Transcript Frailty - Age UK

Living well with frailty
JOHN YOUNG
National Clinical Director for the
Frail Elderly & Integration,
NHS England
A LTC rarely travels alone …………
Kent Whole Population Dataset: Interim Report
2014
The burden of multimorbidity
Applying NICE guidelines to a 78 yr old woman with previous
myocardial infarction; type-2 diabetes; osteoarthritis; COPD; and
depression…………………..
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11 drugs (and possibly another 10)
9 lifestyle modifications
8-10 routine primary care appointments
8-30 psychosocial interventions
Smoking cessation appointments
Pulmonary rehabilitation
(Hughes et al Age & Ageing 2013)
“I’d like my life back please!”
Frailty: key issues
• Related to the ageing process
(Clegg, Young et al Lancet 2013)
• Around 10% of over 65s have frailty
(Collard et al. JAGS 2012: 60; 1487-92)
• Increases to 25-50% of over 85s
(Collard et al. JAGS 2012: 60; 1487-92)
• Independently associated with adverse
outcomes, which are expensive
(Falls; dependency; hosp admission; care home admission)
• Best understood as a long-term condition
(Harrison, Young, Clegg, Conroy Age & Ageing 2015)
Frailty: what is it?
A summary label ?
OR
An abnormal health state?
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Disability
Long-term care
Falls
Mortality
Prevalence rate estimates for frailty
(Systematic review of 21 cohort studies)
65-69 =
70-74 =
75-79 =
80-84 =
Over 85 =
4%
7%
9%
16%
26%
Collard et al. JAGS 2012: 60; 1487-92
Distinguishing fit from frail; and frail from fit:
the most pressing clinical task of our age?
Frailty is ………………
“She was a fall
waiting to happen.”
Home care staff
Mrs Greenaway was found on
the floor (“FLOF”) with new
confusion by the home care
staff and taken to hospital
where is was found to be
poorly mobile.
 Fall
 Delirium
 Immobility
Frailty as a progressively abnormal health state
(ie a LTC)
Clegg, Young, Iliffe, Olde-Rikkert, Rockwood. Frailty in elderly people. Lancet 2013
Frailty as a long-term condition ?
A LTC is:
“A condition that cannot, at present, be cured but is controlled by
medication and/or other treatment/therapies” (DH 2012)
Frailty is:
• Common (25-50% of people over 80 years)
• Progressive (5 to 15 years); and therefore gradable
• Episodic deteriorations (delirium; falls; immobility)
• Preventable components
• Potential to impact on quality of life
• Expensive
(Harrison, Young, Clegg, Conroy Age & Ageing 2015)
Pro-active care models
Supportive
selfmanagement
C&SP
Ten years ago
Two years ago
One month ago
CGA
Hands up who’s
frail?
Phenotype Frailty Model
(Cardiovascular Health Study [n=5210] Fried et al 2001)
Weight loss:
> 4.5kg or > 5% per year
Fatigue:
US Centre for Epidemiological Studies Depression Scale
Sedentary Life:
< 383 Kcal/week men
< 270Kcal/week women
Slow gait speed:
Standardised cut-off times to walk 4.57m stratified by sex
& height
Weakness:
Dynamometer measurement stratified by sex & BMI
Phenotype Frailty Model
(Cardiovascular Health Study [n=5210] Fried et al 2001)
Weight loss:
> 4.5kg or > 5% per year
Fatigue:
US Centre for Epidemiological studies depression scale
Sedentary Life:
< 383 Kcal/week men
< 270Kcal/week women
Slow gait speed:
Standardised cut off times to walk 4.57M stratified by sex
& height
Weakness:
Dynamometer measurement stratified by sex & Body
Mass Index
The 4m walking speed test detects frailty
Taking more than 5
seconds to walk 4m
predicts future:
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4M
Disability
Long-term care
Falls
Mortality
Van Kan et al JNHA 2009; 13:881
Systematic Review of 21 cohorts
Diagnostic Test Accuracy (DTA) for simple
frailty instruments (Systematic Review)
Sensitivity
Specificity
Gait Speed <0.8m/s
99%
64%
Gait Speed <0.7m/s
93%
78%
TUGT >10s
93%
62%
PRISMA 7
83%
83% (wide CIs)
Self-reported Health
83%
72% (wide CIs)
Groningen Frailty Indicator
58%
72%
Polypharmacy (>5 meds)
67%
72%
GP clinical assessment
58%
72%
(Frailty instruments assessed against a reference standard)
(Clegg, Teale, Young. Age Ageing 2014)
Identification of frailty: summary
1 Comprehensive geriatric assessment (CGA)
(Structured, multi-dimensional, multi-disciplinary assessment)
2. Simple assessments
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Gait speed/timed-up-and-go test
Questionnaires (e.g. PRISMA 7)
Brief clinical tools (e.g. Edmonton frail scale;
“Rockwood 9”)
3. Routine data
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Primary care electronic Frailty Index (eFI)
Cumulative Deficit Model of Frailty: Frailty Index
(Rockwood et al)
“The more things that are wrong with you, the more
likely you are to be frail”
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Frailty Index counts “deficits”
A deficit is a thing that is wrong with you (symptom, sign,
disease or disability)
Frailty Index = the proportion of deficits accumulated over time
Simple calculation:
• Zero deficits from list of 50: FI = 0/50 = 0
• Ten deficits from list of 50: FI = 10/50 = 0.20
• Frailty Index(s) based on deficit accumulation closely related to
risk of death (Mexico, China, Canada, Europe etc. …)
Development of the primary care eFI
Existing primary care EHR
Read Codes (>80,000
8,000
2,200)
Read codes map onto 36 ‘DEFICITS’
Tested in “ResearchOne” (n=227,648 ≥65y)
Internal Validation Process (n=227,063 ≥ 65y)
External Validation Process (n=516,107 ≥ 65 y)
eFI: >2000 Read codes; 36 deficit variables
Primary care electronic Frailty Index (eFI): survival
plots (n=227,648; >65y)
Fit
Mild frailty
Moderate frailty
Proportion
alive
Severe frailty
Time
5 yrs
Clegg; Bates; Young et al Age Ageing 2016
National Spread of eFI (Year 1)
Clinical Commissioning Groups
Partners
Engagement
Count
GP Practices
22
CCGs (n=211)
35
CSU
1
SCN
1
CLAHRC
1
Public Health
(regional)
3
Industry Partners
2 (ACG Systems)
VCS
1 (Age UK Y&H)
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“at risk” populations
De-prescribing
EoLC/ACPs
Supported-self management
Falls prevention
etc, etc………..
FIT
32%
MILD MOD
41% 20%
SEV
7%
Candidate Preventable Components for “Frailty”
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Alcohol excess
Cognitive impairment
Falls
Functional impairment
Hearing problems
Mood problems
Nutritional compromise
Physical inactivity
Polypharmacy
Smoking
Social isolation and loneliness
Vision problems
Stuck et al. Soc Sci Med. 1999
(Systematic review of 78 studies)
Additional topics:
• Look after you feet
• Make your home safe
• Vaccinations
• Keep warm
• Get ready for winter
• Continence
• Preserving memory
A Practical Guide to Healthy Ageing
Frailty is ………………
“She was a fall
waiting to happen.”
Home care staff
Mrs Greenaway was found on the
floor (“FLOF”) with new confusion
by the home care staff and taken to
hospital where is was found to be
poorly mobile.
 Fall
 Delirium
 Immobility
Another view of Mrs Greenaway ………
85 years
Lives alone
Recently in hospital following a fall
Broken hip 2011
Chronic heart failure
Diabetes
Chronic Kidney Disease
Taking 10 medications
Review 1
Review 2
Review 3
Review 4
System designed to fragment care into
packages
……. and the frailty??? ……
Yet another view of Mrs Greenaway
What are the most
important things you’d like
to discuss today?
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2.
3.
4.
The pain in my feet
Difficulty sleeping
Getting out for a chat
I don’t like all these
tablets; do I really need
them all?
“It’s Care Planning
Jim, but not as we
know it!”
Care Plan vs Care Planning
Care plan: focus on disease or problem management
Care planning: the focus on person management
When I make a care plan:
1. I make an assessment of the patient
True / False
2. I pass on lots of information to the patient
True / False
3. I do most of the talking
True / False
4. I follow a template very closely
True / False
NHS England Older People & Frailty
TODAY
‘The Frail Elderly’
(i.e. a label)
Presentation late & in crisis
(e.g. delirium, falls, immobility)
Hospital-based: episodic,
disruptive & disjointed
TOMORROW
“An older person living with
frailty"
(i.e. a long-term condition)
Timely identification for
preventative, proactive care by
supported self-management &
personalised care planning
Community-based: personcentred & co-ordinated
(Health + Social + Voluntary
+ Mental Health)