Frailty Lead Charing Cross Hospital Imperial College Healthcare NHS Trust Frailty Objectives To understand what is meant by Frailty To understand the importance of diagnosing frailty To understand the different ways we identify frailty ID: 1048574
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1. Claire SolomonConsultant GeriatricianFrailty Lead Charing Cross HospitalImperial College Healthcare NHS TrustFrailty
2. ObjectivesTo understand what is meant by FrailtyTo understand the importance of diagnosing frailtyTo understand the different ways we identify frailtyTo understand successful (and the ineffective) interventions for frailtyThe Frailty Service at ImperialCase studies
3. What is frailty?Inflammation, immune system failure and dysregulation of neuroendocrine pathways leading to skeletal muscle declineThere is no gold standard for diagnosis It IS however a distinct entity from ‘old age’ or ‘multi-morbidity’ or ‘cognitive impairment’ Some older patients remain fit, well and active while others have gradual, unrelenting functional decline 4 to 16 % in men and women aged 65 and older (USA)
4. What is frailtyA clinical state of vulnerability with inherent risks for adverse clinical outcomesHallmark geriatric syndromePoor functional reserve - small insults result in large, steep, sudden declines in function and/or cognition
5. Why do we need to identify frailty?Frailty is central to the activity of every healthcare providerFrailty increases the risk of acute unscheduled admissionFrailty predisposes patients to poorer outcomes (falls, procedural complications, institutionalisation, disability, death) Frailty is a pre-terminal diagnosis 1/3 of patients ‘not managing at home’ will be dead within 12 months
6. Frailty screeningUtilised to identify older adults at high risk of adverse outcomes in a variety of clinical settings Important to target the correct patients for intervention – not those ‘too well’ or ‘too sick’ Their direct prognostic ability or clinical role is limited and challengingAs an exercise in Frailty recognition and improving care, are effective.
7. Identifying FrailtyMuch research exists now looking at frailty as a clinical and physiological entityDifferent frailty scores: no gold standard2 categories –The Frailty Phenotype (FRAIL, Rockwood)The accumulation-of-deficits model – the more medical conditions and impairments a person has, the more frail (eFI, Edmonton)Only as good as the team using themMany now in routine clinical use
8. The Edmonton Frailty Scale
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10. FRAIL screening tool●Fatigue ("Are you fatigued?")●Resistance ("Can you (not) climb one flight of stairs?")●Ambulation ("Can you (not) walk one block?")●Illnesses (greater than five)●Loss of weight (greater than 5 percent)"Yes" to three or more questions indicates frailty. "Yes" to one or two questions indicates pre-frailty
11. eFIUses data from the GP electronic health record to identify and grade frailtyData from around one million UK patients Identifies older people who are fit or mildly, moderately or severely frail It accurately predicts risk of nursing home admission, hospital admission, length of hospital stay and mortalityUses routinely available data (36 domains), without the need for an additional clinical assessment.Implemented into the SystmOne GP electronic health record and the two other main UK GP electronic health records (EMISWeb and Vision) is at an advanced stage. Community programmes case-finding using eFI include developing a tiered community frailty service for older people identify patients for pharmacist-led medication reviews identifying patients for proactive falls prevention treatment.
12. MRNNameBirth DateSexEncounter Identifier MillenniumConsultantAdmit Date & TimeCurrent / Last FacilityCurrent / Last BuildingCurrent / Last WardCurrent / Last RoomCurrent / Last BedFirst Frailty Scale Category Male11/09/2018 15:04CXHCX Twr 10 SCX 10SBay DBed 015 Female11/09/2018 06:30CXHCX Twr 10 SCX 10SSide Room BSR B4 Female08/09/2018 14:43CXHCX Twr 11 NCX 11NLarge BayBed 107 Male10/09/2018 05:50CXHCX Twr 11 SCX 11S NeuroBay EBed 046 Female07/09/2018 02:30CXHCX Twr 04 SCX 4SBay ABed 025 Male11/09/2018 09:17CXHCX Twr 06 NCX 6NBay ABed 034 Female09/09/2018 19:14CXHCX Twr 06 NCX 6NBay EBed 024 Female08/09/2018 19:41CXHCX Twr 06 NCX 6NBay EBed 046 Female07/09/2018 13:51CXHCX Twr 06 NCX 6NBay KBed 015 Male10/09/2018 18:14CXHCX Twr 06 NCX 6NSide Room CSR C4 Female07/09/2018 14:11CXHCX Twr 07 NCX 7NBay ABed 023 Female09/09/2018 10:36CXHCX Twr 07 WCX 7W RavBay FBed 046 Male07/09/2018 08:55CXHCX Twr 08 SCX 8SBay FBed 035 Female10/09/2018 18:02CXHCX Twr 08 WCX 8W MFEBay ABed 036 Female08/09/2018 12:30CXHCX Twr 08 WCX 8W MFEBay FBed 017Imperial Daily Frailty Report: all over 70s scored 3 or above, last 72 hours
13. The common frailty syndrome presentations are: deliriumfallsacute or sub acute decline in mobility not managing at homerecurrent attendances/frequent contact with servicesweight lossnot eating and drinkingincontinence pressure ulcerssleep disorders + sensory deficitsfatigue dizziness
14. Frailty interventions: what works?Specialist organised multidisciplinary geriatric diagnostic and treatment process as represented by a CGA (comprehensive geriatric assessment) is the gold standard of care (Cochrane 2011, 2017)CGA domains include:Functional capacityFalls riskCognitionMoodPolypharmacySocial supportFinancial concernsGoals of careAdvance care preferences
15. Efficacy of CGAMeta-analyses have consistently found CGA improves detection and documentation of geriatric problems Whether CGA improves outcomes depends on CGA models and their settingsHome geriatric assessment and acute geriatric care units have been shown to be consistently beneficial for several health outcomes. Co-management programmes eg orthogeriatrics has increasing evidence The data is conflicting for post-hospital discharge, outpatient geriatric consultation, and inpatient geriatric consultation services.
16. The best evidence is for:OT interventionsExerciseNutritionMedication reviewsAdvanced care plans/goal setting incl. palliative care involvement
17. There is no evidence for……Testosterone supplementation Growth hormone supplementationDHEA-S supplementationAnti-inflammatory interventions
18. Frailty Services at Charing CrossED + CDU liaison Monday – Friday, 9-5 OPRAC (Older Persons Rapid Access Clinic) Patients needing Comprehensive Geriatric Assessment, therapy and diagnostics within approx. 1 week/at risk of admission – within 24 hrs if urgent – referrals via e-RSFrailty Unit Monday -Friday Short-stay admissions (24-48hrs) CGA plus – other assessments/defined treatments/diagnostics/increases or new POC – no monitored beds Email advice ICHC-tr.adviceelderlymedicine-imperial@nhs.netTelephone advice line Monday – Friday, 9-5: CX 02033115162, SMH 07789 618954
19. OPAL (older persons assessment and liaison) Team Frailty team working on the AMU MFE wards 48 beds across 2 wardsRehabilitation ward 15 bedsClinics OPRAC Falls GeneralThe Virtual Ward CIS plus Imperial consultant geriatric input ‘hospital-at-home’ Liaison with OPRAC Referrals from GPs or hospital on DC
20. Other trust frailty servicesSMHHHOrthogeriatricsCardiology liaisonVascular liaisonRenal liaisonTrauma liaisonMFE bedsAMU-based frailty service/OPALMemory clinicMFE bedsGeneral MFE clinicFalls clinicGeneral MFE clinic
21. OPRAC case study: 1Mr P, 75, referred by GPRapidly deteriorating mobility and cognitive functionCame to OPRAC accompanied by wifeAssessment:CGA incl. therapy ax and medication RV dementia bloods CT head ECGurinalysis MOCADiagnosis:Likely advanced vascular dementia, possible normal pressure hydrocephalusSevere visual-spatial awareness deficits causing decreased mobility, in particular at doorways, on tiles, on darker coloured rugs.Interventions: Neurology review in OPRAC plus f/up arrangedOP MRI brain to exclude NPHCarer education on dementia related gait disturbance, visual aids etc. Direct discussion with St Vincent’s to ensure prompt review in memory clinicCommencement of a new POC
22. OPRAC case study: 288 year old man GP referral with worsening DIB despite treatment for chest infection and a history of fallsAssessment:CGA CXR bloods incl. d-dimer and BNPsats. on mobilising ECG CTPADiagnosis Acute exacerbation of heart failureInterventions:IV diuretics – patient kept over night on Frailty Unitup – titration heart failure medicationReferred to community HF teamwalking stick provided, patient declined referral to falls clinicD/Cd next morning - GP asked to continue monitoring U&Es and weight
23. OPRAC case study: 384 year old lady GP referral Advanced dementia and pressure ulcer over the hip – worsening pain + discharge from pressure ulcerPressure relieving mattress pre-arranged for OPRACAssessment: CGACT pelvis with contrastReview by infectious diseases team with wound swabDiagnosis: Clean pressure ulcer without underlying osteomyelitisTreatment:No need for antibioticsOT provided rota stand to facilitate transfers,Community OT referral made Up-titration of analgesia Advance care planning discussions with family