Salted Watermelon and Heart Failure:A Team-Based Approach to Complex Decision Making

Marianthe Grammas, MDAssistant Professor & Medical Director

Clinical Director of Ambulatory Care TransitionsUAB 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

• Impact• Functional limitation & disability• Frailty• Nursing home placement• Diminished quality of life• Treatment complications• Avoidable inpatient admissions

BACKGROUND

Wolff JL, et al. Arch Intern Med. 2002.Fortin M, et al. BMJ 2007.

• Staggering healthcare utilization and costs

• The two-thirds of Medicare beneficiaries with multi-morbidity 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

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?

Boyd C, et al. JAMA. 2005

• 12 medications• $406/month• Complicated diet regimen• Monitoring BG, BP• Exercise recommendations

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-adults-with-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…

OptometryPublic Health/UMDentistryAudiology

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 frailFried 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?