CHAMP: Bedside Teaching
Determination and Assessment of the Frail Aging Hospitalized Patient
Paula M. Podrazik, MD
Frailty and Hospitalization
Teaching Trigger:
Case example:
An 80 year old female presents to the hospital for readmission due to ongoing weight loss and progressive confusion over the course of 1 year. Patient lives alone without social supports. On exam patient is A, O x 2 without focal neurologic exam or evidence of delirium.
Words that trigger the consideration of frailty include patient’s advanced age, confusion, weight loss, no social supports, A, O x2.
Clinical Questions:
1. What is frailty?
2. Who to screen?
3. Why identify the frail aging patient in the hospital?
4. What are key areas to screen in the suspected frail or failing older hospitalized patient?
5. What can we impact with identification of the at risk frail hospitalized older patient?
Teaching Points:
1. Background definitions:
Many definitions of frailty represent a continuum of a clinical syndrome. One example of a constellation of symptoms including weight loss, weakness, fatigue, with decreased food intake, decrease in muscle mass, gait and balance problems, deconditioning, osteopenia probably represents one end of the frailty continuum—the failing patient. Also, this kind of phenotypic definition of frailty may vary across the components and these components present are not always the same from individual to individual. Hence, investigators have looked at the “risk” of frailty or how to identify the “vulnerable” aging patient. This kind of identification would potentially allow time for intervention. This approach looks at indicators or measures of frailty—including extremes of age, multiple co-morbid conditions, and disability—decrease in function—each used as a measure of frailty “risk”.
Using Medicare Current Beneficiary Survey—Assessing Care of the Vulnerable Elders (ACOVE) investigators determined that functional status is a more important predictor of death and functional decline than any specific medical condition. Asking about age, self-rated health, functional disabilities and limitations predicted functional decline and death. A scoring system developed identified 32% of a nationally represented sample as vulnerable: 4x risk of death or functional decline over a 2-year period than the lower-scoring majority of the sample. ACOVE investigators also identified the prevalence of selected medical conditions using hospital surveys—these conditions accounted for 43% of acute hospital admissions and 33% of office visits.
2. ID and teach about frailty:
Suspect frailty and consider screening for cognition, functional assessment (e.g., Activities of Daily Living (ADLs)/ Instrumental Activities of Daily Living (IADLs)), sensory impairments and doing a psychosocial assessment in the hospitalized aging patient. Suspect increased risk of frailty and teach about it if you see the following factors that either identify increased risk of frailty or predict poor hospital outcomes. These would include:
● advanced age (usually 80+ years of age) w/or w/out
●multiple co-morbidities
●cognitive impairment
●functional impairments
●hospital readmission/s
●psychosocial issues
●sensory impairments
3. Older patient have high rates of hospitalization.
They account for 47% of all inpatient days (but represent only 13% of the population). Patients at advanced age (one of the triggers for frailty risk) specifically age 85 and over, have twice the hospitalization risk.
In addition, they have high rates of readmission—25% of hospital admissions represent readmission of older adults. In one study, risk factors for re-admission included age over 80, inadequate social supports, multiple active chronic health problems, history of depression, moderate-severe functional impairment, multiple hospitalizations past 6 months, hospitalization in the past 30 days, fair or poor health self rating, history of non-adherence to medical regiment. This list reads like a risk profile for frailty.
Some the costs of hospitalization of the aging patient include besides nursing home placement, hospital readmission, caregiver stress, mortality:
Iatrogenic Complications—occur in 29-38% of hospitalized older adults, a rate 3-5 times higher than younger patients.
Functional decline—34-50% of older hospitalized patients experience functional decline, associated with prolonged hospital stays, increased need for rehab & home care services, higher rates institutionalization, more healthcare expenditures.
Impairments associated with worse outcomes:
One such study example showed that cognitive impairment was associated with functional decline during acute illness and greater the risk of nursing home placement at hospital discharge and nursing home placement at 90 days post-hospitalization. The greater the degree of cognitive impairment in the aging patients studied the greater the risk of placement in long term care.
4. Screening:
●functional impairments, e.g., ADLs/IADLs, gait-timed get up and go or other gait/falls assessment
●cognitive impairment, e.g., mini-cog, Folstein Mini Mental State Examination (MMSE)
●depression, e.g., Geriatric Depression Scale (GDS)
●sensory impairment e.g., hearing, sight
●psychosocial issues
5. Prevention is one key.
The YaleHospital Elder Life Program: Patients ≥ age 70, admitted to acute care hospital are screened for cognitive impairment, sleep deprivation, immobility, dehydration, vision or hearing impairment. With a series of targeted interventions the impact on functional and cognitive decline showed impressive gains in cognition and ADLs with interventions: only 8% declined in MMSE by 2 points or more (26% decline in control group) and only 14% declined in ADLs by 2 or more points (control 33%).
Some of the aspects of the elder life program can be incorporated into the care of your patients including parts of the program’s protocols on hearing, vision, non-pharmacologic sleep enhancement, early mobilization, oral volume repletion/feeding assistance, cognitive cueing with a orientation board (today’s date, nurse, daily activities) and cognitive stimulation three times a day (word games, discussion of current events).
The proper transition of care is the other.
Study evidence suggests that discharge planning using a nurse practitioner to coordinate care can lead to less readmission after a hospitalization, overall fewer hospital admissions, and shortened length of hospital stay in this frailer patient population.
Discharge planning should begin on the first hospital day –esp. for those patients identified as being at advanced age, having psycho-social issues, cognitive decline, functional impairments, multiple active medical problems/medically ill, and/or multiple recent hospital admissions.
Finally, discharge planning involves a team effort and coordination of discharge planning. The hospital team including nursing, physicians, physical therapy, social work and/or case manager coordinates this care transition with the patient, patient’s family, patient’s primary care physician, and the personnel at outside facilities who will be involved in the patient’s care after hospital discharge, e.g., nursing home, rehab facility, visiting nurse.
Bibliography
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CHAMP (Curriculum for the Hospitalized Aging Medical Patient)
University of Chicago
Supported by a Donald W. Reynolds Foundation grant