Frailty: Tailoring Care to Need & Vulnerability John Muscedere, - - PowerPoint PPT Presentation

John Muscedere, Scientific Director & CEO Canadian Frailty Network

Frailty: Tailoring Care to Need & Vulnerability

Disclosure

• Scientific Director for the Canadian Frailty Network
• Funded by the Government of Canada through the

Networks of Centers of Excellence

• Partner with other NGOs, governments and industry
• Conduct industry sponsored clinical trials in the ICU
• N8 pharma, Shionogi, Polyphor

Outline

• Aging in Canada
• Overview of frailty
• Why we should care about frailty
• Tailoring care based on frailty assessment

– Examples of frailty care innovations

Canadian Frailty Network (CFN)

Who are we?

• Not-for-profit pan-Canadian network since 2012
• Funded by the federal government through Networks of Centres of Excellence
• Multi-disciplinary network which includes investigators, stakeholders,

trainees, partners, citizens, and caregivers

What do we do?

• We aim to improve care for older adults living with frailty and to support their

family and friend caregivers through practice and policy change

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Our Conceptual Framework

Aging in Canada

• Number and proportions
• f seniors over age of 65

are increasing rapidly

• Older segments of

population growing most rapidly

• Number of working

adults for every senior is dropping

Source: Government of Canada — Action for Seniors report, 2014. Data from Stats Canada and Office of the Superintendent of Financial Institutions.

Volume of Health Services by Age

Per-capita services by patient age and gender, 2015-16

• ~216 million physician services

delivered in 8 provinces surveyed.

• >70 million (1/3rd) services to

patients aged 65+.

• Service utilization rates increase

steadily with age.

• Data: 2015-2016; 8 provinces surveyed
• Slade, S., Shrichand, A., & DiMillo, S. 2019. Health Care for an Aging Population: A Study of how Physicians

Care for Seniors in Canada. Ottawa, Ontario. The Royal College of Physicians and Surgeons of Canada.

• Original Data Source: Canadian Institute for Health Information, National Physician Database, 2015-16

Healthcare consumption

Evolution of Aging…

Function Age

Healthy Aging

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Frailty Health State

• Frailty is defined as a state of increased vulnerability resulting from

reduced physiological reserve and loss of function across multiple systems reducing the ability to cope with normal or minor stressors.

• ‘Minor’ events trigger major changes

in health status

• Associated with increased risk of

physical, cognitive and functional decline, adverse health outcomes and mortality

Source: e: Xue e Q, The e Frai ailty Syndr drom

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: Defi fini nition n and d Na Natur ural Hist stor

• ry. Clin

n Ge Geriat atr Me Med 2012. 12. Clegg egg A, The e frai ailty synd ndrom

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sear arch h Age gend nda a for

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ailty in Olde der Adul ults.

• s. J Am Ge

Geriatr Soc 2006. 06.

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Common Features of Frailty

Frailty…Impact and Determinants

• Frail patients have functional loss, many require caregivers, are at

higher risk of institutionalization and are frequent users of healthcare services

• Vast majority of long term care residents are frail
• Majority of elderly patients who are hospitalized are frail
• Frail patients often have worse outcomes when they receive

medical interventions

• Determinants of frailty include public health aspects:

– Social isolation/loneliness, nutrition, vaccination, inactivity, polypharmacy, community organization

Frailty in Canadians

Sources:

• 1. statcan.gc.ca/pub/82-003-x/2013009/article/11864-eng.htm
• 2. Kehler et al, BMC Geriatrics 2017

(> 65 y.o.)

Prevalence of frailty is high and growing in Canada

That’s approximately 1,500,000 Canadians Expected to be 2,000,000 by end of next decade

statcan.gc.ca/pub/82-003-x/2013009/article/11864-eng.htm

Older Adults: Frailty prevalence increase with age

Kehler et al, BMC Geriatrics 2017

Sex: Prevalence of frailty higher in women

Mitnitski et al. JAGS 53:2184–2189, 2005

Systematic review of seven international studies showed that women have higher frailty scores than men at any age.

Gordon et al. Sex differences in frailty: a systematic review and meta-analysis. Exp Gerontol 2017;89:30-40.

Socioeconomic Status: Prevalence of frailty

0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18 0.2 Wealthiest 2 3 4 Least wealthy

Level of wealth Frailty Index

Least deprived 2 3 4 Most deprived

Predicted frailty index by wealth and neighborhood deprivation, both split by quintiles, in fully adjusted models

Lang et al. Socioeconomic status, neighborhood deprivation, and frailty in older adults. JAGS 2009

First Nations People and Frailty

Walker (2017) Canadian Journal on Aging, 1-12. Hoover et al. (2013) Health Reports, 24(9): 10–17.

Figure A – Frailty patterns over age groups in general Canadian population. Canadian Community Health Survey, as published by Hoover et al. (2013) Figure B – Frailty categories across age groups in First Nations people living on-reserve and in northern First Nations communities 20% 30% 50%

50% 50% 50%

• Over 60 frailty assessment instruments have been

described – Reliability, validity poorly studied for many of them – Variable agreement between scales – Variable data collection burden

• Two conceptual models: Phenotype or as an accumulation
• f deficits
• Common (and best studied) assessment instruments:

– Frailty phenotype model – Deficit Accumulation (Frailty Index) – Clinical Frailty Scale

How is Frailty measured?

Buta et al. 2016, Ageing Res Rev. 26: 53–61. Viña et al, 2016, Molecular Aspects of Medicine 50; 88–108

Frailty – Accumulation of Deficits

Frailty Index =

Number of deficits in an individual Total number of potential deficits measured

Source: Rockwood et al, CMAJ 2011. DOI:10.1503/cmaj.101271

e.g. in a dataset with 50 health measures, a person with 10 things wrong (10 deficits) has a frailty index of 10/50 = 0.20.

Frailty associated with worsened outcomes, hospitalization and mortality

Rockwood et al, CMAJ 2011. DOI:10.1503/cmaj.101271

Frailty Phenotype Criteria

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Fried et al, J Gerontol A Biol Sci Med Sci. 2004

Criteria Definition

• 1. Weight loss/Sarcopenia

> 10 lb weight loss/year

• 2. Weakness

Grip strength

• 3. Slowness

15 feet Walking time

• 4. Low Activity Level

Kcal/week expended

• 5. Exhaustion

Self-reported Frailty: > 3 Criteria Present Pre-Frail: 2 Criteria Present

Clinical Frailty Scale

Rockwood et al, CMAJ 173 (5): 489

Other screens for frailty

• Hand grip strength

– Better marker of frailty than age, correlates with mortality – Correlates with post operative, CVD outcomes – Easy to measure

• Four meter gait speed

– Gait speed of longer than 5 seconds to walk 4 metres (<0.8 m/s) suggests an increased risk of frailty

• Timed up and Go

– Time to get up from a chair, walk 3 meters and back – Correlates with frailty, outcomes and falls – Reliable and valid

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Care of older adults – Paradigm change

Disease-centred paradigm Patient-centred & Function-centred paradigm

Better care for seniors living with frailty will only come through improvements in BOTH health and social care.

Frailty is not solely a health care issue

How can we address frailty?

• 1. Primary and secondary prevention

– Frailty is not an inevitable part of aging – Promotion of healthy ageing

• 2. Tailoring care to the degree of frailty

– Not sufficient to identify frailty unless care is tailored to its determinants, modifiable factors – Frailty determination needs to lead to more detailed evaluation

CFN Public Health Campaign

Frailty is NOT an inevitable part of aging

CFN Public Health Campaign

Fact: Primary care family physicians provide about half of all seniors’ medical services

• Family physicians comprise 57% (n=30,515) of all physicians

included in the 2015-16 study data.

• Family physicians provided 57% (n=122.23 million) of all fee-for

service care.

• At just over 35 million services, family physicians delivered

51% of all services provided to patients aged 65+ (highest volume of services provided to seniors among all specialty groups).

• Almost one-third (29%) of all family physicians’ services were

provided to patients aged 65+.

Slade, S., Shrichand, A., & DiMillo, S. 2019. Health Care for an Aging Population: A Study of how Physicians Care for Seniors in Canada. Ottawa, Ontario. The Royal College of Physicians and Surgeons of Canada.

Advancing Frailty Care in the Community: Collaborative with CFHI

Goal: Enhance frailty care in primary care and the community across Canada using a quality improvement approach. Objectives: – Improve identification and assessment of frailty in primary care.

• Systematically identify frailty in adults 75 years of age and over.
• Using case finding approach identify frailty in those 65 years

and over.

• Practices will use the Clinical Frailty Scale or 4 meter gait

speed/handgrip strength – Implement person-centred evidence-informed frailty interventions and customized care plans utilizing a interprofessional team and community supports.

Future state of frailty care in Canada

Integrated care – Individualized patient-centred care

Older adults (fit) Older adults (mild/moderate frailty) Older adults (severe/very severe frailty) Older adults (pre-frail)

Comprehensive Assessment

• Medications
• Medical issues
• Physical capabilities
• Functional capabilities
• Psychological capabilities
• Social Factors
• Environmental Factors

Frailty Case Finding

Improving frailty care in the Emergency Department and Hospital

• ERs and hospitals are hostile environments for frail patients
• Example: Acute Frailty Network- NHS in the UK

– national quality improvement collaborative designed to support acute hospitals in England to deliver evidence-based care for

• lder people with frailty
• 70 hospital sites - principles

– Implementation of frailty screening presenting to the ER – If screen positive – multidisciplinary assessment  CGA – Targeted care plans – Education and training of key staff – Strengthen links to services inside and outside hospital

Van Oppen et al, Eur Geri J, 2019; 10:559 Conroy et al, Acute Med, 2016; 15: 185

Process of Acute Frailty Network

Outcomes of Acute Frailty Network

• Individual case studies
• Significantly improved care

– Reduction in Length of Stay – Reduction in the number of long stay patients – Avoidance of admissions – High Satisfaction with care – Reduced costs

Frailty is a risk factor for poor surgical outcomes

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1) Lin et al., 2016. Frailty and post-operative outcomes: a systematic review. BMC Geriatrics (2016) 16:157. 2) Lin et al., 2018. Frailty and anesthesia – risks during and post-surgery. Local Reg Anesth. 2018; 11: 61–73.

• Increasing recognition of the

association between frailty & increased mortality (30 days, 90 days & one year follow-up), post-operative complications, increased LOS and increased costs

• Increasing number of

intervention studies.

Frailty Severity and Cardiac Surgery

Higher frailty score associated with: – Longer post-surgical hospital LOS – Increased 1-year mortality

38 Green et al. JCIN 2012;5:974-981

Improving outcomes in frail surgical patients

• Prehabilitation

– pre‐operative interventions aimed at increasing patients’ physiological reserve so that they can better withstand the stress

• f surgery and thus avoid complications

– Nutrition and exercise are two main modalities – Prelim evidence - patient satisfaction, safety and feasible, improved outcomes – Large RCTs underway (Dr. McIsaac – PREPARE trial)

• Shared Decision Making

– More informed discussion with patient about risks and benefits

• f procedure

– Dr. Hirsch – Frailty assessment to inform care decisions

Conclusion

• Frailty prevalence increases with age but is not inevitable

part of aging

• Frailty associated with worsened outcomes
• Assessment frailty should lead more detailed assessment
• r tailored care plan
• To improve outcomes we need to improve both health and

social care

Thank You! Questions?

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