SAFE ClinicSuccessful Aging & Frailty EvaluationUniversity of Chicago – Geriatrics and Palliative Medicine

Internal Medicine Resident RotationKatherine Thompson, MD & Patricia Rush, MD

Objectives: SAFE Clinic

• Define frailty and identify frail patients

• Practice and interpret:

• cognitive assessment

• functional assessment

• Appreciate importance of interdisciplinary care

for frail patients

• Appreciate relevance of geriatric assessment to your

future practice

Case StudyMrs. Thomas (82 y/o woman) comes to Clinic with her son.

Son is concerned that Mrs. Thomas is not doing well.

On exam, patient is pleasant, quiet, cooperative.

BP 154/70, HR 70 regular, RR 16. Weight 154 lb.

Exam is generally unremarkable. HEENT, Cardiac, Lungs, Abdomen all negative. Has 1+ edema over ankles. Has good sitting balance, but uses arms to arise from chair and stumbles on her way to the exam table.

Labs: CBC, BMP, TSH from 3 months ago were basically normal.Hgb 11.2. GFR 50.

WHAT ELSE DO WE NEED TO KNOW?

Case Study

BACKGROUND:• Mrs. Thomas is a widow. Husband died 6 yr ago• Mrs. Thomas lives alone. Sons brings her groceries once a week.

Pt administers her own medication.• Son feels mother is depressed - does not attend family events. • Son states patient is slow to answer phone when he calls and

seems sort of confused. Last week, she thought he was his father (deceased 6 yr ago)

• Son suspects mother has fallen because he sees bruises. Mrs. Thomas denies she has fallen

• Review of chart shows patient has lost 7 lb in past 2 years.

WHAT IS GOING ON ??

Definition of Frailty• Diminished capacity to withstand stress • Progressive• At risk - adverse health outcomes,

increased mortality• Associated with chronic disease• Worsens with advancing age• Marked by a transition from

independence to dependence on caregivers

Measurement of Frailty

• Clinical features: ≥ 3 meets Criteria for Frailty• Weakness• Weight loss• Poor energy • Low physical activity• Slowness

• At risk for adverse outcomes• Falls• New or worsened ADL impairment• Hospitalization• Death

Syndrome of Frailty

• Other associated features– Cognitive impairment– Balance/motor impairment– Depression, anxiety, loneliness– Poor quality sleep– Low self-rated health– Inadequate social support

Biologic Basis of Frailty

• Dysregulation across more than one of these physiological systems is associated with greater risk of frailty

• Despite growing understanding of biology, diagnosis of frailty remains clinical

Biologic Basis of Frailty

• Loss of skeletal muscle• Decreases in estrogen, testosterone, growth

hormone, and insulin-like growth factor 1• Increases in interleukin 6, C-reactive protein,

tissue plasminogen activator, and D-dimer• No diagnostic laboratory test is available

Under-recognition of Frailty by Clinicians

• Frailty does not fit into classic organ-specific models of disease.

• Subtle decline may not be evident to clinicians, family members, or patients

• Declines in strength, endurance, and nutrition may not cause patients to seek medical attention and may hinder their doing so

Why should I care?• Frail patients are internal medicine

patients (increasing numbers every year)

• Ability to identify frailty will affect your medical decision-making and treatments regardless of specialty– from chemotherapy to cardiac

catheterization to colon cancer screening

• Inability to identify frailty will result in bad outcomes for you and your patients

Frailty Assessment as a Prognostic Tool: Survival by Frailty Stratification

How does Frailty comparewith CoMorbidity and Disability?

CoMorbidity = presence of 2 or more significant chronic illnesses

Disability = inability to perform 1 or moreActivities of Daily Living (ADL)

Ambulating, Toileting, Showering, Dressing, Eating

Frailty: distinct entity

Fried, LP et al. Journal of Gerontology, 56A: M146-156, 2001

Clinical Application of Frailty AssessmentPreoperative Surgical Risk

Makary, Martin, et.al. Frailty as a Predictor of Surgical Outcomes in Older Patients, J Am Coll Surg 2010; 210:901–908

• Standard indications for medical or surgical interventions might not be generalizable to older patients because physiologic changes from aging can alter the risk-to-benefit analysis.

• Goal: reduce postoperative complications in older patients

• Postoperative complications in patients aged 80 and older increase 30-day mortality by 26%

Johns Hopkins Dept of Surgery – 2010

Frailty as Risk for Surgical OutcomesMakary, Martin, et.al. Frailty as a Predictor of Surgical Outcomes in Older Patients,

J Am Coll Surg 2010; 210:901–908

STUDY DESIGN:

• Prospectively measured Frailty in 594 patients (age 65 years or older) presenting to a university hospital for elective major surgery between July 2005 and July 2006.

• Frailty was classified using a validated scale (0 to 5) – Fried’s Criteria- weakness, weight loss, exhaustion, low physical activity, and slowed walking speed.

• Main outcomes measures: 30-day surgical complicationsLength of stayDischarge disposition.

RESULTS: Frailty and Surgical Outcomes

• Preoperative frailty was associated with an increased risk for postoperative complications– Intermediately frail: odds ratio [OR] 2.06– Frail: OR 2.54;

• Increased length of stay– Intermediately frail: incidence rate ratio 1.49– Frail: incidence rate ratio 1.69

• Discharge to a skilled or assisted-living after living at home– Intermediately frail: OR 3.16– Frail: OR 20.48

• Frailty improved predictive power (p 0.01) of each risk index (American Society of Anesthesiologists, Lee, and Eagle scores).

SAFE ClinicSuccessful Aging & Frailty EvaluationUniversity of Chicago – Geriatrics and Palliative Medicine

Research – Patient Care

SAFE Clinic AssessmentResearch

• Informed consent obtained

• Demographics (age, race, education, income, living situation, height, weight, BMI)

• EPIC data (problem list, meds)

• MD Progress note (acute issues, sensory impairment, assist devices-cane or wheelchair, recent hospitalizations, other pertinent)

SAFE – Initial Assessment• Vulnerable Elder Survey

(VES-13) Self-rated health & functional status

• Comorbidities (Charlson comorbidity index)

• Falls (AGS falls questions)• Sleep (Pittsburgh Sleep Index)

• Depression (PHQ-2)• Pain (Pain map & pain thermometer)• Stress• Caregiver strain

SAFE – Initial Assessment• Cognition (MOCA +/- MMSE)

• Physical function (Short physical performance battery)

1) Stands (side-by-side, semi-tandem, tandem, hold for 10 seconds)2) Chair stands (5 stands from chair, without using arms)3) Measured walks (2 timed 4-meter walks, take faster time, goal = less than 8.7 sec)

Frailty (Fried’s Frailty Criteria)≥ 3 meets Frailty Criteria

• Weakness– Low grip strength– Standardized using a dynamometer

• Weight loss– > 5% weight loss, or 10 lbs in 1 year– “In the last year, did you lose 10 lbs or more,

not on purpose?”

• Slowed gait speed– Time to walk 15 feet at usual pace– Slow = ≥ 6 or 7 sec. depending on gender, height

Frailty (Fried’s Frailty Criteria)≥ 3 meets Frailty Criteria

• Fatigue/low energy– “How often in the last week did you feel that everything you did

was an effort?” and “How often would you say you could not get going?”

– Significant response = “moderately often” or more on ≥ 3 days in the last week

• Low physical activity– Calculated Kcal expenditure based on standardized instrument

(Minnesota leisure time activities questionnaire)

SAFE Clinic: Patient Care

• Identify patients: Not FrailPre-frail or intermediate,

or Frail• Provide individualized education, resources• Management strategies:

– Improve core manifestations of frailty: physical activity, strength, exercise tolerance, nutrition

– Exclude modifiable precipitating factors– Minimize consequences of vulnerability

Patient Care: Return Visit

• Interdisciplinary team– Assessment– Care planning

• Patient follow up– Results of assessment– Recommendations provided to patient & PCP– Patient education materials and resources– Consult letter dictated with recommendations

• Anticipate follow up visits q6-12 months for tracking

SAFE: Patient Recommendations

Vigorous - Not Frail:

Focus on:• exercise• social support• vision/hearing screen• preventive evaluations• tight control of medical

conditions such as HTN, DM• smoking cessation

SAFE: Patient Recommendations

Pre-frail – OPPORTUNITY• Emphasize exercise or PT

for strength and balance, fall prevention.

• Nutrition assessment• Driving - home safety eval• Social support• Watch for depression and

cognitive changes • Regular medical followup;

smoking cessation.

SAFE: Patient Recommendations

Frail: Fragile – Handle with Care

Focus:• Hospitalization avoidance• Fall prevention• Review benefits/burdens of treatments• Advance Care Planning• Medication management

- minimize # of meds # doses• Anticipate caregiver stress

SAFE Clinic Team Members:

• FACULTY:– Patricia Rush, MD MBA– Katherine Thompson, MD– William Dale, MD PhD– Joseph Shega, MD

• Geri Fellow: Megan Huisingh-Scheetz, MD

• Adv Practice Nurse: Lisa Mailliard, Geri Specialist

• Social Work:– Patricia MacClarence, LCSW– Jeffrey Solotoroff, LCSW