Cutting Edge:Cutting Edge: Update on Research Advances in Geriatrics

Janet E. McElhaney, MD, FRCPC, FACP

Professor of Medicine

Allan M. McGavin Chair, Geriatrics Research

UBC, PHC and VGH Division Head, Geriatric Medicine

Objectives

What’s hot, what’s not – but should be; transforming seniors’ care

Assessment of the older patient – Right view, Right care, Right discharge and follow-up

Interprofessional collaborative practice to integrate clinical strategies, optimize best practice, and improve quality of care – in BC, it’s the law!

Seniors’ Health: Seniors’ Health: Adding Life To YearsAdding Life To YearsSeniors’ Health: Seniors’ Health: Adding Life To YearsAdding Life To Years

60 70 80 9060 70 80 9060 70 80 9060 70 80 90AgeAgeAgeAge

2000’s2000’s2000’s2000’s

1990’s1990’s1990’s1990’s

1980’s1980’s1980’s1980’s

Successful Successful AgingAging

Usual AgingUsual Aging

Frail Frail SeniorsSeniors

Seniors in Seniors in LTCLTC

Chronic diseases increase risk for catastrophic disability

Risks Associated with Hospitalization

65+ population are hospitalized 3X more often than younger adults; 36% of hospitalizations and 50% of hospital expenditures

At discharge, 33% are more disabled

5% die in hospital, 20-30% die in the year after hospitalization

Elixhauser A et al; AHRQ Pub. No. 00-0031, HCUP Fact Book No. 1, 2000Covinksy KE et al; J Am Geriatr Soc; 51:451, 2003

Transforming Seniors Care – what’s not hot but should be

Strategy: Implement Best Practice Informed Geriatric Care

• Consistent, evidence-informed guidelines– Catheter use (bladder and bowel care) – Medication use in elderly – Nutrition and hydration – Delirium (including PPO) – Functional mobility – “Every day is an activation day”

• Rapid development and implementation• Build on existing structures and processes• Complement Evidence Based work

Seniors Care: Estimated “recoverable” acute days

• Local evidence shows 5 times the savings:– Geriatric Medicine Unit at PHC

reduced ALOS:ELOS ratio by 0.5 (1.35 to 0.83)– Acute Care for Elders (ACE) unit at VGH

ALOS reduction of 4.8 days

• Conservative demand savings account for:– Different implementation approach, Broader scope (entire HA)

• Resources:– Reallocation of existing network/continuum staff to support

coordination and evaluation at each entity– Identify existing guidelines and support local implementation

Demand savings from Seniors Transformation

ALC

ELOS

LOS

Acute days that exceed ELOS

Prevent 20% of cases from becoming ALC

Remove 50% of acute days that exceed ELOS

Acute

Reduction of acute days by 16,556 per yearReduction of acute days by 16,556 per year

Total Savings Possible for “Target Group”

Includes:

CMGs grouped by guideline

Seniors aged 70+

VCH residents only

Excludes:

COPD (CMG 139) & Stroke

Seniors Transformation Opportunity in Vancouver by Guideline - (Days; Percentage of Total)

Catheter; 1399; 17%

Delirium; 2479; 30%Functional

mobility; 1644; 20%

Medication; 1293; 16%

Nutrition / Hydration / Friction /

Seating; 1388; 17%

Assessment of the Older Patient

Right view – predisposing factors Confidence in mobility Competence in decision-making ability Connection to community

Right care – precipitating factors Appropriate medical management – acute on chronic Understands risks of proposed interventions

Manages complexity and risk for increased frailty - TSC Right follow-up – perpetuating factors

Managing transitions across the points of care Patients (and their families) as partners to establish goals of

care

One presentation of dynamic frailty

Picture an 82 year old woman who presents in the ED with a cough andincreasing SOB while walking with her 3 K-a-day Club on the Sea Wall.

Dynamic frailty can be a mask that limits our view of possible outcomesDynamic frailty can be a mask that limits our view of possible outcomes

Picture an 82 year old woman who presents in the ED with confusion and a cough. She was walking with her 3 K-a-day Club on the Sea Wall 2 days ago.

Learn to look behind the mask …Learn to look behind the mask …

Catastrophic DisabilityCatastrophic Disability

Ferrucci et al. JAMA 277:728, 1997Ferrucci et al. JAMA 277:728, 1997

Acute Illness: Prevent or Minimize DisabilityAcute Illness: Prevent or Minimize Disability

80 80 80 80 80Age

Cardiovascular DiseaseCardiovascular DiseaseDiabetesDiabetesOsteoporosisOsteoporosisChronic Lung DiseaseChronic Lung DiseaseCognitive ImpairmentCognitive Impairment

Dynamic Dynamic FrailtyFrailty

Usual Usual AgingAging

IADL IADL FrailtyFrailty

ADL ADL FrailtyFrailty

We’re all in the same boat!We’re all in the same boat!

Interprofessional Collaborative Practice

ICP integrates clinical strategies, optimizes best practice, and improves quality of care

Reasons for ICP Patient safety – evidence is unequivocal Staff recruitment and retention Quality of care Sustainability

Health Professions Act (April 2008) – it’s the law

Regulations pursuant to the Act were amended to state that all colleges of health disciplines will require its members to work in a way that supports “interprofessional collaborative practice”

Collaborative Practice:

Care that integrates best available research evidence with professional judgment and patient values

First, think of collaboration as a continuum …

Then, see the continuum from the patient’s perspective

Accommodate: Multidisciplinary professionals intervene on an autonomous, parallel basis.

Cooperate then Coordinate: Interdisciplinary team members cooperate then coordinate assessments and care plans.

Collaborate: Professionals have a narrower margin of autonomy but the team as a whole is more autonomous and its members better integrated

Transforming seniors’ care Focus on best practice for common geriatric conditions Appropriate management that understands risk Predisposing, precipitating and perpetuating factors managed

across the transitions in points of care Potential for recovery:

Confidence in mobility Competence in decision-making Connection to “community”

Knowledge translation through ICP To optimize prevention strategies and maintain independence Sustainable health care