PERSONS 75+ A PRIMARY CARE INITIATIVE TO ADDRESS FRAILTY AND - PowerPoint PPT Presentation

“C5-75”: C ENTRE FOR FAMILY MEDICINE C ASE- FINDING FOR C OMPLEX C HRONIC C ONDITIONS IN PERSONS 75+ A PRIMARY CARE INITIATIVE TO ADDRESS FRAILTY AND ASSOCIATED COMPLEX GERIATRIC CONDITIONS L. Lee, MD, MClSc(FM), CCFP(COE), FCFP T. Patel, BScPharm, PharmD Sept 2018

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Centre for Family Medicine Family Health Team  Established in 2005  Serving 28,309 patients 19 Academic in Kitchener, Waterloo, Family Practices and Wellesley, Ontario Addressing challenging gaps in community-based health care :  Pro-active “C5-75” Primary Care  Primary care-based Frail Memory Clinic  Interprofessional Older Adults  Evidence-informed  Efficient, feasible  Evaluative research Practice

Measures of Frailty At least 67 frailty instruments have been developed… • Clinical phenotype of (i) slowed walking speed, (ii) low physical activity, (iii) unintentional weight loss, (iv) low energy and (v) low grip strength (weakness) where 3 of 5 = frail [Fried Phenotype] • Counting of accumulated deficits across multiple domains, eg. Frailty Index • Clinical judgment, eg. CSHA Clinical Frailty Scale Buta BJ, et al. Ageing Res Rev 2017 Bouillon K, et al. BMC Geriatr 2005 Fried LP, et al. Geronto A: Biol Sci Med Sci 2001 Minitski AB, et al. BMC Geriatr 2002 Rockwood K, et al. Can Med Assoc J 2005

C5-75: Development 1. Conducted and published reviews of the frailty literature to inform our program development  Systematic review of frailty markers or risk tools validated in the ambulatory care setting (Lee, Patel, Hillier, et al. Geriatr Gerontol Int 2017;17:1358-77)  We found none that were clinically useful and psychometrically sound  Review of frailty in primary care (Lee, Heckman, Molnar, et al. Can Fam Physician 2015;61:227-31) 2. Demonstrated the use of gait speed and handgrip measures together to be an accurate, precise, specific, and sensitive proxy for the Fried frailty phenotype (Lee, Patel, Costa, et al. Can Fam Physician 2017;63:e51-7)

C5-75: Development 3. Design of C5-75 program informed by iterative process of testing and evaluation, using feedback obtained from patients, healthcare providers, staff, and knowledge users (physicians) to refine program elements and processes 4. Awarded funding support in 2013 as a Ministry of Health and Long Term Care Medically Complex Demonstration Project 5. Recently demonstrated that the C5-75 program is feasible and acceptable in a less-resourced family practice setting through collaboration with community pharmacy (presented at the 2017 Canadian Geriatric Society Annual Scientific Meeting) 6. C5-75 program description and outcomes published (Lee, Patel, Hillier, et al. Geriatrics 2018;3, doi:10.3390/geriatrics3030039)

C5-75: Level 1 and Level 2 Level 1 Screening - nurses offer to all patients 75+during a regular office visit, annually • Frailty – 4-meter gait speed + hand grip strength Results and specific • Exercise – self-reported level of physical activity recommendations sent • COPD – Canadian Thoracic Society screening questions to physician via • Falls Electronic Medical • Exertional dyspnea / Heart Failure Records Level 2 Screening – interprofessional assessment for those identified as frail (gait speed ≥ 6 seconds and hand grip strength <14kg/24kg) , or those with Heart Failure or high risk of falls • Nutrition • Cognitive impairment • Urinary Incontinence Results and specific • Depression, Anxiety, Social Isolation recommendations sent • Caregiver burden, if applicable to physician via • Falls/Fracture risk • Full medication review Electronic Medical • Assessment Urgency Algorithm (AUA) – those identified Records at highest risk to be referred to Geriatric Medicine

C5-75: Level 1 and Level 2  C5-75 is feasible to implement within a busy family practice Level 1: • Implemented during regular office visits, annually • < 7 minutes to complete • Over 5 years, 1,073 older adults have been assessed (75% of persons aged 75+ in our Family Health Team) Level 2: • < 30 minutes to complete • Requires extra appointment but only for those who are frail (7%) or at high risk (Heart Failure, falls)  Within nurse and AHP scope of practice  Low cost • Minimal staff training • Dynamometer - $300-$400 CAD

Research: C5-75 • Screening for frailty • Case-finding in C5-75 • Medication use • Community pilot

Screening for Frailty: Applicability in Family Practice  Goal: to improve practicality and feasibility of screening for frailty in primary care  Study objective: examine relative accuracy of individual Fried frailty phenotype measures in identifying the Fried frailty phenotype in a primary care setting  Fried phenotype : • Gait speed (# seconds/ 4m) • Hand grip (dynamometer) • Self-reported exhaustion, low physical activity, unintended weight loss  Retrospective chart review  516 patients aged 75 years+ completed C5-75 screening Lee, Patel, et al. Can Fam Physician, 2017;63:e51-7

Combined Gait Speed and Grip Strength Positive predictive Criteria Sensitivity Specificity value Accuracy Gait speed 87.5% 94.6% 52.5% 94.2% Hand grip 100% 90.5% 42.4% 91.1% Combined 87.5% 99.2% 87.5% 98.4% N = 383 patients with complete frailty screening data Frailty prevalence ( ≥ 3 more frailty criteria) = 6.5%  Gait speed or grip strength alone were sensitive and specific as a proxy for the Fried phenotype  Dual-trait measure of grip strength with grip strength was more accurate, sensitive, and specific Lee, Patel, et al. Can Fam Physician, 2017;63:e51-7

C5-75 Case Finding (April 2013-December 2016) Total # # repeated assessments # unique annual Level completed patients assessments Level 1 1,461 965 496 Level 2 640 582 58 Lee, Patel et al., Geriatrics, 2018;3:39

Patient Population Characteristics N = 965 Mean age (years ± SD): 81 ± 5 Gender, female (n, %): 505, 52% 60 50 50 40 Percent 31 30 26 23 23 21 20 11 11 10 0 Hypertension Heart Failure Hyperlipidemia Diabetes Osteoporosis CAD (MI, Atrial Fibrillation MCI/Dementia Angina, CABG) Lee, Patel et al., Geriatrics, 2018;3:39 COPD – Chronic Obstructive Pulmonary Disease; CAD – Coronary Artery Disease; MI – Myocardial Infarction; CABG – Coronary Artery Bypass Graft; MCI – Mild Cognitive Impairment

Level 1 Screening Results Exercise (N = 945) Frailty (N = 965) Falls (N = 750) 60 16 6 14 5 48 14 50 5 12 4 40 36 4 Percent 10 Percent 30 Percent 3 8 7 20 16 6 2 10 4 1 0 2 Physically active: Physically active: Not physically 0 30+ min occasionally or active beyond 0 moderate during some activities of daily 2+ in past 6 Falls in past 6 intensity 5+ seasons activities Gait Speed Gait Speed _ months months requiring days/week Hand Grip medical attention Lee, Patel et al., Geriatrics, 2018;3:39

Level 2 Screening Results Screening Component n (%) Fracture Risk (N = 119) Prescribed medications for osteoporosis 23 (19%) Not prescribed medication for osteoporosis /T-L spine x-rays were ordered 27 (23%) Not prescribed medication for osteoporosis/ BMD testing ordered. 51 (43%) Mental Health Screening PHQ-9 – positive screen for depression (N = 50) 11 (7%) GAD-7 – positive screen for anxiety disorder (N = 94) 4 (3%) LSNS-6 – positive screen for social isolation (N = 117) 29 (20%) Zarit Caregiver Burden – positive screen for high burden (N = 103) 15 (15%) Cognition Screening (N = 119) Mini-Cog – positive screen 26 (22%) Urinary Incontinence Screening (N = 147) Patients reporting symptoms of urinary incontinence 47 (39%) A ssessment Urgency Algorithm (N = 68) 21 (31%) Level 1 8 (12%) Level 2 22 (32%) Level 3 5 (7%) Level 4 1 (1%) Level 5 10 (15%) Level 6 Lee, Patel et al., Geriatrics, 2018;3:39

Medication Use in Frailty (April 2013 – August 2015; Pharmacist Review) Initial medication review (n = 41) Total medications/patient (mean/range) 11 (5 – 23) Prescribed medications/patients (mean/range) 8 (3 – 15) Over the Counter Medication per patient (mean/range) 4 (0 – 9) PRN per patient (mean/range) 1.44 (0 – 8) High Risk Drug (HRD) per patient (mean/range) 3.27 (0 – 7) % patients on 1+ HRD 95% % patients on 5+ prescribed medications 90% % patients on 5+ total medications 100% Patel T, Bauer J, Lee L et al. CPJ 2016; 149: S27

Review of Medications in C5-75 Top 10 prescription medications (n = 142) High risk drugs used by patients with an initial medication review (n = 41) 100% 100% 90% 90% 77% 90% Initial medication review 80% % of patients using ≥1 70% 80% % of patients using ≥1 56% 60% 70% 63% 50% 43% 60% 42% 42% 40% 32% 50% 30% 30% 27% 27% 30% 40% 32% 20% 30% 10% 17% 20% 15% 0% 10% 7% 10% 0% Insulin CV meds NSAIDs O/N BD2 AP/AC Other CV meds: Digoxin, antihypertensive medications; NSAIDS: Nonsteroidal anti- Anti-HTN: Antihypertensives; HMG-CoA RI: 3-hydroxy-3-methyl-glutaryl-coenzyme inflammatory drugs; O/N: Opiods/Narcotics; BD 2 : Benzodiazepines and analogues; A reductase inhibitor; AP: Antiplatelet (including ASA); GI Protection: Histamine 2 AP/AC: Antiplatelets/Anticoagulants blocker or proton pump inhibitor; AD: Antidepressants; Topicals: Topical creams/ointments/lotions; APAP: Acetaminophen; BP: Biphosphates/bone modifying agents Patel T, Bauer J, Lee L et al. CPJ 2016; 149: S27 Hu C. Can J Ger