The care of acutely ill frail older adults Kenneth Rockwood Professor of Geriatric Medicine Dalhousie University Halifax (the one in Canada)

Disclosures Through Dalhousie’s Industry Liaison Office, I have asserted copyright of the Clinical Frailty Scale, made freely available for education, research & not-for-profit health care. Users are asked not to change or commercialize it. I founded DGI Clinical Inc., which provides outcome measures & data analytics to pharma. Routinization of frailty actions in our hospital remains aspirational; we’re operator dependent.

Objectives Describe criteria for frailty in older adults Describe the concept of accumulation of deficits in the context of frailty. Understand the implications of frailty for a vulnerable older adult. Describe strategies to evaluation and manage frail older adults when acutely ill.

The older people are the more likely they are to die… Log scale 0.368 0.135 0.050 0.018 0.007 0.002 100 10 20 30 40 50 60 70 80 90 100 But individuals do not die from old age. They accumulate different health problems, become more vulnerable More vulnerable they become, more likely they die, and this occurs with age The rate of mortality is a measure of the number of deaths in a population, scaled to the size of that population, per unit time. The rate of mortality is presented in the natural scale (Panel A) and in the logarithmic scale (Panel B). The linear part of the graph (after about 45-50 years) corresponds to the exponential increase of the rate of mortality (the Gompertz law) indicated by the straight line (Panel B). Age (years) Statistics Canada: Canadian birth cohort 1900-1901.

… but not everyone of the same age has the same risk of death Log scale 0.368 0.135 0.050 0.018 0.007 0.002 10 20 30 40 50 60 70 80 90 100 But individuals do not die from old age. They accumulate different health problems, become more vulnerable More vulnerable they become, more likely they die, and this occurs with age The rate of mortality is a measure of the number of deaths in a population, scaled to the size of that population, per unit time. The rate of mortality is presented in the natural scale (Panel A) and in the logarithmic scale (Panel B). The linear part of the graph (after about 45-50 years) corresponds to the exponential increase of the rate of mortality (the Gompertz law) indicated by the straight line (Panel B). Age (years) Statistics Canada: Canadian birth cohort 1900-1901.

Case: An 84 year old woman in the ER Came by ambulance. Neighbour called 911, as woman was not answering her telephone. Confused, agitated, has a cough. Living alone. Pulse 140(ish); bp = 100/40; Sa02=90%, T=37.9C WBC=16,000; 78%neutrophils Cr=145; Na+130;K+3.0 CXR=RML pneumonia ECG = A fib; non-specific ST-T

What now? Give haloperidol for agitation. Obtain CT head. Cardiovert the atrial fibrillation. All of the above. None of the above.

Frailty as unmeasured hetereogeneity Vaupel J, Manton K, Stollard E. The impact of heterogeneity in individual frailty on the dynamics of mortality. Demography 1979; 16:439-54 Missoy & Vaupel. Society for Industrial & Applied Mathematics Review 2015;57:61-70. 10

Deficit accumulation can be estimated with the Frailty Index Frailty Index score = Number of deficits in an individual Total number of deficits measured e.g. in a dataset with 50 health deficits, a person with 10 things wrong (10 deficits) has a frailty index score of 10/50 = 0.20. In this way, we can quantify the degree of frailty Expressing deficit as a frailty index allows the regular behaviour of deficit accumulation to be revealed. This underscores the idea of frailty as measuring biological age.

One Last Question Before the Operation: Just How Frail Are You? Paula Span THE NEW OLD AGE The New York Times, OCT. 27, 2017 https://www.nytimes.com/2017/10/27/health/elderly-surgery-frailty.html

Deficits accumulate characteristically in old age 1.0 0.5 Legend 0.3 0.2 Mean accumulation of deficits The slope is ~0.03-0.035 Community samples n=33,559 ALSA CSHA-screen 0.1 NHANES NPHS SOPS 0.05 US-LTHS Log scale H70-75 65 70 75 80 85 90 95 Age (years) Mitnitski, et al., J Am Geriatr Soc, 2005;53:2184-9

Age, electronic frailty index score and mortality. Relationship between age, electronic frailty index score and mortality (internal validation cohort). Andrew Clegg et al. Age Ageing 2016;ageing.afw039 © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.

What I’ve said so far Frailty is a multiply determined risk state manifest as not everyone of the same age having the same risk of death (or other adverse outcomes). It arises due to the stochasticity of age-related deficit accumulation across the life course. (People are frail when they have lots of things wrong with them.)

Where do we go next? How do we apply this in the acute of older adults who are acutely ill? ”Geriatric giants”, the Clinical Frailty Scale and some data questions about the merit of separating underlying frailty from resnet illness acuity 23

Frailty screening Frailty States: 1. Very Fit 2. Well 3. Managing Well 4. Vulnerable 5. Mildly Frail 6. Moderately Frail 7. Severely Frail 8. Very Severely Frail 9. Terminally ill © Geriatric Medicine Research Unit, Dalhousie University, 2008 This is the Clinical Frailty Scale screening tool, not used by hundreds of groups around the world. We make it available on the condition that people do not change or commercialize it, which mostly has worked. 25 K Rockwood et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173:489-495.

Purpose: Examine the relation between frailty, acuity and mortality. 8202 people aged ≥75 years in a large tertiary hospital (all specialties) in England. Retrospective review of all first non-elective inpatient episodes

Frailty Measurement Clinical Frailty Scale (CFS): A frailty instrument that evaluates pre-admission comorbidity, cognitive impairment, health attitude, mobility and disability. Original CFS categories collapsed into four ordinal categories: CFS 1 to 4: Fit/well/treated/”apparently vulnerable” CFS 5: mildly frail CFS 6: moderately frail CFS 7 or 8: severely or very severely frail *patients with a CFS of 9 (‘terminally ill’ without being evidently frail) were excluded from the analyses Romero-Ortuna et al. 2016

Acute Illness Severity Measurement Modified Early Warning Score (ED-MEWS): used to measure acute illness severity. ED-MEWS ≥ 4 defined high acuity in the analyses. Romero-Ortuna et al. Q J Med 2016

Distribution of CFS and ED-MEWS Frailty levels 31.7% very fit to apparently vulnerable (CFS 1 to 4), 12.5% mildly frail (CFS 5), 16.1% moderately frailty (CFS 6), 11.0% severely or very severely frail (CFS 7 or 8). 0.6% (n=49) CFS of 9 and were excluded 28.1% missing CFS data. ED-MEWS: 28.4% ED-MEWS of ≥4 points, 63.2% ED-MEWS of < 4, and 8.4% missing ED-MEWS data. Romero-Ortuna et al. 2016

Romero-Ortuna et al. 2016

Fig 1. 30-day inpatient mortality by CFS categories and ED-MEWS status Romero-Ortuna et al. 2016

Purpose: Examine the relationship between the FI score and survival to 30 and 300 days in comparison with several commonly employed ICU prognostic scores. Prospective cohort study of 155 ICU patients ≥65 year old admitted to a specialized geriatric ICU in a Chinese hospital Patients were followed for 300 days

Zeng et al. 2015

AUC = 0.89 (0.83-0.95) Zeng et al. 2015

What we did for our patient. Called the neighbour. Screened for frailty based on how she walked, thought, interacted and cared for herself two weeks ago. Continued aggressive resuscitation and gave the ICU a “heads up” call.

Geriatric Giants immobility instability incontinence impaired intellect/memory impaired independence Isaacs B. The Challenge of Geriatric Medicine. OUP 1980 “sensitive but non-specific signs of illness in older adults”

Comprehensive Geriatric Assessment Form © Geriatric Medicine Research, Dalhousie University, 2008

Instrumental Activities of Daily Living Comprehensive Geriatric Assessment Form: function signals illness severity Instrumental Activities of Daily Living Baseline (two weeks ago) Current (today)

Instrumental Activities of Daily Living Comprehensive Geriatric Assessment Form: function signals illness severity Instrumental Activities of Daily Living Baseline (two weeks ago) Current (today)

Comprehensive Geriatric Assessment Form: function allows care planning Instrumental Activities of Daily Living Baseline (two weeks ago) Current (today)

Halifax Infirmary Case series of referrals of older adults to MTU-ED Team, 2012-2014

Mean FI-Acute scores by Clinical Frailty Scale in patients referred to Medicine

LTC Discharge by baseline frailty (Panel A) and frailty/acuity score (Panel B)

Length of stay by baseline (A) and frailty/acuity (B)

Mortality by baseline frailty (A) and frailty / acuity (B)

Survival by baseline frailty (A) and frailty/acuity (B)

Baseline frailty and frailty/acuity in relation to 6-month mortality (Cox regression analysis) HR Lower CI Upper CI Sig. Age 0.988 0.956 1.021 0.472 Sex (females) 0.826 0.494 1.381 0.467 CFS (per 1 point) 1.245 1.055 1.470 0.010 FI-acute (per 0.01 score) 1.025 1.004 1.046 0.020

A Frailty Index based on a Comprehensive Geriatric Assessment identifies a group at the highest risk of dying. FI-CGA 1 0.1 0.8 0.2 Survival probability 0.6 0.3 0.4 0.2 0.5 0.4 10 20 30 40 50 60 70 Survival time (months) Rockwood, Rockwood, Mitnitski, J Am Geriatric Soc 2010;58:318-323. 38

CGA & care planning We do a CGA to develop a care plan. The initial contact captured in the CGA needs to be verified and updated to serve as an accurate baseline. This requires the best available information, not simply a record of “what the client says”.

The care plan Care plans are negotiations: what patients/carers desire vs what’s achievable. Sometimes these conflict, and often their reconciliation requires judgment. Some people are better judges than others; processes are important.

Pictorial Fit-Frail Scale: Acute Version

Pictorial Fit-Frail Scale: Acute Version

Time, extent of recovery in mobility & balance, by the initial (48-h) treatment response. Figure 1. Hatheway et al., Age Ageing 2017; 43

Acknowledgments Arnold Mitnitski Olga Theou Susan Howlett Funding sources: Canadian Institutes of Health Research Fountain Family Innovation Fund , Queen Elizabeth II Health Sciences Foundation Nova Scotia Health Research Foundation Mathematics, Information Technology & Computer Science program, National Research Council of Canada Alzheimer Society of Canada National Natural Science Foundation of China China Scholarship Council Dalhousie Medical Research Foundation Colleagues & students: Arnold Mitnitski Olga Theou Melissa Andrew Samuel Searle Tommy Brothers Lindsay Wallace Oliver Hathaway Judah Goldstein Kathryn Hominick Swadhin Taneja Quikui Hao Rob Beiko Andrew Rutenburg Xiaowei Song Susan Howlett

Pictorial Frailty Assessment

Clinical Frailty Scale Scores FI-Acute (CGA Current + LAB) Scores   All patients Patients with valid Clinical Frailty Scale Scores FI-Acute (CGA Current + LAB) Scores N N=415 N=387 N=382 (33 missing) Age 80.6 ± 8.4 (range 57-103) 80.4 ± 8.4 80.9 ± 8.4 % Women 58.1% (241/415) 58.4% (226/387) 59.7% (228/382) % Admitted from Long term Care 14.3% (59/414) 14.3% (55/386) 14.4% (55/381) % Discharged in Long Term Care 17.9% (72/402) 18.1% (68/375) 18% (67/373) % Discharged home 64.2% (258/402) 63.7% (239/375) 64.3% (240/373) Mean MMSE 21.2 ± 10.2 21.2 ± 10.4 21.0 ± 9.6 Mean N Medications 6.99 ± 3.70 6.94 ± 3.67 7.09 ± 3.65 Mean N Comorbidities 8.02 ± 3.35 8.06 ± 3.34 8.12 ± 3.40 % Admitted to inpatient unit 77.3% (321/415) 77.3% (299/387) 80.4% (307/382) Mean LOS for admitted patients 26.9 ± 45.8 (range 0-326) 27.2 ± 46.5 27.4 ± 46.6 % LOS >=30 days 17.9% (73/407) 17.9% (68/380) 18.8% (71/377) % Died < 30 days 13.3% (55/415) 13.7% (53/387) 13.1% (50/382) % Dead at 6 months 20.2% (84/415) 21.2% (82/387) 20.4% (78/382) Mean time to death (for those who died within 6-months) 37.2 ± 49.1 37.9 ± 49.6

Frailty Index variables Frailty Index used ICU admission records: acute medical conditions, chronic diseases, symptoms, signs, premorbid function (from an informant), lifestyle, health attitude, psychological health, and laboratory measures 23-items FI-Chronic Workload of accompany people Balance Desire for survival Activities of daily living (ADL) Instrumental activities of daily living (IADL) Functional Assessment Staging (FAST) Consciousness New York Heart Function Assessment (NYHA) Emotion Sleeping Speech Hearing Eyesight Daytime sleepiness Diseases in Urinary system Diseases in respiratory system Diseases in digestive system Diseases in Cardiovascular system Diseases in central nervous system Diseases in Endocrine system MCV Blood sugar urea/creatinine ratio <10 with Cr 31-item FI-Acute Cardiac rhythm Nausea and vomiting Temperature Systolic blood pressure Heart rate Diastolic blood pressure Respiration rate Central venous pressure Oxygenation index Blood sugar Procalcitonin urea/creatinine ratio <10 with Cr Platelet White blood cell count Hemoglobin Serum sodium Serum potassium Total Bilirubin INR Albumin Lactic acid Urea Creatinine Bowel function Urine volume Partial pressure of oxygen Carbon dioxide partial pressure Actual bicarbonate PH Value Blood HCT MAP 52-item all-factor FI Blood sugar and urea/creatinine ratio were included in both FI-chronic and FI-acute Zeng et al. 2015

FI34 scores by age in “offspring of long-lived parents” (OLLP) and “offspring of short-lived parents” (OSLP) of the Louisiana Healthy Aging Study / Healthy Aging Family Study . Kim S, Jazwinski SM. Healthy Aging Res 2015;4:26 Doi10.12712/har.2015.4.26