Introductory Webinar Better Care, Better Health, Better Value A - PowerPoint PPT Presentation

Transitioning to a Regional Rehabilitative Care Program in Waterloo Wellington LHIN Frail Senior Care Pathway – Introductory Webinar Better Care, Better Health, Better Value A Better Rehabilitative Care System

What will we cover today? • Cases • Frailty, complexity and risk • Overview of pathway • Back to the cases • Questions/discussion

Case 1: The acute care “veteran” 94 year old man: Second world war veteran • Dementia: probably mild Alzheimer’s disease • Heart failure: ischemic, ejection fraction 45% – History of hypertension, diabetes (diet controlled) – Mild renal insufficiency – Optimal heart failure medications and doses • Yet, 3 ED visits with 1 admission for recurrent heart failure in 2 months, and referred to HF clinic

Case 2: Meet Mrs. Jones 87-year-old woman with generalized weakness • Last year: gradual functional decline, fatigue, poor energy • Last 2 months: unintentional 15 pound loss (now 80 lbs) • Last 2-3 weeks: – most of day in bed sleeping – diarrhea 3-4 times per day – decline in cognition: requires cuing to eat and drink, help dressing / bathing / transfers – Family stressed

FRAILTY, COMPLEXITY AND RISK

Patterns of aging • Successful aging: – avoidance of disease and disability – maintenance of physical and cognitive function – sustained engagement in social, productive activities • Clearly, not all people achieve this – at progressively higher risk of poor outcomes – They are “FRAIL” Rowe & Kahn, The Gerontologist (1997) 37 (4): 433-440.

What is frailty? Bergman et al. J Gerontol 2007;62A:7;731-7 • Vulnerability to stressors • Predisposes to resulting from the age- – Functional impairment / related accumulation of disability impairments in multiple – Caregiver burden and ill- systems health – Falls • Stressor – illness – Homecare utilization – iatrogenic – Institutionalization – environmental (e.g. – Hospitalization roadside curb) – Death

Deconstructing frailty • Is the problem – Multimorbidity? – Disability? – Geriatric syndromes? – All of the above?

Multimorbidity burden Rapoport et al, 1999; National Population Health Survey, Chronic Dis Canda 2004 Age Number of chronic conditions 0 1 2 3+ 40-59 44% 30% 14% 12% 60-79 20% 25% 25% 30% 80+ 12% 24% 22% 41%

Source : CIHI Jan 2011

Not all seniors with multimorbidity are frail Bergman et al 2007 Rockwood et al CMAJ 2005

Is it disability? Gilmour & Park, Suppl Health Reports, Stats Can 2005 • 2003 Canadian Community Health Survey of 28617 adults > 65 (17205 women) Age Basic ADL Instrumental ADL Men Women Men Women 65-74 4% 4% 9% 18% 75-84 8% 9% 21% 36% 85+ 20% 23% 46% 65%

Not all frail seniors are disabled ... Bergman et al 2007 Rockwood et al CMAJ 2005

What about “geriatric syndromes”? Ann Intern Med 2007;147:156-64 • Health and Retirement Study – 11093 Americans 65 years and over – Community and nursing homes • Assess association between disability and – Chronic diseases (active or severe) – Geriatric “conditions”

HRS Geriatric conditions and age Number of 65-74 75-84 85+ geriatric conditions 1 or more 40% 56% 76% 2+ 12% 23% 44% 3+ 4% 10% 32%

Chronic Prevalence Geriatric Prevalence Disease Condition Musculo- 29.7% Hearing 25.7% skeletal impaired Diabetes 13.2% Dizzy 13.4% Heart disease 9.2% Incontinence 12.7% Psychiatric 7.1% Injurious 9.6% disorder fall Lung disease 5.8% Vision 8% impaired Stroke 5.4% Cognitive 7.3% impairment Cancer 4.8% Low BMI 2.9%

HRS: Disability Condition Risk ratio of disability Number of geriatric conditions 1 2.1 2 3.6 3+ 6.6 Stroke 3.0 Diabetes 1.3 Heart disease 1.2 Cancer 1.0

Concurrence of ... • comorbidities • disabilities • geriatric syndromes • gaps in social support • interacting with one another leading to a downward spiral ... • How is this recognized ?

“Eyeball test” • Can you tell frailty just by looking at it? • Experts can … to a point • Non-experts prone to bias • Need something better…

FREID Frailty Phenotype Fried et al 2001

Fried predicts outcomes?

Frailty and deficit accumulation Rockwood & Mitnitski J Gerontol Med Sci 2007; Mitnitski et al BMC Geriatrics 2002 • Concept: The more things wrong with you, the more frail you are • Secondary analysis from Canadian Study on Health and Aging – Random sampling of 10267 persons 65 years+ – 2914 underwent structured clinical assessment at baseline – 1338 survivors assessed 5 years later – 64% women, age 82.0 (SD 7.4) • Developed Frailty Index of 70 deficits associated with cognitive and functional decline

65% is bad, regardless of how you get there

Data from the Canadian National Population Health Study Song et al J Am Geriatr Soc 2010 What do you see? • Dose response relationship • Predicts mortality

CSHA Clinical Frailty Scale Correlates well with Frailty Index Predicts frailty outcomes Key indicator: “slowed up” Rockwood et al CMAJ 2005

Institutionalization risk Rockwood et al CMAJ 2005

PERFORMANCE MEASURES Can we assess frailty more quickly?

• Gait velocity • Grip strength Studenski et al JAMA 2011

Grip Strength Ling et al CMAJ 2010

FEATURES OF FRAILTY: GERIATRIC SYNDROMES

Geriatric syndromes share risk factors Tinetti et al, JAMA 1995 • Prospective cohort study of 927 community-dwelling seniors, aged 72 or higher, with Baseline and 1 year follow-up

Frailty is important • Multiple ways to recognize – Various length to complete – Each has its own strengths and drawbacks – Each predicts outcomes in a graded, dose- response relationship • Over the medium to long-term • Persons with frailty are at risk of multiple geriatric syndromes – Inter-related via shared risk factors – Therefore, opportunity to intervene at multiple levels at once

Fundamental “Equations” of geriatrics • Frailty = Vulnerability • Frailty x Stressor = Bad outcome • From patient/system perspective the issue is RISK

Managing frail seniors • Stressor Management: HELP program • Frailty: Comprehensive Geriatric Assessment

Comprehensive Geriatric Assessment Abellan 2010 Multidimensional interdisciplinary process focused on determining a frail older persons’ medical, psychological and functional capacity in order to develop a coordinated and integrated plan for treatment and long-term follow-up

The process: Comprehensive Geriatric Assessment • Identify and understand individual’s deficits, problems and strengths – Medical and psychiatric health, medications – Function, Mood, Memory – Resources, including $, supports, caregiver • Understand the person’s level of frailty • Develop a proper multidisciplinary plan of management tailored to the level of frailty

Living situation and means of transportation Socio-demographic Informal Caregiver and other social supports, Elder abuse Advance directives Overall performance Cognition Behavioural issues and psychosis Psychiatric Mood and Anxiety Function Basic and Instrumental Activities of Daily Living (BADLs, IADLs) Mobility Gait problems and gait aids, Falls Senses Vision and Hearing Elimination Bladder and bowel function Nutrition Pain Health indicators Cardiorespiratory Skin integrity Substance abuse Primary prevention (e.g. immunization) Medical Secondary and tertiary (optimal chronic illness management) Polypharmacy / medication review

Geriatric Assessment works Stuck, Lancet 1993; Day, NZHTA Report 2004; Schmader Am J Med 2004; Beswick Lancet 2008; Challis 2004 • CGA leads to – More optimal prescribing – Better function, cognition – Less institutionalization – Less hospitalization – Lower mortality • NEED TO TARGET THE RIGHT PATIENT • DEGREE OF RISK DETERMINES WHO AND WHEN

Overview of process September 2013 – April 2014

Assessment Urgency Algorithm Development Study (Ontario, Canada) • Focus group with GEM nurses and ED physicians – Predict: referral to special geriatric services or home care, admission, long-stay/ALC • Created an ED assessment based on items from: – Community intake version assessment – Items clinicians felt important for ED patients # Hospitals Number of ED • Assessed ED patients age 75 + assessments (N=860) – Mean Age: 83 (SD: 5.2) 1 Cambridge Memorial Hospital 119 – 60% Female 2 Grand River Hospital 44 – Triage Acuity (CTAS): • Resuscitation: 0% 3 Grey Bruce Health Services 126 • Emergent: 21% 4 Haliburton Highlands Health Services 34 • Urgent: 48% 5 Peterborough Regional Health Centre 175 • Less Urgent: 24% St. Joseph’s Health Centre • 6 120 Non-Urgent: 7% 7 St. Mary’s Hospital 225 8 Trillium Health Centre 20 41 Courtesy A. Costa, J. Hirdes

42 Courtesy A. Costa, J. Hirdes