Promises to Your Grandparents: Opportunities to improve the quality and

safety of geriatric care

Douglas G. Merrill MD MBAChief Medical Officer

Senior Associate Dean for Quality and SafetyUniversity of California Irvine Health

Conflict of Interest Statement

To my knowledge, I have no conflicts of interest represented by this presentation.

ObjectivesAfter this presentation, the attendee should be able to • understand the import of geriatric care to patient outcomes

and healthcare costs• understand how to reverse frailty, improve social connections,

mental illness and care planning in the geriatric population.• understand what UC Irvine Health is doing or planning to do in

order to help support providers in the care of geriatric patients.

“For decades we have been told by our pediatriccolleagues that “children are not simply little adults.”Perhaps we are to realize that older patients are not

simply young patients with more birthdays.”

Johnson RG .The Elderly Are Different: Resection for Non-small Cell Lung Cancer.CHEST 2011; 140 (4):839-840.

IN CONCLUSION: My to-do list• Support an initiative to evaluate semi-annually for frailty in all outpatients over the age of 65

years old, in all outpatient clinics• Institute a shared decision making program for all elderly or at risk patients who are under

consideration for invasive therapy, electively: e.g., surgery, hemodialysis, transplant, etc. Make sure they discuss risk of death, but also of ‘never return home’.

• Amplify the Advanced Directive Outpatient Initiative to reach 75% of patients who are seen more than once by a UCI clinician as an outpatient.

• Continue to increase the number of elderly patients seen by the Transitions of Care team on Day 1 of admission, or pre-admission for elective admissions.

• Support the increased linkage of UC Irvine Health to the best skilled nursing facilities (SNFs) for both interim post-discharge and long-term post-discharge care.

• Augment the availability of Pharmacy consultation for elderly patients admitted and pre-discharge• Implement support for a pre-op algorithm for ELECTIVE surgery, which refers for frailty, anemia,

low platelets, renal failure, cancer, COPD, RA, steroid use, or no social structure – sending patients to OT, PT, Nutrition, PM &R, and PCP; Case Management to visit their home and have the patient and family pick a list of three SNFs that they would prefer (and have them visit those).

• Reduce the incidence of transfer of patients for whom our care will be futile• Reduce the introduction of futile care options for inpatients at the end of life

IN CONCLUSION: Your to do list• Study the differences between adult and elderly adult physiology carefully.• Learn about the variation in metabolism of medication between the “normal” elderly, infirm elderly, and

the normal or ill adult who is not elderly. • Learn what causes re-admission and learn to anticipate those conditions in your patients• Avoid benzodiazepines and sedatives – consult Psychiatry early for elderly patients with delirium• READ THE NOTES FROM YOUR CONSULTANTS!!!• Learn about the surgical procedures most associated with re-admission in the elderly and prepare your

patients for not being discharged after those elective procedures. Download “Optimal Preoperative Assessment of the Geriatric Surgical Patient: A Best Practice Guideline” from the ACS NSQIP and American Geriatric Society and read it. https://www.facs.org/~/media/files/quality%20programs/nsqip/acsnsqipagsgeriatric2012guidelines.ashx

• Learn about the risk of never returning home for your pre-op “clearance” patients with documented frailty, anemia, low platelets, renal failure, cancer, COPD, RA, steroid use, or no social structure – • prep them early and get Case Management involved on day one.• Involve OT, PT, Nutrition, PM &R, and Case Management early. • Get Case Management to visit their home. • Engage the patients in discussion about transition from single living at home

• Engage your patients in Advanced Directive Discussions• Consult with Palliative Care and the Acute Pain Service early in the care of your elderly patients

Agenda

•The importance of being elderly: • frailty, •social isolation, •mental illness • lack of care planning •Impact on the healthcare delivery system•How UC Irvine Health will help you to help them.

The Aging of America

• In 2000, 12% of all Americans were over the age of 65 years.• By 2030, 20% of all Americans will be over the age of 65 years.• By 2050, 80 million Americans will be over age 65 years, • The proportion of the population over 85 years is expanding at 6x

the rate of the general population• 2 out of 3 people over the age of 65 have chronic conditions and

their care takes up 67% of all expenditures, private and public, on healthcare.• And that 67% is only going to grow…

Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept. of Health and Human Services; 2013.www.cdc.gov/aging Lin RY J Hospital Medicine 2015;10:586–591

So, we’re old and getting older…so what?

• Social Isolation is increased• Living alone is higher risk for

morbidity and mortality• Financial independence is

decreased• Medication errors by patient and

prescriber increase, as does impact• Co-morbidities increase• Trauma risks increase• Incidence of Delirium is increased• Incidence of Depression and

Suicide are increased• All-cause risk of death is higher

• Risk of elder abuse, including financial scams by family or others• Lengths of stay increase due to • Increased number and severity of

co-morbidities • Lack of funding for long term care

or in home care• Sometimes due to family

pressure• Regulatory pressure to discharge

increases• Financial losses to the health

system increases

Focusing on…

• Frailty (nutrition, mobility, muscle tone, gait, stamina)• Mental illness (depression and delirium)• Social isolation (including potential for abuse) • Care planning (Advance Directives, Shared-Decision Making,

Health Docents, choosing safe living sites)

Why care about frailty?

• Incidence recognized among those in the community:• 10.7% of ages 65 to 80• 15.7% of those aged 80 to 84, • 26.1% of those aged 85 or older.

• Frailty is associated with increased risk of functional impairment, hospitalization, and mortality, with the risk of individual mortality being better predicted by frailty than by chronological age.

• It increases costs to the healthcare system (re-admission is an increasing cost to institutions, including fines by CMS reaching 7 figures per year).

• Associated with higher mortality in the peri-op period; elderly patients have surgery at 4x the rate of non-elderly and already cost the system much more for surgery than does a younger patient. With over 20% of the US population destined to be over 65 years of age by 2030, this is an important aspect of health and healthcare cost.

• Most importantly, it is reversible!

Collard RM, et al. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):1487-92. Shamliyan T, et al. Association of frailty with survival: a systematic literature review. Ageing Res Rev 2013;12(2):719-36.Buigues C., et al. Arch Gerontology and Geriatrics, 2015; 61: 309–321

Measuring Frailty• Frailty is not a necessary outcome of chronological age!• There is no single test for frailty, but several very simple ones are

valid.• Grip Strength is alone the most specific and sensitive• Fried-Hopkins frailty index – weak grip, weight loss, exhaustion, low level of

physical activity, slow walking 15 feet. Score of 4-5 = “frail”• A simple clinic strategy:• Gait speed – time to walk 15 feet; FAIL if more than 6 seconds• Hand grip strength FAIL if < 30kg for men or < 20kg for women• Mobility: time to rise from a chair, walk 15 feet and return to the chair = FAIL if

> 15 seconds• BMI < 25 or >30

• There are other measures, but any of these test algorithms can be done in clinic by an MA and followed longitudinally.

Cameron et al. BMC Medicine 2013, 11:65-75.Anaya DA, et al. Summary of the Panel Session at the 38th Annual Surgical Symposium of the Associate of VA Surgeons. JAMA Surgery. 2014; 149(11): 1191-1197.

9 Techniques that succeed in reversing frailty

• In a study of patients average age 83, a 12 month RCT showed 15% of the study group were no longer frail and mobility improved, while the control group saw a decline in indices of frailty and mobility.

• NB: the difference between groups was not significant at 3 months – it took 12 months. This is a long term process to correct.

• Dietary consultation and nutritional supplementation as needed, including home-delivered meals. BMI < 18.5 kg/m2, or mid-upper arm circumference was <the 10th percentile led to nutritional supplementation using commercially available, high energy, high protein supplements.

• Referral to psychology or psychiatry if exhaustion criterion was met and the Geriatric Depression Scale score was high.

• Day activity groups and links with phone volunteers, if socially isolated. • 1x per month PT (including mobility work) at home and a home exercise program for

patients who meet the weakness, slowness or low energy expenditure criteria. • A Weight-bearing for Better Balance (WEBB) program was used to improve mobility, increase

physical activity and prevent falls for those who were identified at risk for falls, performed 3-5x per week.

• Physical Therapist was the coordinator and re-assessed monthly at home sessions, identifying needed additional health interventions.

• Comprehensive evaluation by Geriatrician or PM&R physician to manage or follow up on pain and other identified conditions, such as urinary incontinence.

Cameron et al. BMC Medicine 2013, 11:65-75

Frailty as a peri-operative risk predictor

• Frailty present pre-operatively predicts postoperative complications • Prolonged LOS • Increased post-op infection rates• Increased post-op delirium• Higher risk for falls requiring surgical intervention• High risk of discharge to long-term care• Increased incidence of never returning to independent living**

in even low risk patients.

Carlisle JB. Pre-operative co-morbidity and postoperative survival in the elderly: beyond one lunar orbit. Anaesthesia 2014, 69 (Suppl. 1), 17–25.Choi JY. J Amer Coll Surg. 2015; 221(3):652-660.

**You may not ever go home again…

For most of your patients, independence is more important than the risk of death, so they ignore surgeon’s warnings about risk of death, imagining that it means that they just won’t wake up…Telling them the truth that they may never return to their home if frailty goes untreated pre-op will have a greater impact on their compliance.In one study, the majority of those patients who were admitted to SNF post-op and then did not return home said they would have refused surgery if they had known that could happen.

Choi JY. J Amer Coll Surg. 2015; 221(3):652-660.Carlisle JB. Pre-operative co-morbidity and postoperative survival in the elderly: beyond one lunar orbit. Anaesthesia 2014, 69 (Suppl. 1), 17–25.

After hip fracture repair, use of one frailty index showed correlation with discharge home

•80% of those scoring as “low” frailty went home. •Only 6% of those who scored as “high” frailty went

home.

Hubbard RE, Story DA. Patient frailty: the elephant in the operating room. Anaesthesia 2014; 69(S1): 26-34.

Frailty as a peri-operative risk predictor

• If you are asked to “clear” a patient for surgery, please test for frailty and discuss its implications with patients. • IF patients fail frailty testing, please recommend consideration of a delay of

ELECTIVE surgery• Emphasize, “you won’t ever go home post-op if we don’t fix this pre-op”…• Consult case management to help arrange for pre-operative fitness

augmentation – try the nine interventions!• Alert the surgical and anesthesia teams to avoid post-op medication that might

induce falls and increased dementia – a pain consult would be good, pre-op• Alert the team to insure that the post-discharge environment is safe – patient

should be seen by case management pre-op to discuss this with patient and family

• Multidisciplinary teams, including RNs and MDs trained in Geriatrics, improve the outcomes if involved prior and following surgery performed in elderly patients.

Choi JY. J Amer Coll Surg. 2015; 221(3):652-660.

Pre-op Intervention: does it work?• Pre-op geriatrician consultation is effective to reduce

delirium and avoid recurrent admission.• Nutritional supplementation improves outcomes and reduces

complications• Pre-op rehabilitative programs to improve function are

effective at decreasing post-op complications & LOS, but re-admission not studied• Exercise and muscle strengthening programs, particularly aimed

at intercostal musculature and reduction in sedentary behavior are useful.• There is evidence that pre-op chemo was made more effective

(tumor size made significantly smaller) by concomitant exercise. West MA et al. British Journal of Anaesthesia. 2015; 114 (2): 244–51.O’Doherty AF et al. Brit J. Anaesth 2013; 110(5):679-89.Carli F. Can Urol Assoc J. 2014; (8):11-12): E884-7.Gillis C. Anesthesiology. 2014 Nov;121(5):937-47.

Delirium• An acute, reversible medical syndrome with an incidence in hospitalized general

medical patient population ranging from 10% to 24% • Incidence is higher in surgical patients (36–46%; up to 60% in postoperative

patients). • Known risk factors include advanced age, greater severity of illness, pre-existing

cognitive abnormalities, the presence of metabolic abnormalities, and treatment with psychoactive and anticholinergic drugs.

• Delirium may be associated with medication, may be associated with pre-existing dementia, or neither.

• The typical patient is a white male with a lower extremity trauma, on opioids, benzodiazepines, antihistamines, other sedatives, steroids, other psychotropic medications and with a history of previous sleep disturbances or altered mentation.

Lin RY et al. Drugs Aging 2010; 27 (1): 51-61.

Preventing Delirium and Treating Dementia: Why?• Delirium and dementia are increasing – for outpatients and for inpatients. Age is the

most significant risk factor for dementia. The prevalence of Alzheimer’s disease increases at a predictable rate, about 5% per year after age 65 years. Half of patients are demented by age 95.

• Dementia is associated with delirium in the hospital…• Hospital costs go up three-fold if delirium or dementia is present. • Delirium in the elderly is associated with longer LOS (1.5-2 days) • Delirium increases the risk of re-admission, increasing cost to the healthcare system

and to the hospital particularly, as well as reducing the hospital’s and the physician’s “quality” assessment on CMS metrics.

• Delirium increases the risk of not returning home after discharge from the hospital, thereby increasing cost to the healthcare system.

• Nursing home costs and home health costs are 10x and 4x the normal patient’s costs, respectively, if delirium or dementia is present.

• Delirium increases the risk of death (50 to 100%) in the peri-hospital periodLin RY J Hospital Medicine 2015;10:586–591.Goldberg A.BMC Geriatrics. 15:69, 2015.

Preventing Delirium and Treating Dementia: How?How to prevent or treat these?• Reduce the use of benzodiazepines, glycopyrrolate or

atropine, and antihistamines for sleep aids (or for anything else).• Actively screen for delirium daily on rounds (look for

confabulation). Partner with nursing on this! Ask the patient and family members about sleep disturbances or evidence of dementia before admission.• Stop transferring elderly patients between rooms! More room

transfers occurring per patient day is associated with an increased incidence of delirium amongst hospitalized elderly patients. • Consult Psychiatry or Psychology Services and Case Management*

Lin RY J Hospital Medicine 2015;10:586–591. Goldberg A.BMC Geriatrics. 15:69, 2015.

*Coming soon to UCI Health: more geriatric psychiatry and overall inpatient/outpatient psychiatry services and social workers/case managers.

Social IsolationLow quality social networks lead to • Isolation increases anxiety and alters immuno-endocrine

function, increases disease and death risk. • Increased risk of poorly managed disease• Increased risk of mental disease• Increased risk of institutionalization• Increased risk of being a victim of violence• Increased risk of death, including suicide

House JS: Psychosom Med 2001;63:273–274Tobiasz-Adamczyk B, et al. Arch Gerontology & Geriatrics, 2014;58(3):388-98.

Cognitive Impairment + Social Isolation + Frailty = High Risk

One study of older adults found that among a general population of 800 patients over 65 years of age• There was a median age of 80 • Over 50% were frail• Almost 50% lived alone• 17% were cognitively impaired• High Risk:• 14.5% for hospitalization• 4.3% were considered high risk of institutionalization• 2.7% for death within one year

O’Caoimh et al. BMC Geriatrics 2014, 14:104.

Treating social isolation• ASK the questions and get case management involved

early – connect with family whenever possible*• Reduce untreated mental disease: psychiatric

intervention reduces isolation(and falls, delirium and early death)• Avoid long term sedative use• Whenever possible, advocate for transportation,

community centers, internet access, and home health visit services for the elderly

*COMING SOON: more case management resources in the outpatient clinics

Segerstrom SC, Miller, GE. Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychol. Bull., 130 (2004), pp. 601–630.

Transitional Care Management Program

TCM Focus: Care Coordination to Reduce Readmissions (and decrease social isolation)

• Ensure the DC Plan formulated by IP team is executed as intended

• What unique intervention will TCM team perform to reduce readmissions (and decrease social isolation) ? • Make follow-up appointments, DME, home health

arrangements• Support navigation of the health care system• Support patient and family compliance with DC plan• Referral to community resources e.g.,

transportation• Referral to in-network complex case managers• Support communication with outside providers

Care Planning: Advanced Directives

A story from a place far, far away and a long time ago

• 83 y.o. male with malignancy, received palliative radiation and chemotherapy as an outpatient. • Admitted with sepsis, treated, went home after 15 days.• Re-admitted two weeks later, again with sepsis, died after 22 days, 20 in the

ICU.• Final week was spent with patient in and out of coma and with family

struggling to decide a care plan. Palliative Care was consulted on day 20. • There was no advance directive and no documentation it was ever discussed

either as an outpatient or after recovery and before discharge from the previous sepsis admission.• When asked, the attending physician who cared for him during the first

admission said, “I don’t see a reason we should have considered such a conversation back then. He recovered and went home.”

Advanced Directives• Elderly patients have a higher risk of dying than the non-

elderly.• Elderly patients with incurable cancer have a very high risk of

dying.• It is appropriate to be open with them about their risk and to

discuss how they want to die.• Giving these patients the option of stating those wishes in

advance, without cutting them off from palliative or heroic care options is accomplished with an Advanced Directive.• At UC Irvine Health, fewer than 6% of our inpatients are

admitted OR DISCHARGED with an advanced directive discussed or on the chart.

Advanced Directives• At UC Irvine Health, we now have a pilot project underway in the

CHAO Cancer Clinic and the CHF clinic: “the Second Visit Visit”.• At the first visit for a new patient at one of these clinics, the patient is offered

an additional half an hour on their next visit to discuss Advanced Directive options with a social worker or RN. He or she is asked to be sure that their likely designated decision maker (spouse or child, typically) comes with him or her.

• The focus is the answer to this question, “If you were unable to speak for yourself, who would you want to do that for you?”

• The intent is not to get the patient to fill out a detailed POLST or other document; it is just to name a designated loved one or friend in an Advanced Directive, someone who will know what they want.

• Also, classes are being held regularly now for our community to teach patients about Advanced Directives• Our goal is to have 75% of all UC Irvine Healthcare staff and

physicians to have had training in how to have that simple conversation (“who would you want…?”) by the end of June.

IN CONCLUSION: My to-do list• Support an initiative to evaluate semi-annually for frailty in all outpatients over the age of 65

years old, in all outpatient clinics• Institute a shared decision making program for all elderly or at risk patients who are under

consideration for invasive therapy, electively: e.g., surgery, hemodialysis, transplant, etc. Make sure they discuss risk of death, but also of ‘never return home’.

• Amplify the Advanced Directive Outpatient Initiative to reach 75% of patients who are seen more than once by a UCI clinician as an outpatient.

• Continue to increase the number of elderly patients seen by the Transitions of Care team on Day 1 of admission, or pre-admission for elective admissions.

• Support the increased linkage of UC Irvine Health to the best skilled nursing facilities (SNFs) for both interim post-discharge and long-term post-discharge care.

• Augment the availability of Pharmacy consultation for elderly patients admitted and pre-discharge• Implement support for a pre-op algorithm for ELECTIVE surgery, which refers for frailty, anemia,

low platelets, renal failure, cancer, COPD, RA, steroid use, or no social structure – sending patients to OT, PT, Nutrition, PM &R, and PCP; Case Management to visit their home and have the patient and family pick a list of three SNFs that they would prefer (and have them visit those).

• Reduce the incidence of transfer of patients for whom our care will be futile• Reduce the introduction of futile care options for inpatients at the end of life

IN CONCLUSION: Your to do list• Study the differences between adult and elderly adult physiology carefully.• Learn about the variation in metabolism of medication between the “normal” elderly, infirm elderly, and

the normal or ill adult who is not elderly. • Learn what causes re-admission and learn to anticipate those conditions in your patients• Avoid benzodiazepines and sedatives – consult Psychiatry early for elderly patients with delirium• READ THE NOTES FROM YOUR CONSULTANTS!!!• Learn about the surgical procedures most associated with re-admission in the elderly and prepare your

patients for not being discharged after those elective procedures. Download “Optimal Preoperative Assessment of the Geriatric Surgical Patient: A Best Practice Guideline” from the ACS NSQIP and American Geriatric Society and read it. https://www.facs.org/~/media/files/quality%20programs/nsqip/acsnsqipagsgeriatric2012guidelines.ashx

• Learn about the risk of never returning home for your pre-op “clearance” patients with documented frailty, anemia, low platelets, renal failure, cancer, COPD, RA, steroid use, or no social structure – • prep them early and get Case Management involved on day one.• Involve OT, PT, Nutrition, PM &R, and Case Management early. • Get Case Management to visit their home. • Engage the patients in discussion about transition from single living at home

• Engage your patients in Advanced Directive Discussions• Consult with Palliative Care and the Acute Pain Service early in the care of your elderly patients

Bibliography

• Collard RM, et al. J Am Geriatric Soc. 2012;60(8):1487-92. • Shamliyan T, et al. Ageing Res Rev 2013;12(2):719-36• O’Caoimh et al. BMC Geriatrics 2014, 14:104.• Anaya DA, et al. JAMA Surgery. 2014; 149(11): 1191-1197.• Buigues C., et al. Arch Gerontology and Geriatrics, 2015; 61: 309–321• Segerstrom SC, Miller, GE. Psychol. Bull., 130 (2004), pp. 601–630.• Khavanin N. American Journal of Otolaryngology. 35(3):332-9, 2014 • Buchanan CC, et al. J. Neurosurg 2014; 121:170-175.• Akins PT et al. Spine. (publ .ahead of print 04/04/2015)• Wang MC, et al. Spine J 12:902–911, 2012• Lavelle K, et al. Brit J. Surgery 2015; 102: 653-667• DeRosa R. J. Urology, 2015; 193(4S):e108.

Thank you!

Fixing Frailty Before Elective Surgery

Transitional Care Management (TCM) vs Transitions of Care (TOC)

Category TCM TOC

Patients Selected patients of those identified at high risk for readmission

Unfunded & under-funded

Focus/ Goal Readmission reduction Facilitate urgently needed care (e.g., Follow-up appt, ancillary service, ED-TOC (averts IP admission)

Funding Source

All comers– funded & unfunded Unfunded & under-funded

IP DC Plan Formulated by IP team Formulated by IP teamHand-off TCM team meets patient while in

hospital – Warm hand-off with IP team

If only TOC patient, TCM team does not meet patient

Care Coordination

Work with providers to coordinate care for first 30 days, minimum

Joint case manage while LOA in effect. Joint case management ends when funding obtained

Not Mutually Exclusive

Patient may be only TCM patient or both TCM & TOC patient

Patient may be only TOC patient or both TOC & TCM patient