Download Complex Decision Making

Salted Watermelon and Heart Failure:
A Team-Based Approach to
Complex Decision Making
Marianthe Grammas, MD
Assistant Professor & Medical Director
Clinical Director of Ambulatory Care Transitions
UAB 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
BACKGROUND
• Impact
• Functional limitation & disability
• Frailty
• Nursing home placement
• Diminished quality of life
• Treatment complications
• Avoidable inpatient admissions
Wolff JL, et al. Arch Intern Med. 2002.
Fortin M, et al. BMJ 2007.
BACKGROUND
• Staggering healthcare utilization and costs
• The two-thirds of Medicare beneficiaries with multimorbidity 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
• 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?
•
•
•
•
•
12 medications
$406/month
Complicated diet regimen
Monitoring BG, BP
Exercise recommendations
Boyd C, et al. JAMA. 2005
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-adultswith-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…
Optometry
Public Health/UM
Dentistry
Audiology
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 frail
Fried 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?