Prioritizing Care for Older Adults with Complex Health

StatusSamuel C. Durso, MD, MBA

Clinical Director, Director of Education

Division of Geriatric Medicine and Gerontology

Johns Hopkins University

ACP Maryland

February 8, 2008

Disclosures

• No financial or other conflicts of interest

Goals

1. Understand the complexity of health status for older adults

2. Propose framework for prioritizing care

Older Adults

• Fifty percent of adults > 65 have 3 or more chronic conditions

• Older adults exhibit a spectrum of frailty, co-morbidity and disability

• For any individual, treating all co-morbid conditions may be dangerous, impractical or burdensome

Durso: JAMA 2006

How does the physician help the patient with multiple

chronic conditions prioritize care?

Health Status

•Frailty •Disability•Comorbidity

Fried, et al. J Gerontol A Biol Sci Med Sci, 2004

Health Status

Frailty

Co-morbidity

Disability

Adapted from Walters et al JAMA, 2001

Individual Preferences

• Individual and unpredictable• May differ from guidelines• May value independence and

function over preventing specific disease

Tsevat J, et al: JAMA 1998

Protheroe J, et al: BMJ 2000

Salkeld G, et al: BMJ 2000

Geriatric Syndromes

• Falls: 31% per year • Dementia: 10% prevalence• Urinary incontinence: 15-30%

prevalence• Polypharmacy: 40% use > 5 meds per

week • Persistent pain: 25-50%• Depression: 15% in primary care setting

Complexity(Adaptive system)

Pre

dict

abili

ty

High

Low

High LowAgreement

Randomness

Zone of Complexity

Order

Plesk: IOM,2001

Durso: Aging Health 2007

Framework

• A quantitative and qualitative framework for prioritizing care– What are the patient’s preferences?

Experiences? – What are the major causes for morbidity

and mortality? – What is the patient’s health status and

average life expectancy?– What is the ARR and time to benefit for an

intervention?

Durso: Aging Health, 2007

Developing Priorities

• Focus on patient’s preferences and goals

• Consider treatment impact in context of patient’s life

• Participatory decision-making

Durso: Aging Health, 2007

Thank you