acute frailty units evidence base - rcp london
TRANSCRIPT
Acute frailty units – evidence base
Professor Stuart Parker Newcastle University
What this talk will cover:
• Frailty - an important clinical syndrome • A definition of CGA • The marriage of CGA and frailty….. • Evidence about delivery of CGA for frail older
people in acute care • Emerging evidence of service innovation • Some conclusions
Acute frailty units – evidence base
Frailty - an important clinical syndrome
“A medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.”
Frailty - an important clinical syndrome
How best to deliver comprehensive geriatric assessment: an umbrella review*
P McCue1, A McLeod1, S Conroy2, H Roberts3, S Kennedy4, S G Parker1
Newcastle University, UK. 2Leicester University, UK, 3Southampton University, UK, 4Sheffield University, UK.
A definition of CGA
*PROSPERO 2015:CRD42015019159
We reviewed 715 titles, 329 abstracts, 108 full articles and selected 12 reviews for data extraction.. The most widely used definition of CGA was:
“a multidimensional, multidisciplinary process which identifies medical, social and functional needs, and the development of an integrated / co-ordinated care plan to meet those needs.”
Odds ratios for living at home at end of
follow-up
Who benefits from CGA?
Odds ratios for living at home at end of
follow-up
Who benefits from CGA?
How best to deliver comprehensive geriatric assessment: an umbrella review*
P McCue1, A McLeod1, S Conroy2, H Roberts3, S Kennedy4, S G Parker1
Newcastle University, UK. 2Leicester University, UK, 3Southampton University, UK, 4Sheffield University, UK.
Who benefits from CGA?
No of Reviews
DESCRIPTION Older person 2
Frail older person 3
Frail elderly person 1
AGE SPECIFIED 55+ 1
60+ 3
65+ 6
70+ 1
75+ 1
TYPE OF ADMISSION Emergency 9
Excluded condition specific intervention 9
Inclusion of specific conditions 3 *PROSPERO 2015:CRD42015019159
0
1
2
3
4
5
6
7
8
<25% (42) 25-49% (17) 50-74% (23) 75-100% (24)
Lower limb (P<0.001)
Frailty (P<0.001)
Physical Performance (P<0.001)
HR QoL (P=0.001)
GDS(P=0.03)
Adherence % (number of participants)
Sc
ore
(va
rio
us
)
Population >70 yrs, 3+ Frailty criteria, Not in residential care,
MMSE>18, Life exp >12 months
Intervention Weight loss – dietary / supplements
Exhaustion (+^GDS) – Psychiatry/Psychology
Weakness / slowness – PT and home exercise
Mobility goal targeting
Medical review
(Comprehensive Geriatric Evaluation)
Comparison Usual health and aged care services
The marriage of CGA and Frailty
How best to deliver comprehensive geriatric assessment: recent trends
P McCue1, A McLeod1, S Conroy2, H Roberts3, S Kennedy4, S G Parker1
Newcastle University, UK. 2Leicester University, UK, 3Southampton University, UK, 4Sheffield University, UK.
CGA for frail older people in acute care
Model Comment
ACE UNIT 7 papers (1 RCT – re-analysis)
Mostly refinements /modifications/detailing of
existing models
ED based 8 papers (1 RCT)
ED geriatrician, AP Nurse, Outreach, embedded
CGA, Risk screening
Other forms 3 papers
Surgical care, heart failure care, mobile team
How best to deliver comprehensive geriatric assessment: recent trends
P McCue1, A McLeod1, S Conroy2, H Roberts3, S Kennedy4, S G Parker1
Newcastle University, UK. 2Leicester University, UK, 3Southampton University, UK, 4Sheffield University, UK.
CGA for frail older people in acute care
Model Randomised
Controlled Trial
Controlled
observational
cohort
Observational
cohort
ACE UNIT 1* 2 4
ED based 1** 2 5
Other forms 1* 1 1
* Reanalysis / subgroup analysis of existing trial ** Pseudo randomised trial
CGA for frail older people in acute care
CGA for frail older people in acute care
Summary and conclusion
Summary and conclusion
o Frailty and CGA are definable and defined.
o They clearly belong together in clinical practice
o Much of the evidence we might assume to be relevant to the development of acute care interventions for frail older people was not developed in trials which stratified for frailty.
o ACE units, Frailty units, and various other “close to the front door” models for targeting older people with frailty with CGA / acute care interventions are at the cutting edge of development, go beyond the evidence base, and are therefore a potentially fruitful source for the generation of new knowledge through research.
Summary and conclusion
“The philosophers have only interpreted the world in various ways; the point, however, is to
change it."