Internal Medicine Resident Rotation Katherine Thompson, MD & Patricia Rush, MD

1. SAFE ClinicSuccessful Aging & Frailty EvaluationUniversity of Chicago – Geriatrics and Palliative Medicine Internal Medicine Resident Rotation Katherine Thompson, MD & Patricia Rush, MD

2. Objectives: SAFE Clinic • Define frailty and identify frail patients • Practice and interpret: • cognitive assessment • functional assessment • Appreciate importance of interdisciplinary care for frail patients • Appreciate relevance of geriatric assessment to your future practice

3. Case Study Mrs. Thomas (82 y/o woman) comes to Clinic with her son. Son is concerned that Mrs. Thomas is not doing well. On exam, patient is pleasant, quiet, cooperative. BP 154/70, HR 70 regular, RR 16. Weight 154 lb. Exam is generally unremarkable. HEENT, Cardiac, Lungs, Abdomen all negative. Has 1+ edema over ankles. Has good sitting balance, but uses arms to arise from chair and stumbles on her way to the exam table. Labs: CBC, BMP, TSH from 3 months ago were basically normal.Hgb 11.2. GFR 50. WHAT ELSE DO WE NEED TO KNOW?

4. Case Study BACKGROUND: • Mrs. Thomas is a widow. Husband died 6 yr ago • Mrs. Thomas lives alone. Sons brings her groceries once a week. Pt administers her own medication. • Son feels mother is depressed - does not attend family events. • Son states patient is slow to answer phone when he calls and seems sort of confused. Last week, she thought he was his father (deceased 6 yr ago) • Son suspects mother has fallen because he sees bruises. Mrs. Thomas denies she has fallen • Review of chart shows patient has lost 7 lb in past 2 years. WHAT IS GOING ON ??

5. Definition of Frailty • Diminished capacity to withstand stress • Progressive • At risk - adverse health outcomes, increased mortality • Associated with chronic disease • Worsens with advancing age • Marked by a transition from independence to dependence on caregivers

6. Measurement of Frailty • Clinical features: ≥ 3 meets Criteria for Frailty • Weakness • Weight loss • Poor energy • Low physical activity • Slowness • At risk for adverse outcomes • Falls • New or worsened ADL impairment • Hospitalization • Death

7. Syndrome of Frailty • Other associated features • Cognitive impairment • Balance/motor impairment • Depression, anxiety, loneliness • Poor quality sleep • Low self-rated health • Inadequate social support

8. Biologic Basis of Frailty • Dysregulation across more than one of these physiological systems is associated with greater risk of frailty • Despite growing understanding of biology, diagnosis of frailty remainsclinical

9. Biologic Basis of Frailty • Loss of skeletal muscle • Decreases in estrogen, testosterone, growth hormone, and insulin-like growth factor 1 • Increases in interleukin 6, C-reactive protein, tissue plasminogen activator, and D-dimer • No diagnostic laboratory test is available

11. Under-recognition of Frailty by Clinicians • Frailty does not fit into classic organ-specific models of disease. • Subtle decline may not be evident to clinicians, family members, or patients • Declines in strength, endurance, and nutrition may not cause patients to seek medical attention and may hinder their doing so

12. Why should I care? • Frail patients are internal medicinepatients (increasing numbers every year) • Ability to identify frailty will affect your medical decision-making and treatments regardless of specialty • from chemotherapy to cardiac catheterization to colon cancer screening • Inability to identify frailty will result in bad outcomes for you and your patients

13. Frailty Assessment as a Prognostic Tool:Survival by Frailty Stratification

14. How does Frailty comparewith CoMorbidity and Disability? CoMorbidity = presence of 2 or more significant chronic illnesses Disability = inability to perform 1 or moreActivities of Daily Living (ADL) Ambulating, Toileting, Showering, Dressing, Eating

15. Frailty: distinct entity Fried, LP et al. Journal of Gerontology, 56A: M146-156, 2001

16. Clinical Application of Frailty AssessmentPreoperative Surgical RiskMakary, Martin, et.al. Frailty as a Predictor of Surgical Outcomes in Older Patients, J Am Coll Surg 2010; 210:901–908 • Standard indications for medical or surgical interventions might not be generalizable to older patients because physiologic changes from aging can alter the risk-to-benefit analysis. • Goal: reduce postoperative complications in older patients • Postoperative complications in patients aged 80 and older increase 30-day mortality by 26%

17. Johns Hopkins Dept of Surgery – 2010Frailty as Risk for Surgical OutcomesMakary, Martin, et.al. Frailty as a Predictor of Surgical Outcomes in Older Patients, J Am Coll Surg 2010; 210:901–908 STUDY DESIGN: • Prospectively measured Frailty in 594 patients (age 65 years or older) presenting to a university hospital for elective major surgery between July 2005 and July 2006. • Frailty was classified using a validated scale (0 to 5) – Fried’s Criteria- weakness, weight loss, exhaustion, low physical activity, and slowed walking speed. • Main outcomes measures: 30-day surgical complications Length of stay Discharge disposition.

18. RESULTS: Frailty and Surgical Outcomes • Preoperative frailty was associated with an increased risk for postoperative complications • Intermediately frail: odds ratio [OR] 2.06 • Frail: OR 2.54; • Increased length of stay • Intermediately frail: incidence rate ratio 1.49 • Frail: incidence rate ratio 1.69 • Discharge to a skilled or assisted-living after living at home • Intermediately frail: OR 3.16 • Frail: OR 20.48 • Frailty improved predictive power (p 0.01) of each risk index (American Society of Anesthesiologists, Lee, and Eagle scores).

19. SAFE ClinicSuccessful Aging & Frailty EvaluationUniversity of Chicago – Geriatrics and Palliative Medicine Research – Patient Care

20. SAFE Clinic AssessmentResearch • Informed consent obtained • Demographics(age, race, education, income, living situation, height, weight, BMI) • EPIC data(problem list, meds) • MD Progress note(acute issues, sensory impairment, assist devices-cane or wheelchair, recent hospitalizations, other pertinent)

21. SAFE – Initial Assessment • Vulnerable Elder Survey(VES-13) Self-rated health & functional status • Comorbidities(Charlson comorbidity index) • Falls(AGS falls questions) • Sleep(Pittsburgh Sleep Index) • Depression (PHQ-2) • Pain (Pain map & pain thermometer) • Stress • Caregiver strain

22. SAFE – Initial Assessment • Cognition(MOCA +/- MMSE) • Physical function(Short physical performance battery)1) Stands (side-by-side, semi-tandem, tandem, hold for 10 seconds) 2) Chair stands (5 stands from chair, without using arms) 3) Measured walks (2 timed 4-meter walks, take faster time, goal = less than 8.7 sec)

23. Frailty (Fried’s Frailty Criteria)≥ 3 meets Frailty Criteria • Weakness • Low grip strength • Standardized using a dynamometer • Weight loss • > 5% weight loss, or 10 lbs in 1 year • “In the last year, did you lose 10 lbs or more, not on purpose?” • Slowed gait speed • Time to walk 15 feet at usual pace • Slow = ≥ 6 or 7 sec. depending on gender, height

24. Frailty (Fried’s Frailty Criteria)≥ 3 meets Frailty Criteria • Fatigue/low energy • “How often in the last week did you feel that everything you did was an effort?” and “How often would you say you could not get going?” • Significant response = “moderately often” or more on ≥ 3 days in the last week • Low physical activity • Calculated Kcal expenditure based on standardized instrument (Minnesota leisure time activities questionnaire)

25. SAFE Clinic: Patient Care • Identify patients: Not Frail Pre-frail or intermediate, or Frail • Provide individualized education, resources • Management strategies: • Improve core manifestations of frailty: physical activity, strength, exercise tolerance, nutrition • Exclude modifiable precipitating factors • Minimize consequences of vulnerability

26. Patient Care: Return Visit • Interdisciplinary team • Assessment • Care planning • Patient follow up • Results of assessment • Recommendations provided to patient & PCP • Patient education materials and resources • Consult letter dictated with recommendations • Anticipate follow up visits q6-12 months for tracking

27. SAFE: Patient Recommendations Vigorous - Not Frail: Focus on: • exercise • social support • vision/hearing screen • preventive evaluations • tight control of medical conditions such as HTN, DM • smoking cessation

28. SAFE: Patient Recommendations Pre-frail – OPPORTUNITY • Emphasize exercise or PT for strength and balance, fall prevention. • Nutrition assessment • Driving - home safety eval • Social support • Watch for depression and cognitive changes • Regular medical followup; smoking cessation.

29. SAFE: Patient Recommendations Frail:Fragile – Handle with Care Focus: • Hospitalization avoidance • Fall prevention • Review benefits/burdens of treatments • Advance Care Planning • Medication management - minimize # of meds # doses • Anticipate caregiver stress

30. SAFE Clinic Team Members: • FACULTY: • Patricia Rush, MD MBA • Katherine Thompson, MD • William Dale, MD PhD • Joseph Shega, MD • Geri Fellow: Megan Huisingh-Scheetz, MD • Adv Practice Nurse: Lisa Mailliard, Geri Specialist • Social Work: • Patricia MacClarence, LCSW • Jeffrey Solotoroff, LCSW