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The Hospitalized Frail ElderThe Hospitalized Frail ElderTeaching Strategies for Teaching Strategies for Identification & AssessmentIdentification & Assessment

Paula M. Podrazik, MDPaula M. Podrazik, MD

University of ChicagoUniversity of Chicago

New AdmissionNew Admission

Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPMrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPadmitted for wt. loss, confusion, falls. Recentlyadmitted for wt. loss, confusion, falls. Recentlyhospitalized at an outside institution.hospitalized at an outside institution.Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax qMeds: glipizide, lisinopril, lasix, asa, celebrex, fosamax qweekweekExam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84RR 16 Lungs clear, Cor RRR, Neuro non-focalRR 16 Lungs clear, Cor RRR, Neuro non-focalER evaluation—unremarkable blood work, CT head—ER evaluation—unremarkable blood work, CT head—no bleedno bleedIntern reports patient is at baseline per daughter andIntern reports patient is at baseline per daughter andcomments patient is just a “FTT.”comments patient is just a “FTT.”

Questions raisedQuestions raised

What is the importance of identifying What is the importance of identifying frailty in the hospital setting?frailty in the hospital setting?

How do you recognize frailty ?How do you recognize frailty ?How do you define frailty in the How do you define frailty in the

aging?aging?What do you need to screen in the What do you need to screen in the

suspected frail patient during suspected frail patient during hospitalization?hospitalization?

Aging patients & the hospital Aging patients & the hospital settingsetting

High rates of hospitalizationHigh rates of hospitalizationAccount for 47% of all inpatient days Account for 47% of all inpatient days

(but represent only 13% of the (but represent only 13% of the population)population)

Age 85 and over, twice hospitalization Age 85 and over, twice hospitalization riskrisk

High rates of readmissionHigh rates of readmission25% of hospital admissions represent 25% of hospital admissions represent

readmission of older adultsreadmission of older adultsCost--outcomesCost--outcomes

Fethke CC, Smith IM, Johnson N. Medical Care. 1986;24:429-437Graves EJ, Gillum BS. National Hospital Discharge Survey: annual summary, 1994. Vital Health Stat. 1997;13:128

Worse outcomes for Worse outcomes for hospitalized hospitalized Older AdultsOlder Adults

DeliriumDelirium Iatrogenic ComplicationsIatrogenic ComplicationsFunctional declineFunctional declineNursing home placementNursing home placementHospital readmissionHospital readmissionCaregiver stressCaregiver stressMortalityMortality

Risk of rehospitalization—one Risk of rehospitalization—one outcomes look at frailtyoutcomes look at frailty

Age over 80Age over 80 Inadequate social supportInadequate social support Multiple active chronic health problemsMultiple active chronic health problems History of depressionHistory of depression Moderate-severe functional impairmentModerate-severe functional impairment Multiple hospitalizations past 6 monthsMultiple hospitalizations past 6 months Hospitalization past 30 daysHospitalization past 30 days Fair or poor health self ratingFair or poor health self rating History of non-adherence to medical regimenHistory of non-adherence to medical regimen

Naylor M, Brooten D, Campbell, et al. JAMA. 1999;17:613-620Naylor M, Brooten D, Campbell, et al. JAMA. 1999;17:613-620

Hospitalization Outcome: The Hospitalization Outcome: The tension tension for the Hospitalized Aging Patientfor the Hospitalized Aging Patient

Baseline Frailty

Acute illness Hazards of the Hospitalization

Hospitalization Outcome

Words that trigger the Words that trigger the need to ID & teach about need to ID & teach about frailtyfrailty

Failure to thriveFailure to thrive Dwindles Dwindles Declining Declining A/O x 1 or 2 A/O x 1 or 2 Confused Confused Poor historianPoor historianMalodorousMalodorousRecent dischargeRecent discharge UnkemptUnkemptNursing homeNursing homeWeight lossWeight lossAge 75 or overAge 75 or overNon-compliantNon-compliantNeeds assistance/ has caregiverNeeds assistance/ has caregiverFallsFalls

New Admission—Triggers to New Admission—Triggers to TeachTeachID/discuss frailtyID/discuss frailty

Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPMrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPadmitted for wt. loss, confusion, falls.admitted for wt. loss, confusion, falls.Recently hospitalized at an outside institution.Recently hospitalized at an outside institution.Meds: glipizide, lisinopril, lasix, asa, celebrex, Meds: glipizide, lisinopril, lasix, asa, celebrex,

fosamaxfosamaxq weekq weekExam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P

8484RR 16 Lungs clear, Cor RRR, Neuro non-focalRR 16 Lungs clear, Cor RRR, Neuro non-focalIntern reports patient is at baseline per daughter Intern reports patient is at baseline per daughter

andandcomments patient is just a “FTT.”comments patient is just a “FTT.”

Describe the Aging PopulationDescribe the Aging Population

Heterogeneous PopulationHeterogeneous PopulationFactors that contribute to Factors that contribute to

heterogeneityheterogeneityAging physiologyAging physiologyCollected co-morbid conditionsCollected co-morbid conditionsFunctional statusFunctional status

Functional Reserve of Older Functional Reserve of Older AdultsAdults

Vision loss: 27% those over age 85Vision loss: 27% those over age 85 Cognitive impairment: 50% over age 85Cognitive impairment: 50% over age 85 Assistance w/ADL: > 50% over age 85 Assistance w/ADL: > 50% over age 85 Functional reserve losses impact on an Functional reserve losses impact on an

acute illness:acute illness:PresentationPresentationTreatment Treatment Morbidity & Survival Morbidity & Survival RecoveryRecovery

What is frailty?What is frailty?

Being dependent on othersBeing dependent on others Having many chronic illnessesHaving many chronic illnesses Experiencing “uncoupling with the environment”Experiencing “uncoupling with the environment” Being at substantial risk of dependency & other adverse Being at substantial risk of dependency & other adverse

health outcomeshealth outcomes Having complex medical & psychosocial problemsHaving complex medical & psychosocial problems Having “atypical” disease presentationsHaving “atypical” disease presentations Having many chronic illnessesHaving many chronic illnesses Being able to benefit from specialized geriatric programsBeing able to benefit from specialized geriatric programs Experiencing accelerated agingExperiencing accelerated aging

Rockwood, et al. Can Med Assoc J 1994;150:489-95.Rockwood, et al. Can Med Assoc J 1994;150:489-95.Bortz WM. J AM Geriatr Soc 1993;41:1004-8. Bortz WM. J AM Geriatr Soc 1993;41:1004-8. Fried L, et al. J Gerontol Medical Sciences 2001; 56A(3): M146-M156.Fried L, et al. J Gerontol Medical Sciences 2001; 56A(3): M146-M156.

Defining FrailtyDefining Frailty

Definition must include:Definition must include:Association with agingAssociation with agingMulti-system impairmentMulti-system impairmentInstabilityInstabilityChange over timeChange over timeAllowance for heterogeneity within the Allowance for heterogeneity within the

populationpopulationAssociation with an increased risk of adverse Association with an increased risk of adverse

outcomesoutcomes

Rockwood K, et al. Drugs & Aging 200 Oct 17(4):295-302Rockwood K, et al. Drugs & Aging 200 Oct 17(4):295-302

ACOVE–a model to ACOVE–a model to ID/define the Vulnerable ID/define the Vulnerable Elder “in vivo”Elder “in vivo”

Assessing the Care of the Vulnerable Assessing the Care of the Vulnerable Elder: ACOVE Project OverviewElder: ACOVE Project OverviewDevelop a definition of “vulnerable elders”—Develop a definition of “vulnerable elders”—

community dwellers, >65 & at high risk of community dwellers, >65 & at high risk of functional decline or deathfunctional decline or death

Develop system to IDDevelop system to IDID medical conditions for which effective ID medical conditions for which effective

methods of prevention& management existmethods of prevention& management existDevelop set of Quality IndicatorsDevelop set of Quality Indicators

Wenger NS, Shekelle PG, et al. Ann Int Med 2001;135(8) Supplement:642-646

Teaching about FrailtyTeaching about Frailty

Triggers to teach about frailty in the Triggers to teach about frailty in the aging hospitalized patientaging hospitalized patientAdvanced ageAdvanced ageMultiple co-morbiditiesMultiple co-morbiditiesSuspected cognitive impairmentSuspected cognitive impairmentSuspected functional impairmentsSuspected functional impairmentsPsychosocial issuesPsychosocial issuesSensory impairmentsSensory impairments

Frailty Suspected:Frailty Suspected:Why to Screen?Why to Screen?

PreventionPrevention Impact on OutcomesImpact on Outcomes

Prognostic Index for 1-year Prognostic Index for 1-year Mortality in Older Hospitalized Mortality in Older Hospitalized AdultsAdults

2 prospective studies—age> 70, assess 2 prospective studies—age> 70, assess 1-year mortality, points assigned—1-year mortality, points assigned—

mortality risk calculated.mortality risk calculated. Independent risk factors:Independent risk factors:

Male sexMale sex#of dependent ADLs#of dependent ADLsCACACHFCHFCr>3.0Cr>3.0Low albumin levelLow albumin level

Walter LC, et al. JAMA June 2001; 285(23):2987-2994

Comprehensive Assessment:Comprehensive Assessment:Impact on outcomesImpact on outcomes

Meta-analysis of Comprehensive Geriatric Meta-analysis of Comprehensive Geriatric Assessment programsAssessment programs

28-controlled trials, 4959 subjects 28-controlled trials, 4959 subjects allocated to one of five CGA types and allocated to one of five CGA types and 4912 controls4912 controls

Outcomes:Outcomes:Mortality—GEMU programs Mortality—GEMU programs 6 month mortality 6 month mortality

by 35%; HAS by 35%; HAS 36 month mortality by 14%36 month mortality by 14%Hospital admission—all CGA programs Hospital admission—all CGA programs

readmission rate by 12%readmission rate by 12%OR for living @ home favorable in all studiesOR for living @ home favorable in all studies

Stuck AE, Siu AL, Wieland GD, et al. Lancet 1993; 342:1032-1036

Hospital Elder Life Program:Hospital Elder Life Program:A program of preventionA program of prevention

Yale hospital system, ≥ age 70, Yale hospital system, ≥ age 70, admitted to acute care hospitaladmitted to acute care hospitalScreened for cognitive impairment, sleep Screened for cognitive impairment, sleep

deprivation, immobility, dehydration, deprivation, immobility, dehydration, vision or hearing impairmentvision or hearing impairment

Targeted interventionsTargeted interventionsOutcomesOutcomes

Decrease in functional & cognitive declineDecrease in functional & cognitive decline

Inouye S, et al JAGS 2000; 48:1697-1706

Teaching about Frailty:Teaching about Frailty:Summary teaching pointsSummary teaching points

Baseline vulnerability or frailty Baseline vulnerability or frailty affects hospital outcomesaffects hospital outcomes

High risk for worse outcomesHigh risk for worse outcomesTake measures to prevent delirium, Take measures to prevent delirium,

falls, functional declinefalls, functional decline Identifying a vulnerable elder Identifying a vulnerable elder

changes the needs of the D/C plan.changes the needs of the D/C plan.

Frailty Suspected:Frailty Suspected:What to Screen?What to Screen?

CognitionCognitionFunctionFunctionAffectAffectOtherOther

Sensory functionSensory functionSocial Social

New Admission—Triggers to New Admission—Triggers to TeachTeachCognitive ScreeningCognitive Screening

Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPMrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPadmitted for wt. loss, confusion, falls.admitted for wt. loss, confusion, falls.Recently hospitalized at an outside institution.Recently hospitalized at an outside institution.Meds: glipizide, lisinopril, lasix, asa, celebrex, Meds: glipizide, lisinopril, lasix, asa, celebrex,

fosamaxfosamaxq weekq weekExam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P

8484RR 16 Lungs clear, Cor RRR, Neuro non-focalRR 16 Lungs clear, Cor RRR, Neuro non-focalIntern reports patient is at baseline per daughter Intern reports patient is at baseline per daughter

andandcomments patient is just a “FTT.”comments patient is just a “FTT.”

How common is dementia?How common is dementia?

Age strongest risk factor for Age strongest risk factor for dementiadementiaAt age 65, prevalence 8-12%At age 65, prevalence 8-12%At age 85, prevalence 50%At age 85, prevalence 50%

Persons with dementia in US- 4 Persons with dementia in US- 4 millionmillion

Projected number by 2040- 14 millionProjected number by 2040- 14 million

Dementia and DeliriumDementia and Delirium

MMSE >24/30MMSE >24/30→→ Delirium risk Delirium risk 2.822.82(1.19-6.65)(1.19-6.65)

Delirium associated with worse outcomesDelirium associated with worse outcomes Orientation board and cognitive Orientation board and cognitive

stimulation decreased confusion 26% vs. stimulation decreased confusion 26% vs. 8% 8%

* Confusion = loss of 2 points on MMSE* Confusion = loss of 2 points on MMSE

Inouye SK, et al Ann Intern Med 1992;119:474-481

Cognitive Impairment & Cognitive Impairment & Functional Decline with AgingFunctional Decline with Aging

Cognitive impairment associated with Cognitive impairment associated with functional decline during acute illnessfunctional decline during acute illness

Study Design:Study Design:Cognitive screen grouped admissions:Cognitive screen grouped admissions: No impairmentNo impairment

Mild impairmentMild impairmentModerate/severe impairmentModerate/severe impairment

ADL/IADL/mobility measured 2 weeks prior ADL/IADL/mobility measured 2 weeks prior admission, discharge, 30 and 90 days.admission, discharge, 30 and 90 days.

Sands L, Yaffe K, Covinski K, et al. Journal of Gerontology: Medical Sciences 2003;58:37-45.Sands L, Yaffe K, Covinski K, et al. Journal of Gerontology: Medical Sciences 2003;58:37-45.

Cognitive status on admission & Cognitive status on admission & risk new NH placement at risk new NH placement at hospital D/Chospital D/C

Cognitive statusCognitive status Rate/odds NH Rate/odds NH

NoneNone 7.5% 1.0 7.5% 1.0

MildMild 13% 1.49(1-2.22) 13% 1.49(1-2.22)

Moderate-severeModerate-severe 29% 3.40(2.48-4.68) 29% 3.40(2.48-4.68)

Risk NH placement at 90 days Risk NH placement at 90 days after hospitalization vs. after hospitalization vs. cognitive statuscognitive status

Cognitive statusCognitive status Rate/Odds NHRate/Odds NH

NoneNone 4.1% 1.04.1% 1.0MildMild 11.7% 2.8011.7% 2.80(1.75-(1.75-

4.46)4.46)

Moderate-severeModerate-severe 26.7% 6.6726.7% 6.67(4.52-(4.52-8.67)8.67)

Screen for Cognitive Screen for Cognitive Impairment: Summary Impairment: Summary Teaching PointsTeaching Points

Prevent deliriumPrevent deliriumPrevent functional declinePrevent functional declinePrevent iatrogenic injury—esp. med Prevent iatrogenic injury—esp. med

choice & avoidance of restraintschoice & avoidance of restraintsTransition care appropriatelyTransition care appropriately

Screening Cognitive ImpairmentScreening Cognitive Impairment

Patient measure:Patient measure:Mini Mental Status Exam (MMSE)Mini Mental Status Exam (MMSE)Mini-cogMini-cog

Proxy measureProxy measure

Folstein MMSEFolstein MMSE

30 point screening test30 point screening test Screens multiple cognitive domainsScreens multiple cognitive domains Not a direct screen of executive functionNot a direct screen of executive function Studies usually use cut off 24 for positive Studies usually use cut off 24 for positive Reliability of results dependent on age & Reliability of results dependent on age &

education education

Folstein M, Folstein S, McHugh P. J Psychiatr Res. 1975;12:189-198Folstein M, Folstein S, McHugh P. J Psychiatr Res. 1975;12:189-198

Troubleshooting the MMSETroubleshooting the MMSE

Validation done under rigorous technique Validation done under rigorous technique Serial 7’s vs. spelling WORLD backwards Serial 7’s vs. spelling WORLD backwards

88thth grade education or < grade education or < →→ WORLD WORLD>8>8thth grade education grade education→→ serial 7’s serial 7’s

Administer in quiet, non-threatening Administer in quiet, non-threatening environment environment

Correct sensory deficits as much as Correct sensory deficits as much as possiblepossible

Reminders about MMSEReminders about MMSE

Screening test for cognitive impairmentScreening test for cognitive impairmentCan help to risk stratify— delirium, Can help to risk stratify— delirium,

functional decline, iatrogenic injury, functional decline, iatrogenic injury, pressure ulcerspressure ulcers

Useful as a baseline to monitor changeUseful as a baseline to monitor changeNot a determination of decision-making Not a determination of decision-making

capacitycapacity

Screening Tools: Mini-cogScreening Tools: Mini-cog

Step 1:Remember & repeat three unrelated wordsStep 1:Remember & repeat three unrelated words Step 2: Clock-drawing test (CDT)—distracter Step 2: Clock-drawing test (CDT)—distracter Step 3: Repeat 3 previously presented wordsStep 3: Repeat 3 previously presented words Step 4: Scoring:1 pnt. for each recalled wordStep 4: Scoring:1 pnt. for each recalled word

• Score=0; + screen for dementiaScore=0; + screen for dementia• Score=1-2 with abnl CDT; + screen for dementiaScore=1-2 with abnl CDT; + screen for dementia• Score=1-2 with nl CDT; neg. screen for dementiaScore=1-2 with nl CDT; neg. screen for dementia• Score=3; neg. screen for dementiaScore=3; neg. screen for dementia

Borson S, et al. Int J Geriatr Psychiatry2000;15:1021-1027

Screening Tests for Cognition:Screening Tests for Cognition:Summary Teaching PointsSummary Teaching Points

Mini-cog—quick bedside toolMini-cog—quick bedside toolMMSE—screening tool onlyMMSE—screening tool only If patient screens positive:If patient screens positive:

Use orientation boardUse orientation boardEarly mobilizationEarly mobilizationDischarge plan—unique D/C needsDischarge plan—unique D/C needsScreen for functional, sensory Screen for functional, sensory

impairmentsimpairments

New Admission—Triggers to New Admission—Triggers to TeachTeachphysical function screeningphysical function screening

Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPMrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPadmitted for wt. loss, confusion, falls.admitted for wt. loss, confusion, falls.Recently hospitalized at an outside institution.Recently hospitalized at an outside institution.Meds: glipizide, lisinopril, lasix, asa, celebrex, Meds: glipizide, lisinopril, lasix, asa, celebrex,

fosamaxfosamaxq weekq weekExam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P

8484RR 16 Lungs clear, Cor RRR, Neuro non-focalRR 16 Lungs clear, Cor RRR, Neuro non-focalIntern reports patient is at baseline per daughter Intern reports patient is at baseline per daughter

andandcomments patient is just a “FTT.”comments patient is just a “FTT.”

Functional Screening:Functional Screening:What are we talking about?What are we talking about?

Gait assessmentGait assessment

Activities of daily living (ADL)Activities of daily living (ADL)

BathingBathing

DressingDressing

ToiletingToileting

TransferringTransferring

FeedingFeeding

Instrumental activities of daily living (IADL)Instrumental activities of daily living (IADL)Use telephoneUse telephoneManage financesManage financesShopShopArrange transportationArrange transportationManage medicationsManage medicationsCookingCooking

Functional Decline Occurs Functional Decline Occurs in the Hospitalin the Hospital

Functional limitations increase with Functional limitations increase with age.age.

Functional decline occurs in approx. Functional decline occurs in approx. 34-50% hospitalized older pts.34-50% hospitalized older pts.

Impact of acute illnessImpact of acute illnessImpact of hospitalizationImpact of hospitalization

Interventions can decrease functional Interventions can decrease functional decline (Hospital Elder Life Program).decline (Hospital Elder Life Program).Functional status determines D/C plan.Functional status determines D/C plan.

Summary of functional Summary of functional outcomes during outcomes during hospitalizationhospitalization

At dischargeAt discharge→→31% declined31% declined At 3 monthsAt 3 months→→59% recovered lost function 59% recovered lost function

but 41% failed to return to pre-admission but 41% failed to return to pre-admission level of functionlevel of function

At 3-monthsAt 3-months→ → 22% re-hospitalized & 22% re-hospitalized & association with functional decline association with functional decline significantsignificant

Functional loss was associated with a Functional loss was associated with a significantly higher 3 month mortalitysignificantly higher 3 month mortality

Patient factors associated Patient factors associated with functional declinewith functional decline

older ageolder agepreadmission functional impairmentpreadmission functional impairment lower MMSE on admissionlower MMSE on admissionre-hospitalizationre-hospitalization

Sager M, Franke T, Inouye S, et al. Arch Intern Med. 1996;156:645-652. Sager M, Franke T, Inouye S, et al. Arch Intern Med. 1996;156:645-652.

Worse health outcomes with Worse health outcomes with functional declinefunctional decline

Prolonged hospital stayProlonged hospital stayHigher mortality—twice the riskHigher mortality—twice the riskHigher rates of institutionalizationHigher rates of institutionalizationHigher health care expenditureHigher health care expenditure

Who is at risk functional Who is at risk functional decline during a hospital decline during a hospital stay?stay?

Hospital based study @YaleHospital based study @YaleProspective cohort studyProspective cohort studyMedical inpatients > 70Medical inpatients > 70What are the risks for functional decline?What are the risks for functional decline?Functional decline: ADL lossFunctional decline: ADL lossTwo part study: Development and ValidationTwo part study: Development and Validation

Inouye S, Wagner R, Acampora D, et al. J Gen Intern Med. 1999;8:645-652.Inouye S, Wagner R, Acampora D, et al. J Gen Intern Med. 1999;8:645-652.

Independent risk factors Independent risk factors associated with functional associated with functional declinedecline

Risk FactorRisk Factor Adjusted RRAdjusted RR

Pressure UlcerPressure Ulcer 2.7(1.4-5.2) 2.7(1.4-5.2)

Cognitive impairmentCognitive impairment 1.7(0.9-3.1)1.7(0.9-3.1)

Functional impairmentFunctional impairment 1.8(1.0-1.8(1.0-3.3)3.3)

Low social activity levelLow social activity level 2.4(1.2-2.4(1.2-5.1)5.1)

How does one assess functional How does one assess functional status?status?

ReportReport

Self-reportSelf-report

Proxy reportProxy report

Direct observationDirect observation

Level of supportLevel of support

IndependentIndependent

Needs assistanceNeeds assistance

DependentDependent

Activities of Daily LivingActivities of Daily Living

BathingBathing

DressingDressing

TransferenceTransference

ContinenceContinence

FeedingFeeding

Instrumental Activities of Daily Instrumental Activities of Daily LivingLiving

Using the phoneUsing the phone

TravelingTraveling

ShoppingShopping

Preparing mealsPreparing meals

HouseworkHousework

Taking medicineTaking medicine

Managing moneyManaging money

Gait-timed Get Up and GoGait-timed Get Up and Go

Quantitative evaluation of general Quantitative evaluation of general

functional mobilityfunctional mobilityTimed command w/Timed command w/rise from chair;rise from chair;

walk 10 feet; turn around; walk back walk 10 feet; turn around; walk back

and sit in chair.and sit in chair.

Wall JC, Bell C, Campbell S, et al J Rehabil Res Dev 200 37(1):109-113

Gait assessment scoringGait assessment scoring

Usual time to completion 10 secondsUsual time to completion 10 secondsFrail elder usually < 20 secondsFrail elder usually < 20 seconds> 20 seconds needs PT evaluation> 20 seconds needs PT evaluationPerformance on test associated with:Performance on test associated with:

ADL/IADL performanceADL/IADL performance

Falls riskFalls risk

Risk of nursing home placementRisk of nursing home placement

Trigger to Teach:Trigger to Teach:Who to screen for functional Who to screen for functional impairment?impairment?

Who to screen?Who to screen? Person over the age of 70Person over the age of 70 Patient who is re-admitted in past monthPatient who is re-admitted in past month Person with at least 1 risk factorPerson with at least 1 risk factor

Cognitive impairmentCognitive impairmentFunctional impairmentFunctional impairmentPressure ulcerPressure ulcerLow social activity scoreLow social activity scoreDepressionDepression

Screen for function, cont.Screen for function, cont.

When to screen?When to screen?After stabilization of acute illnessAfter stabilization of acute illnessPrior to hospital dischargePrior to hospital discharge

What to do?What to do?Chart orders- walking and range of motion Chart orders- walking and range of motion

TIDTIDAmbulation problem- physical therapyAmbulation problem- physical therapyDressing/bathing/feeding- occupational Dressing/bathing/feeding- occupational

therapy therapy

Function & the hospitalized elder: Function & the hospitalized elder: Summary teaching pointsSummary teaching points

Functional limitations increase with ageFunctional limitations increase with age Functional decline occurs in 30-50% of Functional decline occurs in 30-50% of

hospitalized older adultshospitalized older adults Acute illness can lead to further functional declineAcute illness can lead to further functional decline Hospital care can contribute to additional Hospital care can contribute to additional

functional declinefunctional decline Models help stratify those at highest risk for Models help stratify those at highest risk for

functional declinefunctional decline Interventions decrease functional declineInterventions decrease functional decline Functional abilities help determine discharge Functional abilities help determine discharge

location and services requiredlocation and services required

Questions raisedQuestions raised

What is the importance of identifying What is the importance of identifying frailty in the hospital setting?frailty in the hospital setting?

How do you recognize frailty ?How do you recognize frailty ?How do you define frailty in the How do you define frailty in the

aging?aging?What do you need to screen in the What do you need to screen in the

suspected frail patient during suspected frail patient during hospitalization?hospitalization?

New AdmissionNew Admission

Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPMrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPadmitted for wt. loss, confusion, falls. Recentlyadmitted for wt. loss, confusion, falls. Recentlyhospitalized at an outside institution.hospitalized at an outside institution.Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax qMeds: glipizide, lisinopril, lasix, asa, celebrex, fosamax qweekweekExam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84RR 16 Lungs clear, Cor RRR, Neuro non-focalRR 16 Lungs clear, Cor RRR, Neuro non-focalER evaluation—unremarkable blood work, CT head—ER evaluation—unremarkable blood work, CT head—no bleedno bleedIntern reports patient is at baseline per daughter andIntern reports patient is at baseline per daughter andcomments patient is just a “FTT.”comments patient is just a “FTT.”

Frailty & the Hospital: Frailty & the Hospital: A Final WordA Final Word

ID and teach about frailtyID and teach about frailtyScreen for cognition, functional Screen for cognition, functional

status, psychosocial, sensory status, psychosocial, sensory impairmentsimpairments

Impairments associated with worse Impairments associated with worse outcomesoutcomes

Prevention one key.Prevention one key.The proper transition of care is the The proper transition of care is the

other.other.

Special ThanksSpecial Thanks

Joseph ShegaJoseph Shega

Don ScottDon Scott

Aliza BaronAliza Baron

Greg SachsGreg Sachs

CHAMP faculty CHAMP faculty

CHAMP faculty course participantsCHAMP faculty course participants