CMAJ 2011. DOI:10.1503/cmaj.101271

Frailty Phenotype Criteria Criteria Definition 1. Weight loss/Sarcopenia > 10 lb weight loss/year 2. Weakness Grip strength 3. Slowness 15 feet Walking time 4. Low Activity Level Kcal/week expended 5. Exhaustion Self-reported Frailty: > 3 Criteria Present Pre-Frail: 2 Criteria Present 23 Fried et al, J Gerontol A Biol Sci Med Sci. 2004

Clinical Frailty Scale Rockwood et al, CMAJ 173 (5): 489

Other screens for frailty • Hand grip strength – Better marker of frailty than age, correlates with mortality – Correlates with post operative, CVD outcomes – Easy to measure • Four meter gait speed – Gait speed of longer than 5 seconds to walk 4 metres (<0.8 m/s) suggests an increased risk of frailty • Timed up and Go – Time to get up from a chair, walk 3 meters and back – Correlates with frailty, outcomes and falls – Reliable and valid 25

Care of older adults – Paradigm change Patient-centred & Disease-centred Function-centred paradigm paradigm

Frailty is not solely a health care issue Better care for seniors living with frailty will only come through improvements in BOTH health and social care.

How can we address frailty? 1. Primary and secondary prevention – Frailty is not an inevitable part of aging – Promotion of healthy ageing 2. Tailoring care to the degree of frailty – Not sufficient to identify frailty unless care is tailored to its determinants, modifiable factors – Frailty determination needs to lead to more detailed evaluation

CFN Public Health Campaign Frailty is NOT an inevitable part of aging

CFN Public Health Campaign

Fact: Primary care family physicians provide about half of all seniors’ medical services • Family physicians comprise 57% (n=30,515) of all physicians included in the 2015-16 study data. • Family physicians provided 57% (n=122.23 million) of all fee-for service care. • At just over 35 million services, family physicians delivered 51% of all services provided to patients aged 65+ (highest volume of services provided to seniors among all specialty groups). • Almost one- third (29%) of all family physicians’ services were provided to patients aged 65+ . Slade, S., Shrichand, A., & DiMillo, S. 2019. Health Care for an Aging Population: A Study of how Physicians Care for Seniors in Canada. Ottawa, Ontario. The Royal College of Physicians and Surgeons of Canada.

Advancing Frailty Care in the Community: Collaborative with CFHI Goal: Enhance frailty care in primary care and the community across Canada using a quality improvement approach. Objectives: – Improve identification and assessment of frailty in primary care. • Systematically identify frailty in adults 75 years of age and over. • Using case finding approach identify frailty in those 65 years and over. • Practices will use the Clinical Frailty Scale or 4 meter gait speed/handgrip strength – Implement person-centred evidence-informed frailty interventions and customized care plans utilizing a interprofessional team and community supports.