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Salted Watermelon and Heart Failure:A Team-Based Approach to Complex Decision Making
Marianthe Grammas, MDAssistant Professor & Medical Director
Clinical Director of Ambulatory Care TransitionsUAB Division of Gerontology, Geriatrics and
Palliative Care
DISCLOSURES
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
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
• 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.
• 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
BACKGROUND• 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.
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
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
3 or More…Managing Multiple Health Problems in Older Adults
CASE PRESENTATION
• Ms. L is a 78 y/o Female• PMHx = heart failure, diabetes, chronic kidney dis.• Osteoarthritis, depression• Peripheral neuropathy, diabetic retinopathy, gingivitis
• 3rd 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!”
BUT WAIT!!!
“Unless someone like you
cares a whole awful lot,
nothing is going to get better.It’s not.”
IT TAKES A VILLAGE…
OptometryPublic Health/UMDentistryAudiology
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
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
FRAILTY
• What do you picture as frailty?
FRAILTY
FRAILTY• 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
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 frailFried L, et al. Journal of Gerontology;
2001
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
INTERDISCIPLINARY TEAM: PRIORITIZING CARE FOR OUR PATIENT
• Is Ms. L frail?• How do we improve Ms. L’s health?• Function?• Quality of Life?
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.
QUESTIONS?