1. Intermediate Care in Canada In search of “sensible medicine” Kenneth Rockwood MD, FRCPC, FRCP, FCAHS Professor of Geriatric Medicine Dalhousie University Halifax, Nova Scotia, Canada

2. Objectives To review the state of intermediate care in Canada To identify the basis of the need for “sensible medicine” To discuss principles of the practice of geriatric medicine

3. “Intermediate Care: a range of definitions” “a level of medical care for certain chronically ill or disabled individuals in which room and board are provided but skilled nursing care is not.” “a unit for patients who do not require intensive care but who are not yet ready to be kept in a regular medical-surgical unit.”

4. Intermediate Care in the United Kingdom Developed to improve care by comprehensive assessment and active rehabilitation by medical leadership, including both hospital specialty and general practitioners, done to ensure a single patient record that can be backed-up and shared.

5. Intermediate Care in the United Kingdom Resisted by geriatricians who retained the tribal memory of the workhouses with “second-rate patients cared for by second-rate physicians in second-rate facilities”. See Evans JG, Tallis RC. BMJ 2001;322:807-808

6. Canada A large country, with 33 million people About 1 person in 8 (13%) is over the age of 65 years. Has a federal government, with 10 provinces

7. Canadian Medicare Medicare provides universal coverage for hospitals and physicians, paid for by taxes It was introduced in the 1950s and 1960s It is funded by the federal government, but administered by the provinces

8. With a growing life expectancy and declining fertility, Canada's population is growing older

9. Concerns about cost are driving new approaches to care

10. Intermediate Care in Canada No designated intermediate care. Proxy intermediate care programs: “restorative care”, “progressive care”, “geriatric assessment and rehabilitation”, “acute infirmaries in longterm care facilities”.

11. Why “sensible medicine”? Much medical care is undertaken in people who have little hope to benefit from the care, and a high chance of harm.

12. What is the focus of sensible medicine? Relieve pain and suffering. Improve function. Prevent premature death.

13. Medicine and the tradition of reductionism Reductionism: “An attempt or tendency to explain a complex set of facts, entities, phenomena, or structures by another, simpler set.”

14. Geriatric medicine and the challenge of complexity Rockwood et al. Can Med Association 1994; 150:499-507 Rockwood et al. J Am Geriatric Society 1996; 44:578-82 Health Attitudes toward Health and health practices Resources Caregiver Illness Disability Dependence on Others Burden on the caregiver

15. Summary - 1 Intermediate care potentially offers the advantages of sensible medicine: focused on the whole patient, aiming to relieve pain and suffering, avoid premature death and improve function.

16. Summary - 2 Intermediate care offers the potential disadvantages of low status, poor access and inadequate services.

17. Summary - 3 Geriatric medicine aims to embrace the complexity of the frail elderly patients who are its chief constituents.

18. Summary - 4 Embracing the complexity of frailty involves: comprehensive geriatric assessment quantifying frailty understanding clinical state variables.

19. Age (years) Proportion Fitness declines with age, and frailty increases; by the age at which people most use health care, most are frail. Green- Fit Red: frail 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 102030405060708090 Who should geriatricians care for?

20. Understanding frailty as deficit accumulation: 1. Most acquired problems accumulate with age (Canadian National Population Health Survey, n= 66,580) Proportion of the individuals with deficit 020406080100 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 arthritis 020406080100 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 vision problems 020406080100 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 Mobility disability 020406080100 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 thyroid problems Age (years) Rockwood & Mitnitski Rev Clin Gerontol 2007;18:1-12.

21. Mitnitski, et al., J Am Geriatr Soc, 2005;53:2184-9 Mean accumulation of deficits Legend 65 707580859095 ALSA CSHA-screen CSHA-exam NHANES NPHS SOPS Breast cancer CSHA-inst Myoc Infarct US-LTHS H70-75 0.1 0.2 0.3 0.5 1.0 0.05 Age (years) Clinical and institutional samples, n=2,573 The slope is ~0.03 Community samples n=33,559 Log scale 2. Deficits accumulate characteristically, both between groups (community vs. institution/ clinical) and within groups* Slope <0.01

22. 3. At any age, women accumulate more deficits than do men. 4. For men & women, deficit accumulation is highly correlated (r>0.95) with mortality Mitnitski et al. J Am Geriatr Soc, 2005;53:2184-9

23. 5. There is a limit to frailty. Canadian Study of Health & Aging, N=8,547 Of 8,547 people at baseline, only 18 had >17/31 possible deficits, and only 7 (of 5586) had >17/31 at follow-up Survival limit close to the frailty Index of about 0.7 A limit to of the number of deficits suggests exhaustion of reserve capacity – is it operationalizable clinically? Mitnitski, Bao, Rockwood. Mech Ageing Dev 2006;127:490-3. Rockwood & Mitnitski Mech Ageing Dev 2006;127:494-6.

24. What else can we learn clinically from other complex systems applications What else can we learn clinically from other complex systems applications?

25. A Frailty Index can be constructed clinically, from the items recorded in a Comprehensive Geriatric Assessment

26. 010203040506070 0 0.2 0.4 0.6 0.8 1 7. Frailty predicts mortality better than age. Age FI-CGA 70 80 90 100 0.1 0.2 0.3 0.40.5 Survival time (months) Survival probability 010203040506070 0 0.2 0.4 0.6 0.8 1 Rockwood, Rockwood, Mitnitski, J Am Geriatric Soc 2010;58:318-323.

27. Summary to now In Canada, geriatric medicine focuses on the frail. Frailty can be understood by counting deficits in a frailty index. A frailty index derived from routinely collected clinical data can offer insights into the biology of aging using mathematics of complex systems.

28. Pattern recognition: many illnesses; worsening dependency

29. Measuring mobility: the HABAM The Hierarchy of Balance & Mobility In bed-mobility – Cannot move off pressure points – Moves side to side – Can push to sit up – Can swing legs over the side MacKnight & Rockwood Age Ageing 1995;24:126-30 MacKnight & Rockwood J Clin Epidemiol 2000;53:1242-7 Rockwood et al. J Am Geriatr Soc, 2008; 56:1213-1217-24

30. Hierarchical Assessment of Balance and Mobility: embracing complexity through pattern recognition in a state variable Rockwood et al., J Am Geriatr Soc, 2008;56:1213-1217

31. Mean HABAM scores over the first 14 days of hospitalization, by outcome Hubbard et al., submitted

32. Risk of death within 30 days in relation to HABAM scores Absolute risk of death of patients who score the lowest on each of the HABAM domains at any point of the hospital stay: 45% (36-54). » Hubbard et al., submitted. Relative risk of death of patients whose HABAM scores decline in the first 48 hours, versus those in whom the scores stay the same or improve: 27.2 (19.4-35.6). » Rockwood, Rockwood & Mitnitski, submitted.

33. Summary In Canada several service delivery models have developed that correspond to intermediate care. The chief benefit of intermediate care is the ability to practice “sensible medicine”. The chief threat of intermediate care is the risk of less effective care for people just because they are old.

34. Summary 2 - sensible medicine The goals of sensible medicine are driven by patient needs, not by processes and procedures: Relieve pain and suffering. Improve function. Prevent premature death.

35. Acknowledgments Funding sources: Canadian Institutes of Health Research Fountain Innovation Fund of the QEII Health Sciences Foundation Mathematics of Information Technology and Computer Science program, National Research Council Alzheimer Society of Canada Dalhousie Medical Research Foundation Colleagues & students: Arnold Mitnitski Nadar Fallah Xiaowei Song Ruth Hubbard Melissa Andrew Michael Rockwood Samuel Searle Paige Moorhouse, Laurie Mallery