The Journal of Nutrition, Health & Aging© Volume 18, Number 5, 2014
COMMENTARY
A STEP FORWARD IN THE RIGHT DIRECTION L. RODRIGUEZ-MAÑAS, M. CASTRO RODRIGUEZ,
Servicio de Geriatría, Getafe University Hospital. Corresponding author: Leocadio Rodríguez-Mañas, Getafe University Hospital, Ctra. De Toledo, Km 12.5; 28905-Getafe, Madrid, Spain. e-mail: [email protected]
The characterisation of the patients who benefit from geriatric management and which is the best approach to achieve the desired outcomes have been causes of concern since the earliest time of Geriatric Medicine. When Marjorie Warren faced the challenge of running a ward full of “chronic older patients” (sometimes it is amazing to see how old-fashion words are maintained artificially alive nowadays), she managed them in a different way to that usual at those times. As a consequence, she got different results to those obtained at that time when assessing and treating this kind of patients was not usual, and many of them were discharged from the hospital to their homes. These findings, published in two articles in Lancet in the 40s of the past century (1, 2), were the hallmark of a new way of practicing Medicine in a, at that time, reduced group of patients. Seventy years later, older patients represent the main bulk of patients to be attended by the Health Care Systems and in fact they are currently the main challenge to face by them. At the same time a huge amount of data have been generated on both the target patient experiencing the highest benefit from this new way to approach and manage older patients and the way to provide it. From this bulk of evidence, some firm conclusions can be extracted and some lessons should be taken into account to avoid a dysfunctional development of Services for the older adults: 1.- Although all older patients benefit from an expert assessment and management carried out by teams with geriatricians or by doctors trained in the basis of geriatric medicine, the highest benefit is observed when the management is targeted toward patients that are in the earliest phases of the disabling process. Because of that, the highest benefit is observed when the priority is put on people at risk for developing disabilities but still non-disabled, then in people with low disability and finally in highly disabled older people (3-5). In the same line, the biggest evidence of the benefits of Geriatric settings of care has been observed in Acute Care Units, where patients are usually less dependent but at the highest risk for developing new disabilities (6). By opposite the weakest and more modest evidence concerns the settings providing care to highly disabled patients (Domiciliary Care, Long-Term Care facilities) (7). 2.- One of the reasons for those different benefits depending upon the level of care where the intervention is provided is related to the type of patients attended in each of them. The likelihood of reversing disability is rather low (8), especially
Received March 16, 2014 Accepted for publication March 17, 2014
when the disability is established. Thus, the later we intervene in the path toward dependence, the lower our chances to prevent or reverse it. In addition, we also know that to make interventions in the whole population of older adults, including those very fitted older persons, do not show an appropriate cost-benefit ratio. Again, within this conceptual and practical framework, the identification of patients not yet disabled but at high risk to become disabled offers the best ratio. And fortunately we now have a category for these patients: they are the frail/pre-frail older adults and they are the population at the highest risk for developing mobility impairment, disability for basic and instrumental activities of daily living and falls, jointly to other undesired outcomes (9). They represent around 50% of people older than 75, an amount of patients potentially beneficiaries of an appropriate geriatric assistance really greater than the figure of 5-10% of older adults with severe disability (9, 10). And with different needs that make necessary to enlarge our focus, covering from a mainly “prosthetic” geriatrics focused on the care of permanently disabled older people to a more preventive one oriented to the prevention of disability and dependency. 3.- The standard for the evaluation of the patients in Geriatric Medicine is the so-called Comprehensive Geriatric Assessment. It stems from the necessity to evaluate the different components of disease and functional impairments in older adults, that are complex in their origins, manifestations, modulation and consequences, and that need a global approach to achieve the desired aims (11). Thus, Comprehensive Geriatric Assessment (a diagnostic and planning process, but not a therapeutic one) has shown to produce several benefits in the management of older patients: it increases the diagnostic accuracy, it provides functional clues and it allows building a management plan fitted to the particular conditions and circumstances of each patient. It must be said that the benefits of CGA are strongly linked to the possibility of implementing the recommendations. But this should not be surprising; surgeons are useful not when they diagnose patients suffering from appendicitis but when they are allowed to operate them. 4.- A coordinated approach to the older patients seems to be the best strategy to achieve the aims of care in them, although there is a lack of evidence to strongly support this assumption. Being chronic patients at risk of functional decline or disability, highly unstable, with rapidly changing needs of care, with comorbidities and taking a high number of drugs, they need a continued care, that will complement the other three classical
465
The Journal of Nutrition, Health & Aging© Volume 18, Number 5, 2014
A STEP FORWARD IN THE RIGHT DIRECTION
characteristics of Geriatric Care: integrated, shared and coordinated. In this issue of JNHA the group of Prof. Vellas at Toulouse reports a very challenging article about the implementation of a so-called Geriatric Frailty Clinic (GFC) and its results after the first year of functioning (12). In this GFC, they have implemented the traditional approach in Geriatric Medicine, including CGA and a follow-up of the patients in coordination with Primary Care to detect and manage frail patients. So it is not surprising that the characteristics of the patients attended are the usual ones in outpatients attended in Geriatric Departments, and the outcomes of the assessment the usual ones: they have detected a huge amount of new diseases and conditions, many of them needing a re-assessment, they have detected many problems in sense organs, they have detected different functional and cognitive problems and they have made many new recommendations for a better management of the patients. New diagnosis of diseases and conditions and new therapies that otherwise never would have been done. And all of these findings are reassuring about the known benefits of the geriatric approach. Additionally they show that simple instruments can be useful in Primary Care to detect some kind of frail older adults. In this regard, when patients sent to the Clinic were reassessed, only 6% of the patients were not frail or pre-frail, showing a very low percentage of False Positives (that means a high specificity), an usual finding regarding the instruments to screen or diagnose frailty. However, an assessment of the sensitivity and their positive predictive values will be probably of interest, as these are the characteristics that use to fail (13). But what is really relevant, what is really of value is how they have adapted their aims and means to the particular conditions of their local Health System to design an intelligent strategy to overcome the barriers that many of our Health Care Systems offer for delivering an appropriate care to the older people. Using a very simple, brief and feasible instrument to screen frail older people, putting efforts in promoting the contact with the doctors working at Primary Care and incorporating other professionals to the team (including a nurse for the coordination of the follow-up) they show how geriatrics model of care can be implemented everywhere. In the next few decades the whole world has the need not to face the challenge of ageing (now is the time for doing so) but to have the solutions implemented. Otherwise the consequences can be dramatic. Regarding the Health Care Systems there are several successful, highly validated models of care to older adults. But these models have not been fully implemented in the major part of the countries due to different circumstances. In this regard the European Union has raised an European Innovation Partnership on Active Healthy Ageing with the aim, among others, of improving the quality of life for older
466
European citizens. One of the strategies has been to declare 32 “Reference Sites” along the European Union based upon their “Best Practices” in the provision of services for older adults, making easy the implementation of those services by doing benchmarking of these different “Best-Practices”. Among these “Best-Practices”, highly, fully developed models of health and social care are included. But also there is place for initiatives like the one provided in Toulouse that, hopefully, will be expanded to other parts in France. They have shown the right way to proceed to provide an integrated, comprehensive, continued and coordinated care to the main target population, the frail and pre-frail older adults, wherever the full model is not available. They have the task to continue making progress along this pathway and providing their results to the Geriatric community, including the effects of the intervention, but many others now do have a nice example on how to give the first steps in this crucial way. Older patients in several European countries and in other parts of the world are waiting. 1.
2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13. 14.
References
Warren MW. A case for treating chronic sick in blocks in a general hospital. Lancet 1943; i: 823-33. Warren MW. Care for the chronic aged sick. Lancet 1946;i: 841-43. Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J.. A randomized trial of care in a Hospital Medical Unit especially designed to improve the functional outcomes of acutelly ill older patients. N Engl J Med 1995; 332: 1338-44. Applegate WB, Miller ST, Graney MJ, Elam JT, Burns R, Akins DE. A randomized controlled trial of a Geriatric Assessment Unit in a Community Rehabilitation Hospital. N Engl J Med 1990; 322: 1572-8. Gill TM, Baker DI, Gottschalk M, Peduzzi PN, Allore H, Byers A. A Program to Prevent Functional Decline in Physically Frail, Elderly Persons who Live at Home. N Engl J Med 2002; 347: 1068-74 Baztán JJ, Suárez-García FM, López-Arrieta J, Rodríguez-Mañas L, RodríguezArtalejo F. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. Br Med J 2009; 338: b50 Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2008; 371: 725-35 Boyd CM, Landefeld CS, Counsell SR, Palmer RM, Fortinsky RH, Kresevic D et al., Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc 2008; 56: 2171-9. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56: M146-56. Garcia-Garcia FJ, Gutierrez Avila G, Alfaro-Acha A, Amor Andres MS, De Los Angeles De La Torre Lanza M, Escribano Aparicio MV, et al. The prevalence of frailty syndrome in an older population from Spain. The Toledo Study for Healthy Aging. J Nutr Health Aging 2011; 15: 852-6 Rubenstein LZ, Josephson KR, Wieland GD, English PA, Sayre JA, Kane RL.. Effectiveness of a Geriatric Evaluation Unit. A randomized Clinical Trial. N Engl J Med 1984; 311: 1664-70. Travassoli N, Guyonnet S, Abellan G, Sourdet S, Krams T, Soto ME et al. Description of 1,108 Older Patients Referred by their Physician to the “Geriatric Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability” at the Gérontopôle. J Nutr Health Aging 2014;18(4):457-464 García-García FJ, Carcaillon L, Fernandez-Tresguerres J, Alfaro A, Larrion JL, Castillo C, Rodriguez-Mañas L. A new operational definition of frailty: The Frailty Trait Scale. J Am Med Dir Assoc 2014, Mar 2 (Epub ahead of print). European Commission. European Innovation Partnership on Active Healthy Aging. Reference Sites. Excellent innovation for ageing. A European Guide. 2013
COMMENTARY
A STEP FORWARD IN THE RIGHT DIRECTION L. RODRIGUEZ-MAÑAS, M. CASTRO RODRIGUEZ,
Servicio de Geriatría, Getafe University Hospital. Corresponding author: Leocadio Rodríguez-Mañas, Getafe University Hospital, Ctra. De Toledo, Km 12.5; 28905-Getafe, Madrid, Spain. e-mail: [email protected]
The characterisation of the patients who benefit from geriatric management and which is the best approach to achieve the desired outcomes have been causes of concern since the earliest time of Geriatric Medicine. When Marjorie Warren faced the challenge of running a ward full of “chronic older patients” (sometimes it is amazing to see how old-fashion words are maintained artificially alive nowadays), she managed them in a different way to that usual at those times. As a consequence, she got different results to those obtained at that time when assessing and treating this kind of patients was not usual, and many of them were discharged from the hospital to their homes. These findings, published in two articles in Lancet in the 40s of the past century (1, 2), were the hallmark of a new way of practicing Medicine in a, at that time, reduced group of patients. Seventy years later, older patients represent the main bulk of patients to be attended by the Health Care Systems and in fact they are currently the main challenge to face by them. At the same time a huge amount of data have been generated on both the target patient experiencing the highest benefit from this new way to approach and manage older patients and the way to provide it. From this bulk of evidence, some firm conclusions can be extracted and some lessons should be taken into account to avoid a dysfunctional development of Services for the older adults: 1.- Although all older patients benefit from an expert assessment and management carried out by teams with geriatricians or by doctors trained in the basis of geriatric medicine, the highest benefit is observed when the management is targeted toward patients that are in the earliest phases of the disabling process. Because of that, the highest benefit is observed when the priority is put on people at risk for developing disabilities but still non-disabled, then in people with low disability and finally in highly disabled older people (3-5). In the same line, the biggest evidence of the benefits of Geriatric settings of care has been observed in Acute Care Units, where patients are usually less dependent but at the highest risk for developing new disabilities (6). By opposite the weakest and more modest evidence concerns the settings providing care to highly disabled patients (Domiciliary Care, Long-Term Care facilities) (7). 2.- One of the reasons for those different benefits depending upon the level of care where the intervention is provided is related to the type of patients attended in each of them. The likelihood of reversing disability is rather low (8), especially
Received March 16, 2014 Accepted for publication March 17, 2014
when the disability is established. Thus, the later we intervene in the path toward dependence, the lower our chances to prevent or reverse it. In addition, we also know that to make interventions in the whole population of older adults, including those very fitted older persons, do not show an appropriate cost-benefit ratio. Again, within this conceptual and practical framework, the identification of patients not yet disabled but at high risk to become disabled offers the best ratio. And fortunately we now have a category for these patients: they are the frail/pre-frail older adults and they are the population at the highest risk for developing mobility impairment, disability for basic and instrumental activities of daily living and falls, jointly to other undesired outcomes (9). They represent around 50% of people older than 75, an amount of patients potentially beneficiaries of an appropriate geriatric assistance really greater than the figure of 5-10% of older adults with severe disability (9, 10). And with different needs that make necessary to enlarge our focus, covering from a mainly “prosthetic” geriatrics focused on the care of permanently disabled older people to a more preventive one oriented to the prevention of disability and dependency. 3.- The standard for the evaluation of the patients in Geriatric Medicine is the so-called Comprehensive Geriatric Assessment. It stems from the necessity to evaluate the different components of disease and functional impairments in older adults, that are complex in their origins, manifestations, modulation and consequences, and that need a global approach to achieve the desired aims (11). Thus, Comprehensive Geriatric Assessment (a diagnostic and planning process, but not a therapeutic one) has shown to produce several benefits in the management of older patients: it increases the diagnostic accuracy, it provides functional clues and it allows building a management plan fitted to the particular conditions and circumstances of each patient. It must be said that the benefits of CGA are strongly linked to the possibility of implementing the recommendations. But this should not be surprising; surgeons are useful not when they diagnose patients suffering from appendicitis but when they are allowed to operate them. 4.- A coordinated approach to the older patients seems to be the best strategy to achieve the aims of care in them, although there is a lack of evidence to strongly support this assumption. Being chronic patients at risk of functional decline or disability, highly unstable, with rapidly changing needs of care, with comorbidities and taking a high number of drugs, they need a continued care, that will complement the other three classical
465
The Journal of Nutrition, Health & Aging© Volume 18, Number 5, 2014
A STEP FORWARD IN THE RIGHT DIRECTION
characteristics of Geriatric Care: integrated, shared and coordinated. In this issue of JNHA the group of Prof. Vellas at Toulouse reports a very challenging article about the implementation of a so-called Geriatric Frailty Clinic (GFC) and its results after the first year of functioning (12). In this GFC, they have implemented the traditional approach in Geriatric Medicine, including CGA and a follow-up of the patients in coordination with Primary Care to detect and manage frail patients. So it is not surprising that the characteristics of the patients attended are the usual ones in outpatients attended in Geriatric Departments, and the outcomes of the assessment the usual ones: they have detected a huge amount of new diseases and conditions, many of them needing a re-assessment, they have detected many problems in sense organs, they have detected different functional and cognitive problems and they have made many new recommendations for a better management of the patients. New diagnosis of diseases and conditions and new therapies that otherwise never would have been done. And all of these findings are reassuring about the known benefits of the geriatric approach. Additionally they show that simple instruments can be useful in Primary Care to detect some kind of frail older adults. In this regard, when patients sent to the Clinic were reassessed, only 6% of the patients were not frail or pre-frail, showing a very low percentage of False Positives (that means a high specificity), an usual finding regarding the instruments to screen or diagnose frailty. However, an assessment of the sensitivity and their positive predictive values will be probably of interest, as these are the characteristics that use to fail (13). But what is really relevant, what is really of value is how they have adapted their aims and means to the particular conditions of their local Health System to design an intelligent strategy to overcome the barriers that many of our Health Care Systems offer for delivering an appropriate care to the older people. Using a very simple, brief and feasible instrument to screen frail older people, putting efforts in promoting the contact with the doctors working at Primary Care and incorporating other professionals to the team (including a nurse for the coordination of the follow-up) they show how geriatrics model of care can be implemented everywhere. In the next few decades the whole world has the need not to face the challenge of ageing (now is the time for doing so) but to have the solutions implemented. Otherwise the consequences can be dramatic. Regarding the Health Care Systems there are several successful, highly validated models of care to older adults. But these models have not been fully implemented in the major part of the countries due to different circumstances. In this regard the European Union has raised an European Innovation Partnership on Active Healthy Ageing with the aim, among others, of improving the quality of life for older
466
European citizens. One of the strategies has been to declare 32 “Reference Sites” along the European Union based upon their “Best Practices” in the provision of services for older adults, making easy the implementation of those services by doing benchmarking of these different “Best-Practices”. Among these “Best-Practices”, highly, fully developed models of health and social care are included. But also there is place for initiatives like the one provided in Toulouse that, hopefully, will be expanded to other parts in France. They have shown the right way to proceed to provide an integrated, comprehensive, continued and coordinated care to the main target population, the frail and pre-frail older adults, wherever the full model is not available. They have the task to continue making progress along this pathway and providing their results to the Geriatric community, including the effects of the intervention, but many others now do have a nice example on how to give the first steps in this crucial way. Older patients in several European countries and in other parts of the world are waiting. 1.
2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13. 14.
References
Warren MW. A case for treating chronic sick in blocks in a general hospital. Lancet 1943; i: 823-33. Warren MW. Care for the chronic aged sick. Lancet 1946;i: 841-43. Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J.. A randomized trial of care in a Hospital Medical Unit especially designed to improve the functional outcomes of acutelly ill older patients. N Engl J Med 1995; 332: 1338-44. Applegate WB, Miller ST, Graney MJ, Elam JT, Burns R, Akins DE. A randomized controlled trial of a Geriatric Assessment Unit in a Community Rehabilitation Hospital. N Engl J Med 1990; 322: 1572-8. Gill TM, Baker DI, Gottschalk M, Peduzzi PN, Allore H, Byers A. A Program to Prevent Functional Decline in Physically Frail, Elderly Persons who Live at Home. N Engl J Med 2002; 347: 1068-74 Baztán JJ, Suárez-García FM, López-Arrieta J, Rodríguez-Mañas L, RodríguezArtalejo F. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. Br Med J 2009; 338: b50 Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2008; 371: 725-35 Boyd CM, Landefeld CS, Counsell SR, Palmer RM, Fortinsky RH, Kresevic D et al., Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc 2008; 56: 2171-9. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56: M146-56. Garcia-Garcia FJ, Gutierrez Avila G, Alfaro-Acha A, Amor Andres MS, De Los Angeles De La Torre Lanza M, Escribano Aparicio MV, et al. The prevalence of frailty syndrome in an older population from Spain. The Toledo Study for Healthy Aging. J Nutr Health Aging 2011; 15: 852-6 Rubenstein LZ, Josephson KR, Wieland GD, English PA, Sayre JA, Kane RL.. Effectiveness of a Geriatric Evaluation Unit. A randomized Clinical Trial. N Engl J Med 1984; 311: 1664-70. Travassoli N, Guyonnet S, Abellan G, Sourdet S, Krams T, Soto ME et al. Description of 1,108 Older Patients Referred by their Physician to the “Geriatric Frailty Clinic (G.F.C) for Assessment of Frailty and Prevention of Disability” at the Gérontopôle. J Nutr Health Aging 2014;18(4):457-464 García-García FJ, Carcaillon L, Fernandez-Tresguerres J, Alfaro A, Larrion JL, Castillo C, Rodriguez-Mañas L. A new operational definition of frailty: The Frailty Trait Scale. J Am Med Dir Assoc 2014, Mar 2 (Epub ahead of print). European Commission. European Innovation Partnership on Active Healthy Aging. Reference Sites. Excellent innovation for ageing. A European Guide. 2013
