Promises to Your Grandparents:
Opportunities to improve the quality and
safety of geriatric care
Douglas G. Merrill MD MBA
Chief Medical Officer
Senior Associate Dean for Quality and Safety
University of California Irvine Health
Conflict of Interest Statement
To my knowledge, I have no conflicts of
interest represented by this presentation.
Objectives
After this presentation, the attendee should be able to
• understand the import of geriatric care to patient outcomes and healthcare
costs
• understand how to reverse frailty, improve social connections, mental
illness and care planning in the geriatric population.
• understand what UC Irvine Health is doing or planning to do in order to help
support providers in the care of geriatric patients.
“For decades we have been told by our pediatric
colleagues that “children are not simply little
adults.”
Perhaps we are to realize that older patients are not
simply young patients with more birthdays.”
Johnson RG .The Elderly Are Different: Resection for Non-small Cell Lung Cancer.
CHEST 2011; 140 (4):839-840.
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IN CONCLUSION: My to-do list
Support an initiative to evaluate semi-annually for frailty in all outpatients over the age of 65 years
old, in all outpatient clinics
Institute a shared decision making program for all elderly or at risk patients who are under
consideration for invasive therapy, electively: e.g., surgery, hemodialysis, transplant, etc. Make sure
they discuss risk of death, but also of ‘never return home’.
Amplify the Advanced Directive Outpatient Initiative to reach 75% of patients who are seen more than
once by a UCI clinician as an outpatient.
Continue to increase the number of elderly patients seen by the Transitions of Care team on Day 1 of
admission, or pre-admission for elective admissions.
Support the increased linkage of UC Irvine Health to the best skilled nursing facilities (SNFs) for both
interim post-discharge and long-term post-discharge care.
Augment the availability of Pharmacy consultation for elderly patients admitted and pre-discharge
Implement support for a pre-op algorithm for ELECTIVE surgery, which refers for frailty, anemia, low
platelets, renal failure, cancer, COPD, RA, steroid use, or no social structure – sending patients to OT,
PT, Nutrition, PM &R, and PCP; Case Management to visit their home and have the patient and family
pick a list of three SNFs that they would prefer (and have them visit those).
Reduce the incidence of transfer of patients for whom our care will be futile
Reduce the introduction of futile care options for inpatients at the end of life
IN CONCLUSION: Your to do list
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Study the differences between adult and elderly adult physiology carefully.
Learn about the variation in metabolism of medication between the “normal” elderly, infirm elderly, and the
normal or ill adult who is not elderly.
Learn what causes re-admission and learn to anticipate those conditions in your patients
Avoid benzodiazepines and sedatives – consult Psychiatry early for elderly patients with delirium
READ THE NOTES FROM YOUR CONSULTANTS!!!
Learn about the surgical procedures most associated with re-admission in the elderly and prepare your patients
for not being discharged after those elective procedures. Download “Optimal Preoperative Assessment of the
Geriatric Surgical Patient: A Best Practice Guideline” from the ACS NSQIP and American Geriatric Society and
read it. https://www.facs.org/~/media/files/quality%20programs/nsqip/acsnsqipagsgeriatric2012guidelines.ashx
Learn about the risk of never returning home for your pre-op “clearance” patients with documented frailty,
anemia, low platelets, renal failure, cancer, COPD, RA, steroid use, or no social structure –
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prep them early and get Case Management involved on day one.
Involve OT, PT, Nutrition, PM &R, and Case Management early.
Get Case Management to visit their home.
Engage the patients in discussion about transition from single living at home
Engage your patients in Advanced Directive Discussions
Consult with Palliative Care and the Acute Pain Service early in the care of your elderly patients
Agenda
• The importance of being elderly:
• frailty,
• social isolation,
• mental illness
• lack of care planning
• Impact on the healthcare delivery system
• How UC Irvine Health will help you to help them.
The Aging of America
• In 2000, 12% of all Americans were over the age of 65 years.
• By 2030, 20% of all Americans will be over the age of 65 years.
• By 2050, 80 million Americans will be over age 65 years,
• The proportion of the population over 85 years is expanding at 6x the rate of
the general population
• 2 out of 3 people over the age of 65 have chronic conditions and their care
takes up 67% of all expenditures, private and public, on healthcare.
• And that 67% is only going to grow…
Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta,
GA: Centers for Disease Control and Prevention, US Dept. of Health and Human Services; 2013.
www.cdc.gov/aging
Lin RY J Hospital Medicine 2015;10:586–591
So, we’re old and getting older…so what?
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Social Isolation is increased
Living alone is higher risk for
morbidity and mortality
Financial independence is decreased
Medication errors by patient and
prescriber increase, as does impact
Co-morbidities increase
Trauma risks increase
Incidence of Delirium is increased
Incidence of Depression and Suicide
are increased
All-cause risk of death is higher
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Risk of elder abuse, including financial
scams by family or others
Lengths of stay increase due to
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Increased number and severity of comorbidities
Lack of funding for long term care or
in home care
Sometimes due to family pressure
Regulatory pressure to discharge
increases
Financial losses to the health system
increases
Focusing on…
• Frailty (nutrition, mobility, muscle tone, gait, stamina)
• Mental illness (depression and delirium)
• Social isolation (including potential for abuse)
• Care planning (Advance Directives, Shared-Decision Making, Health
Docents, choosing safe living sites)
Why care about frailty?
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Incidence recognized among those in the community:
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10.7% of ages 65 to 80
15.7% of those aged 80 to 84,
26.1% of those aged 85 or older.
Frailty is associated with increased risk of functional impairment, hospitalization, and
mortality, with the risk of individual mortality being better predicted by frailty than by
chronological age.
It increases costs to the healthcare system (re-admission is an increasing cost to
institutions, including fines by CMS reaching 7 figures per year).
Associated with higher mortality in the peri-op period; elderly patients have surgery at
4x the rate of non-elderly and already cost the system much more for surgery than does a
younger patient. With over 20% of the US population destined to be over 65 years of age
by 2030, this is an important aspect of health and healthcare cost.
Most importantly, it is reversible!
Collard RM, et al. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):148792.
Shamliyan T, et al. Association of frailty with survival: a systematic literature review. Ageing Res Rev 2013;12(2):719-36.
Buigues C., et al. Arch Gerontology and Geriatrics, 2015; 61: 309–321
Measuring Frailty
• Frailty is not a necessary outcome of chronological age!
• There is no single test for frailty, but several very simple ones are valid.
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Grip Strength is alone the most specific and sensitive
Fried-Hopkins frailty index – weak grip, weight loss, exhaustion, low level of physical
activity, slow walking 15 feet. Score of 4-5 = “frail”
A simple clinic strategy:
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Gait speed – time to walk 15 feet; FAIL if more than 6 seconds
Hand grip strength FAIL if < 30kg for men or < 20kg for women
Mobility: time to rise from a chair, walk 15 feet and return to the chair = FAIL if > 15 seconds
BMI < 25 or >30
There are other measures, but any of these test algorithms can be done in clinic by an
MA and followed longitudinally.
Cameron et al. BMC Medicine 2013, 11:65-75.
Anaya DA, et al. Summary of the Panel Session at the 38th Annual Surgical Symposium of the
Associate of VA Surgeons. JAMA Surgery. 2014; 149(11): 1191-1197.
9 Techniques that succeed in reversing frailty
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In a study of patients average age 83, a 12 month RCT showed 15% of the study group were no longer
frail and mobility improved, while the control group saw a decline in indices of frailty and mobility.
NB: the difference between groups was not significant at 3 months – it took 12 months. This is a long
term process to correct.
Dietary consultation and nutritional supplementation as needed, including home-delivered meals. BMI <
18.5 kg/m2, or mid-upper arm circumference was <the 10th percentile led to nutritional supplementation
using commercially available, high energy, high protein supplements.
Referral to psychology or psychiatry if exhaustion criterion was met and the Geriatric Depression Scale
score was high.
Day activity groups and links with phone volunteers, if socially isolated.
1x per month PT (including mobility work) at home and a home exercise program for patients who meet
the weakness, slowness or low energy expenditure criteria.
A Weight-bearing for Better Balance (WEBB) program was used to improve mobility, increase physical
activity and prevent falls for those who were identified at risk for falls, performed 3-5x per week.
Physical Therapist was the coordinator and re-assessed monthly at home sessions, identifying needed
additional health interventions.
Comprehensive evaluation by Geriatrician or PM&R physician to manage or follow up on pain and other
identified conditions, such as urinary incontinence.
Cameron et al. BMC Medicine 2013, 11:65-75
Frailty as a peri-operative risk predictor
• Frailty present pre-operatively predicts postoperative complications
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Prolonged LOS
Increased post-op infection rates
Increased post-op delirium
Higher risk for falls requiring surgical intervention
High risk of discharge to long-term care
Increased incidence of never returning to independent living**
in even low risk patients.
Carlisle JB. Pre-operative co-morbidity and postoperative survival in the elderly: beyond one
lunar orbit. Anaesthesia 2014, 69 (Suppl. 1), 17–25.
Choi JY. J Amer Coll Surg. 2015; 221(3):652-660.
**You may not ever go home again…
For most of your patients, independence is more important than the risk of
death, so they ignore surgeon’s warnings about risk of death, imagining that it
means that they just won’t wake up…
Telling them the truth that they may never return to their home if frailty goes
untreated pre-op will have a greater impact on their compliance.
In one study, the majority of those patients who were admitted to SNF postop and then did not return home said they would have refused surgery if they
had known that could happen.
Choi JY. J Amer Coll Surg. 2015; 221(3):652-660.
Carlisle JB. Pre-operative co-morbidity and postoperative survival in the elderly: beyond one lunar orbit. Anaesthesia 2014, 69 (Suppl. 1), 17–2
After hip fracture repair, use of one frailty index
showed correlation with discharge home
• 80% of those scoring as “low” frailty went home.
• Only 6% of those who scored as “high” frailty went
home.
Hubbard RE, Story DA. Patient frailty: the elephant in the operating room. Anaesthesia 2014; 69(S1): 26-34.
Frailty as a peri-operative risk predictor
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If you are asked to “clear” a patient for surgery, please test for frailty and
discuss its implications with patients.
IF patients fail frailty testing, please recommend consideration of a delay of
ELECTIVE surgery
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Emphasize, “you won’t ever go home post-op if we don’t fix this pre-op”…
Consult case management to help arrange for pre-operative fitness augmentation – try
the nine interventions!
Alert the surgical and anesthesia teams to avoid post-op medication that might induce
falls and increased dementia – a pain consult would be good, pre-op
Alert the team to insure that the post-discharge environment is safe – patient should be
seen by case management pre-op to discuss this with patient and family
Multidisciplinary teams, including RNs and MDs trained in Geriatrics, improve the
outcomes if involved prior and following surgery performed in elderly patients.
Choi JY. J Amer Coll Surg. 2015; 221(3):652-660.
Pre-op Intervention: does it work?
• Pre-op geriatrician consultation is effective to reduce delirium and avoid
recurrent admission.
• Nutritional supplementation improves outcomes and reduces complications
• Pre-op rehabilitative programs to improve function are effective at
decreasing post-op complications & LOS, but re-admission not studied
• Exercise and muscle strengthening programs, particularly aimed at
intercostal musculature and reduction in sedentary behavior are useful.
• There is evidence that pre-op chemo was made more effective (tumor size
made significantly smaller) by concomitant exercise.
West MA et al. British Journal of Anaesthesia. 2015; 114 (2): 244–51.
O’Doherty AF et al. Brit J. Anaesth 2013; 110(5):679-89.
Carli F. Can Urol Assoc J. 2014; (8):11-12): E884-7.
Gillis C. Anesthesiology. 2014 Nov;121(5):937-47.
Delirium
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An acute, reversible medical syndrome with an incidence in hospitalized general medical
patient population ranging from 10% to 24%
Incidence is higher in surgical patients (36–46%; up to 60% in postoperative patients).
Known risk factors include advanced age, greater severity of illness, pre-existing cognitive
abnormalities, the presence of metabolic abnormalities, and treatment with psychoactive
and anticholinergic drugs.
Delirium may be associated with medication, may be associated with pre-existing
dementia, or neither.
The typical patient is a white male with a lower extremity trauma, on opioids,
benzodiazepines, antihistamines, other sedatives, steroids, other psychotropic medications
and with a history of previous sleep disturbances or altered mentation.
Lin RY et al. Drugs Aging 2010; 27 (1): 51-61.
Preventing Delirium and Treating Dementia: Why?
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Delirium and dementia are increasing – for outpatients and for inpatients. Age is the most
significant risk factor for dementia. The prevalence of Alzheimer’s disease increases at a
predictable rate, about 5% per year after age 65 years. Half of patients are demented by age 95.
Dementia is associated with delirium in the hospital…
Hospital costs go up three-fold if delirium or dementia is present.
Delirium in the elderly is associated with longer LOS (1.5-2 days)
Delirium increases the risk of re-admission, increasing cost to the healthcare system and to the
hospital particularly, as well as reducing the hospital’s and the physician’s “quality” assessment
on CMS metrics.
Delirium increases the risk of not returning home after discharge from the hospital, thereby
increasing cost to the healthcare system.
Nursing home costs and home health costs are 10x and 4x the normal patient’s costs,
respectively, if delirium or dementia is present.
Delirium increases the risk of death (50 to 100%) in the peri-hospital period
Lin RY J Hospital Medicine 2015;10:586–591.
Goldberg A.BMC Geriatrics. 15:69, 2015.
Preventing Delirium and Treating Dementia: How?
How to prevent or treat these?
• Reduce the use of benzodiazepines, glycopyrrolate or atropine, and
antihistamines for sleep aids (or for anything else).
• Actively screen for delirium daily on rounds (look for confabulation).
Partner with nursing on this! Ask the patient and family members about
sleep disturbances or evidence of dementia before admission.
• Stop transferring elderly patients between rooms! More room transfers
occurring per patient day is associated with an increased incidence of
delirium amongst hospitalized elderly patients.
• Consult Psychiatry or Psychology Services and Case Management*
*Coming soon to UCI Health: more geriatric psychiatry and overall inpatient/outpatient
psychiatry services and social workers/case managers.
Lin RY J Hospital Medicine 2015;10:586–591. Goldberg A.BMC Geriatrics. 15:69, 2015.
Social Isolation
Low quality social networks lead to
• Isolation increases anxiety and alters immuno-endocrine function, increases
disease and death risk.
• Increased risk of poorly managed disease
• Increased risk of mental disease
• Increased risk of institutionalization
• Increased risk of being a victim of violence
• Increased risk of death, including suicide
House JS: Psychosom Med 2001;63:273–274
Tobiasz-Adamczyk B, et al. Arch Gerontology & Geriatrics, 2014;58(3):388-98.
Cognitive Impairment + Social Isolation + Frailty =
High Risk
One study of older adults found that among a general population of 800 patients over
65 years of age
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There was a median age of 80
Over 50% were frail
Almost 50% lived alone
17% were cognitively impaired
High Risk:
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14.5% for hospitalization
4.3% were considered high risk of institutionalization
2.7% for death within one year
O’Caoimh et al. BMC Geriatrics 2014, 14:104.
Treating social isolation
• ASK the questions and get case management involved early – connect with
family whenever possible*
• Reduce untreated mental disease: psychiatric intervention reduces
isolation(and falls, delirium and early death)
• Avoid long term sedative use
• Whenever possible, advocate for transportation, community centers,
internet access, and home health visit services for the elderly
*COMING SOON: more case management resources in the outpatient
clinics
Segerstrom SC, Miller, GE. Psychological stress and the human immune system: a meta-analytic study
of 30 years of inquiry. Psychol. Bull., 130 (2004), pp. 601–630.
Transitional Care Management Program
TCM Focus: Care Coordination to Reduce
Readmissions (and decrease social isolation)
• Ensure the DC Plan formulated by IP team is executed as
intended
• What unique intervention will TCM team perform to reduce
readmissions (and decrease social isolation) ?
• Make follow-up appointments, DME, home health
arrangements
• Support navigation of the health care system
• Support patient and family compliance with DC plan
• Referral to community resources e.g., transportation
• Referral to in-network complex case managers
• Support communication with outside providers
Care Planning: Advanced Directives
A story from a place far, far away and a long time
ago
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83 y.o. male with malignancy, received palliative radiation and chemotherapy as an
outpatient.
Admitted with sepsis, treated, went home after 15 days.
Re-admitted two weeks later, again with sepsis, died after 22 days, 20 in the ICU.
Final week was spent with patient in and out of coma and with family struggling to
decide a care plan. Palliative Care was consulted on day 20.
There was no advance directive and no documentation it was ever discussed either
as an outpatient or after recovery and before discharge from the previous sepsis
admission.
When asked, the attending physician who cared for him during the first admission
said, “I don’t see a reason we should have considered such a conversation back
then. He recovered and went home.”
Advanced Directives
• Elderly patients have a higher risk of dying than the non-elderly.
• Elderly patients with incurable cancer have a very high risk of dying.
• It is appropriate to be open with them about their risk and to discuss how
they want to die.
• Giving these patients the option of stating those wishes in advance, without
cutting them off from palliative or heroic care options is accomplished with
an Advanced Directive.
• At UC Irvine Health, fewer than 6% of our inpatients are admitted OR
DISCHARGED with an advanced directive discussed or on the chart.
Advanced Directives
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At UC Irvine Health, we now have a pilot project underway in the CHAO Cancer
Clinic and the CHF clinic: “the Second Visit Visit”.
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At the first visit for a new patient at one of these clinics, the patient is offered an additional
half an hour on their next visit to discuss Advanced Directive options with a social worker or
RN. He or she is asked to be sure that their likely designated decision maker (spouse or
child, typically) comes with him or her.
The focus is the answer to this question, “If you were unable to speak for yourself, who
would you want to do that for you?”
The intent is not to get the patient to fill out a detailed POLST or other document; it is just
to name a designated loved one or friend in an Advanced Directive, someone who will
know what they want.
Also, classes are being held regularly now for our community to teach patients
about Advanced Directives
Our goal is to have 75% of all UC Irvine Healthcare staff and physicians to have
had training in how to have that simple conversation (“who would you
want…?”) by the end of June.
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IN CONCLUSION: My to-do list
Support an initiative to evaluate semi-annually for frailty in all outpatients over the age of 65 years
old, in all outpatient clinics
Institute a shared decision making program for all elderly or at risk patients who are under
consideration for invasive therapy, electively: e.g., surgery, hemodialysis, transplant, etc. Make sure
they discuss risk of death, but also of ‘never return home’.
Amplify the Advanced Directive Outpatient Initiative to reach 75% of patients who are seen more than
once by a UCI clinician as an outpatient.
Continue to increase the number of elderly patients seen by the Transitions of Care team on Day 1 of
admission, or pre-admission for elective admissions.
Support the increased linkage of UC Irvine Health to the best skilled nursing facilities (SNFs) for both
interim post-discharge and long-term post-discharge care.
Augment the availability of Pharmacy consultation for elderly patients admitted and pre-discharge
Implement support for a pre-op algorithm for ELECTIVE surgery, which refers for frailty, anemia, low
platelets, renal failure, cancer, COPD, RA, steroid use, or no social structure – sending patients to OT,
PT, Nutrition, PM &R, and PCP; Case Management to visit their home and have the patient and family
pick a list of three SNFs that they would prefer (and have them visit those).
Reduce the incidence of transfer of patients for whom our care will be futile
Reduce the introduction of futile care options for inpatients at the end of life
IN CONCLUSION: Your to do list
•
•
•
•
•
•
•
•
•
Study the differences between adult and elderly adult physiology carefully.
Learn about the variation in metabolism of medication between the “normal” elderly, infirm elderly, and the
normal or ill adult who is not elderly.
Learn what causes re-admission and learn to anticipate those conditions in your patients
Avoid benzodiazepines and sedatives – consult Psychiatry early for elderly patients with delirium
READ THE NOTES FROM YOUR CONSULTANTS!!!
Learn about the surgical procedures most associated with re-admission in the elderly and prepare your patients
for not being discharged after those elective procedures. Download “Optimal Preoperative Assessment of the
Geriatric Surgical Patient: A Best Practice Guideline” from the ACS NSQIP and American Geriatric Society and
read it. https://www.facs.org/~/media/files/quality%20programs/nsqip/acsnsqipagsgeriatric2012guidelines.ashx
Learn about the risk of never returning home for your pre-op “clearance” patients with documented frailty,
anemia, low platelets, renal failure, cancer, COPD, RA, steroid use, or no social structure –
•
•
•
•
prep them early and get Case Management involved on day one.
Involve OT, PT, Nutrition, PM &R, and Case Management early.
Get Case Management to visit their home.
Engage the patients in discussion about transition from single living at home
Engage your patients in Advanced Directive Discussions
Consult with Palliative Care and the Acute Pain Service early in the care of your elderly patients
Bibliography
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Collard RM, et al. J Am Geriatric Soc. 2012;60(8):1487-92.
Shamliyan T, et al. Ageing Res Rev 2013;12(2):719-36
O’Caoimh et al. BMC Geriatrics 2014, 14:104.
Anaya DA, et al. JAMA Surgery. 2014; 149(11): 1191-1197.
Buigues C., et al. Arch Gerontology and Geriatrics, 2015; 61: 309–321
Segerstrom SC, Miller, GE. Psychol. Bull., 130 (2004), pp. 601–630.
Khavanin N. American Journal of Otolaryngology. 35(3):332-9, 2014
Buchanan CC, et al. J. Neurosurg 2014; 121:170-175.
Akins PT et al. Spine. (publ .ahead of print 04/04/2015)
Wang MC, et al. Spine J 12:902–911, 2012
Lavelle K, et al. Brit J. Surgery 2015; 102: 653-667
DeRosa R. J. Urology, 2015; 193(4S):e108.
Thank you!
Fixing Frailty Before Elective Surgery
Transitional Care Management (TCM) vs
Transitions of Care (TOC)
Category
TCM
TOC
Patients
Selected patients of those identified at
high risk for readmission
Unfunded & under-funded
Focus/ Goal
Readmission reduction
Facilitate urgently needed care (e.g.,
Follow-up appt, ancillary service, ED-TOC
(averts IP admission)
Funding Source All comers– funded & unfunded
Unfunded & under-funded
IP DC Plan
Formulated by IP team
Formulated by IP team
Hand-off
TCM team meets patient while in
hospital – Warm hand-off with IP team
If only TOC patient, TCM team does not
meet patient
Care
Coordination
Work with providers to coordinate care
for first 30 days, minimum
Joint case manage while LOA in effect.
Joint case management ends when
funding obtained
Not Mutually
Exclusive
Patient may be only TCM patient or both Patient may be only TOC patient or both
TCM & TOC patient
TOC & TCM patient