SAFE Clinic Successful Aging

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SAFE ClinicSuccessful Aging Frailty
EvaluationUniversity of Chicago Geriatrics and
Palliative Medicine

• Internal Medicine Resident Rotation
• Katherine Thompson, MD Patricia Rush, MD

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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

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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?

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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 ??

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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

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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

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Syndrome of Frailty

• Other associated features
• Cognitive impairment
• Balance/motor impairment
• Depression, anxiety, loneliness
• Poor quality sleep
• Low self-rated health
• Inadequate social support

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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

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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

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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

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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

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Frailty Assessment as a Prognostic Tool
Survival by Frailty Stratification
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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

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Frailty distinct entity
Fried, LP et al. Journal of Gerontology, 56A
M146-156, 2001
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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

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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.

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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).

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SAFE ClinicSuccessful Aging Frailty
EvaluationUniversity of Chicago Geriatrics and
Palliative Medicine

• Research Patient Care

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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)

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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

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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)

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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

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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)

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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

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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

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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

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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.

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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

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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