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SAFE Clinic Successful Aging

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SAFE Clinic Successful Aging & Frailty Evaluation University of Chicago Geriatrics and Palliative Medicine Internal Medicine Resident Rotation – PowerPoint PPT presentation

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Title: SAFE Clinic Successful Aging


1
SAFE ClinicSuccessful Aging Frailty
EvaluationUniversity 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 11.2. 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

10
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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 comparewith CoMorbidity and
Disability?
  • CoMorbidity presence of 2 or more significant
    chronic illnesses
  • Disability inability to perform 1 or
    moreActivities of Daily Living (ADL)
  • Ambulating, Toileting, Showering, Dressing,
    Eating

15
Frailty distinct entity
Fried, LP et al. Journal of Gerontology, 56A
M146-156, 2001
16
Clinical Application of Frailty
AssessmentPreoperative Surgical RiskMakary,
Martin, et.al. Frailty as a Predictor of
Surgical Outcomes in Older Patients, J Am Coll
Surg 2010 210901908
  • 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 2010Frailty as
Risk for Surgical OutcomesMakary, Martin, et.al.
Frailty as a Predictor of Surgical Outcomes in
Older Patients, J Am Coll Surg 2010 210901908
  • 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 2006.
  • 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 20.48
  • Frailty improved predictive power (p 0.01) of
    each risk index (American Society of
    Anesthesiologists, Lee, and Eagle scores).

19
SAFE ClinicSuccessful Aging Frailty
EvaluationUniversity of Chicago Geriatrics and
Palliative Medicine
  • Research Patient Care

20
SAFE Clinic AssessmentResearch
  • 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
  • gt 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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