Frailty Project Dr Maliha Chowdhury GP Fellow in Urgent & Acute Care South Warwickshire Foundation Trust Ley Hill Surgery, Four Oaks

Outline What is frailty? The Geriatric Giants Who should we screen? Frailty index My Project What did I find? How can we take it forward?

Let’s face the numbers 10million >65yrs (1) increasing by 5.5million in 20yrs Mortality decreased from 48% to 14% (2) Women live 21 yrs extra, men 19yrs extra NHS cost £5,200 for retired households cf £2,800 Increasing cost of long term conditions vs declining resources/tight budget (3)

What is frailty? The statistics: (4-7) 10% prevalence >65yrs Avg age 82yrs 20% prevalence in IHD/MI patients Late presentations & in crisis often to secondary care with falls >650,000 falls/yr to ED £275 million/yr cost to NHS

What is frailty? Clinically recognised state of increased vulnerability Results from ageing associated with a decline in body’s physical & psychological reserves Varies in its severity individuals should not be labelled as being frail or not frail but simply that they have frailty. The degree of frailty of an individual is not static it naturally varies over time can be made better and worse. Frailty is not an inevitable part of ageing it is a long-term condition like diabetes or Alzheimer’s disease.

Fit for Frailty – British Geriatric Society. The Geriatric Giants Immobility Instability/falls Incontinence Intellectual/cognitive impairment Iatrogenic/polypharmacy ‘Invisibility’ Fit for Frailty – British Geriatric Society. Accessed on 13/08/15. URL: http://www.bgs.org.uk/campaigns/fff/fff_full.pdf.

Screening BGS: Two part assessment: No evidence of health improvement in general population screening However, National Audit of Community Rehab 2012: 1 or more LTC 77% frailty 2 or more LTC 41% frailty Two part assessment: Gait Assessment PRISMA 7

Screening Gait speed: ‘Timed up-and-go test’ (TUGT): taking more than 5 seconds to cover 4 metres ‘Timed up-and-go test’ (TUGT): a cut off score of 10 seconds to get up from a chair, walk 3 meters, turn round and sit down (exclude obvious Knee OA)

Screening

(Score of >3 is positive for frailty) PRISMA 7 1] Are you more than 85 years? 2] Male? 3] In general do you have any health problems that require you to limit your activities? 4] Do you need someone to help you on a regular basis? 5] In general do you have any health problems that require you to stay at home? 6] In case of need can you count on someone close to you? 7] Do you regularly use a stick/walker/wheelchair to get about? (Score of >3 is positive for frailty)

Frailty Index Recognising & maintaining a frailty register Computer softwares: Prediction of individuals At Risk of Readmissions (PARR) Advanced Clinical Groupings (ACG) Based on: individual’s previous service use/admission number of meds prescribed diagnosis of certain long term conditions Recognising at risk groups that we can’t modify anything

Project Findings 43 patients aged 82 Invited via telephone Went through the proform on attendance Deemed frail based on PRISMA 7 & Gait Ax

Project Findings 10 recognised as frail Drugs: 5 with 3 co-morbidities/LTC 3 with 2 co-morbidities/LTC 1 with 4 & 1 with 6 co-morbidities/LTC Drugs: 33 non-frail on >2 drugs = 24 Frail = 6/10 >6 drugs, 8/10 >2 drugs

Forward Plans

Forward Plans Physiotherapy interventions (8) 20% reduction in falls after group therapy 15% decrease in falls risk after individual exercise programmes

Forward Plans STOPP START BZD, NSAIDs, SSRIs, loop diuretics http://www.rcpsych.ac.uk/pdf/Aziz%20Stopp-START%20tool%20paper%20-%20Victor%20Aziz.pdf BZD, NSAIDs, SSRIs, loop diuretics 2 studies based in Ireland & Spain (Cahir et al, 2014; Mera et al 2011): >50% of >85yrs old patients on inappropriate prescriptions

What are your suggestions? Forward Plans What are your suggestions?

References The ageing population: key issues for the 2010 parliament. Accessed on 06/08/15. URL: http://www.parliament.uk/business/publications/research/key-issues-for-the-new-parliament/value-for-money-in-public-services/the-ageing-population/. Office for National Statistics 2011b and 2013c. Accessed on 20/08/15. URL: http://www.ons.gov.uk/ons/index.html. NHS England Risk Stratification. Accessed on 13/08/15. URL: http://www.england.nhs.uk/wp-content/uploads/2015/01/nxt-steps-risk-strat-glewis.pdf.

References 4. Primary Care Supplement, an index of frailty. Accessed on 19/08/15. URL: http://www.hsj.co.uk/resource-centre/supplements/primary-care-supplement-an-index-of-frailty/5065467.article#.VczBzXjFv-Z. 5. Chartered Society of Physiotherapy. Accessed on 20/08/15. URL: http://www.csp.org.uk/news/2014/10/01/csp-web-tool-shows-falls-cost-nhs-england-275million-year. 6. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. Journal of American Geriatric Society 2012; 60: 1487-1492. 7. McShane M, Young J. ‘The frailty paradox’, The Long Term Conditions Year of Care Data RCGP Annual Conference Oct 2014. Accessed on 20/08/15. URL: http://www.slideshare.net/NHSIQ/ltc-year-of-care-data.

References 8. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 2012 (9).