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January 16, 2018 | Author: Anonymous | Category: , Science, Health Science, Geriatrics
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Promises to Your Grandparents: Opportunities to improve the quality and safety of geriatric care Douglas G. Merrill MD MBA Chief Medical Officer Senior Associate Dean for Quality and Safety University of California Irvine Health

Conflict of Interest Statement To my knowledge, I have no conflicts of interest represented by this presentation.

Objectives After this presentation, the attendee should be able to

• understand the import of geriatric care to patient outcomes and healthcare costs

• understand how to reverse frailty, improve social connections, mental illness and care planning in the geriatric population.

• understand what UC Irvine Health is doing or planning to do in order to help support providers in the care of geriatric patients.

“For decades we have been told by our pediatric colleagues that “children are not simply little adults.” Perhaps we are to realize that older patients are not simply young patients with more birthdays.” Johnson RG .The Elderly Are Different: Resection for Non-small Cell Lung Cancer. CHEST 2011; 140 (4):839-840.

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IN CONCLUSION: My to-do list Support an initiative to evaluate semi-annually for frailty in all outpatients over the age of 65 years old, in all outpatient clinics Institute a shared decision making program for all elderly or at risk patients who are under consideration for invasive therapy, electively: e.g., surgery, hemodialysis, transplant, etc. Make sure they discuss risk of death, but also of ‘never return home’. Amplify the Advanced Directive Outpatient Initiative to reach 75% of patients who are seen more than once by a UCI clinician as an outpatient.

Continue to increase the number of elderly patients seen by the Transitions of Care team on Day 1 of admission, or pre-admission for elective admissions. Support the increased linkage of UC Irvine Health to the best skilled nursing facilities (SNFs) for both interim post-discharge and long-term post-discharge care. Augment the availability of Pharmacy consultation for elderly patients admitted and pre-discharge

Implement support for a pre-op algorithm for ELECTIVE surgery, which refers for frailty, anemia, low platelets, renal failure, cancer, COPD, RA, steroid use, or no social structure – sending patients to OT, PT, Nutrition, PM &R, and PCP; Case Management to visit their home and have the patient and family pick a list of three SNFs that they would prefer (and have them visit those). Reduce the incidence of transfer of patients for whom our care will be futile

Reduce the introduction of futile care options for inpatients at the end of life

IN CONCLUSION: Your to do list • • • • • •



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Study the differences between adult and elderly adult physiology carefully. Learn about the variation in metabolism of medication between the “normal” elderly, infirm elderly, and the normal or ill adult who is not elderly. Learn what causes re-admission and learn to anticipate those conditions in your patients Avoid benzodiazepines and sedatives – consult Psychiatry early for elderly patients with delirium READ THE NOTES FROM YOUR CONSULTANTS!!! Learn about the surgical procedures most associated with re-admission in the elderly and prepare your patients for not being discharged after those elective procedures. Download “Optimal Preoperative Assessment of the Geriatric Surgical Patient: A Best Practice Guideline” from the ACS NSQIP and American Geriatric Society and read it. https://www.facs.org/~/media/files/quality%20programs/nsqip/acsnsqipagsgeriatric2012guidelines.ashx Learn about the risk of never returning home for your pre-op “clearance” patients with documented frailty, anemia, low platelets, renal failure, cancer, COPD, RA, steroid use, or no social structure –

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prep them early and get Case Management involved on day one. Involve OT, PT, Nutrition, PM &R, and Case Management early. Get Case Management to visit their home. Engage the patients in discussion about transition from single living at home

Engage your patients in Advanced Directive Discussions Consult with Palliative Care and the Acute Pain Service early in the care of your elderly patients

Agenda

• The importance of being elderly: • frailty, • social isolation, • mental illness • lack of care planning

• Impact on the healthcare delivery system • How UC Irvine Health will help you to help them.

The Aging of America • In 2000, 12% of all Americans were over the age of 65 years. • By 2030, 20% of all Americans will be over the age of 65 years. • By 2050, 80 million Americans will be over age 65 years, • The proportion of the population over 85 years is expanding at 6x the rate of the general population

• 2 out of 3 people over the age of 65 have chronic conditions and their care takes up 67% of all expenditures, private and public, on healthcare.

• And that 67% is only going to grow… Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept. of Health and Human Services; 2013. www.cdc.gov/aging Lin RY J Hospital Medicine 2015;10:586–591

So, we’re old and getting older…so what? • •

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Social Isolation is increased Living alone is higher risk for morbidity and mortality Financial independence is decreased Medication errors by patient and prescriber increase, as does impact Co-morbidities increase Trauma risks increase Incidence of Delirium is increased Incidence of Depression and Suicide are increased All-cause risk of death is higher





Risk of elder abuse, including financial scams by family or others Lengths of stay increase due to

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Increased number and severity of comorbidities Lack of funding for long term care or in home care Sometimes due to family pressure

Regulatory pressure to discharge increases Financial losses to the health system increases

Focusing on… • Frailty (nutrition, mobility, muscle tone, gait, stamina) • Mental illness (depression and delirium) • Social isolation (including potential for abuse) • Care planning (Advance Directives, Shared-Decision Making, Health Docents, choosing safe living sites)

Why care about frailty? •



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Incidence recognized among those in the community:

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10.7% of ages 65 to 80 15.7% of those aged 80 to 84, 26.1% of those aged 85 or older.

Frailty is associated with increased risk of functional impairment, hospitalization, and mortality, with the risk of individual mortality being better predicted by frailty than by chronological age. It increases costs to the healthcare system (re-admission is an increasing cost to institutions, including fines by CMS reaching 7 figures per year). Associated with higher mortality in the peri-op period; elderly patients have surgery at 4x the rate of non-elderly and already cost the system much more for surgery than does a younger patient. With over 20% of the US population destined to be over 65 years of age by 2030, this is an important aspect of health and healthcare cost. Most importantly, it is reversible! Collard RM, et al. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):148792. Shamliyan T, et al. Association of frailty with survival: a systematic literature review. Ageing Res Rev 2013;12(2):719-36. Buigues C., et al. Arch Gerontology and Geriatrics, 2015; 61: 309–321

Measuring Frailty • Frailty is not a necessary outcome of chronological age! • There is no single test for frailty, but several very simple ones are valid. • • •

Grip Strength is alone the most specific and sensitive Fried-Hopkins frailty index – weak grip, weight loss, exhaustion, low level of physical activity, slow walking 15 feet. Score of 4-5 = “frail” A simple clinic strategy:

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Gait speed – time to walk 15 feet; FAIL if more than 6 seconds Hand grip strength FAIL if < 30kg for men or < 20kg for women

Mobility: time to rise from a chair, walk 15 feet and return to the chair = FAIL if > 15 seconds BMI < 25 or >30

There are other measures, but any of these test algorithms can be done in clinic by an MA and followed longitudinally. Cameron et al. BMC Medicine 2013, 11:65-75. Anaya DA, et al. Summary of the Panel Session at the 38th Annual Surgical Symposium of the Associate of VA Surgeons. JAMA Surgery. 2014; 149(11): 1191-1197.

9 Techniques that succeed in reversing frailty • •

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In a study of patients average age 83, a 12 month RCT showed 15% of the study group were no longer frail and mobility improved, while the control group saw a decline in indices of frailty and mobility. NB: the difference between groups was not significant at 3 months – it took 12 months. This is a long term process to correct.

Dietary consultation and nutritional supplementation as needed, including home-delivered meals. BMI < 18.5 kg/m2, or mid-upper arm circumference was
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