Gateway Geriatric

Education Center

Saint Louis University

Division of Geriatric Medicine

Planning for Sustainable

Long Term Care

1.Monaco

89.6

2.Macau

84.6

3.Japan

83.9

4.Singapore

83.7

8.Hong Kong

82.2

9.Australia

81.9

15.Spain

81.2 51.USA

78.5

96.China

74.8

220. South Africa

49.0

221.Chad

48

The Hospital is a

Place

Creditor, Ann Int Med, 1993

HOME

Nursing Home

Hospital

Group Home

Alzheimer’s Village

Subacute Care

(Geriatric Hospital)

DayCare

ED

Models of Care around the World

• Social 14

• Nurse 14

• Physician 8

In 6 countries 2 models predominated

DEMENTIA VILLAGE

FRAILTY DEFINITIONS

“Occurs when under stressful conditions the person has

diminished ability to carry out important practiced

social activities of daily living.It needs to be distinguished

from disability”

Renoir, 1915

Blonde a la rosa

0 10 20 30 40 50 60 70 80 90 100

Age (years)

Co

gn

itiv

e R

eser

ve

VO

2 m

ax

Car

dia

c o

utp

ut

Bal

ance

Mu

scle

str

eng

th

Frailty

Threshold

Frailty Cascade PSYCHOLOGICAL

Depression

Cognition

Anxiety

Fear of Falling

Fatigue

Health Perception

SOCIAL

Environment

Income

Support System

Health Literacy

Activity

BIOLOGICAL

Genetics

Muscle

Hormones

Cytokines

Disease

Deficits

FRAILTY

Functional Deficit

(IADLs/ADLs)

Hospitalisation

Nursing Home

Death

Importance of cognitive assessment as part of the “Kihon Checklist” developed by the

Japanese Ministry of Health, Labor and Welfare for prediction of frailty at a 2‐year follow

up

Geriatrics & Gerontology International

pages n/a-n/a, 22 NOV 2012 DOI: 10.1111/j.1447-0594.2012.00959.x

http://onlinelibrary.wiley.com/doi/10.1111/j.1447-0594.2012.00959.x/full#ggi959-fig-0002

Fatigue

Resistance (Climb 1 flight stairs)

Aerobic (Walk one block)

Illnesses

Loss of weight

FRAILTY (IANA)

FIVE VALIDATIONS Australia(2) Hong Kong St Louis Europe

9-year OR of ADL deficit or Mortality

in persons not lacking ADLs ADLs

PreFra

il

Frail p

FRAIL 2.74 20.76 .001

SOF 3.09 3.48 .001

CHS 2.40 6.47 .001

Rockwood 2.36 5.65 .001

MORTALITY

PreFrail Frail p

1.58 3.99 .001

1.47 1.40 NS

1.35 2.42 .01

2.50 2.66 .001

Specificity of Scales in

Hong Kong Study

MALE MALE FEMALE FEMALE

MORTALITY Physical Limit MORTALITY Physical Limit

Rockwood 96.4% 98.4% 93.8% 98%

CHS 99.2% 100% 99.4% 99.9%

FRAIL 99.1% 99.4% 99.9% 100%

Hubbard 98% 99.6% 96.1% 95.1%

All had poor Sensitivity

SARC-F

• Strength: difficulty in lifting or carrying 10 lbs

• Assistance with walking

• Rise from a chair

• Climb stairs

• Falls

St Louis SARC-F Longitudinal

SARC-F in Baltimore Longitudinal Study

60+ years

Odds Ratio

P-value

Gait Speed <0.8 m/s

9.41(2.51-35.27)

0.001

Mortality

3.07(1.60-5.73)

0.001

SARC-F

Physical function as independent predictors of SARC-F ≥ 4 in multiple binary

logistic regression analysis

n B S.E. P OR 95% C.I. for OR

4m walking speed 202 -4.913 .851 .000 .007 0.001-0.039

TUG* completed 76 -4.018 .781 .000 .018 0.004-0.083

TUG time 25 .071 .022 .001 1.074 1.029-1.121

SPPB#

76 -.572 .084 .000 .565 0.479-0.665

Grip strength 28 -.139 .025 .000 .870 0.828-0.915

SARC-F CHENGDU

SARC-F: Hong Kong

Sarcopenia classified using the SARC-F, EWSOP,

IWGS and AWGS all increased the risk of physical

limitation, and poor performance measures at

follow-up in men and women.

The magnitude of the relative risk were similar for

all criteria involving measurements (ranging from

1.6 to 3.6)

Those for the SARC-F were much higher (ranging

from 5.6-18.6

Families and physicians fail to recognize

dementia.

Mini-Mental Status Examination Folstein et al. 1975

1. Educationally dependent

2. Both false positives and false negatives

3. Minimal testing of visuospatial system

ROCs For SLUMS &MMSE for

MCI > HS Education

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

1-Specificity

Sen

siti

vity

Area Under Curve = 94.1%

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

1-Specificity

Sen

siti

vit

y

Area Under Curve = 64.3%

SLUMS MMSE

Rapid Cognitive Screen and MCI (5 words, clock, story with country)

RCS vs MiniCog RCS

2.5 minutes to complete

Jean Woo , Ruby Yu , Moses Wong , Fannie Yeung , Martin Wong , Christopher Lum

Frailty Screening in the Community Using the FRAIL Scale

Elderly Centers in the New Territories East Region of Hong Kong SAR China.

Frailty Screening in the Community Using the FRAIL Scale

The prevalence of pre-frailty and frailty were 52.4% and 12.5%, respectively. The prevalence for frailty increasing with age from 5.1% for those aged 65–69 years to 16.8% for those ≥75, being greater in women compared with men (13.9% vs 4.2%). Of those who were pre-frail or frail (n = 529), 42.5% had sarcopenia and 60.7% had mild cognitive impairment. Among those who were frail (n = 102), 63.7% had both sarcopenia and mild cognitive impairment, and only 8.8% had neither.

Fatigue

Resistance (Climb 1 flight

stairs)

Aerobic (Walk one block)

Illnesses

Loss of weight

FRAILTY

(IANA)

Fatigue Syndrome (CFS; myalgic

encephalitis)

Anemia

Treatment excess eg hypotension,

chemotherapy

Illnesses eg vitamin B12 deficiency,

heart failure, renal failure, cancer

Gulf War Syndrome (? toxin

exposure)

Unhappy (Depression)

Endocrine (Hypothyroid, Addison’s,

Diabetes mellitus)

Sleep Disorders (Sleep apnea, restless

legs, insomnia)

Resistance and balance

exercises

And protein

Aerobic Exercise

And protein

Reduce polypharmacy

Medications

Emotional (depression)

Alcoholism,anorexia tardive, abuse (elder)

Late life paranoia

Swallowing problems

Oral problems

Nosocomial infections,no money (poverty)

Wandering/dementia

Hyperthyroidism,hypercalcemia,hypoadrenalism

Enteric problems (malabsorption)

Eating problems (eg. Tremor)

Low salt, low cholesterol diet

Shopping and meal preparation problems, Stones (cholecystitis)

Causes of Weight Loss

Morley JE, Silver AJ. Ann Intern Med 1995;123:850-859.

? PsycoSocial Frailty ?

Environment Modulates Longevity

After the fall of the Berlin Wall

East Germans rapidly developed a

survival equivalent to West Germans

Stressful Social Events increase

Mortality in oldest-old males

in Hong Kong

Outcomes in Nonagerians after Earthquake

in Wenchuan, May 12 2008

SOCIAL Sadness

Outside activity

Cognition

Income adequacy

Attachment to neighborhood

Lethargy

Univariate Analysis of Variance*

Mean+Standad Deviation P-Value

Variables Robust (0-

1)

Pre-Frail (2-

3)

Frail (4-6)

ADL disabilities 0.58+1.5 1.00+1.9 1.86+2.5 <.001b,d

IADL disabilities 0.77+1.6 1.26+2.0 2.64+2.7 <.001b,d

Short Physical Performance Battery 8.44+2.8 7.28+3.2 5.53+4.03 <.001a,d

Lower Body Functional Limitations 1.51+1.7 2.30+1.9 3.46+1.7 <.001a,d

One-Leg Stand 17.90+11.6 11.91+10.7 11.79+10.1 <.001a,d

Grip Strength 33.41+12.2 29.11+10.7 27.85+10.0 .015a,d

Binary Logistic Regression

Odds Ratio

95% CI

P-Value

Mortality

Robust

Pre-frail

Frail

Ref

2.30

2.46

1.57-3.37

1.14-5.30

<.001

.022

SOCIAL overlap with FRAIL and CHS

Social

3.0%

FRAIL

9.2% 1.9%

SOCIAL 47/955 (4.9%)

FRAIL 106/955 (11.1%)

SOCIAL 36/872 (4.1%)

CHS 93/872 (10.7%)

Social

2.8%

CHS

9.3%

1.4%

Effects of Exercise in the Frail

Theo et al, J Aging Res 2011

• Increase functional performance

• Increase walking speed

• Increase chair stand

• Increase stair climbing

• Increase balance

• Decrease depression

• Decrease fear of falling

Studies mostly 3 months

Need at least 45 to 60 mins

3x a week

80% of 1 repetition maximum

with 3 sets of 8

Effects of High-Intensity Progressive Resistance Training and Targeted Multidisciplinary Treatment of Frailty on Mortality and Nursing Home Admissions after Hip Fracture: A Randomized Controlled Trial

Nalin A. Singh MBBSa, Susan Quine PhDb, Lindy M. Clemson PhDc, Elodie J. Williams BApplScd, Dominique A. Williamson BApplScd, Theodora M. Stavrinosd, Jodie N. Grady BApplScd, Tania J. Perry BApplScOTd, Bradley D. Lloyd

MScd, Emma U.R. Smith PhDd, Maria A. Fiatarone Singh MDe, ,

• Comprehensive Geriatric Assessment and 12 months resistance training twice weekly

• Mortality OR 0.19 (0.04 – 0.91)

• Nursing Home OR 0.16 (0.04 – 0.64)

• ADL’s p <0.02

• Assistive Device p<0.01

Cochrane Review 2012 Woods, Aguirre, Orrell, Spector

15 trials, 407 treatment and 311

controls participants

Length of intervention varied: 1 to 24

months

MMSE difference at follow up = 1.74

points (Z = 5.57, p < 0.00001)

Holden Communication Scale SMD

= 0.47 (Z = 3.22, p = 0.001)

Wellbeing/QoL SMD = 0.38 (Z =

2.76, p = 0.006)

Depression (GDS) SMD = 0.34 (Z =

1.88, p = 0.06)

No benefits to ADL, behaviour, or

carers measures

Numbers needed to treat for cognition = 6

CST trial: Other results

Cost-effectiveness (Knapp et al.,

2006)

CST is more cost-effective than usual activities

using both outcome measures:

• Incremental cost-effectiveness ratio: £75.32

per additional point on MMSE (111 euros),

£22.82 per point on QoL-AD (33.2 euros)

• Donepezil had considerably larger cost per

incremental outcome gain (AD2000, 2004)

Cognitive Stimulation Therapy : NHC Nursing Home

0

2

4

6

8

10

12

14

16

SLUMS BIMS

Mental Status

PRE POST

USA Nursing Home Trends

• Decreased movement to nursing homes (Assisted Living, Greenhouses, Home Care)

• MDS 3.0……PHQ-9 • Decreased Transitions • Hospice (end of Life) care • Increased person center

care • Increased dependence on

technology for care • Enhanced rehabilitation

“The Cloud”—improving diagnosis and drug monitoring

• Sleep monitors

• Monitor for sleep apnea

• Monitor for hypo/hypertension

• Monitor for falls

Exoskeleton : Paraplegia

The Companionable project

Is it time for geriatricians to teach about Robo

Sapiens ?

Harry

Health Assistant Robot

for Rich Years

Paro

Aibo

Are Nursebots the Future ?

Comprehensive

Geriatric Assessment

• GEMU 1.68 (1.17 - 2.41)

• Hospital 1.49 (1.12-1.98)

• Home assessment 1.20 (1.05 – 1.37)

Comprehensive geriatric assessment: a meta-analysis of controlled trials

Stuck et al, Lancet 342:1032, 1993

LIVING AT HOME

Sustainable Long Term Care

• Focus on keeping seniors at home

• Screen regularly for FRAILTY (Physical, Cognitive, Social)

• Focus on preventing disability in this group (Exercise, CST, Geriatric Assessment)

• FUTURE: Introduction of ROBOTIC Care?