“Holistic and comprehensive
approach in Chronic
Diseases Management in
Family Practice”
Профессор Йан Дегрис
MD PhD
Geriatric Conference St Petersburg
October 15th 2013
2
3
Objectives
• To understand about the nature of multi-morbidity
• To understand the goals of care in (older) patients with
multi-morbidity
• To understand about «frailty ».
• To understand about Wagner’s Chronic Care Model
• To be able to describe the different levels of preventive
interventions.
• To become familiar with the principles of comprehensive
geriatric assessment and it’s applications in the community
setting..
4
Overview
• Demographic background & the multi-morbidity
epidemic
• A paradigm shift from disease-oriented towards goaloriented care
• The nature of multi-morbidity
• The objectives of preventive care for elderly.
• Frailty: an emerging concept in primary health care
• Comprehensive Geriatric Assessment as new
meaningful approach
• How to implement CGA in practice ?
5
1950
2050
Source: short textbook of public health for tropics
6
The Grey Epidemic
Eurostat. Demography Report 2010. European Commission.
7
Demographics
Evolution of the older population in the EU
(% population)
45
40
35
30
25
20
65+
15
80+
10
80+ / 65+
5
2050
2040
2030
2020
2010
2000
1990
1980
1970
1960
1950
1940
1930
1920
0
Year
(EUROSTAT 2010)
8
Demographics
Evolution of the older population in the EU
(% population)
45
40
35
30
25
20
65+
15
80+
10
80+ / 65+
5
2050
2040
2030
2020
2010
2000
1990
1980
1970
1960
1950
1940
1930
1920
0
Year
(EUROSTAT 2010)
9
The grey epidemic
• In 2050 22% of the world population will be aged 60 or
older and 12,4 % of that population will be aged 80 or
over.
• In 2050, 71% of all octogenarians will live in developing
countries.
United Nations. Department of Econ and omicsocial Affairs,
population division. World Population Prospect: the 2008 revision
10
Introduction
• Misses Jones, 82 years, widow.
• Osteoporosis, osteoarthritis, diabetes, hypertension
and COPD
Boyd CM, et al. JAMA 2005;294;716-24.
11
Misses Jones Patient tasks
•Joint protection
•Energy conservation
•Self monitoring of blood glucose
•Exercise
•Non weight-bearing if severe foot disease
•Administer vaccine
is present and weight bearing for
osteoporosis
•Pneumonia
•Aerobic exercise for 30 min on most days
•Influenza annually
•Check blood pressure at all clinical visits and •Muscle strenghtening
sometimes at home
•Range of motion
•Evaluate self monitoring of blood glucose
•Avoid environmental exposures that might
exacerbate COPD
•Foot examination
•Wear appropriate footwear
•Laboratory tests
•Limit intake of alcohol
•Microalbuminuria annually if not present
Physical
normal therapy
body weight
•Creatinine and electrolytes at least•Maintain
1-2
Ophtalmologic
examination
times a year
Pulmonary rehabilitation
•Cholesterol levels annually
•Liver function biannually
•HbA1C
Foot
care biannally to quarterly
Clinical tasks
Referrals
Patient education
Osteoartritis
COPD medication and delivery system training
Diabetes
12
Following the official guidelines:
• 12 different drugs
• 19 doses per day in 5 different gifts
• A series of instructions that are contradictory .
The « clinical guidelines» don’t provide any advice
on what choices schould be made in case of presence
of multiple pathologies.
Boyd CM, et al. JAMA 2005;294;716-24.
13
Conflicting guidelines: why?
• By a lack of evidence !
• Most of the clinical trials are about:
– Patients with one single pathology
– Middle aged patient.
– Hospitalised patients.
14
The need of a paradigm shift
Disease oriented Care
Goal oriented Care
Reuben &Tinetti et al NEJM 2012
Mold, Fam Med 1991
15
• The problem-oriented model upon which much of
modern medical care is based has resulted in
tremendous advancements in the diagnosis and
treatment of many illnesses. Unfortunately, it is less well
suited to the management of a number of modern
health care problems, including chronic incurable
illnesses, health promotion and disease prevention, and
normal life events such as pregnancy, well-child care,
and death and dying. It is not particularly conducive to
an interdisciplinary team approach and tends to shift
control of health away from the patient and toward the
physician. Since when using this approach the enemies
are disease and death, defeat is inevitable.
Mold, Fam Med 1991 16
Proposed here is a goal-oriented approach that is well
suited to a greater variety of health care issues, is more
compatible with a team approach, and places a greater
emphasis on physician-patient collaboration. Each
individual is encouraged to achieve the highest possible
level of health as defined by that individual.
17
Goal oriented care
“Ultimately, good medicine is about doing right for the
patient. For patients with multiple chronic diseases,
severe disability, or limited life expectancy, any
accounting of how well we’re succeeding in providing
care must above all consider patients’ preferred
outcomes”
18
Goal oriented care
Reuben &Tinetti et al NEJM 2012
19
Overview
• Demographic background &the multi-morbidity
epidemic
• A paradigm shift from disease-oriented towards goaloriented care
• The nature of multi-morbidity
• The objectives of preventive care for elderly.
• Frailty: an emerging concept in primary health care
• Comprehensive Geriatric Assessment as new
meaningful approach
• How to implement CGA in practice ?
20
Multi-morbidity
• 50% of the 65+ has at least 3 chronic conditions *
• 20% of the 65+ has 5 or more chronic conditions*.
• Approximately half of the patients suffering from one
chronic condition present multi-morbidity**.
* Anderson et al. 2004
** Taylor et al. BMC Health Services Research
21
Comorbidity as a central issue.
0 - 1 chronic condition
2 chronic conditions
3 chronic conditions
more than 3 chronic conditions
100%
90%
15.9
15.2
23.2
24.4
32.3
80%
16.4
20.4
70%
13.8
21.9
60%
15.7
24.2
50%
40%
19.1
29.4
18.3
25.5
30%
43.8
43.6
20%
28.3
33.4
33.7
Leiden 85+
CMR Nijmegen
10%
0%
Rotterdam
LASA
Study
RNGP
Study
population-based setting
GP setting
22
Multi-morbidity: what conditions should
be accounted for ?
Quid
Risk Factors
•
•
•
•
Quid
Hypertension
Hypercholesterolaemia
Osteoporosis
Nicotine abusus
Geriatric Syndromes
• Continence problems
• Visual impairment
• Auditive impairment
Quid
Symptomatic conditions with high impact
• Irritable bowel syndrome
Quid
Psychosocial problems
Quid
Rare diseases ?
• Amyotrophic sclerosis
23
How should multi-morbidity be
measured or quantified ?
•Simple disease count
•Weighted index
i.e. : Charlson Comorbidity Index
Selection of chronic conditions weighted according to their
association with mortality.
i.e. : Cumulative Illness Rating Scale
All conditions. Categorized in 14 anatomical domains:
cardiac, respiratory, endocrinologic, psychiatric
Weighted according to the severeness of the affection.
24
Multi-morbidity and mortality
CHARLSON
DISEASE COUNT
COMORBIDITY
(n:22)
INDEX
CUMULATIVE
ILLNESS RATING
SCALE
Hospitalisation
Adjusted Hazard Ratio’s for mortality and hospitalization
Mortality
Hospitalization
Adjusted for age, gender and BMI
Charlson comorbidity
Index
0-4
5-6
>6
Cumulative Illness Rating 0-3
Scale
4
>4
Disease Count
0-3
4-5
>5
1.8 (1.1-2.9)
2.5 (1.5-4.2)
1.8 (1.1-2.9)
2.5 (1.5-4.2)
1.2(1.1-1.3)
2.2(1.5-3.3)
1.9 (1.4-2.6)
2.0 (1.5-2.6)
1.5 (0.9-2.3)
2.2 (1.4-3.4)
1.8 (1.3-2.4)
2.4 (1.8-3.2)
Disability (limited ADL)
Disability
YES
Age
mean (SD)
P –value
Crude ODDS for
disability
NO
86 (4)
84 (3)
< 0.001
1.126 (1.068-1.188)
Female gender
(%)
n
75 (67.0%)
276 (61.7%)
0.307
0.796 (0.514-1.233)
Disease Count >3
(%)
n
79 (70.5%)
236 (52.8%)
<0.001
2.140 (1.369-3.346)
Charlson Comorbidity
Index >5
n (%)
63 (56.3%)
187 (41.8%)
<0.05
1.788 (1.177-2.715)
Cumulative
Illness
Rating Scale
>3
n(%)
86 (76.8%)
201 (45.0%)
<0.001
4.048 (2.514-6.520)
Low MMSE n (%)
34.8%
17.2%
<0.001
2.567 (1.621-4.066)
Frailty
30.0%
4.2%
<0.001
9.756 (4.935-19.288)
n (%)
Functional decline...
Adjusted Odds Ratio’s for physical and medical decline.
Physical decline
Mental decline
Adjusted for age, gender and BMI
Charlson comorbidity
Index
Cumulative Illness
Rating Scale
Disease Count
0-4
5-6
>6
0-3
1.1 (0.7-1.8)
1.1 (0.6-2.1)
1.1 (0.6-1.4)
1.5 (0.8-2.9)
4
>4
0-3
4-5
>5
0.7 (0.4-1.3)
0.9 (0.6-1.6)
1.2 (0.6-2.1)
1.5 (0.9-2.6)
1.0 (0.6-1.6)
0.8 (0.5-1.4)
0.8 (0.4-2.4)
1.1 (0.6-2.0)
Overview
• Demographic background &the multi-morbidity
epidemic
• A paradigm shift from disease-oriented towards goaloriented care
• The nature of multi-morbidity
• The objectives of preventive care for elderly.
• Frailty: an emerging concept in primary health care
• Comprehensive Geriatric Assessment as new
meaningful approach
• How to implement CGA in practice ?
29
Statements:
1. Organising care for patients with multi-morbidity is one
of the biggest challenges for the primary care in the
next 20 years.
2. Demographic evolution makes prevention a key
element of future care in older persons.
But what are the objectives of preventive
care in (older) persons with multi-morbidity?
Prevention of functional decline and
Disability
30
Older persons and the health care system
Rehabilitation
Acute care
Nursing Home
Community
31
Prevention in geriatrics: Mortality and disability
Survivors (%)
100
Mortality
90
80
70
60
50
40
30
20
Age
10
0
0
10
20
30
40
50
60
70
80
90 100 110 120
(Bissig, 1991)
32
Prevention in geriatrics: Mortality and disability
Survivors (%)
100
Mortality
90
80
70
60
50
40
30
20
10
Age
0
0
10
20
30
40
50
60
70
80
90
100 110 120
(OFSP, 2001) 33
Life expectancy without disability at birth in
Belgium, by gender.
Life expectancy
without disability
(years)
80
6,2
7,5
60
40
70,3
75
Men
Women
Dependent
Independent
20
0
34
WHO 2006
Prevention in geriatrics: Mortality and disability
Survivors (%)
100
Mortality
90
80
70
60
Disability
50
40
30
20
10
Age
0
0
10
20
30
40
50
60
70
80
90
100 110 120
(Bissig, 1991) 35
Prevention in geriatrics: Mortality and disability
Survivors (%)
100
Mortality
90
80
70
60
Disability
50
40
30
20
10
Age
0
0
10
20
30
40
50
60
70
80
90
100 110 120
(Bissig, 1991) 36
Demographics: Compression of morbidity or pandemia ?
Survivors (%)
100
Mortality
90
80
70
60
Disability
50
40
30
20
10
Age
0
0
10
20
30
40
50
60
70
80
90
100 110 120
37
Demographics: Compression of morbidity or pandemia ?
Survivors (%)
100
Mortality
90
80
70
60
Disability
50
40
30
20
10
Age
0
0
10
20
30
40
50
60
70
80
90
100 110 120
38
Demographics: Compression of morbidity or pandemia ?
Survivors (%)
100
Mortality
90
80
70
60
Disability
50
40
30
20
10
Age
0
0
10
20
30
40
50
60
70
80
90
100 110 120
39
What makes the difference between them?
Misses X: 70 years old
Mister Y: 70 years old
Courtesy H.Bergman
40
Chronic Care Model (Wagner 1998)
41
Health care interventions in older persons:
Conceptual framework
Type of older person
Level 3
Complex needs
Disabled
(15-20% older popul.)
Level 2
High risk for disability
2+ chronic dis. / frail
(20-40% older popul.)
Level 1
Healthy / 1 chronic disease
(50% - 60% older popul.)
Health Pomotion
42
(Monod S, Seematter L, Büla CJ. Swiss Health Obs, 2007)
Health care interventions in older persons:
Conceptual framework
Type of services
• Integrated care in network by
multidisciplinary team
• Coordinated care, with
supecialists support and
rehabilitative care
• Specific care pathways (ex.
diabetes)
Type of older person
Type of prevention
Level 3
Complex needs
Disabled
(15-20% older popul.)
Level 2
High risk for disability
2+ chronic dis. / frail
(20-40% older popul.)
Tertiary
Level 1
Healthy / 1 chronic disease
(50% - 60% older popul.)
Secondary
Health promotion
Primary
Prevention 43
(Monod S, Seematter L, Büla CJ. Swiss Health Obs, 2007)
A paradigm shift.
From a
Disease-oriented medical approach,
towards a:
Goal-oriented integrative approach.
Targetting prevention of functional decline, maintenance of
autonomy and further loss of resources
The missing clinical concept is that of « FRAILTY »
44
Overview
• Demographic background &the multi-morbidity
epidemic
• A paradigm shift from disease-oriented towards goaloriented care
• The nature of multi-morbidity
• The objectives of preventive care for elderly.
• Frailty: an emerging concept in primary health care
• Comprehensive Geriatric Assessment as new
meaningful approach
• How to implement CGA in practice ?
45
Definition of frailty
• Age-related alteration in physiology with loss of organ
system reserve that leads to vulnerability, limited
capacity to respond internal and environmental
stresses, unstable homeostasis and poor medical and
functionional outcomes
Adapted from:
Studenski JAGS 2004;62;1560-66
Ferruci J.Endocrionol Inverst 2002; 25;10-8
46
Frailty and reserve capacity
47
The dynamic nature of frailty…
Gill , et al. Arch. Int. Med. , 166:4.; 418-423
48
The natural history of frailty…
Gill et al 2006
49
The operationalization of the Frailty concept
• Theoretical approach
–
–
–
–
Models
Mechanisms, factors
Theoretical definitions
Modelised outcomes
A Syndrome?
A Condition?
• Operational approach
–
–
–
–
Criteria
Operational outcomes
Operational definition
Tools and measures
Some 30 different
frailty -indicators
were described
50
Frailty model
Swinne 2008
51
The disablement process
Frailty
Pathology
Impairments
Functional
Limitations
Disability
Mortality
Impairments include dysfunction and significant structural abnormalites in
specific body systems.
Functional limitations include restrictions in performing basic physical and
mental activities in daily life
Disability refers to functional limitations in a social context.
Frailty: a precursor state of functional limitations.
Verbrugge & Jette (1994)
52
Frailty, multimorbidity and disability.
Belfrail Study
Boeckstaens et al 2013
53
Criteria for the Frailty Phenotype
Fried L et al (J of Gerontol Med Sci 2001)
Three or more of the following:
1.
2.
3.
4.
5.
Muscle weakness (grip strenght)
Exhaustion/fatigue (anamnesis)
Less physical activity
Slow gait speed
Weight loss (4,5kg in the previous year)
Operational approach
• Domains
–
–
–
–
–
–
–
Nutrition
Mobility
Activity
Strength
Endurance
Cognition
Mood
• Balance between assets and deficits will determine the
consequences for an individual; dynamic nature
– adaptability, physical environment & social resources are important
determinants of the impact of frailty.
Lebel P et al 1999
Studenski S, et al. J Am Geriatr Soc 2004
Bergman H et al. Gérontologie et société 2004
Frailty in LASA
(Puts et al 2006)
Static definition of Frailty
Dynamic definition of frailty
• BMI < 23
• Lowest quintile peak expiratory
flow
• MMSE < 24
• Poor vision
• Poor hearing
• Incontinence
• Lowes quitinle mastery
• Depression (CES-D) > 16
• Lowest quintile physical activity
• Weight loss > 4 kg
• Decline peak expiratory flow
•
•
•
•
•
•
•
Decline MMSE
Decline vision
Decline hearing
New incontinence
Decline mastery
More depressive complaints
Decline physical activity
Frailty= three or more indicators
Consequences of Frailty
• Falls (Fried et al. J of Gerontol Med Sci 2001)
• Functional decline (Chin A Paw et al. 1999 J Clin Epi, Fried et al.
2001, Puts et al. 2005 J of Clin Epi)
• Hospitalisation (Fried et al. 2001)
• Nursing home admission (Rockwood et al. 1996 JAGS,
Rockwood et al. 1999 Lancet, Puts et al. 2005 Eur J Ageing)
• Death (Chin A Paw et al. 1999, Fried et al. 2001, Mitnitski et al
2002, Rockwood et al. 1999, Puts et al. 2005 JAGS)
• Lower quality of life. (Strawbridge et al. 1998 J of Gerontol Psy
Sci)
57
Frailty is measurable
•Different instruments
have been proposed
as case-finding tools
•They are used as a
part of a two-step
approach
•They are devised as a
simple to use multidimensional frailty
index.
58
Groningen Frailty Indicator
Mobility / ADL
1. Shopping
2. Walking outdoors
3. Undressing
4. Toilet visit
Physical Fitness
5. Fitness
Vision
6. Vision
Hearing
7. Hearing
Nutritional state
8. Weight loss
Co-morbidity
9. Medication (> 3 different medications)
Cognition
10. Memory loss
Psycho-social
11. Loneliness
12. Miss people
13. Social support
14. Feeling down
15. Feeling anxious
59
Relevance of the frailty concept
• Improves our understanding of the aging process and
ability to characterise the heterogeneity of older
persons
• At population and clinical level: characterises health
and functional status beyond disability and co morbidity
• Identifies a subset of vulnerable older adults at high risk
of adverse outcomes
– older persons who are functionally independent with apparently
normal cognitive function may be overlooked even if they have
identifiable frailty markers and are highly vulnerable for adverse
health outcomes and increased utilisation of health services
Bergman, Hogan, Karunananthan. Frailty: A clinically relevant concept?
60
Care for people with multi morbidity
•Define priorities
•Increasing life span while maintaining an optimal
quality of life
•Involve your patient as an active partner
•Idenfiy together with your petient unmet needs and
objectives (goals)
•Individualised holisitc care in stead of standaridized
care.
Who defines goals ?
« Treat to target »
« Treat the patient »
62
Guidelines for taking care of multi-morbidity:
which way to go ?
Thank you for your attention
63
Overview
• Demographic background &the multi-morbidity
epidemic
• A paradigm shift from disease-oriented towards goaloriented care
• The nature of Multi-morbidity
• The objectives of preventive care for elderly.
• Frailty: an emerging concept in primary health care
• Comprehensive Geriatric Assessment as new
meaningful approach
• How to implement CGA in practice ?
64
Comprehensive Geriatric Assesment in primary care ?
WHY AND HOW ?
Two examples at both ends of a spectrum of strategies….
65
About « unmet needs »
• Unmet need is relatively common
• No help seeking for complex reasons
• Withdrawal, resignation and low expectations.
Walters K, Iliffe S & Orrell M An exploration of help-seeking behaviour in older people
with unmet needs Family Practice 2001; 18(3):277-282
66
Example 1: the SPICE acronym
Level 3
Complex needs
Disabled
(15-20% older popul.)
Level 2
High risk for disability
2+ chronic dis. / frail
(20-40% older popul.)
SPICE
Level 1
Healthy / 1 chronic disease
(50% - 60% older popul.)
Iliffe S, Lenihan P, Orrell M, Walters K, Drennan V, See Tai S and the
SPICE research team Involving the public in changing clinical practice:
the development of a short instrument to identify common unmet needs
in older people in general practice BJGP 2004;54:914-918
67
SPICE as a “heuristic”
• Senses (hearing & vision)
Do you have any difficulty with your sight or hearing?
• Physical activities
Do you have difficulty getting about indoors or outside?
• Incontinence (urinary)
Do you ever find you have difficulty getting to the toilet in time and find
yourself wet?
• Cognition
Do you have difficulties with your memory, for example getting muddled or
forgetful at times?
• Emotion (anxiety or depression)
Do you often feel sad, fed up, frightened or worried?
68
Transitional questions
In a routine consultation
• Open a discussion
• If a problem is recognised, offer opportunity to talk later
• Use a more complex tool later
Iliffe S, Lenihan P, Orrell M, Walters K, Drennan V, See Tai S and the
SPICE research team Involving the public in changing clinical practice:
the development of a short instrument to identify common unmet needs
in older people in general practice BJGP 2004;54:914-918
69
Example 2: the GAZETO approach
Level 3
Complex needs
Disabled
(15-20% older popul.)
Level 2
High risk for disability
2+ chronic dis. / frail
(20-40% older popul.)
SPICEGAZETO
Level 1
Healthy / 1 chronic disease
(50% - 60% older popul.)
70
Background
In Belgium patients aged older than 65 have a as an average 9,7 contacts with
theire Family physician. After the age of 85 the number of contacts has increased to
14,1 as an average.
Bayingana K, Demarest S, Gisle L, Hesse E, Miermans PJ, Tafforeau J, Van der Heyden J.
Enquête de Santé par Interview, Belgique, 2004 Service d'Epidémiologie, 2006; Bruxelles
Institut Scientifique de Santé Publique N° de Dépôt : D/2006/2505/3, IPH/EPI REPORTS N° 2006 – 034
71
Main principles of our project
1. How can we make these multiple contact more
meaningful ?
2. For what kind of « unmet needs » is enough evidence
availablee that that an organized screening/case
finding strategy is meaningful ?
3. How can we integrate this into the busy agenda of the
Family Physician ?
72
An IT tool that support our daily work
•
•
•
•
•
•
•
•
•
•
•
Cognition
Vision
Hearing
Depression
Vaccination
Nutrition
Osteoporosis
Sarcopenia
Fall prevevention
Urinary incontinence
Anticipated Care Planning
73
Thank you !