Frailty
Something real or just a fad?
Mr AS 81
• Admitted DGH April ‘Dry’ AKI. ‘Diarrhoea’
• Discharged, no care, after 2/7 GP called as ‘confused’bloods taken – no real action
• July readmitted with CP – diagnosis is IHD and CCF,
discharged with care from Soc serv,
• 1 week later – acute immobility - readmitted – found
hypotensive – meds all changed
• Referral to CCT for ‘incontinence’ on discharge, patient
weighed – no change – but increasing confusion
• GP x 2 visits – different GPs eventually calls Comm Ger
Mr AS Continued….
• Comm Ger visits and finds;
– Pats family very confused about drugs so reverted
to previous drugs from GP/2nd hospital admission
– Has had diarrhoea on and off for 6 months with
incontinence (not recognised)
– BP Very low, pt dry and delerious
– Progressive cognitive decline over 6 – 12 months.
• Patient readmitted – 4th Admission in 6
months – very, very unwell.
Mrs Andrews story
What is Frailty?
A state of impaired homeostasis leading to increased
vulnerability to minor stressor events.
In other words;
Older people living with frailty are at risk of adverse outcomes
such as dramatic changes in their physical and mental
wellbeing after an apparently minor event which challenges
their health, such as an infection or new medication.
Adverse outcomes include reduced mobility, loss of
independence or death.
Trajectory of Frailty
From Clegg et al – Lancet 2013
Is this just Old Age?
Bronze Age
Iron Age
Stone Age
Rowe 2005
What is the evidence of a separate
group.?
CHS 2001
USA
5317
Hospitalisation
subjects Intermediate
Severe
Frailty
7 year
Follow
up
Phenotype of frailty;
•
•
•
•
•
1.11(1.031.19)
Unintended Weight Loss
Slow Gait Speed
Low Energy Expenditure
Self Reported Exhaustion
Poor Grip Strength ( sarcopenia)
Fried et al 2001
Frailty
Disability
Intermedi
ate
Frailty
Death
Severe
Frailty
Intermedi
ate
Frailty
Severe
Frailty
1.27(1.11 1.55(1.38 1.79(1. 1.32(1.13 1.63(
- 1.46)
- 1.75)
472.17)
- 1.55)
1.272.08)
Rockwood CFS 2004
Canadian Study 2004
CSHA 2004
Song,
Rockwood
et al.
Cumulative
Deficit model of
frailty.
How does it fit with multimorbidity?
Frailty
26.6
46.2
5.7
Disability
From CHS Fried et al 2001
21.5
Multimorbidity
How do we recognise Frailty?
• Models of frailty
– Phenotype( Fried)
•
•
•
•
•
Unintended weight loss
Loss of muscle strength(sarcopenia)
Self reported exhaustion
Slow Gait speed
Low Energy Expenditure
– Cumulative deficit (Rockwood)
• A number of things(signs, symptoms and diseases)
accumulating
BGS.org.uk Download ‘Fit for Frailty’
Recognising Frailty using tests..
– Gait Speed < 0.8 m/s or >5s to walk 4m.
– Timed up-and-go test >10secs
– Questionnaire
Prisma 7 Questionnaire
Prisma 7 Questions
1] Are you more than 85 years?
2] Male?
3] In general do you have any health problems that require you to limit your activities?
4] Do you need someone to help you on a regular basis?
5] In general do you have any health problems that require you to stay at home?
Positive Response to 3 or
more;
Sensitivity of 0.83 Spec 0.80
PPV= 40%
6] In case of need can you count on someone close to you?
7] Do you regularly use a stick, walker or wheelchair to get about?
All have limitations;
• Acceptability
• Response rate
• High Sensitivity but low specificity( eg Gait Speed PPV = 33% for over 75’s)
Recognising Frailty Using Clinical Info
Frailty syndromes
–
–
–
–
–
–
–
–
Falls(collapse, flof)
Reduced mobility(stuck on toilet, wobbly, cant walk)
Delirium(acute confusion or change in function)
Incontinence - urgency
Sensitivity to drug effects
UTI !!!
ACOPIA(!)
‘Social admission’.
Treating Frailty;
• Changing Severity ( in due course)
– with nutrition?
– exercise programmes to address the sarcopenia-details unclear
but definite evidence for intensive resistance exercise( which is
hardly available)
– Multi faceted approach to target the characteristics
– Eg Cameron et al 2013.
• Managing the Effects of Frailty;
‘Frailty marks the point at which disease based guidelines are
no longer the priority’ .
Comprehensive Geriatric Assessment( a process of care)
Managing Frailty
Comprehensive Geriatric Assessment
Ellis et al 2011.
Metanalysis of controlled trials of CGA in acute hospitals
– Less likely to die
– More Likely to end up living at home in 6/12
NNT = 13
Beswick 2008 and 2012
- Complex interventions can reduce hospital admissions in those
with frailty and reduce admission to NH ( NNT = 33)
Mental/
Psychological
Functional
Social
Physical
Environmental
Assessment
Regular
Planned
Review
Creation of
stratified
problem list
Interventions
Identification
of Goals
Bespoke
Care Plan
What is CGA?
Multiprofessional, holistic review,
PERSONALISED problem/goal list and
care plan, with intervention and review.
The Silver Book
2012
Fit for Frailty
Parts 1 and 2
BGS 2014 and 2015
Both available from the BGS website= bgs.org.uk
Philp et al ‘Reducing Hospital Bed Use’
Int J Integrated Care2013
• 2007 – date- 48 studies;
– 8 metanalyses, 9 systematic reviews, 5 literature
reviews, 8RCT and 15 others.
– Prevention Hospital Admission;
• Care Coordination
• Preventive health Checks
• Care Home Liaison
– Reducing LOS and Preventing Readmission
• Linking Hospital and community care inc discharge
planning, Information sharing and RRR in home.
– No Value; Falls prevention, Meds review, Ex Prog,
Nutrition and Nurse led Intermediate care
Medication Review
Works
• When uses Evidence Based guidance
• When part of an Holistic Med Review (so possibly
not effectively done by pharmacists alone)
• To avoid Potentially Inappropriate Drug Use in
OP- PIDU• To avoid Adverse Drug Reactions(3-5% adm)
• Number of drugs is a strong RF for ADR( ? Good outcome
indicator)
• Only 6% of ADR are due to PIDU
• Possibly improves patient outcomes?
Screening Tool of Older Persons’ Prescriptions
(STOPP) version 2
http://ageing.oxfordjournals.org/content/early/2014/11/18/ageing.afu145
Section A: Indication of medication
•
1. Any drug prescribed without an evidence-based clinical indication.
•
2. Any drug prescribed beyond the recommended duration, where treatment duration is well defined.
•
3. Any duplicate drug class prescription e.g. two concurrent NSAIDs, SSRIs, loop diuretics, ACE inhibitors, anticoagulants (optimisation of
monotherapy within a single drug class should be observed prior to considering a new agent).
Sections B- J – relate to body systems
Section K: Drugs that predictably increase the risk of falls in older people
•
1. Benzodiazepines (sedative, may cause reduced sensorium, impair balance).
•
2. Neuroleptic drugs (may cause gait dyspraxia, Parkinsonism).
•
3. Vasodilator drugs (e.g. alpha-1 receptor blockers, calcium channel blockers, long-acting nitrates, ACE
inhibitors, angiotensin I receptor blockers, ) with persistent postural hypotension i.e. recurrent drop in systolic
blood pressure ≥ 20mmHg (risk of syncope, falls).
•
4. Hypnotic Z-drugs e.g. zopiclone, zolpidem, zaleplon (may cause protracted daytime sedation, ataxia).
Section L: Analgesic Drugs
Section N: Antimuscarinic/Anticholinergic Drug Burden
Anticholinergic Burden
Screening Tool to Alert to Right Treatment
(START)
http://ageing.oxfordjournals.org/content/early/2014/11/18/ageing.afu145
•
Section A: Cardiovascular System
Statin therapy with a documented history of coronary, cerebral or peripheral vascular disease, unless the patient’s
status is end-of-life or age is > 85 years
•
Section B: Respiratory System
•
Section C: Central Nervous System& Eyes
•
Section D: Gastrointestinal System
•
Section E: Musculoskeletal System
•
Section F: Endocrine System
•
Section G: Urogenital System
•
Section H: Analgesics
•
Section I: Vaccines
Also Beers Criteria – AGS- https://www.dcri.org/trial-participation/the-beers-list
Crime Criteria( CRIteria to assess approp Medication
use Among Elderly complex pts)
Drugs and Aging 2014 Italy.
Diabetes
•
Recommendation 1: In patients with limited life expectancy(\5 years) or functional limitation, intensive glycemic control (HbA1c<7 %) is not
recommended.
•
Recommendation 2: In patients with a history of falls or cognitive impairment or dementia, intensive glycemic control (HbA1c of <7 %) or use of
insulin is not recommended.
•
Recommendation 3: In patients with a recent fall or high risk of falls or orthostatic hypotension, intensive blood pressure lowering (\130/80 mmHg) is
not recommended.
•
Recommendation 4: Use of statins in older adults with limited life expectancy (\2 years) or advanced dementia is not recommended.
•
Recommendation 5: Metformin should be avoided in malnourished (body mass index\18.5 kg/m2) older adults.
Hypertension
•
Recommendation 1: In patients with dementia or cognitive impairment or functional limitation, a tight blood pressure control (\140/90 mmHg) is not
recommended.
•
Recommendation 2: In patients with dementia or cognitive impairment or functional limitation, use of more than three antihypertensive drugs
should be avoided.
•
Recommendation 3: In patients with limited life expectancy (\2 years), a tight blood pressure control (\140/90 mmHg) is not recommended.
•
Recommendation 4: In case of falls associated with orthostatic hypotension (or symptomatic orthostatic hypotension),the number of
antihypertensive drugs should be reduced and concomitant use of multiple antihypertensive agents should be avoided.
Congestive Heart Failure
•
Recommendation 1: In the presence of orthostatic hypotension or falls, increasing the dosage of antihypertensive drugs is not recommended; the
reduction of drug dosages should be considered.
•
Recommendation 2: The chronic use of diuretics in asymptomatic or minimally symptomatic older adults with a history of falls and increased fracture
risk is not recommended.
•
Recommendation 3: Pursuit of low blood pressure targets (systolic blood pressure\130 mmHg) in older adults with dementia or cognitive impairment
is not recommended.
•
Crime Criteria( CRIteria to assess approp Medication use
Among Elderly complex pts) contd…
Atrial Fibrillation
•
Recommendation 1: In patients with non-valvular atrial fibrillation and limited life expectancy (\6 months), avoid the use of oral anticoagulants
Recommendation 2: In non-valvular atrial fibrillation,the use of warfarin in the presence of malnutrition or irregular food intake is not recommended.
•
Recommendation 3: In non-valvular atrial fibrillation,the use of anticoagulants is not recommended in elderlypatients with dementia if any of the following
characteristics are present: unable to manage medications and living alone or high risk for falls.
•
Recommendation 4: In patients with non-valvular atrialfibrillation and high risk for falls or poor physical performance,the use of anticoagulants is not
recommended if the risk for stroke is low. (i.e.CHADS2 score \2 or CHA2DS2-VASc \2)
•
Recommendation 5: In patients with known difficulties in managing therapy (i.e. cognitive impairment) and lack of assistance (i.e. caregiver), the use of
drugs with a narrow therapeutic index, including digoxin and warfarin, is not recommended.
Coronary Artery Disease
•
Recommendation 1: The use of statins for secondary prevention in older adults with limited life expectancy (<2 years) or advanced dementia is not
recommended.
•
Recommendation 2: In case of orthostatic hypotension, the dosage of antihypertensive drugs should be reduced and the concomitant use of
multiple antihypertensive agents should be avoided.
Effect on Patient Outcomes?
Hospitalised Patients with Frailty. Drug use during admission
CRIME study 2014 Age Ageing.
• PIDU using STOPP criteria associated with ADR – OR = 2.36(1.1- 5.06)
• PIDU using STOPP (2 or more drugs) associated with Functional Decline
OR= 3.5(1.77- 6.91)
BP management
Ogliari G et al
Age and Ageing 2015; 44: 932–937
75 yrs + cohort study
Mental/
Psychological
Functional
Social
Physical
Environmental
Assessment
Regular
Planned
Review
Creation of
stratified
problem list
Interventions
Identification
of Goals
Bespoke
Care Plan
What is CGA?
Multiprofessional, holistic review,
PERSONALISED problem/goal list and
care plan, with intervention and review.
‘I ‘Statements for Older people – from ‘I’m
still me’
Age UK, UCL Partners, National Voices and NHS E
December 2014.
Independence
• I am recognised for what I can do rather than making assumptions about what I cannot
• I am supported to be independent
• I can do activities that are important to me
• Where appropriate, my family are recognised as being key to my independence and quality of
life
• Community interactions
• I can maintain social contact as much as I want
Decision making
• I can make my own decisions, with advice and support from family, friends or professionals if I
want it
Care and support
• I can build relationships with people who support me
• I can plan my care with people who work together to understand me and my carer(s), allow me
control, and bring together services to achieve the outcomes important to me
• Taken together, my care and support help me live the life I want to the best of my ability
Also made the point that OP do not like being called frail!....
In more detail –
where does care
take place?
Patterns of Care
• Challenges for community services and primary care
•
•
•
•
•
Supporting Self care, informal care and communities
Supporting Choices and priorities
Cognition, capacity and best interests(for the whole not the disease)
Recognising End of Life – ‘The Surprise Question’ and planning for it
Supporting Carers
• Challenges for specialists Availability at all times and places
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–
–
–
–
Planning and escalation
Avoiding silos and parallel service streams
Communication direct and technological
Education of teams and patients
Recognition that the whole may be more important than the components.
e.g Hb level, blood sugar, drug formulary
The scourge of the specialist
From Barnett at al – 2012 Lancet 380 37-43
Where are the vulnerable points?
•
•
•
•
•
•
Getting to the pathway – falling, memory etc
New diagnosis of frailty/ dementia
Admission to hospital
Leaving hospital
Changing medications
Declining to engage
Leaving hospital
Medicines-related results from the 2011 Care Quality Commission Survey of Adult
Inpatients, carried out by the Picker Institute, are presented below. There is considerable
room for improvement, particularly with regard to counselling about side effects.
Why do it in hospital at all?
But….
• Investment in Community Services has not
followed the increase in NHS Budget
– Numbers of DN’s fell by 38% between 2001 and
2011( RCN 2013)
• ‘Primary care in crisis’
• ‘The staff we will have are the staff we
already have’ Imison C, Kings Fund 2014
– So we need to work differently and where the patients are –
aligning the workforce to the work- should pharmacists follow
patients up at home?
Back to Mr Stewart
• What could have happened…
– Frailty Recognised and proactive care plans in situ for
management of diarrhoea and drug review
– First admission recognised previous work and full
communication with GP/Comm Team and community
pharmacist
– After second admission (if needed) no changes in
drugs made in hospital – but followed up at home for
treatment and drug review between pharmacist and
GP
– Probably no third or fourth admission
A thought
‘We’ve been wrong about our job in medicine…..it is to
enable wellbeing. And wellbeing is about the reasons
one wishes to be alive.’