CHAMP
Improving Hospital Systems of Care:
Making the Case for Identifying and Assessing
the Frail Elderly
Paula Podrazik, MD
University of Chicago
1
New Admission
Mrs.G 80 y/o BF DM type II, htn, s/p CVA, 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.”
2
Questions raised:
How do you recognize frailty ?
How do you define frailty?
What is the importance of identifying
frailty in the hospital setting?
What do you need to screen in the
suspected frail patient during
hospitalization?
Can you prevent hospitalizationassociated decline?
3
Overview:
Inpatient Setting Important for the Elderly
• Crucial step in the health care continuum
– 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. Risk factors affecting readmission to the health care system. Medical Care. 1986;24:429-437
Graves EJ, Gillum BS. National Hospital Discharge Survey: annual summary, 1994. Vital Health Stat. 1997;13:128
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Iatrogenic Problems—a subset of
Hazards of Hospitalization
Affects nearly 1 in 3 hospitalized elderly patients
Adverse drug reactions are the most common form
• Other complications of hospitalization:
Deconditioning
Delirium
Falls
Nosocomial Infection
Pressure ulcers
Malnutrition
Dysphagia→Aspiration Pneumonia
Polypharmacy
Atypical Presentations,
Multiple Causes
• Functional decline, altered mental status
e.g., delirium or falls due to UTI or fecal impaction
• Misleading symptoms
e.g., pneumonia with normal or low temperature & normal
or low WBC count
• Signs of one disease obscured by another
e.g., Pneumonia obscured by CHF
● Inability to communicate
e.g., new pressure ulcer obscured in patient post –CVA w/
aphasia or with dementia
● No presentation symptoms
e.g., silent MI , painless acute abdomen
Determinates of
Hospitalization Outcome
Baseline Frailty
Hospitalization Outcome
Acute illness
Podrazik PM, Whelan CT. Med Clin N Am 2008
Hazards of the
Hospitalization
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
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New Admission—Triggers to Teach
ID/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.”
9
Geriatricians ID frailty features
At least 50% of Geriatricians cited each of the following characteristics
associated w/frailty
– Under nutrition
– Functional dependence
– Prolonged bedrest
– Pressure sores
– Generalized weakness
– Aged >90
– Wt loss
– Anorexia
– Fear of falling
– Dementia
– Hip fracture
– Delirium
– Confusion
– Going outdoors infrequently
– Polypharmacy
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Fried LP, Walston J. Principles of Geriatric
Medicine & Gerontology 5th ed. 2003:1487-1502.
Compression of Morbidity
A Public Health Blueprint for Healthy Aging. Linda P Fried MD MPH
Describe the Aging Population
Heterogeneous Population
Factors that contribute to heterogeneity
Aging physiology
Collected co-morbid conditions
Functional status
Life style/environmental factors
Genetics
What happens to reserves w/aging?
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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
What is 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
 Can include co-morbidities
 Can include a disability
Rockwood K, et al. Drugs & Aging 2000 Oct 17(4):295-302
Fried LP, et al. J Gerontol Med Sci.2001 56A;M146-M156
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ACOVE - A model to ID/define the at risk
Vulnerable Elder
 Assessing the Care of the Vulnerable Elder: ACOVE
Project Overview
 Developed a definition of “vulnerable elders”—
community dwellers, >65 & at high risk of functional
decline or death using a retrospective look at Medicare
data
 Developed a screen to ID frail elders→the VES 13:
includes age, self-perceived health, aspects of functional
status.
 if screen “frail” on the VES 13 then anticipate an
increased risk of morbidity & mortality
 Developed set of Quality Indicators
Wenger NS, Shekelle PG, et al. Ann Int Med 2001;135(8) Supplement:642-646
Frailty Suspected:
Why screen?
Impact on Outcomes
Prevention
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Risk of rehospitalization—one outcomes
look at frailty
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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
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Prevention
Frailty suspected…
What about prevention of hazards of
hospitalization?
 Delirium—Inouye model—orientation & cognitive exercises, early
mobilization, prevent dehydration, hearing aides/glasses
 Deconditioning—out of bed, PT/OT
 Falls—bed alarms, pads
 Pressure ulcers—nutrition, frequent repositioning, special mattresses
 Adverse drug reactions—med review for best drug choices
 Comprehensive discharge planning—recognize need @ admission w/
social work involvement
Models of improved care for frail elders:
HELP (Hospital Elder Life Program), GEM (Geriatric
Evaluation and Management) unit, ACE ( Acute Care of
the Elderly)unit models
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 delirium rate in intervention group
Decrease in functional decline (14%vs. 33%)
Decrease in cognitive decline (8%vs. 26%)
Inouye S, et al JAGS 2000; 48:1697-1706
Inouye SK, et al. NEJM. 1999;340:669-676
Inouye SK , et al. Ann Intern Med. 1993;119:474-481
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Targeted Interventions
Cognitive
Impairment
Orientation/
Activities
Sleep Deprivation
Non-drug; sleep
enhancement
Immobility
Early
Mobilization
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Targeted Interventions
Visual
Impairment
Visual Aids,
Devices
Hearing Impairment
Hearing devices,
Remove earwax
Dehydration
Early recognition
& po repletion
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Prevention Protocols
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Inouye SK, et al. NEJM. 1999;340:669-676
SEE CHALK
Predicting Delirium:
Predisposing Risk Factors
DEVELOPMENT COHORT
N=107
RR
1.  Vision
2. Severe Illness
3.  Cognition
4. BUN/Cr > 18
3.5 (1.2-10.7)
3.5 (1.5-8.2)
2.8 (1.2-6.7)
2.0 (1.1-4.6)
VALIDATION COHORT
N=174
RR
1. Low Risk (0)
1.0
2. Int. Risk (1-2)
2.5
3. High Risk (3-4) 9.2
Cognitive Impairment (MMSE < 24); Vision Impairment > 20/70;
BUN/CR > 18/1; Severe Illness= APACHE II > 16 OR CHARLSON
ORDINAL CLINICAL = RATED AS SEVERE
Inouye SK , et al. Ann Intern Med. 1993;119:474-481
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Triggers to Recognize &
Screen for Frailty
Advanced age (>70, > 75, > 80???)
Suspected functional impairments
Suspected cognitive impairment
Consider if /and
Multiple co-morbidities
Psychosocial issues
Sensory impairments
Severe acute illness
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What to screen?
Cognition
Function
Affect
Sensory
Social
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Comprehensive Geriatric Assessment
Functional Ability
Physical assessment
Cognitive assessment
Psychological assessment
Social/environmental assessment
New Admission—Triggers to recognize &
screen for cognition
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.”
30
New Admission—Triggers to recognize & screen
for physical function
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.”
31
ID patients at significant risk for
functional decline while hospitalized
Independent Risk Factors
1) Pressure ulcer?
2) Baseline cognitive deficits?
3) Baseline functional impairments?
4) Baseline low social activity level?
Score risk for functional decline:
no =8%risk; yes to 1-2 questions =28% risk;
yes to > 2 questions=63% risk
Inouye SK, et al.J Gen Intern Med1993;8(12):645-52.
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Functional decline occurs in the hospital
Functional limitations increase with age.
Functional decline occurs in approx.
34-50% hospitalized older pts.
Higher mortality—twice the risk
Higher rates of institutionalization
Prolonged hospital stay
Interventions can decrease functional
decline (Hospital Elder Life Program).
Functional status determines D/C plan.
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The Hospital CGA? –a comprehensive
assessment of functional status
● Screen ADLs(Activities of Daily Living) &
IADLs(Instrumental Activities of Daily Living).
● Evaluate physical mobility
● Evaluate for sensory impairments—hearing &
sight
● Screen for dementia
● Screen for depression
● Screen for environment/social factors
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Functional impairment and age as
measured by ADLs
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Activities of Daily Living
Bathing
Dressing
Transference
Continence
Feeding
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Instrumental Activities of Daily Living
Using the phone
Traveling
Shopping
Preparing meals
Housework
Taking medicine
Managing money
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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
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Gait assessment scoring to assess
physical mobility
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
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Trigger to Recognize & Teach:
Who to screen for functional
impairment?
Who to screen?
 Patients @ advanced age (>70, >75, >80 ???)
 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
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Screening for Functional Status in the
Hospitalized Elderly
When to screen?
 Review ADLs/IADLs prior to the patient’s hospitalization
 Determine new set of ADLs/IADLs after stabilization of acute
illness
 Readdress patient’s ADLs and IADLs prior to hospital discharge
What to do?
 Chart orders- walking and range of motion TID
 Ambulation problem- physical therapy
 Dressing/bathing/feeding- occupational therapy
 Discharge planning early in hospitalization w/social work
intervention
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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
25% of older hospitalized adults admitted
to medicine have impaired cognition
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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 8% vs. 26%.
* Confusion = loss of 2 points on MMSE
Inouye SK, et al Ann Intern Med 1992;119:474-481
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Cognitive Assessment
–Screen with 3 item recall in 1 minute
–Mini-Cog
–Folstein Mini-Mental State Examination (MMSE)
–Clock-drawing test
–Montreal Cognitive Assessement
–St. Louis University Mental Status Exam
Screening Tools: Mini-cog
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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
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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
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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
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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
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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
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Depression and functional status
Hospitalized elderly with higher depression
scores had worse outcomes
Dependent 1 ADL
3.23(1.76-5.95)
Dependent >/= 3 IADL
2.67 (1.33-3.56)
Not satisfied with life
3.05(1.06-8.75)
Fair to poor health
3.11(1.65-5.87)
*Similar results 30 and 90 days
Covinsky K, Fortinsky R, Palmer R. Relation between symptoms of depression and health status
outcomes in acutely ill hospitalized older persons. Ann of Int Med. 1997;126:417-425.
Psychological Assessment
– Screen with “Do you often feel sad or
depressed?”
– Perform Geriatric Depression Scale
– Assess risk of suicide
– Ask about anxieties and worries and recent
bereavement
Geriatric Depression Scale
(GDS)
• Short form
– 15 items from the original 30
– Score ≥ equal to 5 → Sensitivity ~90%, specificity
70%
Geriatric Depression Scale:
Short Form
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you in good spirits most of the time?
6. Are you afraid that something bad is going to happen to you?
7. Do you feel happy most of the time?
8. Do you often feel helpless?
9. Do you prefer to stay at home, rather than going out & doing new
things?
10. Do you feel you have more problems with memory than most?
11. Do you think it is wonderful to be alive now?
12. Do you feel pretty worthless the way you are now?
13. Do you feel full of energy?
14. Do you feel that your situation is hopeless?
15. Do you think that most people are better off than you are?
Sheikh et al. J Psychiatric Res 1983;17:37-49.
Frailty & the Hospital:
A Final Word
 Frail elders occupy approx. 25% medicine beds.
 Frail elders @ high risk for worse outcomes.
 Screen for cognition, functional status,
psychosocial, sensory impairments.
 Screen based on advanced age (>70) & suspected
functional impairments.
 Take measures to prevent delirium, falls and
functional decline.
 Recognizing frailty begs for a comprehensive
D/C plan and Med Review.
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Special Thanks
• CHAMP investigators, faculty & course
participants
• Joseph Shega
• Don Scott
• Aliza Baron
• Greg Sachs
• Vinay Kutagula
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CHAMP Website & Materials
CHAMP Website @
http://champ.bsd.uchicago.edu
Reynolds Foundation supported Portal of
Geriatric Online Education website @
www.pogoe.com
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