Paige Moorhouse

Palliative and therapeutic harmonization: a model for appropriate decision-making in frail older adults.

Frail older adults face increasingly complex decisions regarding medical care. The Palliative and Therapeutic Harmonization (PATH) model provides a structured approach that places frailty at the forefront of medical and surgical decision‐making in older adults. Preliminary data from the first 150 individuals completing the PATH program shows that the population served is frail (mean Clinical Frailty Score = 6.3), has multiple comorbidities (mean 8), and takes many medications (mean = 9). Ninety‐two percent of participants were able to complete decision‐making for an average of three current or projected health issues, most often (76.7%) with the help of a substitute decision‐maker (SDM). Decisions to proceed with scheduled medical or surgical interventions correlated with baseline frailty level and dementia stage, with participants with a greater degree of frailty (odds ratio (OR) = 3.41, 95% confidence interval (CI) = 1.39–8.38) or more‐advanced stage of dementia (OR = 1.66, 95% CI = 1.06–2.65) being more likely to choose less‐aggressive treatment options. Although the PATH model is in the development stage, further evaluation is ongoing, including a qualitative analysis of the SDM experience of PATH and an assessment of the effectiveness of PATH in long‐term care. The results of these studies will inform the design of a larger randomized controlled trial.

Evidence-Informed Guidelines for Treating Frail Older Adults With Type 2 Diabetes: From the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) Program

Clinical practice guidelines specific to the medical care of frail older adults have yet to be widely disseminated. Because of the complex conditions associated with frailty, guidelines for frail older patients should be based on careful consideration of the characteristics of this population, balanced against the benefits and harms associated with treatment. In response to this need, the Diabetes Care Program of Nova Scotia (DCPNS) collaborated with the Palliative and Therapeutic Harmonization (PATH) program to develop and disseminate guidelines for the treatment of frail older adults with type 2 diabetes. The DCPNS/PATH guidelines are unique in that they recommend the following: 1. Maintain HbA1c at or above 8% rather than below a specific level, in keeping with the conclusion that lower HbA1c levels are associated with increased hypoglycemic events without accruing meaningful benefit for frail older adults with type 2 diabetes. The guideline supports a wide range of acceptable HbA1c targets so that treatment decisions can focus on whether to aim for HbA1c levels between 8% and 9% or within a higher range (ie, >9% and <12%) based on individual circumstances and symptoms. 2. Simplify treatment by administering basal insulin alone and avoiding administration of regular and rapid-acting insulin when feasible. This recommendation takes into account the variations in oral intake that are commonly associated with frailty. 3. Use neutral protamine Hagedorn (NPH) insulin instead of long-acting insulin analogues, such as insulin glargine (Lantus) or insulin detemir (Levemir), as insulin analogues do not appear to provide clinically meaningful benefit but are significantly more costly. 4. With acceptance of more liberalized blood glucose targets, there is no need for routine blood glucose testing when oral hypoglycemic medications or well-established doses of basal insulin (used alone) are not routinely changed as a result of blood glucose testing.Although these recommendations may appear radical, they are based on careful review of research findings.

Frailty and Mortality in Dialysis: Evaluation of a Clinical Frailty Scale

BACKGROUND AND OBJECTIVES Frailty is associated with poor outcomes for patients on dialysis; however, previous studies have not taken into account the severity of frailty as a predictor of outcomes. The purpose of this study was to assess if there was an association between the degree of frailty and mortality among patients on incident dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A cohort study of incident chronic dialysis patients was conducted between January of 2009 and June of 2013 (last follow-up in December of 2013). On the basis of overall clinical impression, the Clinical Frailty Scale (CFS) score was determined for patients at the start of dialysis by their primary nephrologist. This simple scale allocates a single point to different states of frailty (1, very fit; 2, well; 3, managing well; 4, vulnerable; 5, mildly frail; 6, moderately frail; 7, severely frail or terminally ill) with an emphasis on function of the assessed individual. The primary outcome was time to death. Patients were censored at the time of transplantation. RESULTS The cohort consisted of 390 patients with completed CFS scores (mean age of 63±15 years old). Most were Caucasian (89%) and men (67%), and 30% of patients had ESRD caused by diabetic nephropathy. The median Charlson Comorbidity Index score was 4 (interquartile range =3-6), and the median CFS score was 4 (interquartile range =2-5). There were 96 deaths over 750 patient-years at risk. In an adjusted Cox survival analysis, the hazard ratio associated with each 1-point increase in the CFS was 1.22 (95% confidence interval, 1.04 to 1.43; P=0.02). CONCLUSIONS A higher severity of frailty (as defined by the CFS) at dialysis initiation is associated with higher mortality.

Disease progression in vascular cognitive impairment: cognitive, functional and behavioural outcomes in the Consortium to Investigate Vascular Impairment of Cognition (CIVIC) cohort study.

BACKGROUND AND PURPOSE Empirical studies to clarify the outcomes in Vascular Cognitive Impairment (VCI) are needed. We compared cognitive, functional, and behavioural outcomes in patients with VCI to patients with no cognitive impairment (NCI), and Alzheimers disease (AD). METHODS Secondary analysis of the Consortium to Investigate Vascular Impairment of Cognition (CIVIC), a multi-centre Canadian memory clinic 30-month cohort study. RESULTS Of 1347 patients, 938 were eligible for follow-up, of whom 239 (24.5%) were lost and 29 (3%) had died. Of the remaining 697 patients, 125 had NCI, 229 had VCI, and 343 had AD at baseline. Compared to people with NCI, of whom 20-40% showed progression based on cognitive and functional measures, those with VCI were more likely to progress (50-65%), as were people with AD (50-80%) (p<0.01). More people with VCI showed progression of affective symptoms (30%) than those with NCI (12%) or AD (15% p<0.01). Progression of impaired judgment (rated clinically) in VCI (15%) was similar to AD (11%) but more common than in NCI (4%, p<0.01). CONCLUSIONS Most people with VCI show readily detectable progression by 30 months. Depressive symptoms were more common and more progressive in VCI than in Alzheimers disease, whereas clinical evidence of progressive executive dysfunction was common in both AD and VCI.

Executive dysfunction in vascular cognitive impairment in the consortium to investigate vascular impairment of cognition study.

BACKGROUND AND PURPOSE The importance of executive dysfunction is increasingly recognized in the dementia syndrome. Although executive dysfunction has been associated with subcortical ischemic lesions, it may not be unique to VCI or to its clinical subtypes. METHODS Secondary analysis of the CIVIC study, a multi-centre memory clinic cohort study. An executive dysfunction index variable was created using 30 items from the clinical evaluation. RESULTS Of 1347 patients, 151 had a baseline diagnosis of no cognitive impairment (NCI), 463 had AD, 324 had VCI, 97 had vascular cognitive impairment not dementia (VCI-ND) and 253 had non-vascular CIND. Those with VCI and AD had higher mean executive dysfunction index values than those with NCI (F=160.2, p<0.01). Within the VCI subtypes, people with VaD and mixed dementia had the highest mean executive dysfunction index values (F=92.5, p<0.01). Higher executive dysfunction index values were significantly correlated with lower MMSE scores (R=0.70, p<0.01), higher Functional Rating Scale scores (R=0.77, p<0.01) and higher Geriatric Depression Score values (R=0.11, p<0.01). Compared to those who had a lower burden of executive dysfunction, patients with more executive dysfunction (index values >=0.2) were more likely to be institutionalized (HR=5.2, p<0.01) or to die (HR=2.4, p<0.01) during the next 30 months. CONCLUSIONS Executive dysfunction is common in both AD and VCI. It is associated with poor performance on other measures of cognition and function. The presence of executive dysfunction is associated with worse near-term outcomes.

Current Concepts in Vascular Cognitive Impairment and Pharmacotherapeutic Implications

Objective: To review evolution of the vascular cognitive impairment (VCI) construct, including diagnosis, pharmacotherapeutic implications, and address challenges that will shape future developments. Data Sources: Literature retrieval was accessed through PubMed, from 1966 to December 2008, using the terms vascular cognitive impairment, vascular dementia, post-stroke dementia, vascular cognitive disorder, mild cognitive impairment, criteria, disease progression, outcomes, treatment, prevention, biomarkers, and neuroimaging. Study Selection and Data Extraction: All articles in published English identified from the data sources were evaluated for inclusion. Regarding pharmacotherapy, prospective double-blind, placebo-controlled studies were included as well as extensions or relevant post hoc analyses. Data Synthesis: In the 1970s, “senile dementia due to hardening of the arteries” was used to describe dementia due to vascular causes. This was a narrow view of what is now known to be a common form of cognitive impairment in older people. Multiple infarct dementia (MID) was first proposed to describe dementia attributable to multiple cerebral infarcts, followed by the vascular dementia (VaD) construct, itself meant to be an improvement over MID. The VaD construct had limitations, not the least of which was that, by the time a patient was diagnosed with VaD, the opportunity for prevention was lost. Thus arose the concept of VCI, representing a group of heterogeneous disorders that share presumed vascular causes. The importance of VCI is centered on the fact that vascular risk factors are treatable, and thus should lead to a reduction in the incidence of cognitive impairment due to vascular causes. There is evidence that treatment of hypertension can lead to a reduction in the incidence of cognitive impairment and dementia, and that treatment of VaD with acetylcholinesterase inhibitors may be beneficial. Conclusions: Careful attention needs to be given to controlling vascular risk factors in at-risk patients. Pharmacists should play an active role in this important area of geriatric pharmacotherapy.

Screening for Frailty in Canada’s Health Care System: A Time for Action

RÉSUMÉ: Avec le vieillissement de la population canadienne, la fragilité–avec son risque accru du déclin fonctionnel, la détérioration de la santé, et le décès–devient de plus en plus répandue. La physiologie de la fragilité reflète son origine parmi organes et systèmes multiples. Environ un quart des Canadiens qui sont âgés de plus de 65 sont fragiles, augmentant à plus de la moitié de ceux âgés de plus de 85. Notre système de soins de santé est organisé pour gérer les systèmes mono-organes, ce qui nuit à notre capacité à traiter efficacement les personnes atteintes de troubles multiples et des limitations fonctionnelles. Pour faire face à la fragilité, il faut reconnaître quand elle se produit, accroître la sensibilisation à son importance, développer des modèles holistiques pour ses soins, et générer des meilleures preuves pour son traitement. La reconnaissance de la façon dont la fragilité impacte la durée de vie permettrait l’intégration des objectifs en matière de soins dans les options de traitement. Les différents organisations de soins responsables variées dans le système de soins de santé canadien nécessiteront des stratégies et outils différentes pour évaluer la fragilité. Les changements dans la politique sera essentiels, étant donné la portée et la complexité des défis que pose la fragilité au système de soins de santé comme cela est organisé actuellement. ABSTRACT: As Canada’s population ages, frailty–with its increased risk of functional decline, deterioration in health status, and death–will become increasingly common. The physiology of frailty reflects its multisystem, multi-organ origins. About a quarter of Canadians over age 65 are frail, increasing to over half in those older than 85. Our health care system is organized around single-organ systems, impairing our ability to effectively treat people having multiple disorders and functional limitations. To address frailty, we must recognize when it occurs, increase awareness of its significance, develop holistic models of care, and generate better evidence for its treatment. Recognizing how frailty impacts lifespan will allow for integration of care goals into treatment options. Different settings in the Canadian health care system will require different strategies and tools to assess frailty. Given the magnitude of challenges frailty poses for the health care system as currently organized, policy changes will be essential.

Comparison of EXIT-25 and the Frontal Assessment Battery for Evaluation of Executive Dysfunction in Patients Attending a Memory Clinic

Background/Aims: The Frontal Assessment Battery (FAB) and the EXIT-25 have emerged as 2 widely used screening instruments for executive dysfunction, but their screening properties have not been evaluated in a head-to-head comparison. Methods: Prospective cohort study of 92 individuals presenting for cognitive assessment at a community hospital. Results: The EXIT-25 took longer than the FAB to complete (mean difference = 9.27 min, 95% CI: 9.86–8.68). EXIT-25 and FAB scores showed significant correlation (Spearman’s r = –0.79, p < 0.001) with one another, and each showed acceptable convergent validity and divergent validity. Conclusions: The 2 tests provide similar information about the presence of executive dysfunction. The FAB takes less time to complete, and appears to be less frustrating for patients, making it more feasible as a screening test for executive dysfunction in a memory clinic setting.

The inclusion of cognition in vascular risk factor clinical practice guidelines.

Background: People with vascular risk factors are at increased risk for cognitive impairment as well as vascular disease. The objective of this study was to evaluate whether vascular risk factor clinical practice guidelines consider cognition as an outcome or in connection with treatment compliance. Methods: Articles from PubMed, EMBASE, and the Cochrane Library were assessed by at least two reviewers and were included if: (1) Either hypertension, high cholesterol, diabetes, or atrial fibrillation was targeted; (2) The guideline was directed at physicians; (3) Adult patients (aged 19 years or older) were targeted; and (4) The guideline was published in English. Of 91 guidelines, most were excluded because they were duplicates, older versions, or focused on single outcomes. Results: Of the 20 clinical practice guidelines that met inclusion criteria, five mentioned cognition. Of these five, four described potential treatment benefits but only two mentioned that cognition may affect compliance. No guidelines adequately described how to screen for cognitive impairment. Conclusion: Despite evidence that links cognitive impairment to vascular risk factors, only a minority of clinical practice guidelines for the treatment of vascular risk factors consider cognition as either an adverse outcome or as a factor to consider in treatment.

The validation of a care partner-derived frailty index based upon comprehensive geriatric assessment (CP-FI-CGA) in emergency medical services and geriatric ambulatory care

BACKGROUND The derivation of a frailty index (FI) based on deficit accumulation from a Comprehensive Geriatric Assessment (CGA) has been criticised as cumbersome. To improve feasibility, we developed a questionnaire based on a CGA that can be completed by care partners (CP-FI-CGA) and assessed its validity. METHODS We enrolled a convenience sample of patients aged 70 or older (n=203) presenting to emergency medical services (EMS) or geriatric ambulatory care (GAC). To test construct validity, we evaluated the shape of the CP-FI-CGA distribution, including its maximum value, relationship with age and gender. Criterion validity was evaluated by survival analysis and by the correlation between the CP-FI-CGA and specialist-completed FI-CGA. RESULTS The mean age was 82.2±5.9 years. Most patients were women (62.1%), unmarried (widowed, divorced and single) (59.6%) and lived in their own home or apartment (78.3%). The mean CP-FI-CGA was 0.41±0.15 and was higher in the EMS group (0.45±0.15) than in GAC (0.37±0.14) (P<0.001). The CP-FI-CGA correlated well with the specialist-completed FI-CGA (0.7; P<0.05). People who died had a higher CP-FI-CGA than did survivors (0.48±0.13 versus 0.38±0.15). Each 0.01 increase in the FI was associated with a higher risk of death (HR 1.04; 95% CI 1.02-1.06). CONCLUSION The CP-FI-CGA has properties that resemble other published FIs and may be useful in busy clinical practice for grading degrees of frailty. It efficiently integrates information from care partners so that it can help guide decision-making.