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and The Rapid Geriatric Assessment RGA in Long Term Care Geriatric Workforce Decline in Geriatricians in the United States 1988 2030 Geriatricians 7128 7750 Geriatricians per older adult ID: 541354 Download Presentation
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Presentation on theme: "Using the Frail-NH"— Presentation transcript
Slide1
Using the Frail-NHandThe Rapid Geriatric Assessment (RGA)in Long Term CareSlide2
Geriatric WorkforceDecline in Geriatricians in the United States
1988
2030
Geriatricians
7,128
7,750
Geriatricians per older adult
1 for every 2,546
1 for every 4,254
Geropsychiatrists
1,596
1,659
Geriatric psychiatrists per older adult
1 for every 11,372
1 for every 20,195Slide3
Geriatric AssessmentGeriatric Assessment is a systematic, interprofessional approach to the older patient
Diagnose geriatric syndromes
Develop targeted treatment plansImprove patient outcomes
Focus on function and quality of life
Not based on chronological age but functional impairment and risk of future decline Slide4
Rapid Geriatric AssessmentEarly detection of health problems when interventions are most likely to be successful
Used for common geriatric problemsIdeally provide a brief, reliable method for detecting common problems
Track changes over time
How to Bill Medicare’s Annual Wellness Visit (AWV)
Diagnosis code V70.0; Initial Annual Wellness Visit G0438; Subsequent Annual Wellness Visit G0439Slide5
Modern Giants of Geriatrics
Frailty
Sarcopenia
Anorexia of Aging
MCISlide6
Saint Louis University
Rapid Geriatric Assessment
*
Miscellaneous
Are you constipated? Y/N
Do you have worrisome incontinence? Y/N
Do you have an advanced directive? Y/N
*There is no copyright on these screening tools and they may be incorporated into the Electronic Health Record without permission and at no cost.
SNAQ
(Simplified Nutritional Assessment Questionnaire)
My appetite is Food tastes
very poor a. very bad
poor b. bad
average c. average
good d. good
very good e. very good
When I eat Normally I eat
I feel full after eating a. less than one meal a day
only a few mouthfuls b. one meal a day
I feel full after eating c. two meals a day
about a third of a meal d. three meals a day
I feel full after eating e. more than three meals a day
over half a meal
d. I feel full after eating
most of the meal
I hardly ever feel full
__________________________________
From Wilson et al. Am J
Clin Nutr 2005;82:1074-81.
Rapid Cognitive Screen (RCS)1. Please remember these five objects. I will ask you what they are later. [Read each object to patient using approx. 1 second intervals.] Apple Pen Tie House Car2. [Give patient pencil and the blank sheet with clock face.] This is a clock face. Please put in the hour markers and the time at ten minutes to eleven o’clock. [2 pts/hr markers ok; 2 pts/time correct]3. What were the five objects I asked you to remember? [1 pt/ea]4. I’m going to tell you a story. Please listen carefully because afterwards, I’m going to ask you about it. Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had three children. They lived in Chicago. She then stopped work and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after. What state did she live in? [1 pt] ______________________________________________ From Malmstrom TK, Voss VB, Cruz-Oliver DM et al. J Nutr Health Aging 2015;19:741-744.
The Simple “FRAIL” Questionnaire Screening Tool(3 or greater = frailty; 1 or 2 = prefrail)Fatigue: Are you fatigued?Resistance: Cannot walk up one flight of stairs?Aerobic: Cannot walk one block?Illnesses: Do you have more than 5 illnesses?Loss of weight: Have you lost more than 5% of your weight in the last 6 months?_________________________________________________From Morley JE, Vellas B, Abellan van Kan G, et al. J Am Med Dir Assoc 2013;14:392-397.
Table I: SARC-F Screen for
Sarcopenia
Component Question Scoring_________
S
trength How much difficulty do you have in None = 0
lifting and carrying 10 pounds? Some = 1
A lot or unable = 2
A
ssistance in How much difficulty do you have None = 0
walking walking across a room? Some = 1
A lot, use aids, or unable = 2
R
ise from a How much difficulty do you have None = 0
chair transferring from a chair or bed? Some = 1
A lot or unable
without help = 2
C
limb stairs How much difficulty do you have None = 0
climbing a flight of ten stairs? Some = 1
A lot or unable = 2
F
alls How many times have you None = 0
fallen in the last year? 1-3 falls = 1
4 or more falls = 2
From
Malmstrom
TK, Morley JE. J Frailty and Aging 2013;2:55-6.Slide7
Fatigue
Resistance (Climb 1 flight stairs)
Aerobic (Walk one block)
Illnesses (more than 5 illnesses)
Loss of weight(>5% in 6 months)
FRAIL
(IANA)
TWENTY
VALIDATIONS
Australia(6)
Hong Kong(2)
St Louis(2)
China
Baltimore
Europe (2)
Turkey
Korea
Taiwan
Mexico(2)
Singapore
1 or 2 PreFRAIL
3 or more FRAILSlide8
0
1
2
Energy
Good/Excellent
Fair
Poor
Transferring
Moves in and out of bed or chair unassisted. Mechanical transferring aides are acceptable
Needs help in moving from bed to chair or requires complete transfer
Needs help in moving from bed to chair or requires complete transfer & KATZ score <3
Mobility
Goes out
Able to get out of bed/chair but does not go out
Bed or chair bound
Continence
Exercises complete self control over urination and defecation
Is partially or totally incontinent of bowel or bladder
Is partially or totally incontinent of bowel or bladder & KATZ score <3
Weight Loss (last 3 months)
No weight loss
1-3kg (2.2 and 6.6 lbs) or does not know
>3 kg (6.6 lbs)
Feeding
Gets food from plate into mouth without help. Preparation of food may be done by another person
Needs partial or total help with feeding or requires parental feeding
Needs partial or total help with feeding or requires parental feeding & KATZ score <3
Dressing
Gets clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoesNeeds help with dressing self or needs to be completely dressed
Needs help with dressing self or needs to be completely dressed & KATZ score <3Total Score 0-14: 0-1 non frail, 2-5 frail, 6-14 severely frailFRAIL-NH ScaleSlide9
Distribution of scores for FRAIL-NH scaleSlide10
Table 4. Logistic Regression models examining the association of frailty with other adverse measures (adjusted for age and sex)
% reporting the measure
Frailty index
(per 0.1 score)
FRAIL-NH scale
(per 1 point)
adj OR (95% CI)
adj OR (95% CI)
High care needs
35.2%
1.91 (1.58-2.30)
1.22 (1.15-1.29)
Dementia
44.1%
2.14 (1.68-2.72)
1.21 (1.14-1.28)
Low satisfaction with care*
23.3%
1.93 (1.05-3.55)
1.15 (1.03-1.29)
Low quality of life*
25.3%
3.50 (2.66-4.62)
1.43 (1.32-1.54)
Poor neuropsychiatric state*
24.8%
2.64 (2.05-3.39)
1.22 (1.15-1.30)
Major disruptiveness*24.5%2.03 (1.62-2.54)1.15 (1.09-1.23)
*poor scores on these measures were defined as the lowest quartileSlide11
FRAIL-NH Scale St LouisKaehr, Malmstrom, Pape and Morley
Deceased or HospicePrefrail: 2.37 (0.77 – 7.30) p=0.135
Frail : 3.96 (1.44-10.87) p<0.007Slide12
Journal of the American Medical Directors AssociationVolume 16, Issue 12, 1 December 2015, Pages 1042–1047
Predicting Adverse Health Outcomes in Nursing Homes: A 9-Year Longitudinal Study and Development of the FRAIL-Minimum Data Set (MDS) Quick Screening Tool
Hao Luo,
PhDa
, b, Terry Y.S.
Lum
, PhDa, c, , , Gloria H.Y. Wong,
PhDa, d, Joseph S.K. Kwan, MDa, e, Jennifer Y.M. Tang, PhDa, Iris Chi, DSWfSlide13
ObjectivesTo examine the predictive validity of a quick frailty screening tool, the FRAIL-NH, for adverse health outcomes in nursing home residents, using variables from the Minimum Data Set (MDS).
The screening items were compiled from the MDS for potential direct application in long-term care facilities using this health information system.Slide14
Design
Longitudinal follow-up study of nursing home residents with annual clinical assessment using the MDS and mortality data between 2005 and 2013.Slide15
Setting
Six nursing homes operated by a nongovernmental organization in Hong Kong.
Participants
Participants
included 2380 nursing home residents aged 65 years or older at study baseline.
Measurements
Frailty assessed using the FRAIL-NH model with items from the MDS. The model covers 8 areas: fatigue, resistance, ambulation, incontinence, polypharmacy, weight loss, nutritional approach, and help with dressing. Adverse health outcomes in subsequent years were measured: incident falls, worsening activities of daily living (ADL) function, hospitalization, and death.Slide16
Fatigue was measured by the presence of (1) periods of lethargy and (2) depressive symptoms in MDS.
Resistance was assessed using the “transfer” item in MDS, which is a proxy measure that reflects functional status of whether support was needed to move between surfaces (
eg, to/from the bed, chair, wheelchair, or standing position).
Ambulation
was measured using the “walk in room” item in the MDS, which records the person's performance in walking between locations in a room.
Incontinence
was measured in terms of both urinary and bowel incontinence. A score of 0 indicates continence, 1 indicating only urinary or bowel incontinence, and 2 for both urinary and bowel incontinence.
Illness (polypharmacy): following Kaehr and colleagues, illnesses was used as a proxyWeight loss was measured using the “weight change” item in MDS, which captures whether there had been a weight loss of 5% or more in the past 30 days or 10% or more in the past 180 days.
Nutritional approach
was assessed in MDS according to whether a resident had a mechanically altered diet or used a feeding tube
Help with dressing
was assessed using the “dressing” item in MDS, which reflects whether support was needed to put on, fasten, and take off all items of street clothing, including donning or removing a prosthesisSlide17
Cumulative distribution of FRAIL-NH raw scores stratified by ADL performance level.
Predicting Adverse Health Outcomes in Nursing Homes: A 9-Year Longitudinal Study and Development of the FRAIL-Minimum Data Set (MDS) Quick Screening Tool
Journal of the American Medical Directors Association, Volume 16, Issue 12, 2015, 1042–1047Slide18
Survival curve estimates over 108 months (9 years) of follow-up by frailty status at baseline for the total sample (n = 2357).
Predicting Adverse Health Outcomes in Nursing Homes: A 9-Year Longitudinal Study and Development of the FRAIL-Minimum Data Set (MDS) Quick Screening Tool
Journal of the American Medical Directors Association, Volume 16, Issue 12, 2015, 1042–1047Slide19
Using a cut-off point of 4, being frail was associated with a 176% higher risk of
mortality in the total sample (HR, 2.76; 95% confidence interval [CI] 2.13-3.57)
Similar results were obtained in the
no ADL
dependence group, with an HR of being frail of 2.00 (95% CI, 1.41-2.83).
FRAIL-MDS predicts Mortality: Hong Kong
A frail resident was twice as likely to experience
incident
fall
(HR, 2.00; 95% CI, 1.41-2.83)
hospitalization
(HR, 2.35; 95% CI, 1.57-3.54),
worsening ADL
(HR, 3.73; 95% CI, 2.69-5.16),Slide20
FRAIL-NH Hong KongConclusions
The FRAIL-NH, has been validated with demonstrated predictive power for major adverse health outcomes.
The tool provides a simple solution to identify residents who are at risk of becoming frail, with minimal extra resources required or assessment burden in long-term care facilities using the MDS health information system.
This will allow timely intervention of the potentially reversible target of frailty.
Although it remains an open question as to what extent early indicators of frailty are reversible in a nursing home population, by identifying residents at the highest risk, interventions to prevent poor outcomes can be provided in a timely manner.Slide21
Modern Giants of Geriatrics
Frailty
Sarcopenia
Anorexia of Aging
MCISlide22
Saint Louis University
Rapid Geriatric Assessment
*
Miscellaneous
Are you constipated? Y/N
Do you have worrisome incontinence? Y/N
Do you have an advanced directive? Y/N
*There is no copyright on these screening tools and they may be incorporated into the Electronic Health Record without permission and at no cost.
SNAQ
(Simplified Nutritional Assessment Questionnaire)
My appetite is Food tastes
very poor a. very bad
poor b. bad
average c. average
good d. good
very good e. very good
When I eat Normally I eat
I feel full after eating a. less than one meal a day
only a few mouthfuls b. one meal a day
I feel full after eating c. two meals a day
about a third of a meal d. three meals a day
I feel full after eating e. more than three meals a day
over half a meal
d. I feel full after eating
most of the meal
I hardly ever feel full
__________________________________
From Wilson et al. Am J
Clin Nutr 2005;82:1074-81.
Rapid Cognitive Screen (RCS)1. Please remember these five objects. I will ask you what they are later. [Read each object to patient using approx. 1 second intervals.] Apple Pen Tie House Car2. [Give patient pencil and the blank sheet with clock face.] This is a clock face. Please put in the hour markers and the time at ten minutes to eleven o’clock. [2 pts/hr markers ok; 2 pts/time correct]3. What were the five objects I asked you to remember? [1 pt/ea]4. I’m going to tell you a story. Please listen carefully because afterwards, I’m going to ask you about it. Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had three children. They lived in Chicago. She then stopped work and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after. What state did she live in? [1 pt] ______________________________________________ From Malmstrom TK, Voss VB, Cruz-Oliver DM et al. J Nutr Health Aging 2015;19:741-744.
The Simple “FRAIL” Questionnaire Screening Tool(3 or greater = frailty; 1 or 2 = prefrail)Fatigue: Are you fatigued?Resistance: Cannot walk up one flight of stairs?Aerobic: Cannot walk one block?Illnesses: Do you have more than 5 illnesses?Loss of weight: Have you lost more than 5% of your weight in the last 6 months?_________________________________________________From Morley JE, Vellas B, Abellan van Kan G, et al. J Am Med Dir Assoc 2013;14:392-397.
Table I: SARC-F Screen for
Sarcopenia
Component Question Scoring_________
S
trength How much difficulty do you have in None = 0
lifting and carrying 10 pounds? Some = 1
A lot or unable = 2
A
ssistance in How much difficulty do you have None = 0
walking walking across a room? Some = 1
A lot, use aids, or unable = 2
R
ise from a How much difficulty do you have None = 0
chair transferring from a chair or bed? Some = 1
A lot or unable
without help = 2
C
limb stairs How much difficulty do you have None = 0
climbing a flight of ten stairs? Some = 1
A lot or unable = 2
F
alls How many times have you None = 0
fallen in the last year? 1-3 falls = 1
4 or more falls = 2
From
Malmstrom
TK, Morley JE. J Frailty and Aging 2013;2:55-6.Slide23
Participants with a total score higher than 4 were classified as having sarcopeniaSlide24
Kentaro
KamiyaSlide25
My appetite is
Very poor
Poor
Average
Good
Very good
When I eat, I feel full after
Eating only a few mouthfuls
Eating about a third of a plateful
Eating over half a plateful
Eating most of the food
Hardly ever
Food tastes
Very bad
Bad
Average
Good
Very good
Normally I eat
Less than one full meal a day
One meal a day
Two meals a day
Three meals a day
More than three meals a day, including snacks
S.N.A.Q
< 15 predicts significant
weight loss within 6 monthsSlide26Slide27Slide28Slide29Slide30Slide31
The Medicare Annual Wellness Visit in Nursing HomesSlide32
ConclusionThe FRAIL-NH predicts poor outcomes and those suitable for hospice in nursing homes
The RGA (FRAIL, SARC-F, SNAQ and RCS) and advance directives can be useful in refining care needs for nursing home residents and older persons at home.Aging.slu.edu
for videos, forms and further information