Using the Frail-NHand

The Rapid Geriatric Assessment (RGA)

in Long Term Care

Geriatric Workforce

Decline 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

20,195

Geriatric Assessment

• Geriatric Assessment is a systematic, interprofessional

approach to the older patient

– Diagnose geriatric syndromes

– Develop targeted treatment plans

– Improve patient outcomes

• Focus on function and quality of life

• Not based on chronological age but functional impairment

and risk of future decline

Rapid Geriatric Assessment

• Early detection of health problems when interventions are

most likely to be successful

• Used for common geriatric problems

• Ideally 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 G0439

Modern Giants of Geriatrics

Frailty

Sarcopenia

Anorexia of Aging

MCI

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

a. very poor a. very bad

b. poor b. bad

c. average c. average

d. good d. good

e. very good e. very good

When I eat Normally I eat

a. I feel full after eating a. less than one meal a day

only a few mouthfuls b. one meal a day

b. I feel full after eating c. two meals a day

about a third of a meal d. three meals a day

c. 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

e. 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 Car

2. [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_________

Strength How much difficulty do you have in None = 0

lifting and carrying 10 pounds? Some = 1

A lot or unable = 2

Assistance in How much difficulty do you have None = 0

walking walking across a room? Some = 1

A lot, use aids, or unable = 2

Rise 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

Climb stairs How much difficulty do you have None = 0

climbing a flight of ten stairs? Some = 1

A lot or unable = 2

Falls 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.

Fatigue

Resistance (Climb 1 flight stairs)

Aerobic (Walk one block)

Illnesses (more than 5 illnesses)

Loss of weight(>5% in 6 months)

FRAIL(IANA)

TWENTYVALIDATIONSAustralia(6)Hong Kong(2)St Louis(2)ChinaBaltimoreEurope (2)TurkeyKoreaTaiwanMexico(2)Singapore

1 or 2 PreFRAIL3 or more FRAIL

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

ContinenceExercises 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 shoes

Needs help with

dressing self or needs to

be completely dressed

Needs help with

dressing self or needs to

be completely dressed

& KATZ score <3

Total Score 0-14: 0-1 non frail, 2-5 frail, 6-14 severely frail

FRAIL-NH Scale

Distribution of scores for FRAIL-NH scale

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 quartile

FRAIL-NH Scale St Louis

Kaehr, Malmstrom, Pape and Morley

Deceased or Hospice

• Prefrail: 2.37 (0.77 – 7.30) p=0.135

• Frail : 3.96 (1.44-10.87) p<0.007

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, DSWf

Objectives

• To 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.

Design

Longitudinal follow-up study of nursing home

residents with annual clinical assessment using the

MDS and mortality data between 2005 and 2013.

SettingSix nursing homes operated by a nongovernmental organization in Hong Kong.

ParticipantsParticipants included 2380 nursing home residents aged 65 years or older at study baseline.

MeasurementsFrailty 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.

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 proxy

Weight 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 prosthesis

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, 1042–1047

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, 1042–1047

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),

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.

Modern Giants of Geriatrics

Frailty

Sarcopenia

Anorexia of Aging

MCI

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

a. very poor a. very bad

b. poor b. bad

c. average c. average

d. good d. good

e. very good e. very good

When I eat Normally I eat

a. I feel full after eating a. less than one meal a day

only a few mouthfuls b. one meal a day

b. I feel full after eating c. two meals a day

about a third of a meal d. three meals a day

c. 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

e. 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 Car

2. [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_________

Strength How much difficulty do you have in None = 0

lifting and carrying 10 pounds? Some = 1

A lot or unable = 2

Assistance in How much difficulty do you have None = 0

walking walking across a room? Some = 1

A lot, use aids, or unable = 2

Rise 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

Climb stairs How much difficulty do you have None = 0

climbing a flight of ten stairs? Some = 1

A lot or unable = 2

Falls 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.

Participants with a total score higher than 4 were classified as having sarcopenia

Kentaro Kamiya

1) My appetite is

1. Very poor

2. Poor

3. Average

4. Good

5. Very good

2) When I eat, I feel full after

1. Eating only a few mouthfuls

2. Eating about a third of a plateful

3. Eating over half a plateful

4. Eating most of the food

5. Hardly ever

3) Food tastes

1. Very bad

2. Bad

3. Average

4. Good

5. Very good

4) Normally I eat

1. Less than one full meal a day

2. One meal a day

3. Two meals a day

4. Three meals a day

5. More than three meals a day, including snacks

S.N.A.Q

< 15 predicts significant

weight loss within 6 months

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

30,0%

<65 65-74 75-84 85+

Not Frail 0,8% 0,8% 1,0% 0,8%

Pre-Frail 1,7% 1,9% 8,1% 6,8%

Frail 15,5% 14,3% 21,3% 27,1%

4 4 5 48 9

39 33

75 69

103

131

FRAIL Results in Nursing Homes484 Patients

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

30,0%

35,0%

<65 65-74 75-84 85+

Normal 1,6% 1,2% 5,5% 3,7%

Sarcopenia 16,2% 16,4% 24,7% 30,7%

86

2718

79 80

121

150

SARC-F Results in Nursing Homes489 Patients

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

30,0%

35,0%

<65 65-74 75-84 85+

Normal 5,7% 2,7% 5,2% 0,9%

MCI 3,0% 5,7% 4,1% 2,3%

Dementia 8% 10% 22% 31%

25

1223

413

2518

10

3542

98

134

RCS Results in Nursing Homes439 Patients

0,0%

2,0%

4,0%

6,0%

8,0%

10,0%

12,0%

14,0%

16,0%

18,0%

20,0%

<65 65-74 75-84 85+

Normal 6,8% 9,8% 15,9% 19,4%

Risk of Weight Loss 10,3% 8,5% 15,1% 14,2%

31

45

73

89

47

39

69 65

SNAQ Results in Nursing Homes458 Patients

The Medicare Annual Wellness Visit in Nursing Homes

Conclusion

• The 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