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POST ACUTE CARE FOR FRAIL OLDER PERSONS: TIME FOR A STANDARDIZED MODEL OF CARE

 

L. Calcaterra1, M. Cesari2,3

 

1. Geriatric Fellowship Program, University of Milan, Milan 20122, Italy; 2. Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy; 3. Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan 20138, Italy

Corresponding Author: Laura Calcaterra, Geriatric Fellowship Program, University of Milan, Milan 20122, Italy, laura.calcaterra@unimi.it

J Frailty Aging 2021;in press
Published online December 10, 2021, http://dx.doi.org/10.14283/jfa.2021.52

 


Key words: Vaccines, geriatrics, frailty, integrated care, social care.


 

With the aging population, healthcare systems are called at evolving their facilities and services to address the new needs and priorities of frail older persons (1). It is well-established that hospitalizations are often responsible for functional decline and increasing dependency in older persons, partly due to the consequences of the acute condition, partly for the so-called iatrogenic disability (2, 3). In this context, the role played by Post-Acute Care (PAC) is growingly considered as pivotal..
PAC facilities are crucial for relieving the pressure on acute hospital beds. It has also been demonstrated that frail patients discharged from PAC have a higher level of independence and a lower risk of hospital readmission compared to those discharged from general hospital care (4). The positive effects (also over the long-term) of PAC can be explained by the person-tailored, multidisciplinary interventions focused on functions that are here implemented. At the same time, the PAC admission after the resolution of an acute condition may better prepare the transition of the frail individual from the hospital to the community.
In the present issue of The Journal of Frailty & Aging, Fompeyrine and colleagues (5) report the association between frailty status on admission to a PAC unit and 12-month mortality. Two critical findings are worth to be mentioned:
1. The clinical complexity of patients at PAC admission is very high, as demonstrated by the high prevalence of frailty (i.e., 54% according to the Fried and colleagues’ phenotypic model) and the high mortality after 12 months (i.e., 22.9%);
2. The frailty condition, despite the risk of a ceiling effect, was still a significant predictor of the study outcome, differently from the participants’ age.

In other words, PAC facilities confirm an essential position in bridging hospital care and community/primary care. The often-advocated continuity of care to be guaranteed to frail older persons, especially after a significant event as a hospitalization, may find in the PAC setting an ally (6).
Nevertheless, PAC professionals often find themselves between the hammer and the anvil. On one side, the chaotic hospital rigidly focused on the diagnosis and treatment of the disease(s). On the other hand, the primary care setting that, with limited resources, tries to counteract the consequences of aging by preserving function. In this scenario, PAC may represent an ideal place to comprehensively assess frail older persons before returning to the community. It could provide the opportunity for reducing the pace and finally starting to consider the real priorities of the individual after the acute manifestation of the disease is over.
Here the need for a standardized language (both in terms of contents and instruments) becomes vital for guaranteeing the proper communication and continuity of care. Unfortunately, there is a gap to fill by research in this area. There are great opportunities out there that are not adequately valorized or disseminated for different reasons. A perfect example is represented by the InterRAI model (7, 8), developed into several setting-specific instruments for the comprehensive geriatric assessment of the older person with frailty. The InterRAI suite also includes the InterRAI Post-Acute Care and Rehabilitation (PAC-Rehab) package, composed of diagnostic and screening tests, outcome measures, clinical assessment protocols, quality indicators, and case-mix tools. The multidimensional and exhaustive approach used in the InterRAI has allowed Kerminen and colleagues (9) to develop a Frailty Index (following the deficit accumulation model proposed by Rockwood and Mitnitski (10)) and explore its predictive capacity for adverse health outcomes in PAC. Unfortunately, as above-mentioned, the InterRAI model is well-established in many countries but not yet so widely worldwide as it could be. A barrier to its diffusion has been indicated in the copyright and costs related to its use, although many possibilities exist for obtaining royalty-free licenses.
Frail older persons require a longer time to recover from acute illness (11). Unfortunately, healthcare systems are too busy focusing on hospital-centered and hyperspecialized care, and seem reluctant at investing in alternative settings of care. It would be important to standardize the PAC setting in the patient’s profiling, the facility organization, and its integration within the healthcare system. This would benefit not only the frail older person (often too early discharged from the hospital) but also the public health system (which will reduce the consequences of chronic conditions through PAC programs). The modernization of the system through proper integration of care will also allow to better value some traditionally neglected settings of geriatric care and the professionals here working in the management of clinically complex, frail older persons.

 

References

1. Astrone P, Cesari M. Integrated Care and Geriatrics: A Call to Renovation from the COVID-19 Pandemic. J Frailty Aging. Published online October 28, 2020:1-2. doi:10.14283/jfa.2020.59
2. Lafont C, Gerard S, Voisin T, Pahor M, Vellas B. Reducing “iatrogenic disability” in the hospitalized frail elderly. J Nutr Health Aging. 2011;15(8):645-660.
3. Martínez-Velilla N, Herrero A, Cadore E, Sáez de Asteasu M, Izquierdo M. Iatrogenic Nosocomial Disability Diagnosis and Prevention. J Am Med Dir Assoc. 2016;17(8):762-764. doi:10.1016/j.jamda.2016.05.019
4. Young J, Green J, Forster A, et al. Postacute care for older people in community hospitals: a multicenter randomized, controlled trial. J Am Geriatr Soc. 2007;55(12):1995-2002. doi:10.1111/j.1532-5415.2007.01456.x
5. Fompeyrine C, Abderhalden LA, Mantegazza N, et al. Frailty Is Associated with Increased Mortality in Older Adults 12 Months After Discharge from Post-Acute Care in Swiss Nursing Homes. J Frailty Aging. Published online October 20, 2020. doi:10.14283/jfa.2020.58
6. Peel N, Hubbard R, Gray L. Impact of post-acute transition care for frail older people: a prospective study. J Frailty Aging. 2013;2(3):165-171.
7. interRAI. Accessed November 16, 2020. https://www.interrai.org/
8. Rolfson DB, Heckman GA, Bagshaw SM, Robertson D, Hirdes JP, Canadian Frailty Network. Implementing Frailty Measures in the Canadian Healthcare System. J Frailty Aging. 2018;7(4):208-216. doi:10.14283/jfa.2018.29
9. Kerminen H, Huhtala H, Jäntti P, Valvanne J, Jämsen E. Frailty Index and functional level upon admission predict hospital outcomes: an interRAI-based cohort study of older patients in post-acute care hospitals. BMC Geriatr. 2020;20(1):160. doi:10.1186/s12877-020-01550-7
10. Mitnitski A, Mogilner A, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal. 2001;1:323-336.
11. Cesari M, Calvani R, Marzetti E. Frailty in Older Persons. Clin Geriatr Med. 2017;33(3):293-303. doi:10.1016/j.cger.2017.02.002

OLDER PERSONS “LOST” TO THE COVID-19 VACCINATION: WHERE ARE THEY?

 

M. Cesari1, B. Vellas2

 

1. Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, University of Milan, Milan, Italy; 2. Gerontopole – Inspire Program, UMR INSERM 1295, Toulouse University Hospital, University of Toulouse Paul Sabatier, Toulouse, France

Corresponding Author: Matteo Cesari, MD, PhD. IRCCS Istituti Clinici Scientifici Maugeri; via Camaldoli 64, 20138 Milan – Italy. Email: macesari@gmail.com; Twitter: @macesari

J Frailty Aging 2021;10(4)308-309
Published online September 17, 2021, http://dx.doi.org/10.14283/jfa.2021.37

 


Key words: Vaccines, geriatrics, frailty, integrated care, social care.


 

The COVID-19 pandemic has substantially changed our lives. It has also acted as a sort of stress test for care systems, letting emerge all the inconsistencies, weaknesses, and contradictions of them. In particular, frail persons have shown to be those paying the most severe consequences of the general disservices (1). To date, in the absence of specific drugs against the SARS-CoV-2, preventive measures against infection and vaccination represent the only available weapons. Social distancing, hand hygiene, and protective personal equipment have been immediately put in place since the very first phases of the pandemic. Starting in December 2020, vaccines against the SARS-CoV2 infection have been made available and mass campaigns of vaccinations have started worldwide.
Given the high-risk profile exhibited by older persons with frailty, these have been usually prioritized in the vaccination campaigns. Today, the vaccine administration is primarily focused to adults and young persons. Whereas it is generally assumed that the older population has now been vaccinated, a recent survey has suggested that many persons aged 80 years and older (almost 20%) are not yet (2). Indeed, as reported, “statistics from the Centers for Disease Control and Prevention showed this population’s vaccination rates soaring through the spring, then hitting a plateau”.
Which are the barriers precluding the vaccination of so many persons at risk of the most severe consequences of COVID-19? Several reasons can be hypothesized:
– Older persons may refuse the vaccination for personal opinions or because influenced by their proxies. In this context, the presence of cognitive impairment and difficulties in judgment might affect the capacity to decide, relying on what younger persons (potentially less concerned by the severity of the virus and more exposed to fake news) choose for them. In this context, it is important to consider that the many no-vax messages might have, directly and indirectly, influenced the most vulnerable ones (due to their frail status and/or low socio-cultural conditions).
– The frailty status of many older persons can complicate the access to the vaccination. Difficulties in the use of technologies for scheduling an appointment, mobility impairment and/or social isolation hampering the possibility to reach the vaccination site, cognitive disorders affecting the capacity to take and retain the appointment… are all examples of potential underestimated barriers.
– The pandemic has made clear that the hospital-centered design of our healthcare systems is not suitable for many persons living with frailty (3). Their protection implies the adoption of a more comprehensive approach, leaving the traditional standalone disease-model in favor of a holistic vision of the individual inclusive of his/her environment. In this context, it cannot be ignored how most of the vaccination campaigns are centered on hubs in the community where persons can go to receive their vaccine dose. However, relatively low interest has been put for supporting primary care and facilitate the vaccination of the frailest individuals who are home-bound. Indeed, the COVID-19 pandemic has exposed the extreme paucity of resources and infrastructures devoted to older persons where they live and age (i.e., in the community). More research is needed to better understand how many and why older persons are still “lost” to our care systems. This is pivotal to develop future strategies allowing the provision of preventive care in the community to the most vulnerable persons.

Access to care has been extremely difficult for many persons over the past months, not only because of the restrictions and lockdowns applied by governments during the hardest moments of the pandemic. Older persons have specially suffered the fragmentation of care and the prolonged disruptions of services (often motivated by the need of facing the COVID-19 emergency). The procrastination of routine clinical evaluations, often combined with the older person’s fear of being infected, has uphold many interventions that were instead needed (4). Furthermore, the lifestyle modifications forcedly brought by the pandemic have negatively impacted on the health status of the most vulnerable persons, worsening their functions and clinical conditions (5,6). The functional loss and social isolation developed by older persons over the past months will likely result in major consequences in the next future, both in terms of 1) frailer and more complex patients, and 2) incapacity of services to adequately address the increasing demands.
Interestingly, a recent study by Ankuda and colleagues (7) has recently described an exponential increase of community-dwelling older persons who have become home-bound (i.e., leaving the house once a week or less) during these months of pandemics. These persons are exposed to particularly high risk of negative outcomes. Their risk profile is further enhanced by their social isolation preventing them from prompt access to care. A further example is coming from Italy. During the vaccination campaign, almost 500-thousand persons (that is about 1% of the Italian population) were untraceable and difficult to reach. They are socially isolated, tend to live in rural areas, have no internet/phone connection, and/or move frequently across the country. In other words, the COVID-19 pandemic is showing the existence of a population of frail individuals for which a completely different model of care is needed. The usual reactive approach is evidently not working for them, and proactive/preventive strategies are needed.
Under the current COVID-19 situation, we would like to stress the importance of the following points:
1. With the aging of our population and the increasing number of socially isolated individuals, the system cannot anymore just wait for the incoming request. The continuation of this obsolete approach will contribute at accelerating the collapse of the systems which are designed for late interventions. It is necessary to reshape our clinical and public health strategies for anticipating the problems and act when the case is still reversible (for the benefit of the person and the community)(8).
2. Instead of waiting that the problem arrives to the attention of clinical and social services, it is necessary to identify the early signs of future issues to preventively intervene. This means the building of multidisciplinary bridges facilitating the sharing of relevant information across settings for the development of person-centered actions.
3. In this context, it is noteworthy the work conducted by the World Health Organization (WHO) to promote the integration and continuum of care (9). The WHO has repeatedly recommended over the past years to modify the approach to older persons by implementing preventive strategies and personalization of interventions (e.g., ICOPE Program)(10). Every point of contact between the individual and the care system should become an opportunity for estimating the residual reserves (i.e., intrinsic capacity) and abilities (i.e., functional ability) (11). The resulting information may then be used to track his/her trajectories and identify deviations from the normality.
4. Finally, the adoption of shared technologies is not an option anymore. Indeed, in a world dominated by technologies, it is not anymore acceptable that persons are “lost” to the care system. It is time to take advantage of technologies as exemplified by the ICOPE Monitor, an innovative digital healthcare program designed for community-dwelling older persons with frailty with the final aim of remote monitoring their health status (via nurse assistance) and facilitating access to preventive services (including COVID-19 vaccination) (12, 13).

 

References

1. Merchant R. COVID-19: role of integrated regional health system towards controlling pandemic in the community, intermediate and long-term care. J Frailty Aging. 2020:1-2. doi:10.14283/jfa.2020.39.
2. Span P. More Than 80 Percent of Seniors Are Vaccinated. That’s ‘Not Safe Enough.’ The New York Times. https://www.nytimes.com/2021/09/02/health/covid-vaccines-seniors.html. Published September 2, 2021. Accessed September 3, 2021.
3. Astrone P, Cesari M. Integrated Care and Geriatrics: A Call to Renovation from the COVID-19 Pandemic. J Frailty Aging. October 2020:1-2. doi:10.14283/jfa.2020.59.
4. Briguglio M, Giorgino R, Dell’Osso B, et al. Consequences for the Elderly After COVID-19 Isolation: FEaR (Frail Elderly amid Restrictions). Front Psychol. 2020;11:565052. doi:10.3389/fpsyg.2020.565052.
5. Kirwan R, McCullough D, Butler T, Perez de Heredia F, Davies IG, Stewart C. Sarcopenia during COVID-19 lockdown restrictions: long-term health effects of short-term muscle loss. Geroscience. 2020;42(6):1547-1578. doi:10.1007/s11357-020-00272-3.
6. Canevelli M, Valletta M, Toccaceli Blasi M, et al. Facing Dementia During the COVID-19 Outbreak. J Am Geriatr Soc. 2020;68(8):1673-1676. doi:10.1111/jgs.16644.
7. Ankuda CK, Leff B, Ritchie CS, Siu AL, Ornstein KA. Association of the COVID-19 Pandemic With the Prevalence of Homebound Older Adults in the United States, 2011-2020. JAMA Internal Medicine. August 2021. doi:10.1001/jamainternmed.2021.4456.
8. Barusch A, Waters D. Social engagement of frail elders. J Frailty Aging. 2012;1(4):189-194.
9. World Health Organization, Department of Ageing and Life Course. Integrated Care for Older People.; 2017. http://www.ncbi.nlm.nih.gov/books/NBK488250/. Accessed March 1, 2019.
10. Integrated Care for Older People (ICOPE): Guidance for Person-Centred Assessment and Pathways in Primary Care. World Health Organization; 2019.
11. World Health Organization (WHO). Decade of Healthy Ageing.; 2020. https://www.youtube.com/watch?v=ShmemfpkVLQ&list=PL1F160112BFDBC1D5&index=2. Accessed April 27, 2021.
12. González-Bautista E, De Souto Barreto P, Virecoulon Giudici K, et al. Frequency of Conditions Associated with Declines in Intrinsic Capacity According to a Screening Tool in the Context of Integrated Care for Older People. J Frailty Aging. August 2020. doi:10.14283/jfa.2020.42.
13. Tavassoli N, Piau A, Berbon C, et al. Framework Implementation of the INSPIRE ICOPE-CARE Program in Collaboration with the World Health Organization (WHO) in the Occitania Region. J Frailty Aging. 2021;10(2):103-109. doi:10.14283/jfa.2020.26.