What  is  frailty?  Iden1fica1on  and  management    

Lelly  Oboh  Consultant  Pharmacist,  Care  of  older  people  

8th  November  2016  

Frailty  in  the  spotlight  

•  Watch  Mrs  Andrews'  Story  –  what  went  wrong?        hMps://youtu.be/I0TVbhHdg4A    

What  is  frailty?  •  Age-­‐associated  decline  in  physiologic  reserve  and  

func3on  across  mul3-­‐organ  systems  leading  to  increased  vulnerability  for  adverse  health  outcomes  (Fried  et  al  2001)  

•  A  dis1nct  health  state  where  a  minor  event  can  trigger  major  changes  in  health  from  which  the  pa1ent  may  fail  to  return  to  their  previous  level  of  health  (Bri1sh  Geriatric  Society)  

•  Progressive  Long  term  condi1on,  with  episodic  deteriora1ons  

Typical  frail  older  person  •  Female,  over  85  years  •  Mul1ple  diseases,  òmobility,  ñdependence,  weight  loss,  fa1gue  

•  Present  clinically  with  frailty  syndromes  such  as  falls,  confusion,  incon1nence,  delirium,  adverse  drug  effects  ðFrequent  and  long  hospital  admissions    

 

For  more  informa+on  on  frailty  read  BGS  Fit  for  Frailty  1&2  h7p://www.bgs.org.uk/index.php/fit-­‐for-­‐frailty  

Reduced  func1onal  reserve  in  frailty      

Frailty,    Morbidity  and  Disability  (Fried  et  al  2004)  

Fried  LP  et  al.  Untangling  the  Concepts  of  Disability,  Frailty,  and  Comorbidity:  Implica1ons  for  Improved  Targe1ng  and  Care.  J  Gerontol  A  Biol  Sci  Med  Sci  (2004)  59  (3):  M255-­‐M263.doi:  10.1093/gerona/59.3.M255    

5.7%  

26.6%  

46.2%  

21.5%  

Phenotype  model  of  frailty  •  Relates  to  what  they  look  like  and  how  they  feel  •  3  or  more  of…  

•  Unintended  Weight  Loss  •  Slow  Gait  Speed  •  Low  Energy  Expenditure  •  Self  Reported  Exhaus1on  •  Poor  Grip  Strength  (  sarcopenia)  

 •  Fried  LP  et  al.  J  Gerontol  A  Biol  Sci  Med  Sci.  2001  Mar;56(3):M146-­‐56.  

hMps://www.ncbi.nlm.nih.gov/pubmed/11253156    

Survival  curves  of  frailty  (phenotype  model)  Fried  JP  et  al.  Frailty  in  Older  Adults:  Evidence  for  a  Phenotype.  Journal  of  Gerontology  2001:  Vol  56A,  No.  3,  M146–M156  

Deficit  model  

•  Accumula1on  of  deficits-­‐  increasing  frailty  index-­‐  increase  risk  of  adverse  outcomes  

•  Relates  to  the  number  of  deficits  i.e  symptoms,  signs  and  disease  e.g.  poor  eyesight,  social  vulnerability    

•  Frailty  Index  is  a  %  of  total  of  deficits    

 

Rockwood  CFS  2004    Rockwood  K  et  al  CMAJ.  2005  Aug  30;  173(5):  489–495.  hMps://

www.ncbi.nlm.nih.gov/pmc/ar1cles/PMC1188185/    

Survival  curves  using  Culmula1ve  Deficit  model    Rockwood  et  al.  2005,    

 

E-­‐Frailty  index  

•  eFI  uses  rou1ne  10  care  data  to  iden1fy  older  people  with  mild,  moderate  and  severe  frailty  

•  Robust  predic1ve  validity  for  outcomes  of  mortality,  hospitalisa1on  and  nursing  home  admission.    

•  Rou1ne  implementa1on  of  t  eFI  could  enable  delivery  of  evidence-­‐based  interven1ons  to  improve  outcomes  

Andrew  Clegg,  et  al.  :  Development  and  valida1on  of  an  electronic  frailty  index  using  rou1ne  primary  care  electronic  health  record  data.  Age  Ageing  (2016)  45  (3):  353-­‐360  doi:10.1093/ageing/afw039l.    

Five-year Kaplan–Meier survival curve for the outcome of mortality for categories of fit, mild frailty, moderate frailty and severe frailty (internal validation cohort).

Andrew Clegg et al. Age Ageing 2016;ageing.afw039

© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.

Iden1fy  frailty  using  tests..  

– Walking  speed  (gait  speed)  -­‐  Gait  speed  is  usually  measured  in  m/s  and  recorded  recorded  over  a  4m  distance.  Speed  <  0.8  m/s  or  >5s  to  walk  4m.  

– Timed  up  and  go  test  -­‐  The  TUGT  measures,  in  seconds,  the  1me  taken  to  stand  up  from  a  standard  chair,  walk  a  distance  of  3  metres,  turn,  walk  back  to  the  chair  and  sit  down.  TUGT  >10secs  

– PRISMA  7  Ques3onnaire  –  A  7-­‐  item  ques1onnaire  to  iden1fy  disability.  Score  of  >  3  is  considered  to  iden1fy  frailty  

 

Iden1fying  frailty  clinical  prac1ce  

Frailty  syndromes    –  Falls    –  Reduced  mobility    –  Delirium  –  Incon1nence  -­‐  urgency  –  Heightened  Sensi1vity  to  drug  effects  –  UTI  –  ACOPIA  and  ‘Social  admission’,  bed  blockers,  frequent  flyers  

Fit  for  Frailty  1  2014    •  Guidance  to  support  health  and  social  care  professionals  in  the  community,  outpa1ent  clinics,  community  hospitals  and  other  intermediate  care  sepngs  and  in  older  people's  own  homes  

•  Advice  about  ac1ons  to  prevent  the  adverse  outcomes  associated  with  frailty  and  help  people  live  as  well  as  possible  with  frailty.  

•  Many  older  people  with  frailty  in  crisis  will  manage  beMer  at  home  of  there  are  the  right  support  systems  For  more  informa+on  on  frailty  read  BGS  Fit  for  Frailty  1&2h7p://www.bgs.org.uk/index.php/fit-­‐for-­‐frailty  

Fit  for  Frailty  2  2014  Premises  underpinning  frailty  services    1.  Interven1ons  across  health  and  social  care  aimed  

at  improving  physical,  mental  and  social  func1oning  to  avoid  adverse  events  like  hospitalisa1on  vs  strictly  disease-­‐  orientated  biomedical  approach    

2.   Individualised  treatment  and  interven1ons  3.   Sustained  support  over  a  long  1me  that  con1nues  

even  through  intervening  crises  and  adverse  events.    

4.  Interven1on  plan  that  enables  par3cipa3on  of  the  older  person.  

5.   Engagement  with  the  family  and/  or  carers    

NICE  (NG56)  Mul3morbidity:  Clinical  assessment  and  management.  2016  •  To  op1mise  care  for  adults  with  mul1morbidity  by  reducing  treatment  burden  (polypharmacy  and  mul1ple  appointments)  and  unplanned  care.    

•  To  improve  QoL  by  promo1ng  shared  decisions  based  on  what  is  important  to  each  person  (treatments,  health  priori1es,  lifestyle  &  goals)    – Who  will  benefit  from  this  approach  – How  to  iden1fy  them  (incl.  frailty)  – What  the  care  involves  

Managing  Frailty  Can  we  stop  or  reverse  frailty?  •  Evidence  for  exercise  train  programmes  to  address  sarcopenia  

•  Mul1  faceted  approach  to  target  the  specific  characteris1cs  (Cameron  et  al  2013)  

 How  do  we  manage  the  effects?  •  Comprehensive  Geriatric  Assessment    •  Meta  analysis  of  controlled  trials  of  CGA  in  acute  hospitals  on  emergency  pa1ents  (Ellis  et  al  2011).  

•  Less  likely  to  die  •  More  Likely  to  end  up  living  at  home,  with  cost  reduc1on  

Comprehensive  Geriatric  assessment  

•  A  mul1dimensional,  interdisciplinary  diagnos1c  process  focused  on  determining  a  frail  older  person’s  medical,  psychological  and  func1onal  capability,  in  order  to  develop  a  coordinated  and  integrated  plan  for  treatment  and  long-­‐term  follow-­‐up    

The  Comprehensive  Geriatric  Assessment  

Care  plan  •  Named  co-­‐ordinator  •  Main  &  Current  Issues    •  Management/Maintenance  Plan  –  With  goals  and  solu1ons,  Who  is  responsible  for  carrying  out?  ,  1mescales,  review  

•  Escala3on  Plan  –  What  to  look  out  for,  What  to  do  /  Who  to  contact?  

•  Urgent  care  Plan-­‐  for  crisis  •  Overall  aim  is  Comfort  –  for  pallia1ve  treatment  only,  even  in  life  threatening  situa1ons    

•  Advanced  care  plan  /End  of  Life  Plan  agreed  /  just  in  case  medicines  

What  principles  can  be  applied  to  medicines  op1misa1on?  

•  iden1fica1on  during  pharmacy  interven1on  e.g  medicines  review  so  we  don’t  cause  harm  by  intervening  

•  Conduct  evidence-­‐based  medica1on  reviews  for  older  people  with  frailty  (e.g.  STOPP  START  criteria).  

•  Use  clinical  judgment  and  personalised  goals  when  deciding  how  to  apply  disease-­‐based  clinical  guidelines  to  the  management  of  older  people  with  frailty.  

•  Generate  a  personalised  shared  care  and  support  plan  (CSP)  outlining  treatment  goals,  interven1ons,  follow  up  review,  crisis  plan  

Frailty  Polypharmacy  and  Medicines  Op1misa1on  

Nina  BarneM  and  Lelly  Oboh  Consultant  Pharmacists,  Care  of  older  people  

November  2016      

Medicines  Op3misa3on  Outcome  focused  approach  to  safe  and  effec3ve  use  of  medicines  that  takes  into  account  the  pa3ent’s  values,  percep3on  and  experience  of  

taking  their  medicines    

hMp://www.rpharms.com/promo1ng-­‐pharmacy-­‐pdfs/helping-­‐pa1ents-­‐make-­‐the-­‐most-­‐of-­‐their-­‐medicines.pdf  

Important  Outcomes  for  adults  •  Improved  quality  of  life  •  Making  a  posi1ve  contribu1on  •  Improved  health  and  emo1onal  

wellbeing  •  Personal  Dignity  •  Control  and  choice  •  Economic  wellbeing  •  Freedom  from  discrimina1on  

Frailty,  polypharmacy  and  mortality    2350  French  older  people  •  Independent  and  combined  effects    of  polypharmacy  and  frailty  on  mortality  risk  

•  6x  increased  risk  of  death  in  frailty  vs.  robust  and  non  polypharmacy  (>5  drugs)  

•  3x  more  likely  to  be  on  5  drugs  •  6x  more  likely  to  be  on  10  drugs      •  High  risk  prescribing  (polypharmacy,  an1cholinergic)  can  contribute  to  frailty  (Gnjidic  D  et  al  2012)  

Herr  M  et  al  2015  Pharmacoepidemiol  Drug  Saf.  2015  Jun;24(6):637-­‐46  

Implica1ons  for  medicines  op1misa1on    

Evidence:  Pharmacist  led  interven3ons  reducing  hospital  admissions  

•  No  evidence  of  impact  of  medica1on  reviews  on  hospital  bed  use  (Philp  I  et  al  IJIC  2013)  

•  Systema1c  reviews  and  Meta  analysis  (Thomas  R  Age  and  Ageing  2014)  –  Interven1ons  led  by  hospital  pharmacists  reduce  unplanned  hospital  

admissions  in  older  pa1ents  with  heart  failure  (3RCTs)  –  Interven1ons  led  by  hospital  or  community  pharmacists  for  the  general  

older  popula1on  do  not  reduce  unplanned  admissions  (16  trials)  

•  Many  interven1ons  that  might  be  expected  to  avoid  admissions,  including  home  based  medica1on  reviews  do  not  (Kings  Fund  2010)    

•  BoMom  line……  No  robust  evidence  that  pharmacist  led  interven1ons  reduce  hospital  admissions  in  older  people  

Moving  towards  medicines  op3misa3on  

Pa3ent  iden3fica3on  •  From  drug  related  to  pa1ent  centred,  real  need  vs  poten1al  need  •  Most  frail  elderly  have  high  risk  factors!  Find  them,  find  the  drugs!  Assessments  and  reviews-­‐  approach  and  scope  •  From  drug  reviews  to  holis1c  and  pa1ent-­‐centred  incl.  social  

vulnerability,  func1onal  status  as  well  as  drugs  and  disease  •  Including  evidence  base,  then  individualising  drug  therapy  

according  clinical  judgement  and  pa1ent  narra1ve  Interven3ons  •  General  fixed  solu1ons  to  individualised  jointly  agreed  solu1ons  •  Working  in  silo  to  collabora1ve  and  MDT/integrated  working  •  Pharmacist  to  pharmacist  referrals  •  Care  coordina1on-­‐led  by  pharmacist  as  expert  in  use  of  medicines   1.  Heather Smith  et  al  2013.  Integrated  Medicines  oP1misA1on  on  Care  Transfer  (IMPACT)  project    

2.  Nina  BarneM  et  al  2016.  Impact  of  an  integrated  medicines  management  service  on  preventable  medicines-­‐related  readmission  to  hospital:  a  descrip1ve  study.  Eur  J  Hosp  Pharm  doi:10.1136/ejhpharm-­‐2016-­‐000984  

3.  Blagburn  J  et  al  2015.  Pa1ent-­‐centred  pharmaceu1cal  care  to  reduce  avoidable  drug  related  readmission.  Eur  J  Hosp  Pharm  2016;23:80-­‐85  doi:10.1136/ejhpharm-­‐2015-­‐000736  

4.  Oboh  L,  Qadir  MS.  Deprescribing  and  managing  polypharmacy  in  frail  older  people:  a  pa1ent-­‐centred  approach  in  the  real  world.  Eur  J  Hosp  Pharm  2016;  doi:10.1136/ejhpharm-­‐2016-­‐001008Heather Smith  et  al  2013.  Integrated  Medicines  oP1misA1on  on  Care  Transfer  (IMPACT)  project    

How  should  we  be  different?  

•  Leading  medicines  op1misa1on  (over  and  above  reviewing  medicines  lists)  

•  Care  co-­‐ordinators  •  Enablers  •  Pa1ent  Advocates    •  Safety  and  Governance  leads  

Improved  Consulta3ons      

•  Clinical  pharmacists  and  pa1ents  encounters  moved  from  giving  informa1on  to  pa1ent  led  conversa1ons,    with  shared  agenda,    shared  treatment  decisions  and  joint  solu1ons  to  problems  iden1fied  

Structuring  a  consulta1on  

Managing  short  consulta3ons  The  Four  E’s  – EXPLORE  – EDUCATE  – EMPOWER  – ENABLE  Requires  a  prac%%oner  engagement  and  empathy  with  the  pa3ent    

BarneM  2011  

A patient-centred approach to managing polypharmacy

 

   

     

 

©  N  BarneM  L  Oboh  K  Smith  NHS  Specialist  Pharmacy  Service  2015    

 Iden1fy  or  receive  referral  for  frail  older    

person  

Thank  you