safe clinic successful aging & frailty evaluation university of chicago – geriatrics and...
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SAFE ClinicSuccessful Aging & Frailty EvaluationUniversity of Chicago – Geriatrics and Palliative Medicine
Internal Medicine Resident RotationKatherine Thompson, MD & Patricia Rush, MD
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
Case StudyMrs. 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?
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 ??
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
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
Syndrome of Frailty
• Other associated features– Cognitive impairment– Balance/motor impairment– Depression, anxiety, loneliness– Poor quality sleep– Low self-rated health– Inadequate social support
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
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
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
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
Frailty Assessment as a Prognostic Tool: Survival by Frailty Stratification
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
Frailty: distinct entity
Fried, LP et al. Journal of Gerontology, 56A: M146-156, 2001
Clinical Application of Frailty AssessmentPreoperative Surgical Risk
Makary, Martin, et.al. Frailty as a Predictor of Surgical Outcomes in Older Patients, J Am Coll Surg 2010; 210:901–908
• 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%
Johns Hopkins Dept of Surgery – 2010
Frailty as Risk for Surgical OutcomesMakary, Martin, et.al. Frailty as a Predictor of Surgical Outcomes in Older Patients,
J Am Coll Surg 2010; 210:901–908
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) – Fried’s Criteria- weakness, weight loss, exhaustion, low physical activity, and slowed walking speed.
• Main outcomes measures: 30-day surgical complicationsLength of stayDischarge disposition.
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).
SAFE ClinicSuccessful Aging & Frailty EvaluationUniversity of Chicago – Geriatrics and Palliative Medicine
Research – Patient Care
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)
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
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)
Frailty (Fried’s Frailty Criteria)≥ 3 meets Frailty Criteria
• Weakness– Low grip strength– Standardized using a dynamometer
• Weight loss– > 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
Frailty (Fried’s 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)
SAFE Clinic: Patient Care
• Identify patients: Not FrailPre-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
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
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
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.
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
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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