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Frailty Assessment of Older Canadians Using Emergency Services with Tablet Technology
Jacques Lee, MD, MSc, FRCPCSunnybrook Research Institute
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Presenter
• Emergency Services Staff Physician and Scientist at the Sunnybrook Research Institute in Toronto
• Director of Research for the Department of Emergency Services at the Sunnybrook Health Sciences Centre
• Assistant Professor, Clinician Scientist and former Director of Resident Scholarly Activities in the Department of Medicine at the University of Toronto
• Research focuses on improving the care of older adults who need emergency services
2017-01-25
Frailty Assessment of Older Canadians Using Emergency Services with Tablet Technology
Jacques Lee,MD, MSc, FRCPC
Frailty assessments of Older
Canadians Using Emergency
Services (FOCUS)
Canadian Frailty Network Webinar
Jacques S. Lee MD, MSc, FRCPC
Acknowledgements
• Canadian Frailty Network (CFN)
Implementation Grant 2015
• No conflicts to declare
Acknowledgments
My Qualifications?
• Knows how to read
• Knows where the library is
Acknowledgements Collaborators
• Dr. Mary Tierney, PhD
• Dr. Mark Chignell, PhD
• Tiffany Tong, PhD (Cand.)
• Dr. Judah Goldstein, PhD
• Dr. Ken Rockwood, MD PhD
• Dr. Marcel Emond, MD, PhD
• Dr. Marie-Josee Sirois
• Dr. David Ryan, PhD
• Mike Nolan, MA
Collaborators
• Dr. Alex Kiss, PhD
• Dr Gary Naglie, MD, MSc
National Coordinator
Joanna Yeung
Why?
Canadians ≤14 versus ≥ 65
Statistics Canada, censuses of population, 1921 to 2011
Demographics
• For the first time in history as of July 2015,
The number of Canadians 65 and
older exceeds the number of
children 14 and younger 1
• The doubling of older people will happen
sooner in Canada than in any other G7
nation.
Are we ready for the Grey
Tsunami?
Our Ability to
provide care with
the CURRENT
overcrowding
raises grave
concerns for the
future…
Assessing Frailty in the ED
Sunnybrook ED - 60,000 visits / year
• 9 ED physicians and 30 nurses assess 160
- 226 patients per day
• 35 – 50 of those are aged 65 plus
• The vast majority are first time encounters
– no familiarity with patients history
• Rapid methods of assessing frailty are
needed for ED staff
Frailty in Older Canadians
• The majority of older Canadians, at any
age, are robust (56% of those ≥ 85)1
• But a significant minority suffer from frailty,
which makes them vulnerable to adverse
events 2-8 including
• Falls, Functional Decline, Infections
• DELIRIUM
Why is ED Delirium Important?
• Delirium is COMMON 9-15
- 10% in ED,
• Delirium is LETHAL16-17
- 1 year Mortality up to 35-40%
- INDEPENDENT RISK (AHR 2.1)
• Delirium is NOT ALWAYS REVERSIBLE
- Average 6-12 months to return to
baseline 18-19, Some never recover
• DELIRUM IS OFTEN UNRECOGNIZED
• Only recognized in 17% - 24% 20 -22
• 17% - 25 % of those with delirium discharged
home 20
• Mortality Risk 3 - 8.5 x higher if sent home with
unrecognized delirium (Kakuma et al.) 22
Why is Delirium in the ED
Important?
Why Do We Miss Delirium?
Hard to see if you aren’t looking for it
Current Knowledge Gap
• The highest sensitivity reported for a
predictive tool targeting the elderly is 72%,
compared to sensitivities of 99 to 100% for
many predictive tools targeting younger
populations.23-27
Prediction in Older People
The minimum number of variables needed to
accurately identify high risk older adults
exceeds the maximum number of variables
that staff are willing or able to collect
FOCUS Study
Solution: Involve the patient & family to
collect a richer data set
FOCUS Study
• To test the real-world implementation of
a user-friendly tablet based technology to
identify high-risk older adults with
• Frailty
or
• Problems with their thinking such as
delirium or dementia
FOCUS Study
• Collaboration across 3 Provinces
- Ontario
- Quebec
- Nova Scotia
• In English & French
FOCUS Study: Caveat
• Previous research has shown that patients
with delirium do not participate in
research…
• Informed consent process systematically
excludes patients at risk for delirium 28
• Therefor we used delirium severity index to
measure “degrees” of delirium
FOCUS Study
• Uses existing evidence-based questions
plus
• Cognitive performance measures from
serious game
FOCUS Study: Measuring Frailty
ClinicalFrailty Score: CFS 29
• 1 to 9 point scale
• From “Very Fit” to “Terminally Ill”
• Previously validated in the community
setting, in-patient settings
• No comparisons of patient and caregiver
assessments to date
FOCUS: Clinical Frailty Scale
FOCUS Study: “Serious Game”
FOCUS Study
306 participants enrolled:
• Ontario: 172 (47.8%)
• Quebec: 100 (32.7%)
• Nova Scotia: 34 (11.1%)
• Average Age: 75.8 years
• Female: 146 (48.7%)
FOCUS Study: Usability
Usability
• Of all ED patients 65 and older
approached only 7.7% unable to use tablet
(injuries, paralysis, visual acuity)
• An additional 1.8% with severe pain were
not included
FOCUS Study Demographics
Median,
(IQR)
MOCA 23
(16 – 26)
CFS
(MD)
3.4
(2-4)
CFS
(Patient)
3.0
(2-4)
Pain
(NRS)
0
(0-5)
FOCUS Study
306 participants enrolled
• Maximum of 3001 data points x 306
participants
= 900,000 data points!
Health Needs, Adverse Outcomes
1 Month
(n= 306)
3 Months
(n= 306)
911 Calls 10
(3.3%)
11
(3.6%)
Return to ED 28
(9.2%)
34
(11.1%)
Admitted 9
(2.9%)
6
(2.0%)
Deceased 10
(3.3%)
14
(4.6%)
Any Outcome 47
(14.4%)
57
(17.5%)
Question 1
• Does the CFS predict Health Needs?
• Compare CFS collected by MD, RA,
Patient and Caregiver
CFS Prediction of Health Needs
CFS ≥ 3 Health Needs,
1 Month
Health Needs,
3 Months
MD 38/47 (80%)* 44/57 (77%)*
RA 35/47 (74%) 43/57(75%)*
Patient 29/47(62%) 38/57 (66%)
Care Giver 6/47 (13%) 6/57 (11%)
Delirium and Serious Game
• 3 enrolled patients met criteria for delirium
• This 1% rate is well below expected
delirium rate from clinical samples (10%)
• Confirms previous studies demonstrating
selection bias
• 24/306 (7.8%) had a delirium severity
score ≥ 4
Question 2:
• Does the FOCUS Serious Game predict
Delirium Severity?
Serious Game Scores & Delirium
• Developed a summative test performance
score
Delirum
Index
Mean Test
Score
(95% CI)
0 - 3 0.61
(0.60 - 0.63
≥ 4 0.70
(0.63 - 0.78)
Discussion & Conclusion
• Use of FOCUS tablet feasible in ED and
Pre-hospital settings, across Provinces
and in 2 languages
• Validated use of CFS in ED setting
• Validated use of serious game to identify
patients at risk for delirium
• Established feasibility of automated
referrals to discharge planning
Next Steps
• Validate in larger samples of patient with
delirium
• Conduct longitudinal studies of patient
during ED stay
• Test preventative interventions
References 1. Rockwood K, Howlett SE, MacKnight C, et al. Prevalence, attributes, and outcomes of fitness
and frailty in community-dwelling older adults: report from the Canadian study of health and
aging. J Gerontol A Biol Sci Med Sci. Dec 2004;59(12):1310-1317.
2. Rockwood K, Fox R, Stolee P, Robertson D, Beattie B. Frailty in elderly people: an evolving
concept. CMAJ. Feb 15 1994;150((4)):489-495.
3. RGPO. Regional Geriatric Programs of Ontario Fact Sheet: The Role and Value of Specialized
Geriatric Services. 2001; www.rgps.on.ca. Accessed July 15, 2016.
4. CDC. National Center for Health Statistics, Data Warehouse on Trends in Health and Aging.
2006; http://www.cdc.gov/nchs/agingact.htm. Accessed July 15, 2016.
5. Speechley M, Tinetti M. Falls and injuries in frail and vigorous community elderly persons. J Am
Geriatr Soc. Jan 1991;39(1):46-52.
6. Madden K, Hogan D, Maxwell C. The prevalence of geriatric syndromes and their effect on the
care and outcome of patients aged 75 years of age and older presenting to an emergency
department. J Can Geriatric Society. 2002;5:69-75.
7. CSHAWG. Canadian study of health and aging: study methods and prevalence of dementia.
CMAJ. Mar 15 1994;150(6):899-913.
8. Hogan DB, Fox RA. A prospective controlled trial of a geriatric consultation team in an acute-
care hospital. Age Ageing. Mar 1990;19(2):107-113.
References 9. Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED
geriatric patients. Am J Emerg Med. 1995 Mar;13(2):142-5.
10. Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and
detection of delirium in elderly emergency department patients. CMAJ, 2000;163:977-
981.
11. Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on
the care of elderly emergency department patients. Ann Emerg Med. 2003;41(5):678-
84.
12. Vasilevskis EE, Han JH, Hughes CG, Ely EW.Epidemiology and risk factors for
delirium across hospital settings. Best Prac Res Clin Anaesth. 2012, 26 :277–287.
13. Siddiqi N, House AO, Holmes J. Occurrence and outcome of delirium in medical in-
patients: a systematic literature review. Age and Ageing 2006; 35: 350–364.
14. Levkoff SE, Evans DA, Liptzin B et al. Delirium. The occurrence and persistence of
symptoms among elderly hospitalized patients. Arch Intern Med 1992; 152(2): 334–
340.
15. Francis J, Martin D & Kapoor WN. A prospective study of delirium in hospitalized
elderly. JAMA 1990; 263(8): 1097–1101.
References
16. McCusker J, Cole M, Abrahamowicz M,Primeau F. Delirium Predicts 12-Month
Mortality. Arch Intern Med. 2002;162:457-463.
17. Han JH, Shintani A, Eden S, Morandi A, Solberg LM, Schnelle J, Dittus RS, Storrow
AB, Ely EW. Delirium in the Emergency Department: An Independent Predictor of
Death Within 6 Months. Ann Emerg Med. 2010;56:244-252.
18. Levkoff SE, Evans DA, Liptzin B, Cleary PD, Lipsitz LA. Wetle TT, Reilly CH, Pilgrim
DM, Schor J, Rowe J. The Occurrence and Persistence of Symptoms Among Elderly
Hospitalized Patients. Arch Intern Med. 1992;152:334-340.
19. McCusker J, Cole M, Dendukuri N, Han L, Belzile. The course of delirium in older
medical inpatients. A prospective study. J Gen Int Med, 2003:18: 696-704.
References
20. Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the
care of elderly emergency department patients. Ann Emerg Med. 2003;41(5):678-84.
21. Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and
detection of delirium in elderly emergency department patients. CMAJ, 2000;163:977-981.
22. Kakuma R, du Fort GG, Arsenault L, Perrault A, Platt RW, Monette J, MorideY, Wolfson C.
Delirium in older emergency department patients discharged home: effect on survival. J Am
Geriatr Soc. 2003;51(4):443-50.
23. Lee JS, Schwindt G, Langevin M, Moghabghab R, Alibhai SM, Kiss A, et al. Validation of the
triage risk stratification tool to identify older persons at risk for hospital admission and
returning to the emergency department. J Am Geriatr Soc. 2008;56(11):2112-7.
24. Stiell IG, Laupacis A, Wells GA. Indications for computed tomography after minor head
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2000;343(21):1570-1.
25. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The
Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N
Engl J Med. 2003;349(26):2510-8.
26. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al.
Decision rules for the use of radiography in acute ankle injuries. Refinement and
prospective validation. JAMA. 1993;269(9):1127-32.
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Prospective validation of a decision rule for the use of radiography in acute knee
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28. Adamis D, Martin FC, Treloar A, Macdonald AJ. Capacity, consent, and selection bias
in a study of delirium. J Med Ethics. Mar 2005;31(3):137-143.
29. Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and
frailty in elderly people. CMAJ. Aug 30 2005;173(5):489-495.
Interobserver Agreement
Patient
MD
Care Giver
R/A 0.61
(0.55 – 0.67)
0.55
(0.48 – 0.62)
0.66
(0.50 – 0.82)
Care
Giver
0.56
(0.36 – 0.76)
0.58
(0.42 – 0.75)
-
MD 0.44
(0.36 – 0.51)
- -
FOCUS Study: Agreement
• Patients, Research Assistants and
Physicians assessed baseline frailty
assessment using Canadian Frailty Scale
• Caregivers provided CFS in a subset
Forming Patient Types
Based on Technology
Use
Q1. Do you own your own
computer or have one in your
home?
Q3. Do you own your own tablet or
have one in your home?
Q4. Have you ever used an
Automated Banking Machine
(ABM)?
Patient Types Based on Technology
Use
Type Computer
Use Tablet Use ABM Use
1 (n = 95) ✓ ✓ ✓
2 (n = 82) ✓ ✕ ✓
3 (n = 17) ✕ ✓ ✓
4 (n = 49) ✕ ✕ ✓
5 (n = 33) ✕ ✕ ✕
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