Why Frail Seniors are Important? A Presentation to the NL Public Sector Pensioners’ Association

Oct 7th 2015 Capital HotelDr. Roger Butler

Associate Professor of Family Medicine MUN

My Mom

Objectives

1.The attendee will be introduced to a model of frailty taking into account the entire population of seniors.2. The attendee will be introduced to the evidence supporting diet and exercise vs drug therapy for the senior age group . 3.The attendee will be introduced to some of the demographic challenges facing the frail seniors in our province .4.The attendee will be introduced to some of the important determinants of health in this age group.

Frailty

Frailty is a clinical state in which there is an increase in an individual’s vulnerability for developing increased dependency and /or mortality when exposed to a stressor.

JAMA Vol 14 ,issue 6, June 2013 pages 392-397

Frailty develops as a consequence of age-related decline in many physiological systems. Between a quarter and half of people older than 85 years are estimated to be frail, and these people have a substantially increased risk of falls, disability, long-term care, and death.

Prevalence and co-occurrence of the three frailty phenotypes.

Josep Garre-Olmo et al. Age Ageing 2013;42:46-51

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Robust VS Frail older adults

Frailty Phenotype ≥3 of unintentional weight loss, exhaustion ,weakness, slow walking , low physical activity and accumulation of medical, functional or social deficitsRobust mobile and functionally independent

Robust patients have a medication focus on prevention, treatment ,and to alleviate symptoms and delay functional decline and mortality .

Frail patients who are approaching end of life need to take a more palliative approach and often one can stop preventative therapies .

Average Life Expectancy tables USA 1997 (Walters)

Males Female

70 75 80 85 9002468

101214161820

top 25%Mid25%Bottom 25%

70 75 80 85 900

5

10

15

20

25

Top25%Mid 50%Bottom 25%

Managing Aggressive Behavior in Dementia

Dr. Roger Butler

Risks of Medicines in Frail Older Adults

1.ADR’s2.Hospitalisation3.Functional impairment 4.Geriatic syndromes5.Impaired hepatic and/or renal function 6.Drugs with anticholinergic and sedative properties7.Antiplatelet ,anticoagulants and hypoglycemic agents.

Can we reverse frailty?

Physical frailty can potentially be prevented or treated with specific modalities:1. Exercise2. Protein calorie supplementation 3. Vit D4. Reduction of Polypharmacy

Jama vol 14, issue 6 ,June 2013 ,pages 392-397

Fact or Fiction

Seniors are costing the health care system too much money?

Do diet and exercise trump medications in the elderly?

It depends….. 1.Combined Impact of Health Behaviours and Mortality in Men and Women : The EPIC –Norfolk Prospective Population StudyJan 2008 Kay –Tee Shaw et al www.plos medicine .org

2.Comparative effectiveness of exercise and drug interventions on mortality outcomes :metaepidemiological study2013 BMJ Huseyin Naci , John PA loannidis director ( London School of Economics)

Combined Impact of Health Behaviours and Mortality in Men and Women : The EPIC –Norfolk Prospective Population Study

20,244 men and women aged 45-79No cardiovascular or cancer at baseline 1993-1997Followed until 2006 Scored 1 point for each of 4 health behaviours:

Current non smoking = 1 point Moderate Alcohol intake = 1 point

Fruit and vegetable 5 servings per day = 1 point Not physically inactive = 1 point

Results

If you have all 4 behaviours you have a 4 fold difference in total mortality in men and women

Equivalent to 14 years chronological ageTrends strongest for cardiovascular

causes.

Comparative effectiveness of exercise and drug interventions on mortality outcomes : metaepidemiolgical study

16 meta-analyses 305 randomized controlled trials 339274 participants…..14716 exercise group remainer drug

trials

Four disease processes examined:1.Effectiveness of exercise on the secondary prevention of coronary heart disease 2.Rehabilitation of stroke 3.Treatment of heart failure4.Prevention of diabetes

Results

No statistically detectable differences were evident between exercise and drug interventions in the secondary prevention of coronary artery disease and prediabetes. Physical activity interventions were more effective than drug treatment among patients with stroke ( exercise more effective than antiplatelets and exercise more effective than anticoagulants.) Diuretics were more effective then exercise in heart failure.

Physical inactivity has been ranked as the fifth leading cause of disease burden in Western Europe

United Kingdom

14% of adults exercise regularly with only 1/3 meeting recommended levels of physical activityUtilization rates for prescription drugs continue to rise :2000 – 11.2 perscriptions for every person 2010-17.7 perscriptions for every person

Newfoundland and Labrador Senior Demographics

Total population 2015 = 527,756Population >65=97,269% >65=18.4%>85=9442Males >85 =3221Females >85=6221Conservative frailty estimate >85 =2500 to 5000>85= I/3 are demented = 3000Stats Canada 2015

1978-Present NL

Staffing reallocation in Nursing Homes (80% of

budget salaries…. MDS)2005 -2007 Have status with have not

infrastructure(10 year)Rising Tide Report Alzheimer’s Canada 2010Alzheimer’s International 2012 Public Health Priority2014 avg NH age 86 /Dementia # 1 diagnosis/90%

DVA2017 ….oldest proportion over 65 in Canada2030 …oldest proportion over 65 in the world

Challenges

Develop a provincial strategy not just for well but for frail elderlyDevelop a consistent home first approachDevelop age friendly communitiesDevelop standards for training of home support workers to meet the needs of todays clientsDevelop standards of care for personal care homesDevelop sustainability of community support organizations

Challenges

Poverty/HousingNutritionIncome supportTransportationAllied health support Medical home modelPalliative Care Advance Care Directives