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Mini-CHAMP Improving Hospital Systems of Care: Making the Case for Identifying and Assessing the Frail Elderly. Paula Podrazik, MD University of Chicago. New Admission. Mrs.G 80 y/o BF DM type II, htn, s/p CVA, OA, OP admitted for wt. loss, confusion, falls. Recently

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Mini-CHAMPImproving Hospital Systems of Care:Making the Case for Identifying and Assessing the Frail Elderly

Paula Podrazik, MD

University of Chicago

new admission
New Admission

Mrs.G 80 y/o BF DM type II, htn, s/p CVA, 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
Questions raised:
  • How do you recognize frailty ?
  • How do you define frailty?
  • What is the importance of identifying frailty in the hospital setting?
  • What do you need to screen in the suspected frail patient during hospitalization?
  • Can you prevent hospitalization-associated decline?
overview inpatient setting important for the elderly
Overview: Inpatient Setting Important for the Elderly
  • Crucial step in the health care continuum
    • 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. Risk factors affecting readmission to the health care system. 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
Worse Outcomes for Hospitalized Older Adults

Delirium

Iatrogenic Complications—3-5x > rate

Functional decline—effects 35% of hosp. elderly

Nursing home placement

Caregiver stress

Mortality

determinates of hospitalization outcome
Determinates of Hospitalization Outcome

Baseline Frailty

Hospitalization Outcome

Acute illness

Hazards of the Hospitalization

words that trigger the need to id teach about frailty
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
New Admission—Triggers to TeachID/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.”

geriatricians id frailty features
Geriatricians ID frailty features

At least 50% of Geriatricians cited each of the following characteristics

associated w/frailty

  • Under nutrition
  • Functional dependence
  • Prolonged bedrest
  • Pressure sores
  • Generalized weakness
  • Aged >90
  • Wt loss
  • Anorexia
  • Fear of falling
  • Dementia
  • Hip fracture
  • Delirium
  • Confusion
  • Going outdoors infrequently
  • Polypharmacy

Fried LP, Walston J. Principles of Geriatric

Medicine & Gerontology 5th ed. 2003:1487-1502.

functional reserve of older adults
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
What is 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
  • Can include co-morbidities
  • Can include a disability

Rockwood K, et al. Drugs & Aging 2000 Oct 17(4):295-302

Fried LP, et al. J Gerontol Med Sci.2001 56A;M146-M156

acove a model to id define the at risk vulnerable elder
ACOVE–a model to ID/define the at risk Vulnerable Elder
  • 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

frailty suspected why screen
Frailty Suspected:Why screen?
  • Impact on Outcomes
  • Prevention
risk of rehospitalization one outcomes look at frailty
Risk of rehospitalization—one outcomes look at frailty
  • 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

hospital elder life program a program of prevention
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 decline (14%vs. 33%)
    • Decrease in cognitive decline (8%vs. 26%)

Inouye S, et al JAGS 2000; 48:1697-1706

triggers to recognize screen for frailty
Triggers to Recognize & Screen for Frailty
  • Advanced age (>70, > 75, > 80???)
  • Suspected functional impairments
  • Suspected cognitive impairment
  • Consider if /and
    • Multiple co-morbidities
    • Psychosocial issues
    • Sensory impairments
what to screen
What to screen?
  • Cognition
  • Function
  • Affect
  • Other
    • Sensory
    • Social
what to prevent
What to prevent?
  • Delirium—Inouye model
  • Deconditioning—out of bed, PT/OT
  • Falls
  • Pressure ulcers
  • Adverse drug reactions—med review
  • Comprehensive discharge planning—recognize need @ admission
predicting delirium predisposing risk factors
DEVELOPMENT COHORT

N=107 RR

1.  Vision 3.5(1.2-10.7)

2. Severe Illness 3.5(1.5-8.2)

3.  Cognition 2.8(1.2-6.7)

4. BUN/Cr > 182.0 (1.1-4.6)

ROC = 0.74 (0.63, 0.85)

VALIDATION COHORTN=174 RR

Low Risk (0) 1.0

Int. Risk (1-2) 2.5

High Risk (3-4) 9.2

ROC = 0.66 (0.55-0.77)

(SEE Pocket Card)

Predicting Delirium:PreDisposing Risk Factors
  • NOTE: COG. IMPAIRMENT (MMSE < 24); VISION IMPAIRMENT > 20/70; BUN/CR > 18/1; SEVERE ILLNESS= APACHE II > 16 OR CHARLSON ORDINAL CLINICAL = RATED AS SEVERE
  • ROC= 0.74 (0.63-0.85)

Inouye SK , et al. Ann Intern Med. 1993;119:474-481

a multicomponent intervention to prevent delirium in hospitalized older adult patients nejm 1999
A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Adult Patients. NEJM. 1999.
  • Design: Prospective, Matched, 852 patients, Medicine Service
  • Inclusion: Age > 70, Not delirious at admit, Intermed. or High Risk
  • Intervention --Focused on 6 risk factors for delirium: Cognitive Impairment, Sleep Deprivation, Immobility, Visual impairment, Hearing impairment, Dehydration
  • 1o End Point = Incident Delirium  Assessed daily until discharge

Inouye SK, et al. NEJM. 1999;340:669-676

targeted interventions
Targeted Interventions

Cognitive

Impairment

Sleep Deprivation

Immobility

Orientation/

Activities

Early

Mobilization

Non-drug; sleep

enhancement

targeted interventions23
Targeted Interventions

Visual

Impairment

Hearing Impairment

Dehydration

Visual Aids,

Devices

Hearing devices,

Remove earwax

Early recognition

& po repletion

prevention protocols
Prevention Protocols

Inouye SK, et al. NEJM. 1999;340:669-676 SEE CHALK

management non pharmacologic
Management: Non-Pharmacologic
  • Cognition: orientation board (carry pen!) & open drapes during day
  • Sleep: minimize deprivation (no 2am labs, no o/n BS/vitals if able, give meds when awake)
  • Mobility: OOBchair asap, PT/OT, no foley/restraints
  • Vision: glasses
  • HOH: get aids; adapt environment; stethoscope trick
  • Dehydration: po fluids; observe at mealtime; avoid “Boost at nightstand”
  • Observation: Involve family (rotate members) or get sitter; move pt to room close to RN station
results
Results
  • USUAL CARE = 15.0%
  • PREVENTION GROUP = 9.9%
  • OR 0.60 (CI 0.39- 0.92)
  • RRR= 40% ARR= 5.1%
  • NNT = 20
  • NO BENEFIT ONCE DELIRIUM OCCURED

Inouye SK, et al. NEJM. 1999;340:669-676.

new admission triggers to recognize do cognitive screening
New Admission—Triggers to recognize & docognitive 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
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
  • 25% of older hospitalized adults admitted to medicine have impaired cognition
dementia and delirium
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 8% vs. 26%.

* Confusion = loss of 2 points on MMSE

Inouye SK, et al Ann Intern Med 1992;119:474-481

screening cognitive impairment
Screening Cognitive Impairment
  • Patient measure:
    • Mini Mental Status Exam (MMSE)
    • Mini-cog
  • Proxy measure
folstein mmse
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
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
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
Screening Tools: Mini-cog
  • 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
    • 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
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 recognize do physical function screening
New Admission—Triggers to recognize & dophysical 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.”

id patients at significant risk for functional decline while hospitalized
ID patients at significant risk for functional decline while hospitalized

Independent Risk Factors

1) Pressure ulcer?

2) Baseline cognitive deficits?

3) Baseline functional impairments?

4) Baseline low social activity level?

Score risk for functional decline:

no =8%risk; yes to 1-2 questions =28% risk;

yes to > 2 questions=63% risk

Inouye SK, et al.J Gen Intern Med1993;8(12):645-52.

functional decline occurs in the hospital
Functional decline occurs in the hospital
  • Functional limitations increase with age.
  • Functional decline occurs in approx.

34-50% hospitalized older pts.

    • Higher mortality—twice the risk
    • Higher rates of institutionalization
    • Prolonged hospital stay
  • Interventions can decrease functional decline (Hospital Elder Life Program).
  • Functional status determines D/C plan.
how does one assess functional status
How does one assess functional status?

Report

Self-report

Proxy report

Direct observation

Level of support

Independent

Needs assistance

Dependent

activities of daily living
Activities of Daily Living

Bathing

Dressing

Transference

Continence

Feeding

instrumental activities of daily living
Instrumental Activities of Daily Living

Using the phone

Traveling

Shopping

Preparing meals

Housework

Taking medicine

Managing money

gait timed get up and go
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
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 recognize teach who to screen for functional impairment
Trigger to Recognize & Teach:Who to screen for functional impairment?

Who to screen?

  • Patients @ advanced age (>70, >75, >80 ???)
  • 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
screen for function cont
Screen for function, cont.

When to screen?

  • Review ADLs/IADLs prior to hospitalization
  • 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
frailty the hospital a final word
Frailty & the Hospital: A Final Word
  • Frail elders occupy approx. 25% medicine beds.
  • Frail elders @ high risk for worse outcomes.
  • Screen for cognition, functional status, psychosocial, sensory impairments.
  • Screen based on advanced age (>70) & suspected functional impairments.
  • Take measures to prevent delirium, falls and functional decline.
  • Recognizing frailty begs for a comprehensive D/C plan and Med Review.
mini champ geriatrics topics
Mini-CHAMP: Geriatrics Topics
  • Theme #1: Identification of the Frail /Vulnerable Elder
  • • Identify and assess the vulnerable hospitalized older patient
  • • Dementia in hospitalized older medical patients: Recognizing and screening for dementia,
  • assessing medical decision making capacity, implications for the treatment of non-dementia
  • illness, pain assessment, improving the post-hospitalization transition of care
  • Theme #2: Recognize and Avoid Hazards of Hospitalization
  • • Delirium: Diagnosis, treatment, risk stratification and prevention
  • • Falls: Assessment and prevention
  • • Foley Catheters: Scope of the problem, appropriate indications and management
  • • Deconditioning: Scope of the problem, prevention
  • • Adverse Drug Reactions and Medication Errors: Principles of drug review
  • • Pressure Ulcers: Assessment, treatment and prevention
  • • Depression: Assessment and treatment
  • Theme #3: Palliate and Address End-of-Life Issues
  • • Pain Control: General principles and use of opiates
  • • Symptom Management in Advanced Disease: Nausea
  • • Difficult Conversations and Advanced Directives
  • • Hospice and Palliative Care and Changing Goals of Care
  • Theme #4: Improve Transitions of Care
  • • The Ideal Hospital Discharge: Core components and determining destination
  • • Destinations of Post-Hospital Care: Nursing homes for skilled rehabilitation and long-term care
mini champ teaching on today s wards
Mini-CHAMP: Teaching on Today’s Wards

Analyzing the process of teaching

  • Goal setting
  • Process mapping tool
  • Barriers to teaching & topic selection
  • Individual & team dynamic
  • Emphasis on teaching ACGME competencies of communication & professionalism

Systems-Based Practice

  • Intro. to QI on the wards

Practice-Based Learning and Improvement

  • Case audit
  • Census audit
how to teach on the wards
How to teach on the wards?
  • Teach at bedside
    • Trigger to teach
    • Summary teaching points
  • Teaching Aides
    • Website materials
    • Tools—D/C work sheet, delirium/opiate conversion cards
    • Methods—audits, mapping
champ website
CHAMP Website

CHAMP Website @

http://champ.bsd.uchicago.edu

Reynolds Foundation supported Portal of

Geriatric Online Education website @

www.pogoe.com links to CHAMP website