1. Salted Watermelon and Heart Failure: A Team-Based Approach to Complex Decision Making Marianthe Grammas, MD Assistant Professor & Medical Director Clinical Director of Ambulatory Care Transitions UAB Division of Gerontology, Geriatrics and Palliative Care

2. DISCLOSURES

3. OBJECTIVES Recognize the global issues involved in the evaluation and management of complex older adults Experience an interdisciplinary team from a variety of perspectives Define the frailty phenotype and apply it to medical decision making in older adults

4. BACKGROUND Multimorbidity/multiple chronic conditions (MCC) Definition Epidemiology 1 in 4 Americans have 2 or more CC 2/3 of Medicare beneficiaries > age 65 have 2 or more 1/3 of Medicare beneficiaries > age 65 have 4 or more Boyd C, et al. JAMA. 2005 http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf

5. Impact Functional limitation & disability Frailty Nursing home placement Diminished quality of life Treatment complications Avoidable inpatient admissions BACKGROUND Wolff JL, et al. Arch Intern Med. 2002. Fortin M, et al. BMJ 2007.

6. Staggering healthcare utilization and costs The two-thirds of Medicare beneficiaries with multi- morbidity account for 96 percent of Medicare expenditures Wolff JL, et al. Arch Intern Med. 2002. Thorpe JL, et al. Health Aff (Millwood) 2010. http://www.partnershipforsolutions.org/DMS/files/chronicbook2004.pdf BACKGROUND

7. Limitations to clinical practice guidelines (CPGs) Fail to address needs of patients with complex comorbid illness Many have been developed using evidence from studies that excluded older adults with multiple chronic conditions Difficult for patients with MCC to apply/implement recommendations Parekh AK, Barton MB. JAMA 2010.

8. How would you like your day to look like this? Boyd C, et al. JAMA. 2005 12 medications $406/month Complicated diet regimen Monitoring BG, BP Exercise recommendations

9. So the American Geriatrics Society decided…How about some guiding principles? Recognize heterogenity in terms of… Severity of illness Functional status Prognosis Risk of adverse events Patient’s priorities for outcomes and health care Source: geriatricscareonline.org/toc/guiding-principles-for-the-care-of-older-adults- with-multimorbidity

10. 3 or More…Managing Multiple Health Problems in Older Adults

11. CASE PRESENTATION Ms. L is a 78 y/o Female PMHx = heart failure, diabetes, chronic kidney dis. Osteoarthritis, depression Peripheral neuropathy, diabetic retinopathy, gingivitis 3 rd admission in 2 months for CHF exacerbation Fatigue, shortness of breath, leg swelling Gets evidence-based management in the hospital Medical team says, “She’s ready to go home!”

12. BUT WAIT!!! “Unless someone like you cares a whole awful lot, nothing is going to get better. It’s not.”

13. IT TAKES A VILLAGE… Optometry Public Health/UM Dentistry Audiology

14. INTERDISCIPLINARY TEAM EXERCISE Our small groups today will role play: Geriatrician/”Clinical” Nurse/Discharge Planner Social Worker PT/OT/SLP Pharmacist Additional input today from: nutrition/dental/audiology/optometry/public health

15. GROUP EXERCISE: 15-20 MINUTES Review the case and the additional information about Ms. L that is learned from your team’s discipline Discuss problems/concerns that add complexity to her case Prioritize 1-2 items from your team’s perspective that will be important to consider in transition planning or future care/treatment goals

16. FRAILTY What do you picture as frailty?

17. FRAILTY

18. What is frailty? Frailty is a syndrome of decreased reserve caused by widespread physiologic changes which results in an increased vulnerability to stress Why does it matter? Delayed recovery Increased likelihood of falling Increased functional impairment  Debility  Dependence  Death

19. FRAILTY PHENOTYPE How do you know if someone is frail? Shrinking: weight loss or 10 lbs or more in past year Exhaustion: lack of vigor, energy or presence of fatigue Weakness: loss of physical strength; skeletal muscle Slowness: lethargic, unsteady, unbalanced gait Low Physical Activity: inactivity or sedentariness 0 = robust 1-2 = intermediate or pre-frail 3 = frail 4-5 = extremely frail Fried L, et al. Journal of Gerontology; 2001

20. APPROACH TO FRAILTY Comprehensive Geriatric Assessment Again, it takes a village… MD/RN/NP, pharmacy, PT/OT, nutrition, psychosocial Vision, hearing, cognition, oral/dentition Minimize stressors Prevention, Modifications, Rehabilitation where possible

21. INTERDISCIPLINARY TEAM: PRIORITIZING CARE FOR OUR PATIENT Is Ms. L frail? How do we improve Ms. L’s health? Function? Quality of Life?

22. SUMMARY Comorbidity is common in older adults. Most CPGs do not consider the impact of their recommendations on older patients with multiple chronic conditions. The frailty syndrome is more common among older adults with multiple diseases and is associated with more risk of complications from stressors. An interdisciplinary team is needed to manage the care of complex older adults and to recognize, address, and prevent manifestations of frailty.

23. QUESTIONS?