Transcript Frailty - Ipswich and East Suffolk CCG

What are we talking about?
14th October 2015
Dr Jane Shoote
Consultant Geriatrician
• Worldwide population is ageing
• Impacts healthcare planning and provision
• The most problematic expression of population ageing is
the clinical condition of FRAILTY
• Around 10% of over 65s have frailty
• Over 25 of over 85s have frailty (in some studies >50%)
“a state of increased vulnerability to
stressors due to age-related declines in
physiologic reserves across neuromuscular,
metabolic, and immune systems”
American Geriatric Society 2004
“a medical syndrome
with multiple causes and contributors
that is characterised by
diminished strength, endurance, and
reduced physiological function,
that increases an individual’s vulnerability for
developing increased dependency
and/or death”
J Am Med Dir Assoc 2013
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Related to the ageing process
Independently associated with adverse outcomes
Common
Progressive
Episodic deteriorations
Preventable components
Impact quality of life
Expensive
Harrison J, Clegg A, Conroy S, Young J. Managing frailty
as along-term condition. Age Ageing 2015;44:732-5.
Impacting quality of life
• Accelerated decrease
in physiological reserve
• Failing homeostatic
mechanisms
Clegg A, Young J, Iliffe S, Rikkert M,
Rockwood K. Frailty in elderly people.
Lancet. 2013; 381: 752 - 762
Clegg A, et al. Frailty in elderly people. Lancet. 2013; 381: 752 – 762.
Sarcopaenia
Less
muscle
mass
Sensation
of
increased
effort
Lower
muscle
mass
Fewer
physical
activities
Frailty lies outside the comfort zone of Guideline Based Medicine
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State of increased vulnerability
Not an inevitable part of ageing
Is a chronic condition
May be made better or worse
• Identification is important and should form part of
any health/social care interaction
Read codes for CTV3:
mild frailty = XabdY, moderate frailty = Xabdb, Severe frailty = Xabdd
1. Comprehensive geriatric assessment (CGA)
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Structured, multidisciplinary assessment
2. Simple assessment
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Gait speed
Timed-up-and-go test (TUGT)
PRISMA-7 Questionnaire
3. Routine data
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Electronic frailty index (eFI)
• Gait speed
• Timed-up-and-go test (TUGT)
• PRISMA-7 questionnaire
• Sensitive but not specific
• Good to exclude those not frail
• Need further clarification on those positive
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Requires a stop watch and 4 metre distance
Median life expectancy 0.8 m/s
> 5 seconds to walk 4 metres
Good, valid, simple single tool to predict disability,
long term care, falls, mortality
• Studies suggest target further examination of gait
speeds slower than 0.6 m/s ??
• Especially informative if no self report of  function
For identifying frailty:
Gait speed <0.8m/s = Sensitivity 0.99, specificity 0.64
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TUGT > 10 seconds
Positive predictive value = 0.17
Negative predictive value = 0.99
Very good for excluding frailty
Similar to gait speed and PRISMA-7 would need
further clarification of results
For identifying frailty:
TUGT>10s = Sensitivity 0.93, specificity 0.62
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≥ 3 or above at risk
Sensitivity 78.3%
Specificity 74.7%S
Used to identify those
who may benefit more
comprehensive
assessment
For identifying frailty:
PRISMA-7 = Sensitivity 0.83, specificity 0.83
‘The more things that are wrong with you, the more
likely you are to be frail’
• Canadian study of health and ageing
• Simple calculation of the presence of absence of a
variable
• Based on 92 baseline variables
• Cumulative effect of individual deficits
• 92 reduced to 36 without loss of predictability
Rockwood K, Song X, Macknight C et al. A global clinical
measure of fitness and frailty in elderly people. CMAJ
2005;173:489-95.
• Validated using 500,000 patients
• >2000 Read codes
• Calculated as cumulative deficit model
E.g. 18 deficits 18/36 = 0.5
• Scoring:
0 - 0.12 = Fit
0.13 – 0.24 = Mild Frailty
0.25 – 0.36 = Moderate Frailty
>0.36 = Severe Frailty
• Runs through SystmOne
• Relates to the risk of adverse outcomes
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Activity limitation
Anaemia & haematinic deficiency
Arthritis
Atrial fibrillation
Cerebrovascular disease
Chronic kidney disease
Diabetes
Dizziness
Dyspnoea
Falls
Foot problems
Fragility fracture
Hearing impairment
Heart failure
Heart valve disease
Housebound
Hypertension
Hypotension/syncope
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Ischaemic heart disease
Memory & cognitive problems
Mobility and transfer problems
Osteoporosis
Parkinsonism & tremor
Peptic ulcer
Peripheral vascular disease
Polypharmacy
Requirement for care
Respiratory disease
Skin ulcer
Sleep disturbance
Social vulnerability
Thyroid disease
Urinary incontinence
Urinary system disease
Visual impairment
Weight loss & anorexia
> 2000 Read codes
CTV3
X76Ao | Frailty
XabdY | Mild frailty
Xabdb | Moderate frailty
Xabdd | Severe Frailty
Read V2
2jd.. | Frailty
2Jd0. | Mild frailty
2Jd1. | Moderate frailty
2Jd2. | Severe frailty
Young J. 2014 Frailty is the
future talk.
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Predictive validity similar to Frailty Index
Good correlation with other scales
Unclear inter-rater reliability
Best used with CGA and geriatrician
Timely assessment
Ongoing studies
Shi et al. Analysis of frailty and survival.
BMC Geriatr. 2011;11:17.
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Non-specific presentations
Multiple co-morbidities
Communication barriers
Disability and complexity
Recognition and interpretation
• 30 – 60% new dependency in ADLs following
admission
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Adverse outcomes
Worsening disability
Falls
Admission to hospital
Increasing length of stay
Risk of admission to long term care
Death
Mrs A a 78 year old lady with COPD and Type II
diabetes, previous MI, depression and
osteoarthritis…………….
• 11 drugs
• 10 possible further drugs recommended
• 9 lifestyle modifications advised
• 8–10 routine primary care appointments
• 8–30 psychosocial interventions
• Smoking cessation appointments
• Pulmonary rehabilitation
Hughes et al. Guidelines for people
not diseases. Age Ageing 2013;42:62-9.
Medication and Falls Risk
Group
Sedatives and
hypnotics
Antipsychotics
Antidepressants
Drugs with
anticholinergic
side effects
Drugs for
Parkinson’s
disease
Common Drug Names
Contributing Factors
Possible Actions for
Prescribers
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Tricyclics - amitriptyline,
dosulepin (Dothiepin),
imipramine, lofepramine
Other sedating – trazadone,
mirtazepine
Orthostatic hypotension,
sedation which can last into the
next day, lightheadedness, slow
reactions, impaired balance,
confusion
orthostatic hypotension,
confusion, drowsiness, slow
reflexes, loss balance. Long
term use - Parkinsonian
symptoms.
Double risk of falls
Drowsiness, blurred vision,
dizziness, orthostatic
hypotension, constipation,
urinary retention
SnRI – venlafaxine and MAOI
Orthostatic hypotension (OH)
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Dizziness, blurred vision,
retention of urine,
confusion, drowsiness,
hallucinations.
Sudden daytime
sleepiness, dizziness,
insomnia, confusion, low
blood pressure, orthostatic
hypotension, blurred vision.
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Temazepam, diazepam, lorazepam,
nitrazepam
Zopiclone, Zolpidem,
chlordiazepoxide, chloral betaine
(Welldorm), clomethiazole
Chlorpromazine, haloperidol,
lithium, promazine,
trifluoperazine, quetiapine,
olanzapine, risperidone
SSRI – citalopram, fluoxetine
Procyclidine, trihexyphenidyl
(Benzhexol), prochlorperazine,
oxybutynin, tolterodine
Co-beneldopa, co-careldopa,
rotigotine, amantadine,
entacapone, selegiline,
rivastigmine.
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Movement disorder with long
term use
Sedating, orthostatic
hypotension
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ACE inhibitors/Angiotensin-II
antagonists
Ramipril, lisinopril, captopril,
irbesartan, candesartan
Vasodilators - Hydralazine
Diuretics - bendroflumethiazide,
bumetanide, indapamide,
furosemide, amiloride,
spironolactone, metolazone.
Beta-blockers - Atenolol,
bisoprolol, carvedilol,
propranolol, sotalol
Alpha-blockers - doxazosin,
alfuzosin, terazosin, tamsulosin
Low blood pressure,
orthostatic hypotension,
dizziness, tiredness,
sleepiness, confusion,
hyponatraemia,
hypokalaemia
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Codeine, tramadol.
Drowsiness, confusion,
hallucinations, orthostatic
hypotension, slow reactions
Unsteadiness & ataxia if levels
high
Phenytoin – permanent
cerebellar damage and
unsteadiness in long term use
Vestibular
Sedatives
Phenothiazines – prochlorperazine
Cardiovascular
drugs
Analgesics
Antihistamines- cinnarazine,
betahistine
Opiates – morphine, oxycodone.
Anti-epileptics
Carbamazepine*, phenytoin*,
phenobarbitone*, primidone*
sodium valproate*, gabapentin
lamotrigine, topiramate,
levatiracetam, pregabalin
Bradycardia, hypotension,
orthostatic hypotension,
syncope
Newer agents – insufficient data
regarding falls risk
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Stop if possible
Long term use will need
slow, supervised withdrawal
No new initiation
Medication and Falls Risk
Review indication and stop if
possible (may need specialist
opinion/support)
Reduce dose/frequency if
unable to stop
Review indication (do not use
amitriptyline as night
sedation)
Stop if possible, may need
slow supervised withdrawal
Populations studies show
increased falls risk with SSRI
but mechanism unclear,
probably safest class to use
Review indication
Reduce dose or stop
Check L&S BP, drugs and
PD itself can cause OH
Poorly controlled PD can
cause falls
It may not be possible to
change the medication
Do not change treatment
without specialist advice
Do not use long term – no
evidence of benefit
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Whilst any medication changes will be finally decided by the doctor (GP or consultant) anyone
working in falls can help to make this review as useful as possible:
Take a comprehensive list of all medications currently taken (NB this should be what they
actually take, not what has been prescribed!). Anyone on FOUR or more medications are at
increased risk of falls.
Check the patient’s understanding of their medication and how they take them. Consider
concordance and compliance aids.
Check lying and standing BP (5 mins lying down, check BP, stand, check BP then every
minute for 3 minutes). A drop of 20 systolic or 10 diastolic is abnormal. Record any symptoms
experienced and send this in to the doctor who is doing the medication review.
Look for high or moderate risk drugs – see chart and highlight these for the doctor.
Medication review:
 Is it still the right drug? (eg methyl dopa should no longer be used for hypertension)
 Is it still necessary? (eg analgesia given for acute flare OA, now resolved)
 Is it a moderate or high risk drug (see chart)? If so what is the risk/balance ratio?
 Is there a safer alternative?
 Could the dose be reduced? (eg 5mg bendroflumethiazide no significant increase in
antihypertensive effects, but significant increase in side effects compared with 2.5mg)
Check L&S BP
Review indication, use
alternative if possible,
especially for alpha blocker
Reduce dose if possible
Symptomatic OH + LVF – if
systolic LVF then try to maintain
ACEi and β Blocker as survival
benefit clear. Stop nitrates, CCB,
other vasodilators and if no fluid
overload reduce or stop diuretics.
 Seek specialist advice if
needed
 Start low, go slow, review
dose and indication regularly
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All patients who present with a fall must have a medication review
with modification/withdrawal (NICE CG 161)
Consider indication (many
used for pain or mood)
May need specialist review
*Consider Vitamin D
supplements for at risk
patients on long term
treatment with these drugs
Never stop or withhold medication without agreement from the medical team
Adapted from © The Ipswich Hospital NHS Trust, April 2014.Dr Julie Brache. All rights reserved. Not to be reproduced in whole, or in part, without the permission of the copyright owner.
 Should they be on calcium and vitamin D? – Ca and Vit D (800iu daily) reduce falls by up to
20% by improving muscle function and reducing body sway. Consider vitamin D level in patients
with falls over age 65 (see pathway for management of deficiency). Consider supplements in all
people who fall and are housebound or in residential or nursing homes. Don’t forget osteoporosis
risk assessment / treatment.
Stopping or reducing medication isn’t always easy and requires commitment and
understanding by the prescriber and patient. Advice on complex cases is always available from the
consultant geriatricians at Ipswich Hospital, in the community sessions or via the Rapid Assessment
Falls Clinic.
The attached table is provided as a guide to medication review in falls only. Each patient must
be assessed as an individual and the risk/benefit for each drug considered and discussed and a
decision made by the prescriber in consultation with the patient.
Higher risk drugs
Moderate risk drugs
Never stop or withhold medication without agreement from the medical team
Adapted from © The Ipswich Hospital NHS Trust, April 2014.Dr Julie Brache. All rights reserved. Not to be reproduced in whole, or in part, without the permission of the copyright
owner.
BGS Spring 2015 Prof J Young, Dr E Burns
Categorise numerically
 Mildly frail – Supported Self Management
 eg Age UK a practical guide to healthy ageing
 Moderately frail – Care and Support Planning
 eg CGA and care plan
 Severely frail – anticipatory care planning
 eg Case management, ACP and end of life care
Preventable components for ‘Frailty’
• Affect (Mood problems)
• Alcohol excess
• Cognitive impairment
• Falls
• Functional impairment
• Hearing 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 your feet
• Make your home safe
• Vaccinations
• Keep warm
• Get ready for winter
• Continence
………others……??
Produced to help people
improve their health and
general fitness,
particularly those aged 70
or over with ‘mild frailty’.
To reorder this guide
please order for free
online via
www.orderline.dh.gov.uk
or call 0300123 1002
quoting reference HA2.
Publication date 01/10/15.
http://infolink.suffolk.gov.uk/kb5/suffolk/infolink/home.page
“Right care,
at the right time,
in the right place”
NHS England. Commissioning for carers principle 3
• Improved access – The ‘Hot Phone’
◦  07930181236
• Regular risk profiling / case finding
• Named accountable GP / Care co-ordinator
• Holistic care plan
• Internal reviews / MDTs of unplanned admissions
• Clinicians and patient with LTC
• Collaborative approach to identify
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What is important to that individual
Goals
Support needs
Action plans
• Progress is monitored
• Continuous process not a one-off event
FAB at a glance
ETT
GP
Routes in
ED
EAU phone
The future:
Hot phone
Email/Phone
Seen within 48
hours
Centre of excellence and resource
Education and outreach
Staff development (GP, ENP etc)
Extended management via virtual ward
Incorporation of falls and other clinics
Full 7 day working
Inreach to IHT wards
Frailty Assessment Base
Comprehensive Geriatric Assessment
Dr, Nurse, Therapy, Dietician, Pharmacist
Routes out
Shared Care
Plan
Frailty Score
Problem list
Action plan
Admitted
Front loaded assessment
and management plans
FAB team ward follow-up
Home
CHT
CAT
Voluntary sector
DIST
ACS
Geriatrician follow-up
ICB
Interface geriatrician case management
• Hot Phone – advice/same day assessment
07930 181236
• Email – 2 working day review
[email protected]
• SHARE SystmOne record
• Advanced frailty means EOL is close and should
trigger a proactive care approach.
• People in their last year of life are admitted an
average of 3.5 times
4 T’s - Reflective practitioner questions
• Think Frailty
• Timid – am I being timid?
• Timeliness – is this the right time?
• Time – do I need to make time?
Uncertainty causes anxiety
• Is important to prepare for and aim to postpone
• Important to recognise as a state of vulnerability to
poor recovery from simple stressor events
• Failure to detect frailty potentially exposes patients
to interventions from which they might not benefit
and may be harmed
• Recognising advancing frailty should trigger a
proactive care approach to EOL care planning
[email protected]
Secretary: 01473 704137
Hot phone: 07930 181236
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NHS England. Toolkit for general practice in supporting older
people with frailty. 2014.
http://www.bgs.org.uk/index.php/fit-for-frailty
http://www.york.ac.uk/inst/crd/effectivenessmatters.htm
Report by the comptroller and auditor general. End of life care. HC
1043 Session 2007-2008 | 26 November 2008.
Morley et al. Frailty consensus: a call to action. J Am Med Dir
Assoc 2013;14:392-7.