Transcript What to Screen? - Curriculum for the Hospitalized Aging Medical

CHAMP
The Hospitalized Frail Elder
Teaching Strategies for
Identification & Assessment
Paula M. Podrazik, MD
University of Chicago
New Admission
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
ER evaluation—unremarkable blood work, CT head—
no bleed
Intern reports patient is at baseline per daughter and
comments patient is just a “FTT.”
Questions raised
What is the importance of identifying
frailty in the hospital setting?
 How do you recognize frailty ?
How do you define frailty in the aging?
What do you need to screen in the
suspected frail patient during
hospitalization?
Aging patients & the hospital setting
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. Medical Care. 1986;24:429-437
Graves EJ, Gillum BS. National Hospital Discharge Survey: annual summary, 1994. Vital Health Stat. 1997;13:128
Worse outcomes for hospitalized
Older Adults
Delirium
Iatrogenic Complications
Functional decline
Nursing home placement
Hospital readmission
Caregiver stress
Mortality
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
Hospitalization Outcome: The tension
for the Hospitalized Aging Patient
Baseline Frailty
Hospitalization
Outcome
Acute illness
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
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.”
Describe the Aging Population
Heterogeneous Population
Factors that contribute to heterogeneity
Aging physiology
Collected co-morbid conditions
Functional status
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
 Functional reserve losses impact on an acute
illness:
Presentation
Treatment
Morbidity & Survival
Recovery
What is frailty?
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Being dependent on others
Having many chronic illnesses
Experiencing “uncoupling with the environment”
Being at substantial risk of dependency & other adverse
health outcomes
Having complex medical & psychosocial problems
Having “atypical” disease presentations
Having many chronic illnesses
Being able to benefit from specialized geriatric
programs
Experiencing accelerated aging
Rockwood, et al. Can Med Assoc J 1994;150:489-95.
Bortz WM. J AM Geriatr Soc 1993;41:1004-8.
Fried L, et al. J Gerontol Medical Sciences 2001; 56A(3): M146-M156.
Defining 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
Rockwood K, et al. Drugs & Aging 200 Oct 17(4):295-302
ACOVE–a model to ID/define the
Vulnerable Elder “in vivo”
 Assessing the Care of the Vulnerable Elder:
ACOVE Project Overview
Develop a definition of “vulnerable elders”—
community dwellers, >65 & at high risk of functional
decline or death
Develop system to ID
ID medical conditions for which effective methods of
prevention& management exist
Develop set of Quality Indicators
Wenger NS, Shekelle PG, et al. Ann Int Med 2001;135(8) Supplement:642-646
Teaching about Frailty
Triggers to teach about frailty in the aging
hospitalized patient
Advanced age
Multiple co-morbidities
Suspected cognitive impairment
Suspected functional impairments
Psychosocial issues
Sensory impairments
Frailty Suspected:
Why to Screen?
Prevention
Impact on Outcomes
Prognostic Index for 1-year Mortality
in Older Hospitalized Adults
 2 prospective studies—age> 70, assess
1-year mortality, points assigned—mortality risk
calculated.
 Independent risk factors:
Male sex
#of dependent ADLs
CA
CHF
Cr>3.0
Low albumin level
Walter LC, et al. JAMA June 2001; 285(23):2987-2994
Comprehensive Assessment:
Impact on outcomes
 Meta-analysis of Comprehensive Geriatric
Assessment programs
 28-controlled trials, 4959 subjects allocated to
one of five CGA types and 4912 controls
Outcomes:
Mortality—GEMU programs  6 month mortality by
35%; HAS 36 month mortality by 14%
Hospital admission—all CGA programs 
readmission rate by 12%
OR for living @ home favorable in all studies
Stuck AE, Siu AL, Wieland GD, et al. Lancet 1993; 342:1032-1036
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 functional & cognitive decline
Inouye S, et al JAGS 2000; 48:1697-1706
Teaching about Frailty:
Summary teaching points
Baseline vulnerability or frailty affects
hospital outcomes
High risk for worse outcomes
Take measures to prevent delirium, falls,
functional decline
Identifying a vulnerable elder changes the
needs of the D/C plan.
Frailty Suspected:
What to Screen?
Cognition
Function
Affect
Other
Sensory function
Social
New Admission—Triggers to Teach
Cognitive Screening
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.”
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
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 26% vs. 8%
* Confusion = loss of 2 points on MMSE
Inouye SK, et al Ann Intern Med 1992;119:474-481
Cognitive Impairment & Functional
Decline with Aging
 Cognitive impairment associated with functional
decline during acute illness
 Study Design:
Cognitive screen grouped admissions:
No impairment
Mild impairment
Moderate/severe impairment
ADL/IADL/mobility measured 2 weeks prior
admission, discharge, 30 and 90 days.
Sands L, Yaffe K, Covinski K, et al. Journal of Gerontology: Medical Sciences 2003;58:37-45.
Cognitive status on admission & risk
new NH placement at hospital D/C
Cognitive status Rate/odds NH
None
7.5% 1.0
Mild
13% 1.49(1-2.22)
Moderate-severe 29% 3.40(2.48-4.68)
Risk NH placement at 90 days after
hospitalization vs. cognitive status
Cognitive status
None
Mild
Moderate-severe
Rate/Odds NH
4.1% 1.0
11.7% 2.80(1.75-4.46)
26.7% 6.67(4.52-8.67)
Screen for Cognitive Impairment:
Summary Teaching Points
Prevent delirium
Prevent functional decline
Prevent iatrogenic injury—esp. med
choice & avoidance of restraints
Transition care appropriately
Screening Cognitive Impairment
Patient measure:
Mini Mental Status Exam (MMSE)
Mini-cog
Proxy measure
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
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
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
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
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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
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
New Admission—Triggers to Teach
physical function screening
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.”
Functional Screening:
What are we talking about?
Gait assessment
Activities of daily living (ADL)
Bathing
Dressing
Toileting
Transferring
Feeding
Instrumental activities of daily living (IADL)
Use telephone
Manage finances
Shop
Arrange transportation
Manage medications
Cooking
Functional Decline Occurs
in the Hospital
Functional limitations increase with age.
Functional decline occurs in approx.
34-50% hospitalized older pts.
Impact of acute illness
Impact of hospitalization
Interventions can decrease functional
decline (Hospital Elder Life Program).
Functional status determines D/C plan.
Summary of functional outcomes
during hospitalization
 At discharge→31% declined
 At 3 months→59% recovered lost function but
41% failed to return to pre-admission level of
function
 At 3-months→ 22% re-hospitalized & association
with functional decline significant
 Functional loss was associated with a
significantly higher 3 month mortality
Patient factors associated with
functional decline
older age
preadmission functional impairment
lower MMSE on admission
re-hospitalization
Sager M, Franke T, Inouye S, et al. Arch Intern Med. 1996;156:645-652.
Worse health outcomes with
functional decline
Prolonged hospital stay
Higher mortality—twice the risk
Higher rates of institutionalization
Higher health care expenditure
Who is at risk functional decline
during a hospital stay?
Hospital based study @Yale
Prospective cohort study
Medical inpatients > 70
What are the risks for functional decline?
Functional decline: ADL loss
Two part study: Development and Validation
Inouye S, Wagner R, Acampora D, et al. J Gen Intern Med. 1999;8:645-652.
Independent risk factors associated
with functional decline
Risk Factor
Pressure Ulcer
Cognitive impairment
Functional impairment
Low social activity level
Adjusted RR
2.7(1.4-5.2)
1.7(0.9-3.1)
1.8(1.0-3.3)
2.4(1.2-5.1)
How does one assess functional status?
Report
Self-report
Proxy report
Direct observation
Level of support
Independent
Needs assistance
Dependent
Activities of Daily Living
Bathing
Dressing
Transference
Continence
Feeding
Instrumental Activities of Daily Living
Using the phone
Traveling
Shopping
Preparing meals
Housework
Taking medicine
Managing money
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
Gait assessment scoring
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
Trigger to Teach:
Who to screen for functional impairment?
Who to screen?
 Person over the age of 70
 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
Depression
Screen for function, cont.
When to screen?
After stabilization of acute illness
Prior to hospital discharge
What to do?
Chart orders- walking and range of motion TID
Ambulation problem- physical therapy
Dressing/bathing/feeding- occupational therapy
Function & the hospitalized elder:
Summary teaching points
 Functional limitations increase with age
 Functional decline occurs in 30-50% of hospitalized older
adults
 Acute illness can lead to further functional decline
 Hospital care can contribute to additional functional
decline
 Models help stratify those at highest risk for functional
decline
 Interventions decrease functional decline
 Functional abilities help determine discharge location
and services required
Questions raised
What is the importance of identifying
frailty in the hospital setting?
 How do you recognize frailty ?
How do you define frailty in the aging?
What do you need to screen in the
suspected frail patient during
hospitalization?
New Admission
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
ER evaluation—unremarkable blood work, CT head—
no bleed
Intern reports patient is at baseline per daughter and
comments patient is just a “FTT.”
Frailty & the Hospital:
A Final Word
ID and teach about frailty
Screen for cognition, functional status,
psychosocial, sensory impairments
Impairments associated with worse
outcomes
Prevention one key.
The proper transition of care is the other.
Special Thanks
Joseph Shega
Don Scott
Aliza Baron
Greg Sachs
CHAMP faculty
CHAMP faculty course participants