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. 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. 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

5. Is it important to screen for frailty?

6. 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

7.  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

8. However, being frailty a potentially reversible
condition it is challenging but possible to reverse it,
also to reduce the health care expenditure.

9. How to deal with frailty complexity?

10. GEM
Geriatric Evaluation and
Management

11.  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!!!!

13.  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)

14. 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

17. OBSERVATIONS UNITS

18. What is the role of informatic devices in ED
setting?

20. HOSPITALIZATION
Which problems we have in managing
hospitalized frail people?

21. 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

24. POLIPHARMACY

26. How to deal with polipharmacy?

27.  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

28.  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

29. What is the role of informatic devices in
dealing with polipharmacy?

31. 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.

34. 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

35. 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

37. Int J Integr Care. 2014 Apr-Jun

38. 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.

39. What is the role of informatic devices in
hospital discharge?

40. 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
http:www.movecare-project.eu

41. 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

43. Thank
you for
the
attention