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Healthcare Information Standards for Frailty: Why, When and How (3 of 5)


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Trillium II /Focus workshop at Informatics for Health2017: Manchester, April 24-27, 2017
Frailty is an age-related state of vulnerability to the risk of adverse health out-comes after a stressor event. The condition predisposes individuals to progressive decline in different functional domains, leading to falls and fractures, disability and dependency on others, hospitalization, institutional placement and ultimately death. We discuss drivers, challenges and opportunities for healthcare information standards related to frailty in old age in an effort to launch a call for coordinated action across research, policy, and academia. Key issues are selected as the back-drop for this discussion: EHR, patient summaries and frailty in a context of coor-dinated care enabled by health IT standards.
Presentation 3 of 5: Sarah Damanti, MD
Geriatric Unit IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
University of Milan, PhD in Nutritional Sciences

Published in: Health & Medicine
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Healthcare Information Standards for Frailty: Why, When and How (3 of 5)

  1. 1. Challenges in frailty-related information use and decision making in clinical practice Sarah Damanti, MD Geriatric Unit IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano University of Milan, PhD in Nutritional Sciences INFORMATICS FOR HEALTH 2017 HEALTHCARE INFORMATION STANDARDS FOR FRAILTY: WHY, WHEN AND HOW
  2. 2. Frailty is a multidimensional dynamic condition, whose prevalence increases with age, but is independent of chronological age, characterized by decreased physiological resilience and a weakened response to stressors. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2013. 68(1): p. 62-67 Romero-Ortuno, R. and R.A. Kenny, The frailty index in Europeans: association with age and mortality. Age and Ageing, 2012
  3. 3. Three months ago, Mr. Smith underwent surgical removal of a prostatic adenoma. After surgery he developed an urinary tract infection from a very aggressive bacterium so he remained hospitalized for 2 weeks . STRESSORS Since the discharge something changed  He lost weight (5 Kg ) without particular reasons or symptoms.  He keeps feeling tired and refuses to leave his house and to perform some of the everyday activities he used to. REDUCED RESILIENCE
  4. 4. Is it important to screen for frailty?
  5. 5. Frail individuals, having a weakened response to stressors, are predisposed to poor clinical outcomes (disability, dementia and falls) and adverse events (hospitalization, institutionalization and mortality). The Lancet, 2013. 381(9868): p. 752-762. Hazzard, W.R., et al., eds. Frailty: in Principles of Geriatric Medicine and Gerontology. 1999, McGraw Hill New York 1119-1156
  6. 6.  Moreover, he has fallen several times without an apparent cause.  The frequency of these falls has increased in the las two weeks POOR CLINICAL OUTCOMES
  7. 7. However, being frailty a potentially reversible condition it is challenging but possible to reverse it, also to reduce the health care expenditure.
  8. 8. How to deal with frailty complexity?
  9. 9. GEM Geriatric Evaluation and Management
  10. 10.  Appropriate Prescribing  Behavioral Disturbances in Dementia  Delirium  Dementia  Depression  Diabetes Mellitus  Falls  Frailty  Insomnia  Lower Urinary Tract Symptoms in Men  Multimorbidity  Nutrition and Weight  Osteoporosis  PainPalliative Symptom Management  Pressure UlcersPreventionPrognosticationSyncope  Urinary Incontinence MULTIDIMENSIONAL BUT….. …..OFTEN TOO LONG!!!!
  11. 11.  Longer to triage  Spend more time in the ED  Consume more resources (laboratory studies, X ray )  Missed or incorrect diagnosis are frequent  Are more frequently admitted  Undergo adverse health oucomes after the discharge  Lack of information OR excess of information  Atypical presentations  Altered laboratory values  Comorbidity  Polypharmacy  Communication problems (aphasia, deafness)  Altered mental status (delirium, dementia)
  12. 12. On arriving to the Emergency Department, Mr. Smith his very confused and agitated. His blood pressure is elevated. Since he kept being agitated and tried to get off the stretcher, he was given a sedative POOR CLINICAL OUTCOME: DELIRIUM It was very difficult for the ED physician to get information he needed because Mr. Smith was unable to refer his medical history and kept complaining of the pain in his leg, while his wife was really frightened. She has forgotten tablet boxes at home and she could not remember the therapy of his husband . DIFFICULTIES IN GETTING INFORMATION
  14. 14. What is the role of informatic devices in ED setting?
  15. 15. HOSPITALIZATION Which problems we have in managing hospitalized frail people?
  16. 16. During his initial evaluation, the admitting physician asked Mr. Smith about which medications he was taking, but the patient could not recall what they were or the doses HOW TO GET THE PROPER INFORMATION IN AN EASIER WAY? The physician on the hospital team contacted Dr. Care, who provided a medical history and general list of medications. The GP provided the hospital team with contact information for urologist as well
  18. 18. How to deal with polipharmacy?
  19. 19.  A structured, critical examination of a patient’s medicines  Optimizing the impact of medicines  Minimizing the number of medication related problems  Reducing waste MEDICATION REVIEW
  20. 20.  the medication prescribed is appropriate for the patient’s needs  the medication is effective for the patient  the medication is a cost effective choice  any required monitoring has been done or arrangements are in place Check that: Consider:  drug interactions  side effects  compliance  complementary medicines  lifestyle and non-medicinal interventions  unmet need
  21. 21. What is the role of informatic devices in dealing with polipharmacy?
  22. 22. Drugs Aging. 2013 Oct;30(10):821-8. Prevention of inappropriate prescribing in hospitalized older patients using a computerized prescription support system (INTERcheck(®)). The use of INTERCheck(®) was associated with a significant reduction in potentially inappropriate medications and new-onset potentially severe DDIs. CPSSs combining different prescribing quality measures should be considered as an important strategy for optimizing medication prescription for elderly patients. Polypharmacy is very common among older adults and can lead to inappropriate prescribing, poor adherence to treatment, adverse drug events and the prevalence of potential drug-drug interactions (DDIs). Electronic prescription database software may help to prevent inappropriate prescribing and minimize the occurrence of adverse drug reactions. INTERcheck(®) is a Computerized Prescription Support System (CPSS) developed in order to optimize drug prescription for elderly people with multimorbidity.
  23. 23. REHAB Lost of many of his previous abilities Not able anymore to walk without cane and only for short sections. Mrs. Smith is very worried about the home reentry. She talks with the social assistant and the geriatrician. Both recommend her to activate home services and adapt the ground floor in the bathroom. RESIDENTIAL HOME
  24. 24. Before going home, the nurse reviewed important information with him and his wife, who was taking him home. Few new prescriptions Necessity to continue rehabilitation at home with a physiotherapist Mrs. Smith should schedule a follow-up appointment with his primary care physician within 3 days Mr. Smith was prescribed wheelchair for displacements out of his house Renovations have been performed and home services made available (support in household tasks for two hours three days a week). CONTINUTY OF CARE REDUCED LEVEL OF AUTONOMY
  25. 25. Int J Integr Care. 2014 Apr-Jun
  26. 26. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD000313. Discharge planning from hospital to home. The evidence suggests that a structured discharge plan tailored to the individual patient probably brings about small reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition.
  27. 27. What is the role of informatic devices in hospital discharge?
  28. 28. MoveCare: Multiple-actOrs Virtual Empathic CARgiver for the Elder MOVECARE aims at supporting the independent living of the elders at home; monitoring their daily activities while promoting their cognitive, physical, and social activities. Project ID 732158
  29. 29. A mobile robot with the needed abilities to assist elder people at home. Fully integrated within the MOVECARE ecosystem to serve as an autonomous assistant for the elder at home The Giraff robotic platform
  30. 30. Thank you for the attention