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Using the Frail-NH
Using the Frail-NH

Using the Frail-NH - PowerPoint Presentation

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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 monthsSlide26
Slide27
Slide28
Slide29
Slide30
Slide31

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