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CHAMP The Hospitalized Frail Elder Teaching Strategies for Identification & Assessment

CHAMP The Hospitalized Frail Elder Teaching Strategies for Identification & Assessment. Paula M. Podrazik, MD University of Chicago. New Admission. Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OP admitted for wt. loss, confusion, falls. Recently hospitalized at an outside institution.

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CHAMP The Hospitalized Frail Elder Teaching Strategies for Identification & Assessment

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  1. CHAMPThe Hospitalized Frail ElderTeaching Strategies for Identification & Assessment Paula M. Podrazik, MD University of Chicago

  2. New Admission Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OP admitted for wt. loss, confusion, falls. Recently hospitalized at an outside institution. Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax q week Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84 RR 16 Lungs clear, Cor RRR, Neuro non-focal ER evaluation—unremarkable blood work, CT head— no bleed Intern reports patient is at baseline per daughter and comments patient is just a “FTT.”

  3. Questions raised • What is the importance of identifying frailty in the hospital setting? • How do you recognize frailty ? • How do you define frailty in the aging? • What do you need to screen in the suspected frail patient during hospitalization?

  4. Aging patients & the hospital setting • High rates of hospitalization • Account for 47% of all inpatient days (but represent only 13% of the population) • Age 85 and over, twice hospitalization risk • High rates of readmission • 25% of hospital admissions represent readmission of older adults • Cost--outcomes Fethke CC, Smith IM, Johnson N. Medical Care. 1986;24:429-437 Graves EJ, Gillum BS. National Hospital Discharge Survey: annual summary, 1994. Vital Health Stat. 1997;13:128

  5. Worse outcomes for hospitalized Older Adults • Delirium • Iatrogenic Complications • Functional decline • Nursing home placement • Hospital readmission • Caregiver stress • Mortality

  6. Risk of rehospitalization—one outcomes look at frailty • Age over 80 • Inadequate social support • Multiple active chronic health problems • History of depression • Moderate-severe functional impairment • Multiple hospitalizations past 6 months • Hospitalization past 30 days • Fair or poor health self rating • History of non-adherence to medical regimen Naylor M, Brooten D, Campbell, et al. JAMA. 1999;17:613-620

  7. Hospitalization Outcome: The tension for the Hospitalized Aging Patient Baseline Frailty Hospitalization Outcome Acute illness Hazards of the Hospitalization

  8. Words that trigger the need to ID & teach about frailty Failure to thrive Dwindles Declining A/O x 1 or 2 Confused Poor historian Malodorous Recent discharge Unkempt Nursing home Weight loss Age 75 or over Non-compliant Needs assistance/ has caregiver Falls

  9. New Admission—Triggers to TeachID/discuss frailty Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OP admitted for wt. loss, confusion, falls. Recently hospitalized at an outside institution. Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax q week Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84 RR 16 Lungs clear, Cor RRR, Neuro non-focal Intern reports patient is at baseline per daughter and comments patient is just a “FTT.”

  10. Describe the Aging Population • Heterogeneous Population • Factors that contribute to heterogeneity • Aging physiology • Collected co-morbid conditions • Functional status

  11. Functional Reserve of Older Adults • Vision loss: 27% those over age 85 • Cognitive impairment: 50% over age 85 • Assistance w/ADL: > 50% over age 85 • Functional reserve losses impact on an acute illness: • Presentation • Treatment • Morbidity & Survival • Recovery

  12. What is frailty? • Being dependent on others • Having many chronic illnesses • Experiencing “uncoupling with the environment” • Being at substantial risk of dependency & other adverse health outcomes • Having complex medical & psychosocial problems • Having “atypical” disease presentations • Having many chronic illnesses • Being able to benefit from specialized geriatric programs • Experiencing accelerated aging Rockwood, et al. Can Med Assoc J 1994;150:489-95. Bortz WM. J AM Geriatr Soc 1993;41:1004-8. Fried L, et al. J Gerontol Medical Sciences 2001; 56A(3): M146-M156.

  13. Defining Frailty • Definition must include: • Association with aging • Multi-system impairment • Instability • Change over time • Allowance for heterogeneity within the population • Association with an increased risk of adverse outcomes Rockwood K, et al. Drugs & Aging 200 Oct 17(4):295-302

  14. ACOVE–a model to ID/define the Vulnerable Elder “in vivo” • Assessing the Care of the Vulnerable Elder: ACOVE Project Overview • Develop a definition of “vulnerable elders”—community dwellers, >65 & at high risk of functional decline or death • Develop system to ID • ID medical conditions for which effective methods of prevention& management exist • Develop set of Quality Indicators Wenger NS, Shekelle PG, et al. Ann Int Med 2001;135(8) Supplement:642-646

  15. Teaching about Frailty • Triggers to teach about frailty in the aging hospitalized patient • Advanced age • Multiple co-morbidities • Suspected cognitive impairment • Suspected functional impairments • Psychosocial issues • Sensory impairments

  16. Frailty Suspected:Why to Screen? • Prevention • Impact on Outcomes

  17. Prognostic Index for 1-year Mortality in Older Hospitalized Adults • 2 prospective studies—age> 70, assess 1-year mortality, points assigned—mortality risk calculated. • Independent risk factors: • Male sex • #of dependent ADLs • CA • CHF • Cr>3.0 • Low albumin level Walter LC, et al. JAMA June 2001; 285(23):2987-2994

  18. Comprehensive Assessment:Impact on outcomes • Meta-analysis of Comprehensive Geriatric Assessment programs • 28-controlled trials, 4959 subjects allocated to one of five CGA types and 4912 controls • Outcomes: • Mortality—GEMU programs  6 month mortality by 35%; HAS 36 month mortality by 14% • Hospital admission—all CGA programs  readmission rate by 12% • OR for living @ home favorable in all studies Stuck AE, Siu AL, Wieland GD, et al. Lancet 1993; 342:1032-1036

  19. Hospital Elder Life Program:A program of prevention • Yale hospital system, ≥ age 70, admitted to acute care hospital • Screened for cognitive impairment, sleep deprivation, immobility, dehydration, vision or hearing impairment • Targeted interventions • Outcomes • Decrease in functional & cognitive decline Inouye S, et al JAGS 2000; 48:1697-1706

  20. Teaching about Frailty:Summary teaching points • Baseline vulnerability or frailty affects hospital outcomes • High risk for worse outcomes • Take measures to prevent delirium, falls, functional decline • Identifying a vulnerable elder changes the needs of the D/C plan.

  21. Frailty Suspected:What to Screen? • Cognition • Function • Affect • Other • Sensory function • Social

  22. New Admission—Triggers to TeachCognitive Screening Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OP admitted for wt. loss, confusion, falls. Recently hospitalized at an outside institution. Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax q week Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84 RR 16 Lungs clear, Cor RRR, Neuro non-focal Intern reports patient is at baseline per daughter and comments patient is just a “FTT.”

  23. How common is dementia? • Age strongest risk factor for dementia • At age 65, prevalence 8-12% • At age 85, prevalence 50% • Persons with dementia in US- 4 million • Projected number by 2040- 14 million

  24. Dementia and Delirium • MMSE >24/30→ Delirium risk 2.82(1.19-6.65) • Delirium associated with worse outcomes • Orientation board and cognitive stimulation decreased confusion 26% vs. 8% * Confusion = loss of 2 points on MMSE Inouye SK, et al Ann Intern Med 1992;119:474-481

  25. Cognitive Impairment & Functional Decline with Aging • Cognitive impairment associated with functional decline during acute illness • Study Design: • Cognitive screen grouped admissions: No impairment Mild impairment Moderate/severe impairment • ADL/IADL/mobility measured 2 weeks prior admission, discharge, 30 and 90 days. Sands L, Yaffe K, Covinski K, et al. Journal of Gerontology: Medical Sciences 2003;58:37-45.

  26. Cognitive status on admission & risk new NH placement at hospital D/C Cognitive status Rate/odds NH None 7.5% 1.0 Mild 13% 1.49(1-2.22) Moderate-severe 29% 3.40(2.48-4.68)

  27. Risk NH placement at 90 days after hospitalization vs. cognitive status Cognitive status Rate/Odds NH None 4.1% 1.0 Mild 11.7% 2.80(1.75-4.46) Moderate-severe 26.7% 6.67(4.52-8.67)

  28. Screen for Cognitive Impairment: Summary Teaching Points • Prevent delirium • Prevent functional decline • Prevent iatrogenic injury—esp. med choice & avoidance of restraints • Transition care appropriately

  29. Screening Cognitive Impairment • Patient measure: • Mini Mental Status Exam (MMSE) • Mini-cog • Proxy measure

  30. Folstein MMSE • 30 point screening test • Screens multiple cognitive domains • Not a direct screen of executive function • Studies usually use cut off 24 for positive • Reliability of results dependent on age & education Folstein M, Folstein S, McHugh P. J Psychiatr Res. 1975;12:189-198

  31. Troubleshooting the MMSE • Validation done under rigorous technique • Serial 7’s vs. spelling WORLD backwards • 8th grade education or < → WORLD • >8th grade education→ serial 7’s • Administer in quiet, non-threatening environment • Correct sensory deficits as much as possible

  32. Reminders about MMSE • Screening test for cognitive impairment • Can help to risk stratify— delirium, functional decline, iatrogenic injury, pressure ulcers • Useful as a baseline to monitor change • Not a determination of decision-making capacity

  33. Screening Tools: Mini-cog • Step 1:Remember & repeat three unrelated words • Step 2: Clock-drawing test (CDT)—distracter • Step 3: Repeat 3 previously presented words • Step 4: Scoring:1 pnt. for each recalled word • Score=0; + screen for dementia • Score=1-2 with abnl CDT; + screen for dementia • Score=1-2 with nl CDT; neg. screen for dementia • Score=3; neg. screen for dementia Borson S, et al. Int J Geriatr Psychiatry2000;15:1021-1027

  34. Screening Tests for Cognition:Summary Teaching Points • Mini-cog—quick bedside tool • MMSE—screening tool only • If patient screens positive: • Use orientation board • Early mobilization • Discharge plan—unique D/C needs • Screen for functional, sensory impairments

  35. New Admission—Triggers to Teachphysical function screening Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OP admitted for wt. loss, confusion, falls. Recently hospitalized at an outside institution. Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax q week Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84 RR 16 Lungs clear, Cor RRR, Neuro non-focal Intern reports patient is at baseline per daughter and comments patient is just a “FTT.”

  36. Functional Screening:What are we talking about? Gait assessment Activities of daily living (ADL) Bathing Dressing Toileting Transferring Feeding Instrumental activities of daily living (IADL) Use telephone Manage finances Shop Arrange transportation Manage medications Cooking

  37. Functional Decline Occurs in the Hospital • Functional limitations increase with age. • Functional decline occurs in approx. 34-50% hospitalized older pts. • Impact of acute illness • Impact of hospitalization • Interventions can decrease functional decline (Hospital Elder Life Program). • Functional status determines D/C plan.

  38. Summary of functional outcomes during hospitalization • At discharge→31% declined • At 3 months→59% recovered lost function but 41% failed to return to pre-admission level of function • At 3-months→ 22% re-hospitalized & association with functional decline significant • Functional loss was associated with a significantly higher 3 month mortality

  39. Patient factors associated with functional decline • older age • preadmission functional impairment • lower MMSE on admission • re-hospitalization Sager M, Franke T, Inouye S, et al. Arch Intern Med. 1996;156:645-652.

  40. Worse health outcomes with functional decline • Prolonged hospital stay • Higher mortality—twice the risk • Higher rates of institutionalization • Higher health care expenditure

  41. Who is at risk functional decline during a hospital stay? Hospital based study @Yale Prospective cohort study Medical inpatients > 70 What are the risks for functional decline? Functional decline: ADL loss Two part study: Development and Validation Inouye S, Wagner R, Acampora D, et al. J Gen Intern Med. 1999;8:645-652.

  42. Independent risk factors associated with functional decline Risk Factor Adjusted RR Pressure Ulcer 2.7(1.4-5.2) Cognitive impairment 1.7(0.9-3.1) Functional impairment 1.8(1.0-3.3) Low social activity level 2.4(1.2-5.1)

  43. How does one assess functional status? Report Self-report Proxy report Direct observation Level of support Independent Needs assistance Dependent

  44. Activities of Daily Living Bathing Dressing Transference Continence Feeding

  45. Instrumental Activities of Daily Living Using the phone Traveling Shopping Preparing meals Housework Taking medicine Managing money

  46. Gait-timed Get Up and Go • Quantitative evaluation of general functional mobility • Timed command w/rise from chair; walk 10 feet; turn around; walk back and sit in chair. Wall JC, Bell C, Campbell S, et al J Rehabil Res Dev 200 37(1):109-113

  47. Gait assessment scoring • Usual time to completion 10 seconds • Frail elder usually < 20 seconds • > 20 seconds needs PT evaluation • Performance on test associated with: ADL/IADL performance Falls risk Risk of nursing home placement

  48. Trigger to Teach:Who to screen for functional impairment? Who to screen? • Person over the age of 70 • Patient who is re-admitted in past month • Person with at least 1 risk factor • Cognitive impairment • Functional impairment • Pressure ulcer • Low social activity score • Depression

  49. Screen for function, cont. When to screen? • After stabilization of acute illness • Prior to hospital discharge What to do? • Chart orders- walking and range of motion TID • Ambulation problem- physical therapy • Dressing/bathing/feeding- occupational therapy

  50. Function & the hospitalized elder: Summary teaching points • Functional limitations increase with age • Functional decline occurs in 30-50% of hospitalized older adults • Acute illness can lead to further functional decline • Hospital care can contribute to additional functional decline • Models help stratify those at highest risk for functional decline • Interventions decrease functional decline • Functional abilities help determine discharge location and services required

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