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Centre for Research in Geriatric Medicine

Centre for Research in Geriatric Medicine

THE ELDERLY SURGICAL PATIENT:

WHERE TO FROM HERE?

Associate Professor Ruth E. HubbardBSc, MBBS, MRCP, MSc, MD, FRACP

22nd October, 2016

Centre for Research in Geriatric Medicine

Yesterday’s Objectives

1. Describe and compare frailty measures

2. Consider frailty in relation to failure of a complex

system

3. Review importance of frailty in older surgical patients

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Objectives

1. Review a new instrument to measure frailty in routine

practice

2. Discuss limitations and potential pitfalls of frailty

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THE FRAILTY INDEX IN CLINICAL

PRACTICE

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FI in clinical practice

Comprehensive Geriatric Assessment (CGA) is used in

geriatric medicine to capture relevant information about

the health status and function of an older person

The information collected as part of CGA comprises

assessments of function, co-morbidities and cognitive/

psychological status

This data can be coded as deficits and used to derive a

Frailty Index score - the FI-CGA

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FI-CGA

Captures loss of

redundancy

As the mean value of the

FI-CGA increases, the

slope of the line in relation

to age becomes smaller

and ultimately is

indistinguishable from 0.

Rockwood, Rockwood, Mitnitski. JAGS. 2010

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FI-CGA in Hip #

FI Group

Low Intermediate High P value

≤0.25 0.25–0.4 FI >0.4

Age, yrs (SD) 74 (12) 82 (9.5) 86 (8.6) < 0.001

Length of stay,

days (SD)

21 (16.5) 36.3 (23.4) 67.8 (39.3) < 0.001

Discharged home

within 30 days

45 (80%) 24 (41.37%) 4 (6.25%) < 0.001

Inpatient mortality 0 3 (5.2%) 18 (28.1%) < 0.001

Krishnan M et al. Age and Ageing 2013

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A Frailty Index for the interRAI suite

interRAI instruments screen a large amount of info

Cross functional, cognitive, sensory, medical domains

Data can be coded as deficits

Potential to explore premorbid vulnerability vs current

health status

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FI-AC Distribution

N=1418

Mean (SD)=0.32 (0.14)

Median (IQR)=0.31 (0.22-0.41)

99th percentile= 0.69

Reference

Hubbard RE, Peel NM, Samanta M,

Gray LC, Fries BE, Mitnitski A,

Rockwood K. Derivation of a Frailty

Index from the interRAI Acute Care

Instrument. BMC Geriatr.

2015;15:27.

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Question

Which adverse outcomes are NOT associated with a

higher FI score?

a/ inpatient mortality

b/ delirium

c/ readmission to hospital

d/ all adverse outcomes are associated with frailty status

Results

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Results: FI-AC vs Discharge Destination

Discharge Destination n (%) FI-AC

Mean (SD)

Community 917 (64.7%) 0.28 (0.12)

Other inpatient care

including rehabilitation235 (16.6%) 0.39 (0.13)

Residential Aged Care 209 (14.7%) 0.41 (0.13)

Died in hospital 57 (4.0%) 0.47 (0.16)

a Comparison of mean FI-AC between groups (ANOVA) significant at p<0.001b Ordinal regression showed progressive frailty OR: 1.92 (1.76-2.10)

a

b

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FI-AC vs Adverse Outcomes a

Outcome Frequency

n (%)

Odds Ratio

(OR) b95%Confidence

Intervals

Inpatient falls 83 (5.9%) 1.29 1.10-1.50

Delirium 322 (23.1%) 2.34 2.09-2.63

Pressure ulcer incidence 42 (3.2%) 1.51 1.23-1.87

Length of stay>28 days 77 (5.4%) 1.29 1.10-1.52

Discharge to a higher level of care

(excluding deaths)294 (21.6%) 1.45 1.31-1.60

Died in hospital 57 (4.0%) 2.01 1.66-2.42

a Logistic regression models adjusted for age and genderb OR interpreted as the odds of adverse outcome for each increase of 0.1 in the FI-AC

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Delirium

OR AUC

Risk screener 8.2 (CI: 6.165, 11.071) 0.760 (CI:0.726, 0.791)

P = 0.030FI 2.3 (CI:2.075, 2.619) 0.795 (CI: 0.766, 0.825)

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Inpatient mortality

OR AUC

Risk screener n/a

FI 2.00 (CI: 1.66, 2.42) 0.78 (CI: 0.71, 0.85)

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Readmission

OR AUC

Risk screener 1.712 (CI:1.278, 2.292 0.553 (CI:0.516, 0.589)

nsFI 1.17 (CI:1.065, 1.284 0.567(CI:0.532, 0.603)

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Compare and Contrast….

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FI vs DRGs

0

5

10

15

20

25

Heartfailure

COPD UTI Syncope

Age

LoS

FI-AC

0.30

0.24

0.34

0.29

0.39

0.41

Stroke ??

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A NEW NURSE

ADMINISTERED

ASSESSMENT

INSTRUMENT

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Nurses hold the key

to assessment &

management of

functional &

psychosocial

problems

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Current nursing assessment forms

Victorian Study

11 hospitals studied

Admission assessment

– 8-27 (median 11) forms

– 150-586 (median 345) items

– 2482 data items universal

– 1283 data items selective

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The problems with current systems

Too long

Inconsistent scoring approaches

Duplication of items

Compliance patchy

Don’t interact with other systems and disciplines

Variable scientific foundations

Limited outputs

21

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The PBA

60 items

15 minutes completion (IQR 11- 20 minutes)

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PBA Base Assessment

Diagnostic

screeners

Delirium

Dementia

Depression

Malnutrition

Risk assessmentDelirium

Pressure ulcer

Falls

Severity measures

Cognition

Communication

Mood

ADL

Nutrition

Clin

ical

ob

se

rva

tio

ns

ProblemsCognition

Mood

Communication

Vision / hearing

Sleep

ADL

Medication

management

Falls

Dyspnoea

Pain

Under-nutrition

Swallowing

Traumatic injury

Pressure injury

Other skin conditions

Continence

Bowel/bladder issues

Smoking & alcohol

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Field testing (Australia)

4 hospitals

– (24 – 700 beds)

1000+ cases

Wide range of clinical

units

Patients aged 18+

iPAD data collection

Frequency

distributions

Inter-rater reliability

User satisfaction

Screener validation

24

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Selected problems

25

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cognitiveskills for

dailydecisions

Short termmemory

Mood- sad ADL-Personalhygiene

ADL-Walking

Acutechange in

ADLs

Falls(prior)

Pain Sleep

18-29

30-39

40-49

50-59

60-69

>70

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FRAILTY: LIMITATIONS

AND PITFALLS

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1. Stigmatisation

The OED defines frailty as “the condition of being weak

and delicate… weakness in character or morals”

In the minds of many older people, frailty may identify their

most feared aspects of the ageing process: wasting,

decrepitude, dependency, decline.

Being labelled by others as ‘old and frail’ might contribute

to a frailty identity …. including a loss of interest in

participating in social and physical activities, poor physical

health and increased stigmatisation.

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2. Heterogeneity of measures

Original Definition of the Fried

Phenotype by Fried et al (2)

Interpretation of Fried Phenotype (n=16)

Slowness

Gait speed

Gait speed (n=13, 81%)

Questionnaire based assessment of physical function (n=2)

Not assessed (n=1)

Weakness

Grip Strength

Dyno metre measurement of grip strength (n=10, 63%)

Questionnaire based assessment of physical function (n=3)

Timed sit-to-stand (n=2)

Self-report (n=1)

Exhaustion

Centre for epidemiological

studies depression scale

Centre for Epidemiological Studies depression scale (n=5)

Patient Self report (n=5)

Short form 36 Questionnaire (n=5)

Short form 12 Questionnaire (n=1)

Shrinkage

>10 pounds of unintentional

weight loss in 12 months

Weight loss over 12 months (n=9, 56%)

Other (BMI, appendicular lean body mass, weight loss over 6

months, investigators’ impression of cachexia) (n=5)

Not measured (n=2)

Low Physical Activity

Estimated kilocalories per week

Estimation of kilocalories (n=5)

Patient self-report (n=5)

Questionnaire based physical activities scale (n=6)

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3. Poor clinical utility

Phenotype

– Reliance on performance based tests

– Dichotomous outcomes

Frailty index

– Complex

– Time consuming

– Mathematical

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4. Conceptual fuzziness

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5. Measurement, measurement…

Libor et al. Prog

Cardiovasc Dis, 2014

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Summary

1. Review a new instrument to measure frailty in routine

practice

derivation of frailty measure from routinely collected

information

2. Discuss limitations and potential pitfalls

need to understand how frailty is being measured,

which intervention is advocated/ discouraged and

consider relevance of outcomes

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Frailty in Older Inpatients