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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?