Okay. So at the Geriatric Rehab Community, I was honored to present great speakers today at our pre-conference session. And we have nationally known speakers, and we are fortunate to have them all available and come to present at the pre-conference level. And I would like to first show you the whole panel here, Dr. Thomas Caprio, Dr. Susan Godstang, Dr. Dale Strasser, and Dr. O'Park. And as we go along, I'll introduce each speaker before their talk. And I am very honored to be part of this geriatric community, and I hope you all enjoy listening to the wonderful speakers today. And let's start with the very first speaker. Before this session starts, I would like to briefly go over the main title, and that is delirium and frailty in older adults, addressing knowledge gap, and implementation in post-acute care, especially in the IRFs. We have quite a few lofty goals here and objectives, and I think as we go along, you can see we'll review the common symptoms and potential causes of delirium in older adults presented by Dr. Caprio. And he will also identify non-pharmacological methods of prevention and management. And we'll have Dr. Dale Strasser, who could not be here in person, but he's pre-recorded and will play the video. And he'll be talking about the delirium and its effects in older adults undergoing rehab in acute, in post-acute setting, I'm sorry. And then we have Dr. Godstang presenting frailty. She will describe the tools for assessment and understand their uses and limitations and identify strategies to improve frailty in specific populations. And finally, Dr. O'Park will be addressing awareness of significant healthcare costs associated with frailty in older adults, not only nationally, but also globally. And she will delineate care models and addresses frailty in continuum of care in the integrated healthcare systems. And I would like to start with the first speaker, Dr. Thomas Caprio. Dr. Caprio received his MD degree from the State University of New York at Buffalo, completed his residency, fellowship, and postdoctoral training, research training at the University of Rochester Medical Center. Then he completed his Master of Public Health degree in the University of Rochester School of Medicine and his Master's Health Professions Education from the University of Rochester Warner Graduate School of Education. With all these degrees, Dr. Caprio is a professor of Medicine, Geriatrics, Psychiatry, Dentistry, Clinical Nursing, and Public Health Sciences at the University of Rochester in Rochester, New York. I'm very proud to be associated with him and he's a Chief Medical Officer of University of Rochester Medicine Home Care and the Medical Director for the University of Rochester Medicine Hospice Program. Dr. Caprio is a Director of Finger Lakes Geriatric Education Center, which oversees the federally funded geriatric workforce enhancement program, providing education and training related to geriatrics, palliative care, and dementia care for healthcare professionals and family caregivers across the state of New York. Dr. Caprio served for over a decade as Program Director for the Geriatric Medicine Fellowship at the University of Rochester. He is Past President of the State Society on Aging of New York, Past President of the National Association of Geriatric Education, and the Past President of the National Association of Geriatric Education Centers. Dr. Caprio is a Fellow of the American College of Physicians, Fellow of American Geriatric Society, and Fellow of the American Academy of Hospice and Palliative Medicine. He is a Certified Medical Director in Long-Term Care and a Certified Hospice Medical Director. We are very, very fortunate to have Dr. Caprio of his caliber to spare his time to our community to address the very important topic of delirium. And without much ado, Dr. Caprio, please go ahead. Thank you so much, Dr. Padouri, and thank you again for the invitation to be part of this symposium. I'm really thrilled to be here, as Dr. Padouri said, as I'm a geriatrician. And I am very familiar, I think, as all of us are in terms of working with our patients that have delirium. This is, I think, both a challenging situation, but an opportunity for us to improve upon care. I just want to verify that my slides are okay, everyone can see? All right. So, thank you again, Dr. Padouri. Dr. Padouri has been just a wonderful colleague and mentor to me as well. And as she has outlined here, is that the learning objectives I'm going to cover is really to kind of do a basic kind of ground level approach at sort of the, what are the specific kind of areas of delirium, define what it is, some of the basic concepts, some of the common symptoms and risk factors are associated with it, and then a little bit in terms of interventions, particularly non-pharmacologic and some of our preventive interventions that we want to look for, particularly when we think about from a risk stratification standpoint. And I'll just briefly touch upon some of the challenges, I think, in terms of our medication management in terms of delirium, particularly the psychotic medications and very limited evidence that those can be helpful in all those cases. But I think in some defined cases as maybe helpful adjuncts to the ongoing management overall of delirium. So, I want to start here and really just focus on what is delirium? What are we talking about in terms of delirium? And I think that there is a lot of confusion over the terminology that we have, is that a lot of times strictly a billing and coding world is what we're talking about, encephalopathy, or we attribute to specific underlying conditions, metabolic encephalopathy, let's say, hepatic encephalopathy, those sorts of things. But there's many of us, I think, that argue that delirium is really kind of a syndrome. And I would actually even argue, particularly for our older patients, kind of one of the geriatric syndromes that we deal with very frequently. And so, when we're talking about delirium through the course of our time together today, I really want us to focus in on the fact that this is primarily a disturbance in consciousness, the level of alertness, poor attention, distractibility, somnolence could be seen with particular patients with delirium. There's also a change in cognitive process. So, memory impairment, disorientation, language, multiple cognitive domains can be affected with it. And one of the other hallmarks is that fluctuation is not uncommon with it. And this could be over the course of even just through hours or days period of time that people can fluctuate in terms of this confusional state. And that can be very frustrating, as you can imagine, for particularly families and for caregivers, because they could see a loved one at one particular moment in time, they seem to be really focused and seem to be on the path of recovery from whatever underlying illness or surgical intervention. And then a few hours later or a day later, they're confused again, talking about dead relatives, hallucinating, all of those sorts of things. So, it can be very, I think, frustrating and difficult to understand. And I do a lot of education, as Dr. Paduri said, as well, and do teaching with students, as I'm sure that many of you do as well. And it's hard to how do we encapsulate this? How do we teach this to our students as well? And I think the underpinning that I'm going to really emphasize here is that this is multifactorial, like a lot of the geriatric syndromes. There's many risk factors and contributions to it. And I think in some ways is that when we try to intervene upon delirium, and where we fix everything, where all the numbers look good, right, the sodium level, like the renal function looks good, we have an expectation that everything should be better, right? And sometimes it's not. And so that becomes frustrating, because there's so many interaction of these kind of different factors that are at play with it. But it's worthwhile for us to think about what is happening with delirium, because it is extremely prevalent. We'll hear in other presentations as well. And depending upon the studies, and whether it's medical or surgical patients with it, ranges between 15 to 60%. I think in general, we're thinking about probably I kind of look at the sort of the intermediate range, probably 30 or 40%, in terms of the prevalence as well. And as Dr. Paduri mentioned, I do a lot of work in hospice care as well. And I would, I would assert to that it is probably close to 90, if not 100%. At some point at end of life care as well. And I'm not going to focus too much on end of life delirium, or sometimes what we talk about in terminal delirium, but we have to think about that as part of the continuum as well. Just like with the dying process that we have other organ failures that you have brain failure that can occur as well in terms of the changes that are occurring as part of the dying process. So very common that we deal with in terms of end of life. I'm not going to go through an extensive kind of literature review here. But I think everyone appreciates that increased length of stay, rehospitalization, morbidity and mortality is clearly associated with delirium. But other things that we don't necessarily think about in terms of falls and fractures, urinary incontinence that may be new, all can have touch points along the way with the development of delirium and consequences of that delirium. A lot of the inpatient efforts that have been undertaken in the hospitals in terms of falls reduction have really focused on delirium, because we know that that is one of the potent risk factors for individuals having a fall during their inpatient care. And I would argue is that not only is this really a burden of care on staff, and we're all challenged with staffing, I know today and all of our clinical care settings as well. So this requires a lot of staffing time, but it also is a source of distress, not only for caregivers and families, but I would assert that this is an area of suffering for many of our patients as well. It can be extremely, have a big impact in terms of their quality of life, delay or prolong their rehabilitation and recovery from underlying illness. And the challenge is that it's oftentimes under-recognized by our staff. And so that's kind of some of the take-home message we have today is that how do we kind of create a culture of being tuned in to both risk factors identification early on of delirium. And I would assert that there's probably about a third of cases that we may actually be able to prevent just by changing care routines and thinking about risk factors. And so I'll get back to that in a second. There are different clinical subtypes of delirium. Hyperactive delirium, I think is what most of us think about, because these are the folks that get the most attention in terms of clinical settings. They're agitated, they're pulling at things, they're at risk for falls. It doesn't really take a lot to be able to recognize, okay, here's a problem that this person is really going to be in bad shape because of this agitation that's occurring. But there is a lot of times too that we have this hypoactive delirium that in terms of folks that are much more withdrawn, they tend to be more sleepy and often is missed. And the reality is the vast majority of cases is probably a mix. And part of the fluctuations that we're seeing is the fluctuation between a hyperactive and hypoactive delirium. But again, I would assert is that hypoactive delirium and being able to recognize that and not just attribute to, oh, they're fatigued, they can't participate in physical therapy today, but maybe hypoactive delirium is occurring, is just as important as us understanding hyperactive delirium that are getting the attention of nurses and the other staff, because both of them together, and particularly this mix and the fluctuation that occurs between it is associated with the poor outcomes for a patient. So, we can't miss these cases of the hypoactive delirium. And how oftentimes is this communicated to us as clinicians across the continuum of care? Oftentimes, this is the calls that I get for folks. Patient is confused trying to get out of bed, right? Oftentimes, this again is associated with the hyperactive delirium. It's important to establish, how is this different from prior baseline? When I have caregivers or staff that say, this is like a light switch has flipped, like this is not how the person was, but suddenly this has changed, that really raises a red flag in my mind. What are specifically the changes that are being observed? And I've used the term already in my talk at this point, but I hate the term of agitation, right? Because agitation really does not describe what is being observed, right? So, I want to know, are they restless? Are they combative? Are they getting up out of a chair? What is happening? What are they talking about? Are there other kind of localizing symptoms? Is it the person with underlying dementia who has now pain that is maybe undertreated and that we can address some of those issues? What does their level of consciousness look like? What is the recent history, right? Our patients aren't just a snapshot in time. They've had hip surgery, they've had prolonged ICU stay, all of those kinds of things we have to consider in terms of the context of what are potential risk factors and what are things that we can address. I want to put a quick plug in here as well, because I think we've created this culture that we always want to blame any sort of confusion on a urinary tract infection. And it's not always a UTI. Now, I'm not saying that UTI and sepsis can't necessarily do it, but I kind of joke about it. I don't know if I'm the one that's coined this term, but I talk about it as the folklore of geriatrics that we oftentimes want to practice uro-psychiatry, right? We want to blame everything on the urine with it. When we know the reality, particularly for older adults, asymptomatic bacteria is common. Having a strong odor, oftentimes that is what's reported to me. My nurse says, oh, it's dark-colored, strong-odored urine. That may actually indicate dehydration, which certainly could be a risk factor for delirium, but may not be sufficient itself to say, okay, this is a UTI. We really want to look at localizing symptoms, fever, maybe check the CBC for elevated white blood count, because what we want to do is make sure that we are still champions of antibiotic stewardship and not creating further resistance. And I see too many times this constant cycle, we're treating again and again for a presumed urinary tract infection, when in reality is that we may have to be looking further that this could be delirium, which has many factors involved and not always a UTI. I kind of joke because I sometimes do slides for students and do this teaching and probably every second or third slide that I have is, but it's probably not a UTI, trying to emphasize again that students to sort of think about, think outside the box. So some of the things to think about, particularly what's documented in the medical record or how we talk about, I actually pulled this out of a chart abstraction of patients that we were looking at the nursing home that we thought had developed delirium. And it's kind of words that we use all the time, agitated, combative, aggressive, resistive to care, rambling speech, confused, disoriented, withdrawn, having hallucinations, emotional, all of those kinds of factors. This doesn't necessarily mean that this is a patient who has delirium, but I would assert to you that this is a red flag, right? When we start talking about that this is what's happening with patients, we need to be thinking about maybe delirium is at play here. I think one of the really important points to think about is distinguishing delirium versus dementia. And I think most clinicians kind of take this for granted of saying, well, yeah, I understand that. But at times I see too many scenarios play out, and particularly when I'm working with residents or the emergency department or others, that they see Alzheimer's disease as part of the problem list or the past medical history for a particular patient. And they automatically attribute to, oh, well, this is their dementia, right? And this is not one of those kinds of situations in which we just can dismiss it based upon what the history is. We have to understand, and this is really where getting a patient's baseline is extremely important, so that we know that this has been an abrupt change. An acute change we'll talk about is one of the sort of diagnostic criteria in terms of delirium. We have to get a sense of history, talking with family and caregivers, thinking about what has happened with this person over a period of time. Dementia tends to be a progressive, slow, kind of insidious decline in terms of cognition and functional behaviors. Sleep disorders and things can occur particularly more late in the course. Psychosis is possible in the late stages or specific types of dementia, if we think about dementia with Lewy bodies and those kind of things, but not usually one of the up-front kind of characteristics for a person that's presenting. But when we talk about what delirium is, that it's really this abrupt onset. Oftentimes, particularly the hypoactive delirium, these are folks that are lethargic. So a patient that is lethargic and not being responsive to our interactions, that's not dementia. I oftentimes refer to dementia as these are people who are awake but confused, right, not somnolent and confused with it. So the challenge here is that one of the major risk factors, and I'll talk about this in a second, is underlying dementia to develop delirium. And so having that superimposed delirium on a dementia, it's important for us to distinguish with it. And I kind of bristle at this term of sundowning. I hear a lot of families talk about sundowning, and I think it's been acculturated with a lot of our staff as well. Sundowning may be true as a systematized kind of behavior that occurs at a regular frequency with dementia, but when we start to talk about or dismiss certain levels of confusion and those kind of things as just sundowning because they have underlying dementia, I want you to sort of pause and say, could this be delirium, right? Are we dealing with delirium as one of those factors as well? And so kind of just having that integrated approach and always questioning, don't take it for granted that just because a person has underlying cognitive changes that associate with dementia that we just dismiss it as the dementia, is that they could have a superimposed delirium on top of that. And so that gets into a lot of the risk factors that we talk about with delirium. Dementia, as I said, is probably a very significant risk factor, but those with major mental illness, long-term mental illness, I'm talking about schizophrenia, major depression, bipolar disorder, we know that they have a higher propensity developing delirium. There's a certain degree of cognitive vulnerability, if you will. Certainly the patients that you're working with that have had a prior stroke, anyone who has brain tumors, other malignancies, and there's actually good literature to support that a lot of the hematologic malignancies, GI and GU malignancies, probably have either sort of an inflammatory effect or cytokines that are part of that disease process that may actually sort of, in a sense, lower the delirium threshold with it. And then infection, certainly pneumonia, sepsis, any of those kind of things, one of the hallmarks or one of the early indications that infection is occurring could certainly be delirium. But we do have to keep in mind that it's not always the UTI, as I mentioned before. We got to continue to think, have a focused workup on it. I also look at any sort of organ changes, so renal hepatic failure, any of those kind of things, metabolic changes, anything that's too high or too low, hyperglycemia, hypoglycemia, hypernatremia, hyponatremia, renal impairments, any of those kind of things, hypoxia. And then we know too, and so these are the patients that you're seeing in rehabilitation settings as well, is any sort of quote-unquote severe illness. There's a very good literature from the geriatric trauma literature, the course of hospitalization, any of those kind of acute illnesses can be a potent risk factor for development of delirium. So I would assert, again, that all of the patients that you're seeing that have this background in terms of history are going to be at significant risk for delirium. And if we look at some of the risk factors that we actually have probably some degree of intervention, not necessarily control, but intervention upon, is looking at some of the potent risk factors that have been described in the literature as well. We know that sensory deprivation is a big factor in terms of development of delirium, particularly visual impairment, but this is why we're always harping upon glasses and hearing aids, adequate lighting, adequate lighting, those kinds of things, orientation to the sort of the outside world. If you just look at a clock, you don't know if it's 3 p.m. and whether it's in the morning or in the afternoon, because the curtains and the shades are closed in that room, it can be very confusing to that person. We know that the acute hospital admission changes of rooms. I see this in the nursing home all the time as well, is that you move a patient to a new room and the confusion begins as well with that. I'm going to come back to this point of medications, because we certainly know is that there are iatrogenic causes in terms of triggers for delirium, particularly anticholinergic medications, which may be very well intended to treat a particular kind of situation for that patient, but could have the unintended consequences of increasing that chance for delirium. And then some of the basic 101, I don't have to describe it to this audience, but outside of the realm in terms of rehabilitation and geriatrics is that I always have to harp on these points that constipation, fecal impaction, urinary retention are all potent risk factors for developing delirium as well, and we can intervene both on a preventive effort, but also identifying what's happened with this individual. I put a little asterisk here because I just want to emphasize the point that we need to, it's important for us to distinguish from alcohol or other kind of drug withdrawal as well. These are the kind of situations you always remember those cases where you kind of got burned in your past care of patients and stuff and I've had several times in terms of the course of my career of everyone's attributing this to delirium and the reality is that no one really took a good history in terms of alcohol intake on a daily basis or the fact that they may be withdrawing from high dose opioids or that they may have been using other substances at home. And now they're having those respite from those kinds of substances or alcohol while in a course of a hospitalization or rehabilitation. So always kind of keep that in mind and our approach is gonna be very different let's say for alcohol withdrawal than it would be for delirium. Some of the other risk factors, physical restraints and this includes things like the urinary catheter as well. I kind of joke about is the urinary catheter is the one point restraint, right? Is the sense that that is a tether for individuals and when we don't need it and we're trying to work in terms of bladder training and those kinds of things we try to get that out as quickly as possible. The polypharmacy aspect and we know that even just adding three medications to a discharge medication profile significantly increases the risk of delirium regardless of what the medication classes are. Probably a surrogate marker for the fact of complexity of that patient and other meds that they're on. And then I wanna really emphasize uncontrolled pain aspects of it. I think we all appreciate in terms of the importance of pain management, particularly through the course of rehabilitation but inadequately managed pain. I had described it as kind of adding fuel to the fire in terms of their delirium. So when we think about delirium in terms of kind of diagnostic criteria of what we go through, I wanna just emphasize kind of the really the classic tool that Dr. Sharon Inouye has really been instrumental in terms of our thinking of delirium. It's kind of the standardized tool. There's various adaptations of the CAM, ICU versions and others as well. But I just wanna emphasize kind of the four main areas that the CAM really encapsulates. It's the first one is acute onset with the fluctuating course. I had mentioned that as some of the distinguishing characteristics of delirium. Inattention and there's a lot of work that is focused on the inattention to really be able to operationalize this in more validated kind of approaches to it. I'm not gonna get into that in great detail here, but we can talk about that. And particularly the panel discussion, the Q&A is that, I think having a systematic way of approaching inattention is important, not just a gestalt about it. Disorganized thinking is the other aspects of the cognitive changes that are occurring. Now, again, this can be very challenging if a person has underlying dementia. And so we need to distinguish that. It may not be as helpful to think about it in that sense. And we're gonna have to then really rely upon some of the other criteria with it. And then the final point is the altered level of consciousness. This can range from, again, being hypervigilant, agitated to being really lethargic or stuporous as well. And so I have fluctuations that can occur through there. And so classically, when we think about the CAM is that scoring of it is that you really need the first and the second, number one and number two, acute change with the fluctuating course and the mental status and the inattention, and then either number three or number four. So the altered level of consciousness is disorganized thinking. So this is really where the individuals with dementia is that we have to really focus in on that alteration of consciousness. If the disorganized thinking, we can't necessarily distinguish from their baseline with it. But this is the classic kind of approach for delirium, an identification of it. How do we work it up? I would say is that we've tried to look at modifiable risk factors with it. But I would say that my very first step, anytime that I'm thinking about delirium is look at medications, right? Looking at the medications, what has been added? What dose has been increased? What has been stopped? Is there a potential association with it? I will tell you that my clinical experience, I would say that well over half, if not three quarters of cases, there's some medication contribution that I could sort of hypothesize. So it's not insignificant. So even before I'm sending blood work or urine and those kinds of things, I wanna really make sure I'm looking at the medications. Evaluate the adequacy of pain control. And I worked in the past with a lot of the orthopedic surgeons, post-operatively and consultation. And as soon as an older patient comes out of the OR and they're delirious, what was the first thing that happened? They stopped all of the opioid medications, right? In a panic that this was contributing to it. And oftentimes I was recommending to actually go up on the medications, right? To try to treat the pain. So I think pain is again, adding fuel to the fire. We wanna make sure we're addressing that. And then I think a focused diagnostic workup. Look at what are some of the contributing factors and the individual risk factors for that particular patient. So, as I mentioned, medications are really key with this. You can look across any sort of class of medications and there probably is some degree of risk with it. But certainly, the opioids I keep touting is that we want adequate pain management. What we all know is that particularly for patients that may be opioid naive is that that could be a contributor. Benzodiazepines, the steroids. We've often talked about steroid psychosis, right? And that could be a contributor to it. Anticholinergic medication, particularly the antihistamines, the diphenhydramines and those sorts of things. The antiemetics are anticholinergic. But even some of the antidepressants, I've seen cases where the only thing we could establish was that maybe it was the SSRI that was added to the medication profile as well. So, don't discount necessarily any medication as benign. If particularly it's a new medication or a dose that's been increased or adjusted, that could be suspect with it. And really what I look at is that for any of our patients, and this is really kind of my approach as a geriatrician as well. So, we look at the potential risk versus the benefit. Focus on medications with low benefit or can we move to safer alternatives? Kind of clean up the medication regimen and minimize some of the harm that's potential with it in terms of the side effects. And our overarching goal in terms of interventions with delirium is really to treat the distressing symptoms. And that may be where a role for pharmacologic intervention is. But I think simultaneously with that is that we want to identify these reversible causes. So, taking a look at the medications, the pain control. But the gold standard with it, and this is really where all the clinical practice guidelines and recommendations are, is that we would try non-pharmacologic options across all individuals as really best evidence with it. And so, that's kind of what I talked about in terms of the risk factors. Sensory aids, adequate lighting, turning on the light in the room when you're examining the patient. Family presence, I think we cannot discount. That is so helpful in terms of, I think, the reorientation, providing some support and connections for that individual. Relieve isolation, but yet kind of what I recommend is for families is short frequent visits is probably better, not a prolonged kind of period of time. We want to have protected time for sleep. This is a big issue in the hospitals. Do we really need to wake person up every four hours for vitals and those kinds of things? Sensory overload. A lot of our facilities are noisy places and alarms and call bells and all of those sorts of things. And that is gonna be disrupted to sleep. Orientation aids, I think, can be helpful. Clock and calendar and those sorts of things. But if they don't have their eyeglasses, they're not gonna be able to see it, right? So we wanna make sure that we're addressing those. And then I think, as you all know very well, encourage mobility as much as possible and as feasible with it. Early mobilization, you know, as safely as possible, but again, trying to get them on the right track with it. Medication treatment, and this is certainly back in my training, we constantly said the Helperidol is the gold standard for the treatment of delirium. And I think it may have a role in some specific cases, but we need to be cautious about this and realize the limitations that exist. Start low and go slow, you know, very, very, very tiny doses with it. If a patient is responding to it, you know, intermittent dosing may not be the preference as opposed to maybe a maintenance dose and then taper as the symptoms stabilize. There are atypical antipsychotic medications and there's variable, and I would describe as limited evidence across there, is that some show some positive effects, others do not. I'm not gonna go through an extensive review of the literature on the antipsychotics, but there's relative lack of clinical evidence in terms of delirium, despite the fact that we often do this as kind of common practice. We have to keep in mind, I already talked about that individuals with dementia are at higher risk for delirium, but we know a lot of these antipsychotic medications with a black box warning for higher risk of mortality and morbidity in those that are treated with the antipsychotics. You know, so again, if we are using these kinds of medications, you know, low dose, shortest duration as possible with acknowledgement of what the risk factors are. This is just one study that I'm quoting here, but there's, you know, ample evidence about the reality that haloperidol in particular and some of our atypical antipsychotics may not actually perform much better than placebo in some cases and higher mortality with those treated with antipsychotics. Now, there is criticisms of some of the studies of metallogic factors and generalizability, but I think this evolving literature has made me take pause of thinking about not just a universal approach to using this kind of pharmacologic interventions for it. When would you not use antipsychotic? I think just, you know, as kind of a words of warning here as well, dementia with Lewy bodies, those individuals can get worse in terms of the treatment with antipsychotic medication. Advanced Parkinson's disease, you have to worry about sort of the competition in terms of the dopaminergic, antidopaminergic activity that's there. And I would say that I use caution particularly, and I do a lot of end-of-life care for these individuals with neurodegenerative conditions. I use caution with the antipsychotics for any of the Parkinsonism and other neurodegenerative conditions. Severe psychotic symptoms in cases, particularly think about dementia with Lewy bodies, quetiapine in a low dose may be a consideration. Probably clozapine is probably the safest in terms of we had to do that. But again, you know, laboratory monitoring and those kinds of things are considerations with those medications. A lot of times there's a pressure to use a benzodiazepine because, right, you can give it to them and they get sedated, right? And so it solves the problem temporarily. But we also have to be concerned about the fact that it can increase risk of falls and confusion. Some patients can have paradoxical reaction. And I certainly, I probably have, I would say one or two cases a month now that benzodiazepine has been tried on a patient and they get worse, right? They get more disinhibited and combative and those kinds of things. So we have to be very cautious about that, be wary of some of this, both the sedative effects and the paradoxical reaction and realize strictly for older patients, prolonged periods of metabolism can occur with that. And so, you know, my approach with this, when we go back and forth about antipsychotics or benzodiazepines with it, is that antipsychotic medication, I'm not saying we would not use, if that person really is having psychosis, psychological distress, then that probably is the appropriate medication for that indication with it. If it's more of an anxiety approach, that may be a judicious use of benzodiazepine could be a consideration. But again, with the benzos, we have to be concerned about the fall risk. You can have rebound anxiety. We see this all the time and people are getting repeated PRN dosing with it. And then they're worse over a period of time. I think there's an evolving discussion or discourse about some other medication classes with it. I'm not necessarily convinced that we have consensus on some of these, but certainly sometimes antidepressants, gabapentin, memantine, and others have been attempted with it. I think the evidence is fairly clear that donepezil, you know, again, we're talking about individuals with dementia, but donepezil is neither helpful as a preventive or as a treatment strategy. It has not borne out in the literature that it's using acetylcholinesterase inhibitor is going to be helpful in the cases of delirium. And I think we had a lot of hope that maybe that was the case, that if this was anticholinergic, this cholinergic deficit that we're using acetylcholinesterase inhibitor may help, but that the literature has not borne out with that. So I just wanna touch upon a couple of points before I conclude here is that American Giraffe Society clinical practice guidelines for post-operative delirium in older adults. Again, the strongest evidence is multi-component non-pharmacologic interventions for prevention, right? Weak evidence for treatment. So, you know, oftentimes we describe it as once the horse is out of the barn, it's hard to get it back in there. If we can focus on preventive efforts of looking at the risk stratification for these patients, providing education and focus medical evaluation and pain management and prevent those cases of delirium, it is much more preferable than trying to kind of play catch up than once delirium has occurred with it. I think a critical component, and this is really where I focus a lot of my work on right now is that family and caregiver teaching about it, their role in terms of being able to support that and have sort of a diagnosis. We got to call it delirium. We have to talk about delirium with our families and the caregivers. I think in the common culture, people talk about being delirious, but they don't appreciate that this is a medical syndrome that we're dealing with, that we're going to potentially manage these kinds of things. We need sort of the tincture of time often in these cases for things to improve with it. But I think this can be very distressing in families and a distressed family is not going to be able to cope as well. And the patient I think is almost like a sponge that just picks up on that distress as well with it. So providing the education support to really empower family members that they provide a critical role, an important role in terms of orientation, providing a sense of safety and comfort is really key, I think in terms of our non-pharmacologic approach to these patients. So I just want to conclude by just emphasizing again, this is distressing for all involved. This is distressing for us as clinicians, our nurses that we work with, everybody that's part of the team with it. This really impedes progress in terms of rehabilitation and recovery. If we pay attention to things in terms of risk factors and identify it early, we can oftentimes identify some of the potentially reversible causes, particularly starting on the medications. Think about the four questions of the criteria, the confusion assessment method, and think about too as well, is that not great evidence or limited evidence in terms of the use of the antipsychotics, but I would assert again, education of the family and caregivers is really key. And for additional resource, a lot of the stuff that I covered as well, I put the reference in here as well. Was honored to co-author this article with Dr. Paduri as well that gives kind of a, again, sort of an overview that was published in the current physical medicine and rehabilitation reports. And with that, I will conclude and hand things back over to Dr. Paduri. Thank you, Dr. Caprio. That was so important for us to know that at the basic level and lots of what you have presented is so realistic and practical approach to managing delirium. Thank you very much. Now let's move on to the next speaker, Dr. Dale Strasser. Dr. Strasser comes from the Emory University. Dr. Strasser is a professor emeritus in the Department of Rehab Medicine at Emory University, School of Medicine. He obtained his MD degree, PM&R residency, and fellowships in arthritis and rehab and geriatric medicine at Northwestern University in Chicago. He retired from direct clinical service since September, 2021. Dr. Strasser remains active in research, education, and advocacy with a primary focus on teamwork and treatment effectiveness in inpatient settings and a secondary focus on geriatric rehabilitation. In recent work, Dr. Strasser examines contested illnesses such as long COVID, ME-CFS, and post-polio syndrome. Dr. Strasser and his colleagues developed and tested the team effectiveness model, that is TEM, through a series of studies. These are merit-review sponsored studies over a 20 plus years time. Team processes, he says, measures, they have proven useful in quality improvement. Dr. Strasser continues to work to address the challenges of geriatric rehabilitation, including polypharmacy. He has done extensive clinical work and expertise in geriatric rehabilitation and geriatric syndromes. Dr. Strasser has an extensive publication record. He has served on several editorial boards of peer-reviewed journals and works closely with colleagues in national and international organizations. He has received numerous regional and national awards and recognitions of professional activities. Dr., I was honored to be closely working with Dr. Strasser in geriatric forum at the Academy and the geriatric rehab in terms of his expertise is unparalleled to anything in the rehab medicine and the literature. He has extensively addressed polypharmacy various platforms at the Academy or the AAP and in coming to Rochester and giving a grand rounds to our residents and faculty. I'm really honored to present Dr. Strasser to talk to us about deleting him in the post-acute care. He was unfortunately unable to be in person talking to us today, but he has given us a video presentation which Devon will be projecting to us. Devon, you can go ahead. Devon, are you there? There you go. I'm Dale Strasser. I'm an artist in department of rehabilitation medicine at Emory University. And I'm gonna be presenting on delirium management in IRFs and skilled nursing facilities. This is part of the geriatric rehab community pre-comprehensive program. This is part of the geriatric rehab community pre-conference session. I do beg your indulgence. Probably the most anxiety provoking part of this presentation is trying to deal with the technology, but bear with me as I've been practicing so I'm better than at least I was. So let's see if I can get this accomplished. So anyways, I told him professor emeritus department of rehabilitation medicine. I also had the pleasure of doing a fellowship in geriatric medicine toward the end of the 1980s. Rehab professionals are quite comfortable with neurocognitive issues in some classic rehab diagnosis, such as TBI, CBA, spinal cord injury and polytrauma. Still, we sometimes are not as sensitive towards the frail elderly individuals which is the focus of this particular session. In addition, I will be offering you a various clinical vignettes, personal stories and clinical pearls. I'll try to distinguish between when things were evidence-based and it's more clinical or informed judgment based. And finally, I wanna tell some personal stories that just try to humanize the experience. My email is listed there. I'm certainly open for contact in the future. And at the end of this presentation and the material that's available, the references will be at the end of the PowerPoint presentation. So I have three take home messages. And if you're not able to get much else of the lecture, these are the three messages I hope that you remember for a long period of time. One, primarily delirium is a warning sign. Something is going on and these something or somethings predict poor outcomes. Components within the causative factors are reversible and we wanna look for those or at least can be managed better. I also propose to you a little controversial that the rehab unit itself and the rehab process can inadvertently cause delirium. And we need to be sensitive to those delirogenic contributions. And finally, that the rehab team itself is key to effective management of delirium in the acute inpatient rehab unit. So I have seven objectives in this lecture. One, appreciate the distinct dynamics of inpatient rehabilitation settings. Two, recognize pre-admission signs and symptoms of delirium. Three, acquire skills to manage delirium in rehab. Four, modify medical nursing therapy and social service interventions in an interim matter which fits and accommodates the patient's current trajectory and course. Six, appreciate teamwork, consistency and continuity of care to achieve a positive outcomes. And finally, a heightened awareness of the environmentally induced aspects of delirium. And I'm gonna start as I hinted at earlier with a personal vignette. The vignette occurred on a Martin Luther King holiday. I was in South Florida with my wife and a sister-in-law and we had five elementary school aged kids and it was raining and we were looking for something to do with it. So we decided that we would take them to a Chuck E. Cheese. Chuck E. Cheese is a franchise, may not be quite as big as it used to be but it's a kid friendly area where kids can go and really eat pizza and drink soft drinks as much as they care to and their parents will allow. It's got a lot of games. There's a lot of very inexpensive tokens they can use. On a holiday like this, it can be a very lively, noisy, clinically stimulating event. Well, you can imagine where I'm going with this. At this setting, the adults in this group were close to delirious, if not just confused after a few hours in this setting. And so internally, within my family, we sometimes call this the Chuck E. Cheese effect of kind of an environmentally induced delirium, at least a confusion. One of the primary theme to communicate here is that delirium is a threshold phenomenon. Many people find it useful to consider pre-morbid or pre-existing factors and precipitating or causative factors. We're going to briefly go through this. Pre-morbid factors include advanced age and associated hearing, visual, sensory, and balance disturbances. Pre-morbid factors also include neurocognitive disorders and characteristics associated with aging, anywhere from mild cognitive impairment to dementia to common neurodegenerative conditions, such as Parkinson's disease and stroke. I would also like to mention, and I'll be going through this in a little more detail, that as people age independent of any disease process, cognition is different. We think and learn differently as children, young adults, middle-aged adults, and older adults. That is kind of a pre-morbid characteristic. And then finally, the other pre-morbid factor from the vantage point of acute rehab would be hospitalization and surgery. What happened during the hospitalization? Was there an ICU course? Was surgery involved? And was there evidence of post-op delirium? So from that perspective of inpatient rehab, the pre-morbid factors have basically already occurred. We can't change those, though we can think about how we optimally manage those. The precipitating factors or the triggering factors are those that we do have more control if we're able to exercise that. That includes the type of hospitalization and how it was managed, immobility, the level of sensory, whether it was sensory deprivation, no sunlight, unfamiliar environment, or sensory overload, the Chuck E. Cheese effect. Other precipitating factors can include sleep deprivation and stress. And stress, I would think of broadly in terms of social, financial, and emotional. And frankly, in the 21st century, if you're in the hospital as an older adult, that in itself is almost inevitably a stressful situation. So again, many people classify the factors into two broad categories, pre-morbid and precipitating factors. So a brief overview of delirium. I know this is being covered in more detail in other lectures. And I also put a little word in here for the American Geriatric Society that can offer us a good reference and resource sites. So brief overview. Delirium is a disorder of attention and awareness that develops acutely and tends to fluctuate. Recognition and diagnosis are key to delirium management. The CAM, the CAM or the confusion assessment method has already been discussed and it's useful in conjunction with other mental status exams. And we commonly use MOCA or the MMSC. Delirious patients do require a thorough evaluation for reversible causes. Delirium, most importantly, is associated with poor outcomes, including death, functional decline, nursing home placement and cognitive decline. Pharmacological intervention should reserve for target symptoms that are a threat to safety or disrupt needed medical care and cannot be managed with non-pharmacological interventions. And finally, prevention of delirium is more effective than treatment. Proactive multifactorial interventions have reduced the incidence, severity and duration of delirium. So through this discussion and the subsequent Q&A, I hope we're able to gain some insights into those aspects of the rehab treatment course and environment where we can make positive interventions. So a few words about the incident, morbidity and outcomes of delirium. For those adults age 70 or older, approximately one third of them demonstrate evidence of delirium in a general medical unit. About half of those cases occur or observed type of admission and about half are acquired in the hospital. Understandably, the rates are higher in the ICU where up to 75% of ventilator patients and 30 to 50% of other ICU patients show signs and symptoms of delirium. Unfortunately, and this is a major take-home message for this lecture, greater than 50% of delirium diagnosis are missed. In acute rehab settings, somewhere around 10% of the patients typically screen positive. I think there's a higher percentage of those who are confusional. Perhaps we could use the term pseudo delirium or pre delirium, but 10% are screen positive. And these in rehab predict poor functional outcomes, cognitive decline, nursing home placement and are associated with increased mortality. In acute rehab, we get a lot of patients who've undergone major surgery. Goes without saying that a significant number of people who undergo major surgeries experience post-operative delirium. Here are just a few percentage points, a few examples anywhere from 25 to 50% of common diagnoses we see in acute rehab. We'd like to briefly talk about delirium types and the accuracy of diagnosis. In common sense understanding and in movies, television and the media, the archetypal delirium is usually a active, hyperactive, behaviorally active, confused individual. In fact, delirium is usually divided into types of hyperactive, hypoactive or mixed hypo-hyperactive. It's important to note that only 25% of all cases are either hyperactive or mixed delirium. 75% of delirium are hypoactive. Understandably, delirium is often not recognized or not appropriately treated, particularly in the hypoactive patients and in both groups of patients. And it may be true in the hypoactive patients, it's associated with even poor outcomes. And again, 50% of delirium patients, a delirium diagnosis are missed in the acute hospital setting. So I'm gonna switch a little bit to delirium screening and impact on acute care transfers. A lot of this work is part of work that Dr. O'Park and her colleagues have been involved with. And I do recommend that you look up the actual references as they're very good and informative and more than just the take-home findings that I'll be discussed. In her first published work on this, Dr. O'Park and her colleagues in 2018 demonstrated the feasibility of using the confusion assessment method or the CAM in an institutional wide quality improvement initiative. I do recommend you look at the article on this because this was quite an effort to institute this in a consistent way such that nurses and physical therapists were able to perform the screen, perform the screen on a regular basis, and get that information to the managing physicians and other team members. It was more than just a check mark. This was a major organizational commitment. In a follow-up, Dr. O'Park participated in a study looking at the relationship of a positive delirium screened outcomes. They looked at over 1,500 patients, nearly 54% of these were female and an average age of nearly 73 years old. 9.1% of these patients screened positive for delirium and those worse outcomes were those who screened positive in several areas. With regards to transfers to acute hospitals, patients who screened positive for delirium were 22.5% versus 10.5% more likely to be transferred to the acute hospital. That's an odds ratio of 1.61. Those that screened positive also showed lower gains in motor function, increased length of stay, and reduced home discharges along with increased transfers to new homes. So those who screened positive for delirium typically had poor outcomes. In a follow-up, Dr. O'Park typically had poor outcomes. So getting back to one of my take-home messages that is delirium is a warning sign. Something is going on that merits our attention. The image you hear is the classic canary in a birdcage. For those of you who aren't familiar with this, this refers to an activity in the earlier days of coal mining where a canary was taking in with the coal miners. If the canary passed out, the coal miners would then evacuate the tunnel realizing there'd been a buildup of toxic gases. In another image that I found online, these birdcages also came with an oxygen canister so you could revive the canary as you were escaping. But a canary in a coal mine is a colloquial way of saying a delirium is a warning sign and something that merits attention. I'm gonna now move to two personal patient vignettes, both of which I encountered early in my fellowship training and also as an attending, which I think emphasize some important aspects of delirium. The first one is going to be a she was in her 80s and she was in a nursing home, probably it would be considered a memory care unit, a very pleasant, socially skilled, elderly woman who was always well-kept, never smelled of urine or that, and she was pleasant and could carry on reasonable, polite conversations. One day on my fellowship, I got word that she had been admitted to the acute hospital and could I go see her. So I heard that she had come to the emergency room, she'd been diagnosed with a UTI and urosepsis and admitted to the general hospital service. I was quite disappointed when I got to her room, she was unkempt, she smelled of urine and she was under restraints. So this was quite striking to me and I think that we could surmise there were several precipitating factors that resulted in her evident delirium. These probably included a sleep deprivation, dehydration, maybe poor pain management and whether or not she had access to a call center or ability to call for it. Many of us have had the experience where we only realize during an interview that a patient is missing a key assistive device such as a hearing aid, a walker or glasses and it's always important to make sure that they have those before you proceed with any further assessment. So I think that's a very important point to make before you proceed with any further assessment. So the next patient I'm gonna tell you about and I'll get back to the slideshow in just a minute was one that also struck me, it was during my fellowship and a patient had been admitted to the acute hospital and since I was the rehab doc doing a fellowship in geriatric medicine, they were interested in me seeing the patient because she had just had a hip fracture. So I go up to see her, she's a quirky personality, she is not very receptive to any sort of physical therapy, she tends to refuse for physical therapy and she kind of blows people off to the extent that it's even hard to do a cognitive exam. Well, what happened after that, with over the next seven to 10 days, for the most part, she continued to review, to continue to refuse therapy and there was a medical workup that was ongoing. Over time, she bonded with the physical therapist, I also had some personal conversations with the physical therapist and the therapist discovered that if broached correctly in her own particular way, so instead of one 45 minute sessions, she had three or four 10 to 15 minute sessions spread out through the day, that the patient in fact enjoyed brief walking, that pain, but only pain in standing was an inhibiting factor. I worked with the managing service to add some pain medicine. I even think we may have used some low dose opioids that we were cautious about not inducing more problems. And then over the next seven to 10 days, she in fact became more cooperative. We discovered that there was a son in town and that he was willing to help out after the discharge and probably hire some home health services. So the decision was made to transfer to the acute rehab unit. So she was a transfer to the acute rehab unit and it happened to this occurred about 2.30 to three on a Friday afternoon. I was there, we worked out that I could see her shortly after she arrived. She may have been there for an hour or so, but I got there. And during the first 45 minutes that I was there, three different rehab therapists came in. This was physical therapy, occupational therapy, and I believe it was a speech screen or it may have been a social work screen. And the first therapist in particular did communicate that she was a little upset the patient had gotten here before 4 p.m. because this meant the patient needed to be seen, evaluated by this patient, by this therapist who wasn't on call over the weekend and that someone else would be picking the patient up. Her evaluation was kind of truncated because the patient wasn't really very cooperative and she went through some motions. A similar thing happened with OT and the social worker. So I returned the next Monday and heard in kind of no uncertain words, the patient was inappropriate for acute rehab. And I hate the term inappropriate. Patients aren't inappropriate. The setting's inappropriate. But anyway, the patient was inappropriate for acute rehab that she would need to be transferred immediately or as quick as possible. And kind of pointing the finger of why did I okay for her to be admitted? And so I offer this as an opportunity to think, to what extent was her poor participation environmentally induced? She came on a Friday afternoon. She saw three different therapists. She saw one group of nurses. Over the next three days, each therapist and each nurse probably differed by the day. So I contend that there was probably an environmental component to her whole cognitive impairment or her whole delirium. So I will now like to talk, this is much my own opinion and clinical experience, but we're gonna make some comments on delirium across the rehab process. And I hope this material becomes fodder for discussion for my colleagues during the Q&A session that's planned at the conclusion of this larger session. But I'll be making some comments about the following sort of aspects of the rehab process. What occurs in the emergency department are other staging areas, such as the direct clinical admission. I'll make some comments on the acute hospitalization and then delve in a little more into the pre-rehab admission evaluation, the inpatient rehab admission and initial evaluation, the comprehensive evaluation and plan of care, mid inpatient rehab treatments and course corrections, and then finally discharge planning, caregiver training and clinical handouts. So a few pearls on the pre-admission evaluation. Of course, the issues in the emergency department and the acute hospitalization are legendary in terms of environmentally induced confusion and probably pushing delirium to the forefront. I don't know how much I really need to go over that, but I am going to spend some time on when the pre-admission process for inpatient rehab is started. One major principle is there needs to be a low threshold for delirium in particularly hypoactive delirium. And some of the pearls that I've seen from skilled evaluators in helping to elicit it is the following. One, direct interaction with the acute managing staff and physicians as early as possible and several times as much as possible to get a sense for how the patient's doing both their progression at different times today and what the patient's goals are. As much as possible, solicit perspectives from professional staff and physicians who know the patient better, commonly clinic-based staff and physicians, including the primary care physician. In the pre-admission, pre-acute rehab admission process, it's very helpful to observe and talk to the acute hospital rehab therapies to get a hands-on perspective of exactly how the individual is performing. In the pre-admission evaluation, you have to have, you wanna look carefully for the accuracy of the recorded medical history, the previous and current medications and the planned medical follow-up. Unfortunately, and it happens all too often that in the admitting history and physical and the list of the previous medications, the people doing that are quite busy, they're rushed, and they may primarily be looking for easily available evidence relevant to their short-term needs, not the broader issues of broad accuracy and the medication list. During the pre-admission screen, there needs to be beginning the assessment of the caregiver support in financial and social support. So you have a sense of sort of what the goals will be if you proceed with inpatient rehab, whether it's skilled nursing or acute inpatient rehab. And then finally, and of course, communicate delirium risk to the admitting rehab professionals so that they have a heads up to look for the risk and potentially amenable factors. Now I'm gonna delve down a little more into the rehab admission and evaluation. I think that that vignette that I told of the late afternoon Friday admission, the Friday evening cross-covering personnel, the weekend personnel, and then the regular new patients coming on Monday show the value of having as much as possible continuity of personnel, continuity of care, or at least accurate handoffs in communication. In the initial rehab admission and evaluation, you need to confirm and expand on information from the pre-admission screen. Over time, patients, families, and the medical records may reveal things that weren't quite as urgent in the initial acute hospitalization. Confirm the medical diagnosis in the course. Screen for delirium. The CAM is a proven method. There are some other standardized screens. There happens to be some comparative data within acute rehab on the CAM, and you frequently supplement the CAM with another mental status exam. MOCAs and MMSCs are two common ones, and then I've dubbed the term pseudo delirium, or at least a confusional state, which I also think is probably a risk factor for a more classic delirium. And frankly, I think most of our patients are in some form of pseudo delirium. Attention needs to be assessed very closely. There are attention aspects of each of the cognitive screens I listed. From a clinical pearl perspective, I frequently find activities that involve doing something in reverse to give me a real quick insight into their attention spans. So numbers in reverse, serial threes, serial fours, serial threes, serial sevens, spelling words in backwards, whatever is the appropriate thing can be an informative short screen on what their attention span. Again, make an effort to get an accurate medical history and accurate and current medication lists. As rehab professionals, we need to be aware of those things which can precipitate delirium. So be mindful of pain, pain management, constipation, incontinence, sleep deprivation, and environmentally induced confusion. And then in the initial admission and initial evaluation, you want to initiate the process of patient-centered goal setting. And I'm going to expand on that a little later. Goal setting is not just a quick checklist, but it's more an involvement of where is this narrative arc going or what's reasonable. As many of you know, I have a particular interest in team care and team functioning. I've done original research showing that high-functioning teams predict improved patient outcomes. Back to the issue at hand, teamwork and care coordination. I wanna briefly discuss these six areas where a well-coordinated, informed teamwork can improve your recognition and management of all patients, but particularly those who have evidence of delirium. First, neurocognition. Neurocognition varies by time of day, by activity, by ethnicity, and by setting. In a high-functioning team, you get those data points and it gives you a firmer picture than just one short screen. So use the team and the team conference or other informal settings to get a sense for exactly how is the patient doing? What is the level of physical functioning? And it's more than just one person's evaluation. What do they do in PT versus OT versus recreational therapy versus speech therapy? Sometimes there's difference, sometimes there's different expectations and those need to be aligned. It's always very insightful to find what motivates patients. For instance, I remember a patient, elderly gentleman who had a hip fracture. He had a very low pain tolerance and standing activities were quite difficult to initiate until we discovered that he loved to play checkers. So of course we came up with a trade-off. We would play checkers with him for extended periods of time, but he had to do it in a standing frame. And over about a two-day period, we increased his standing tolerance from a little less than three minutes to over 20 minutes. Other performance motivators may be the person has a strong interest in golf or tennis. And you can use Wii, another computerized game to do that. They may like arts and crafts and you can incorporate fine motor activity into those. They may be particularly concerned about their grandchild's graduation from high school and you can use the motivation, the patient's participation in attending that graduation. So find what those hooks, those performance motivators are and incorporate those into your treatment. Caregiver education, I'll get to the goals left. Caregiver education differs among the frail elderly as opposed to younger inpatients. Caregiver education usually involves the involvement of adult children or a spouse, current significant other partner who may have their own medical issues. Caregiver education is figuring out what is the interest level and ability for the caregivers to learn. And then finally, of course, at the end of the rehab process, you want to have meaningful handoffs. So meaningful handoff is more than just sending a brief, a vowel and treat form to a home health agency or the computerized records to a skilled nursing facility, even though that may be helpful. Meaningful handoffs are those that usually have a personal contact for particular pivotal issues. I find it very important to have a personal contact, whether it's with the receiving physician or their representative, such as a PA. Our therapist will give the patient, the therapist, the inpatient rehab therapist, name and contact number so a community therapist can give them a call and to go over the specifics of what worked and what didn't work and what's meaningful for the patient. And then my last point that I'll make in terms of teamwork and care coordination is patient goal setting. Goal setting, I think, should be a process of articulating and defining sort of patient-centered important activities in context that's reasonable and helping to come up with a patient narrative arc. Old, frail individuals who are at risk for delirium are frequently at a turning point or a transition point, a pivot point in their life course. And we need to help articulate sort of what's the reasonable next step and how do we optimize function within that regard. So refining goals and facilitating the development of a narrative arc, I see as a broad activity of the rehab team. I'm going to offer something that is a little controversial. It is controversial, and you can follow this up in discussions at the Q&A end of this session. I'm asking the question, is there an age bias in acute inpatient rehab facilities? And I'm going to briefly quote three studies. There's some others in the references that I list. I did a study late in my fellowship and early as attending where I surveyed rehab patients, this happened to be at the Rehab Institute of Chicago, on their perception of the rehab treatment. Many people were surprised to find that patients 65 or older had a more negative, less positive impression of the rehab environment versus the younger patients. It was kind of interesting when I presented this as a fellow, my rehab, didn't believe the work, just could not believe that staff would experience, patients would experience staff, older patients would experience staff more negatively than younger patients. A very similar theme was found in a 2001 study. My study was published in the Journal of American Geriatric Society. The 2001 study was published, I believe in the archives of PMNR, Rabanovick and others, surveyed over 970 staff from nine disciplines, and they had a vignette, and they asked the surveyed staff on their perception of the patient's behavior in the participation in therapy. In general, there wasn't a difference by age. However, when the vignette was tweaked where the patient was not ideal, not compliant, the staff had more negative judgments about the patients and they kind of, whether or not inpatient rehab was the appropriate set or not. Also of interest note, when looking at patients who were depressed, staff had more negative responses to older depressed patients than they did to younger depressed patients. And then finally, with regard to potential for age bias, many of us are aware that in studies on medication and other medical interventions, there can be age and gender bias, that we don't have enough of the old, old in medication studies, that in an earlier era, men were more likely to be studied than women, or gay nor in others, and I believe this was an agent aging, published an article in 2014, which showed that in stroke rehabilitation studies, they emphasized more younger versus older patients. There's some mitigating issues that may come to play here, but still it is an important study, an important observation to be made. And I'm gonna offer some ideas on the possible manifestations of age bias. I'm sorry, I'm unable to participate in real time on a discussion of this, but here are some possible manifestations, and we'll see how it goes in discussion. I think aspects of the rehab social and physical environment can be delirium inducing. So levels of noise, sleep deprivation, blood draws, categorizing one aspect where the rehab unit itself may inadvertently worsen the situation. Another issue I would ask, what about therapies? How receptive and how flexible are the pacing and timing of therapies to the needs of patients? Does a patient with a new hip fracture or other source of pain who only has pain when they're in therapy, do they get the pain medication at the right time? And how is that communicating and coordinated? If the patient does better with shorter, more frequent therapy sessions, are the therapists able to accommodate that? And then related to my earlier comments, in goal setting, do the rehab, are the goals set specifically for the frail elderly individual in mind, or is it more a checklist thing? How customized is it? I wanna bring up the issue of urinary incontinence. Commonly, the issues of urinary incontinence are seen more frequently in the purvey of nursing and medicine. You know, is there a UTI? Are there bladder outlet obstructions from BPH or a cystocele? Is there some prolapse or pelvic floor weakness causing incontinence? No, those are appropriate questions. But I would argue that the broader act of urinary incontinence is a complicated neurophysiological event that involves perception, vision, hearing, attention, alertness, and participation. Is the call bell close at hand and can it be reached? What is the timeframe to get to the call bell? Are the therapists emphasizing toileting when the patient is engaged in other activities, activities therapy, speech therapy, whatever? Is that accommodated for when there's a level of urgency? Are some of the programs such as bladder training, time bladder, modified Kegel exercises, scheduled toileting, are those incorporated? A urinary incontinence is a large problem impacting rehab and rehab outcomes. And my own clinical experience is that commonly acute inpatient rehab units aren't as attuned to those. And finally, I wanna just bring up the notion of learning styles. People learn things at different ages in different ways. Early elementary school differs from junior high or middle school. Middle school differs from high school. Boys differ from girls in terms of timing and how they respond to learning. We know young adults, middle-aged adults, and old adults all differ in terms of what is appropriate or what's effective learning styles. And this can be independent of any sort of disease process. We know that older learners, even those without any sort of neurocognitive disorder are more risk averse than younger learners. The optimal level of environmental stress and stimulation may differ by age. And is that incorporated into the rehab process? Because frankly, rehab shares a lot of similarities with education and learning. We teach our patients motor skills and then we think we have achieved our goals when the patient's able to perform them. So in conclusion, I want to return to my three primary take-home messages. One is environmentally induced delirium or whether or not the stimuli setting in an acute rehab is appropriate for the need of a patient. And that was a whole Chuck E. Cheese story. That delirium is a warning sign, delirium is a warning sign, a canary in the cage, so to speak, that needs further investigation. And finally, the most effective rehab, the management of delirium in a rehab setting most commonly is a highly integrated, high-functioning team approach much like the rest of acute inpatient rehab. So with that, I will close my lecture. The rest of the slides have some references and again, feel free to contact me if you have any other questions or things that you want to share. Have a good rest of the day. Goodbye. Thank you, Dr. Strasser. That's an excellent lecture, very practical for the rehab world. Our well-meaning, well-intended rehab team can induce delirium. That's a take-home message, I get it here. And as you said, on admission, three therapists are working on the patient. Patient is transitioning from acute to the rehab, not realizing whether they're going to be comfortable there, whether they're going to achieve their goals. And then you impose a lot of things on them on the day one and then brand them non-cooperative, refusing, whatnot. Anyway, it's a very interesting and very realistic approach to managing delirium on the rehab unit. Thank you. And we'll move on to the next speaker, Dr. Susan Garstang. Dr. Garstang comes from the University of Utah, from the Department of PM&R at Salt Lake City, Utah. The next slide. Dr. Garstang received her medical degree from Washington State University School of Medicine, followed by residency training in PM&R at Baylor College of Medicine in Houston, and a fellowship in spinal cord injury medicine at what is now known as Kessler Institute of Rehab at Rutgers New Jersey Medical School. She's board certified in PM&R and also holds a subspecialty certification in spinal cord injury medicine and brain injury medicine. Dr. Garstang is currently Associate Chief of Staff for Academic Affiliations at the VA Salt Lake City, a healthcare system in Salt Lake City, Utah, where she's also a staff physician in PM&R. In addition, Dr. Garstang serves as a Clinical Associate Professor of PM&R and Associate Program Director for Spinal Cord Injury Medicine Fellowship at the University of Utah School of Medicine. She has served the field of PM&R in many volunteer and leadership positions with various organizations, including serving as a member of the ACGME Review Committee for PM&R. She has also had extensive service on committees and initiatives for the Association of Academic Physiatrists including several terms on the Board of Trustees. She is now serving a sixth year term on the ABPM&R Board of Directors. In her clinical practice, Dr. Garstang focuses on musculoskeletal medicine in women, in veterans, as well as spinal cord injuries, stroke, and ALS, including ultrasound-guided musculoskeletal and spasticity procedures. I have known Dr. Garstang for many years and she is a live wire, and she's a very present individual, and she's full of enthusiasm for rehab and teaching students, residents, and even faculty sometimes. Dr. Garstang, please go ahead and give us a talk on frailty in the world of adults. Thank you for the nice introduction. And I, yes, I tend to be pretty energetic and I tend to talk fairly quickly. So hang on, everybody. I'm going to talk about frailty in the older adult as a construct and the assessment and some tips on management of frailty and prevention of frailty progressing to a disability or even morbidity and mortality. I have no disclosures. I work for the government, but the contents of this presentation do not represent the position of the federal government. And I'm going to be talking about concepts, the consequences, like why we care about frailty, the pathophysiology, the patient experience, and then some intervention strategies. So frailty is an aging-related syndrome. So as we age, we become more frail. It's a syndrome of physiologic decline and it's due to a reduction in function and in physiologic reserves. And the hallmark is really this inability to deal with acute stressors. So patients who, as they become frail, become much more vulnerable to adverse health outcomes. So they may be going along in their home environment and they're doing fine, and then something happens, they have a fall, they start having some angina or have an MI, and all of a sudden they sort of tip over the edge and that frailty sets them up for worse health outcomes than if they weren't frail. They often come in with an increased burden of symptoms. So weakness and fatigue is sort of characteristic of frailty. They can be medically complex. We'll talk about that a little bit more. And then they don't have as much tolerance for the interventions that they may need. Awareness of frailty and the associated risks for adverse outcomes can improve care for this vulnerable subset of patients. So in terms of prevalence, so you can look at frailty as a continuum. So you have robust, and then pre-frail is you're at risk of frailty. You may fulfill some of the criteria, but not all. And then people that fall into the frail category. So pre-frailty, if you look at patients over 65, and these studies are generally done in people that are living in the community, and the prevalence for pre-frailty over 65 is between 28 and 44%. And then obviously depending on the study. Then if you look at frailty, prevalence ranges from four to 16%, ages 55 and up. And if you look at the subset of patients in that age group that have cancer, up to 43% will meet the criteria for frailty. If you look at patients as they age, so another study looked at people 90 and older, the prevalence of frailty was 24%. And if they're, that was 90 to 94. And if they're 95 and older, so our oldest of old patients, up to 40% are categorized as frail. So how does frailty relate to comorbidity and disability? These terms are often used, not as much in the literature a little bit though, but I think in our kind of our common, speaking in our vernacular, we look at frailty, comorbidity and disability as kind of the same thing, right? This sort of older adults that is having some issues with function and are vulnerable. And we use those terms interchangeably. But there's actually, there's a difference in the definition. And frailty is really a physical state. It's essentially like a syndrome. It exists before the occurrence of disability. You can be frail and disabled, but there are a lot of patients that are frail and they're on this continuum. So they start off robust, they go pre-frail and then frail, and then they may end up being disabled on that continuum from frailty. Frailty can cause disability independent of a clinical disease. You can have a healthy, older adult who becomes frail and then becomes disabled without another hypertension or a heart attack or something causing that disability. And so it's thought that this frailty syndrome is a physiologic precursor and a factor in the development of disability. These things are interrelated, but again, they're separate. And so just to give you a quick example, you can have somebody who has a disability, but they're healthy, right? So you can have a 25-year-old with a spinal cord injury, right? They're not frail. They may not have comorbidities. Or in the literature, they're using the term multimorbidity. So a comorbidity is really somebody comes into the hospital with urosepsis. Their comorbidities may be hypertension and diabetes. Multimorbidity is more, you're a community-dwelling adult, older adult, and you have hypertension, diabetes, heart disease, but you're not currently ill. And so those are sort of the multimorbidity, that burden of disease you're carrying with you. And then again, frail is a separate thing, being frail. And you can see there's overlap, but they can also be completely separate conditions. So how do people progress from robust to frail? So if you look just first at the numbers, in a study of nearly 6,000 community-dwelling men, ages 65 and older, they followed them for 4.55 years-ish. And at that five-year mark, 54% who were robust at the beginning of the study were still robust. 25% of those fell into that pre-frail category. 1.6% became frail. 5.7% died, so not great. Five years from being healthy to dead, right? And then the remainder lost to fall. But unfortunately, probably in the frail or deceased category for some of those other people as well. This is just a pictorial, and I try to put these through my presentation to help explain the concepts a little better. So you start at the top, and here you are, you're robust. And then as you develop frailty, it's thought to be sarcopenia, malnutrition or undernutrition, really. And then polypharmacy can intervene. And over on the right side are kind of the interventions. We'll talk about those later. So you go from robust to frail. So now you're sitting at frail, and then you have your stroke or your pneumonia or your hip fracture. All those things, the polypharmacy, the undernutrition, the sarcopenia, those things also feed into it, and then you end up with your disability. And so you sort of slide down that slope, if that makes sense. So what are the consequences? Frail older adults are less able to tolerate or adapt to stressors such as acute illness, a surgical or medical intervention, or a trauma, right? So this is the person that's getting along okay, living at home by themselves. you know, they're frail and you're worried about them, and then they have a fall and break their hip or they start having angina and they need a bypass or something, you know, something happens and it's like a hit that their body just can't tolerate and that tips them over the edge. So this increases the risk for procedural complications. So let's say they have a hip replacement, much more likely to have complications, falls or hospitalization or institutionalization, right? Having to not live at home anymore because of that kind of tipping point. And then like we talked about developing disabilities and then death. And this is even when you adjust for all of their medical comorbidities or those multimorbidities, it's still a separate risk for all these other things. It also predicts adverse outcomes related to things like renal transplant, general surgeries, both elective and emergency and cardiac surgery. And when you look at the literature, it's interesting, the literature on frailty does not live in the PM&R literature as much as it lives in other literature. So obviously our geriatrician colleagues are all over this conceptually. There's a growing awareness of this in the oncology literature, right? Who should get radiation? Who's going to tolerate chemotherapy? Do we do half strength chemotherapy or none because they're so frail? What if they need an elective cardiac procedure? Or what if they come into your emergency room again, they have a hip fracture and you don't think they're going to tolerate the hip replacement or the hip pinning, right? So an understanding and again, those other fields are like, wow, this really makes a difference to understand this concept. And so I think as physiatrists really, we have to think about this in terms of prehabilitation and reversing that continuum. So they're more robust. So if they have that fall or that illness, they can tolerate it better. So just looking at a study on cardiac surgery, they looked at the outcomes for pre-frail. And so if you're pre-frail as opposed to robust, you have a 1.5 times risk of adjusted operative mortality, which is pretty significant, right? And then midterm mortality, usually this is at about a year, depending on the study, 2.3 times higher risk of mortality at that point. If you're frail, two times higher risk of adjusted operative mortality, three times risk of midterm. So at a year. And if it's adjusted for other things, 1.4 times risk. And then sternal wound complications, twice as likely, prolonged hospital stay, 1.8 times as likely, and a risk of discharge to a non-home setting, 2.7 times as likely. Increased mortality with frailty is a big issue. So lots of different studies, and I just put a couple up here to get you some different numbers. So there was a longitudinal women's health initiative observational study looked at women with baseline frailty and showed that if you follow them over time, mortality was increased and those that were frail at baseline. So hazard ratio of 1.71. In a European study, they looked at, and they use different tools I'll talk about in a sec. So they use the frailty index and the Edmonton scale. And they showed that mortality was three to five times higher in patients that were frail than patients that were not frail when they had another event or again, a stressor. And then the longitudinal aging study from Amsterdam, which is one of the great studies we get out of our countries that have socialized medicine, where they have these big databases, looked at 2,874 adults, and these were between 64 and 84. They followed them for 21 years. So nice, nice time span. And they showed that frailty was associated with greater four-year mortality with an odds ratio of 2.79%. So really significantly problematic, right? And sets you up for bad outcomes. So frailty assessment. I found this slide. I thought it was super cute. I'm sorry. It's a little pixelated. So how do we find the frail older adult? Well, you have to assess it. You can't assume it, right? So I hope that I'm this person when I'm 90 or however old this person is. So frailty is a construct. And so there's really two general ideas or concepts. So the first one is this physical or phenotypic frailty. And so this results from multi-system biologic decline that leads to specific symptoms. Weight loss, weakness, reduced walking speed, or reduced activity. And these constructs define either the presence or an absence of the condition of frailty that, again, increases risk. And some of them, like I said, have robust, pre-frail, frail. But it's still like either you fit in the category or you don't. The other model that we look at is this deficit accumulation or index frailty method. And this tabulates health deficits. So it looks at comorbidities, psychological factors, symptoms, social factors, and disabilities. And it adds all of these things together and it gets you a number. And it measures the capacity to accumulate deficits. So as you get more and more hits or things on your deficit list, you get a higher number. And this is useful because you can track frailty in both directions, right? The number's going down, the number's going up. How much is this person accumulating these deficits that lead them to be more frail? So more of a continuum. So frailty as a phenotype is the first one I'm going to talk about. So this is a constellation of clinical attributes. It's not organ-specific, right? It's with a syndrome, essentially. This is a complex relationship between sarcopenia, physical activity, nutritional intake, and energy expenditure. Those are like the pillars of frailty. Sarcopenia leads to poor muscle strength. This limits mobility and physical activity. It reduces energy expenditure. Therefore they're not as hungry, right? So they don't want to eat as much. And there's other things we'll talk about in a little bit in terms of what makes older people not eat as much. And then they lose weight, their sarcopenia gets worse, and that's a cycle, right? And so that's kind of this frailty phenotype. This construct is the most useful in people that are not disabled. And so they're frail, but they don't have another disability. This is probably my favorite pictorial slide in this presentation, because it kind of puts it all in one place. And so if you start at the upper left, you have this neuroendocrine dysregulation. So a lot of things that are occurring that is predisposing our body to this aging. Then you have anorexia, so they don't want to eat. They're chronically undernourished. They start to lose muscle mass, become sarcopenic. And then there's musculoskeletal changes in aging and senescence. You can maybe layer disease on top of that. As you lose your muscle mass, you have decreased metabolic rate. You don't burn as much energy. You don't need to eat as much. And so that becomes cyclical. You decrease your strength and power. You decrease your walking speed. This ends up becoming disability and then dependency. Again, they're not active. They don't burn energy, and around and around we go. And so these are kind of the pillars of this phenotype and the things we can intervene on when we start talking about making this better. So frailty phenotypes, so the FRAI frailty tool is probably the most commonly mentioned one in the literature. Just so you know, there's over 200 frailty assessment tools. I was going to do a nice little presentation of all the different ones, and there's way too many. So I'm going to give you about seven different constructs just to give you a sense of what's out there. This is the most common one. It's from the early 2000s. It was developed to identify physical frailty in community of dwelling older adults and then validated in a study of 5,000 adults. It basically requires the patient to participate. They have to be either in front of you or with somebody that can measure things if you're doing video, which I think we did more during the pandemic, right? And then you need to be able to measure grip strength and look at walking speed. And there are five points on this. Three out of five defines frailty. So weight loss greater than 5% in the last year, exhaustion, and that one's just a question, weakness. So decreased grip strength, slow walking speed, again, you just measure that, and then decreased physical activity and looking at how much activity they're getting in a week. If you have one or two of these characteristics, you're pre-frail, you're not frail or robust if you have none, and then three, four, or five is frail. Another scale that's kind of nice, it's got a little mnemonic if you like mnemonics. I generally don't because I can never remember what the mnemonic stands for, but if you do, so frail. So F is fatigue. And again, it's yes or no. Resistance. Do you have trouble climbing a flight of stairs? Ambulation. Do you have trouble walking a block? This one includes some illnesses. So illnesses including hypertension, all those multi-morbidities we talked about. And then you'll see five or greater, you get a point. Fewer than five, you don't, which is good since it has things like arthritis, right, which most people have by the age of 65. And then have you lost weight? So that more than 5% number is important. And again, you're going to get frail to, frail is three to five, pre-frail one to two and robust means you don't have any. Cardiovosteoporotic fractures is a super quick tool. If you want to like plug something into a, you know, a template, this is super quick. So two of three is frail and it's weight loss of 5%, inability to rise from a chair five times without using your arms and a no on the fatigue question, do you have a lot of energy? So super quick, like I say, and that one you can do, you know, you can do it over video, you can do it over the phone, fairly straightforward to ask. So that's a useful one. Frailty index is an example of the other type of construct. So the deficit accumulation or index approach to measuring frailty is based on the accumulation of indexes, functional and cognitive decline and social situations. So the original index was 70 items, both medical and functional questions. Obviously 70 items is a lot, right? We now have scales that have more like 20 or 30 items, still a lot. The more deficits you have, the higher the score. And this can be from the medical record. So you don't have to do an exam for most of these indices. They're things like social support and illnesses and those sorts of things. The nice thing about these, like I mentioned before, is they're continuous in nature. You may need to have something called a comprehensive geriatric assessment, which I'll talk about in a second. It's basically sort of a team-based approach to assess all these different things. And you can tell if an intervention is working, right? So if that number gets less, you've done good things, you're doing a good job. This does not have a cutoff. You don't go, oh, I'm frail, now I'm disabled. It's just a continuum. And again, it's numerical and useful in that way. Clinical frailty scales, the last one I'm going to mention. So this is a rapid screening tool. You score it between one and nine. It used to be one through seven, and then they added eight and nine to kind of guide the way people think about end-of-life care. And I'll just show you a picture real quick. And this is easy to find. If you Google frailty, this is actually one of the first things that pops up. And so you can see this goes from very fit, well, managing well, vulnerable, mildly frail, all the way down to terminally ill. And there is an adjustment for dementia that you can use. And this is a nice number, too, maybe for a rehab team, right? Like, oh, this person is a four on the clinical frailty scale. It's a snapshot, essentially. So let's talk about the pathophysiology. So increasing evidence that a dysregulated stress response, so immune system, endocrine system, and the energy response systems are important in the development of frailty. The thought is that these are, and this is where you have to wave your hands a little bit, aging-related molecular changes, maybe some genetics, chronic environmental exposures. We don't know what those are. You think about, like, air quality these days, right? And then specific disease states. And again, like we talked about, sarcopenia is a key component. The thought is that the decline in the skeletal muscle function and mass, which is sarcopenia, is a consequence of these hormonal changes and inflammatory changes. And so bear with me for this for just a minute. This is just to show you that over on the left, we have these sort of the things that are triggering this, and we don't really know, but senescence, mitochondrial damage, oxidative stress. In the middle, you have all the different things that are going up and down, so inflammatory markers. And then you become frail. So we're on the right-hand side. And so what do we see? We see decreased growth hormone in adults with frailty, decreased insulin-like growth factor, and it's associated with lower strength and decreased mobility. We see decreased DEHA, which has a role in maintaining muscle mass and prevents the activation of inflammatory pathways. We see increased cortisol, which impacts the immune system and skeletal muscle, and decreased vitamin D. We also see interleukin-6 go up, CRP. And if you think about the formula, I don't know if you guys have been taught like your SED rate should be your age, right, or there's a correction factor for age. Why is that? Why is the SED rate higher when you're 65? Like I never understood that. And we still don't know, but something is turned on in your body in terms of inflammation. And so these things have been shown to be elevated in community-dwelling frail older adults. And these are associated, as you know, with cardiovascular events and mortality. There's a lot of stuff in the rheumatology literature. Patients with rheumatoid arthritis that have high inflammatory levels have cardiovascular diseases as they progress, and so there's definitely a link there. And one of the things is that IL-6 is a transcription factor, and so it impacts skeletal muscle, impacts appetite, immune system function, cognition, anemia. Patients can be hypercoagulable. So lots of things are going on with this immune system. So just a couple slides on evaluation, and I'm going to check my time. Okay. Plenty of time. So persons over 70 and adults with chronic disease that have lost 5% of weight in a year should be screened. You can pick your tool. I would suggest that you do something that's a phenotype and something that's a deficit accumulation so you have a number to track. And you want to look at energy levels, fatigue, how are they doing activities, can they walk to their mailbox? That's always my question for my veterans. Usually walking around the block, they just kind of laugh. Some of them not. And then can they stand up from a chair without arms? Can they walk across the room? And then differentially, you just want to make sure you're not missing something, right? Depression, do they have an occult malignancy? Do they have rheumatologic disease, an endocrine problem, cardiovascular disease that's impacting function and activity, renal disease, hematologic disease, and then of course the neurologic disease. A whole bunch of things to rule out. And then again, labs, looking at just basic stuff. There are great assays at this point where you can measure, say, an interleukin-6 level and say, oh, therefore you are more susceptible to X or Y. So I think those tests are just becoming more helpful but not predictive at this point. And then the comprehensive geriatric assessment. And I'm going to go quickly because this is kind of bread and butter PM&R. So this is a multidimensional collaborative assessment. It's done by a team and it looks at all aspects of their being. So when you do a CGA, you look to improve their function, optimize medications, decrease nursing home placement, hospitalization mortality, and improve satisfaction. And the team is usually either a geriatrician or somebody else that knows about the care of older adults, so a physiatrist perhaps, and then a nurse, a social worker, a pharmacist, and physical or occupational therapy. And you basically look at five domains, so their physical health and their nutrition, their mental and emotional health, including cognition, functional health, social issues, and environmental issues. And this is just a nice picture. This is sort of funny when I was looking at the literature on this because it's like, well, this is kind of PM&R. Like, what? Why is this a special thing that we have to use, right? Like we do this every day. But anyway, so you've got your five domains. You do your assessment. You come up with a problem list, your goals, and then you come up with a plan. And so all the things you can fix come out of this. And again, you can use this to populate those deficit accumulation indices. So how do we manage frailty? And this I'm going to mention. This is a super cool program, nonexistent in Utah. And so I was like, I don't know much about this outpatient PACE. And so this is a Medicare program. It's a program for all-inclusive care for the elderly, so PACE. And it's a prepaid capitated comprehensive health service. It's designed to help frail, older adults stay in their homes and in their communities. And it includes home nursing, physical and occupational therapy, transportation, aid service, adult daycare. It's like amazing, like everything you want. The issue with this, so the criteria are 55 or older, which scares me because that means I qualify, living in the service of a PACE or a service area of a PACE organization eligible for nursing home care. They have to be able to live in the community still. And so basically it's the adult that's in the community kind of just hanging on, right? That frail, older adult that would be eligible for nursing home care because of their needs. This is something that's paid for by Medicare, but the state can offer it to people under Medicaid. And then it ends up being a great program because you basically, Medicare and Medicaid as a combination will pay for the entire thing. So the issue with this is there's only PACE, there are PACE centers, so it's actually a physical location. There are only 30 states that have these. There's 272 centers, very, very common in California. Other states have a few, and then a lot that don't have any, about 55,000 participants, which is really low and very sad, right, for a program like this. And basically a PACE center is a comprehensive care center. And so this is somewhere the patient can go that has the primary care office, social services, rehabilitation functions, has recreational things. You can go there and exercise, you can meet with a nutritionist, you can have mental health services. It's everything that that patient needs to live in their home and they can go every day. So it's Monday through Friday, adult daycare all day, they can go once a week if they need to be checked up on, they need to be weighed because they're not eating, they need to exercise, they can go monthly. And so it's basically this sort of embedded everything you need in one place, which again sounds fabulous. Advantages are it gives you everything you need. It doesn't give nursing care at home, but it does give aid services at home, keeps people out of institutions, it's comprehensive care. The problem is that most states don't have PACE programming, and if they do, it's in a specific area. And out here in the, over in the West part of the country, like the areas are huge here. I have patients that come from Montana to Utah to see me because there are no physiatrists anywhere closer to them, right? So these are only serving like a little bitty area when you look at these states that have these big rural areas. You have to switch to the PACE physician. It's not 24-hour care. So some people, you have to have family support or you can't be in a PACE program. And then if you don't qualify for Medicaid, it's about 5,000 a month co-pay. And for most people, that's not doable. Not necessarily less expensive than a nursing home, but they may just have to struggle along without this. All right. I'm going to talk for a few minutes on interventions. So conceptually, you want primary prevention, keep people robust. Secondary prevention keeps people from going pre-frail to frail, and then improving quality of life to the tertiary patient. And there are four key interventions, exercise, vitamin D, addressing undernutrition, and reducing polypharmacy. Exercise is super important, as we know, I'm preaching to the choir, right? So resistive and aerobic training improves functional outcomes, prevents disability. And so this is super important. And this actually can reverse that sarcopenia, help with muscle mass, gait speeds, exercise tolerance. So this is what you need. This is really the thing for frailty, right? As you know, there are guidelines for exercise. This is American College of Sports Medicine. There's a CDC. It's a joint guideline, and it basically says, like, you should do everything that everybody else does, right? So 150 minutes a week, at least two days a week for strengthening, 150 minutes a week for aerobic, and then something that improves balance, like standing on one foot, obviously not falling over, right? And if they can't do it, five minutes a day is fine. Two minutes of stretching, right? Like any of these things, anything they can do will help them. Supplements, so vitamin D may be helpful, not necessarily to improve sarcopenia alone may prevent falls. In that literature, that's like a whole nother lecture, right? Address their weight loss and their undernutrition, right? So make sure that they have dentures that work, make sure that they have an appropriate diet and they don't have dysphagia, help them with feeding or shopping or cutting things up if they need it, get rid of those horrible tasting low salt and low fat diets, right? Make the food palatable, provide appealing foods. You know, you can use finger foods if people have trouble cutting and they have low vision, frequent small meals, they can eat when they choose to, and then obviously treat depression if there's other things, right? If they're hypothyroid, like other reasons they're not eating, address those medical issues. Data on caloric supplementation is really mixed. So if you give them a good diet and if you get them exercising and they feel, you know, they get more energetic, they want to eat more, that's the best thing. The American Geriatric Society has this choosing wisely initiative that really shows that high calorie supplements don't help quality of life, mood, function, or survival in older adults. Maybe a very small gain in weight or a very small mortality benefit, but like just giving people Ensure It Every Meal doesn't really fix the problem because of all those other things, right? The inflammatory things and the hormonal things and the low activity, right? If you're not moving, like you're not going to be as hungry, your muscles don't burn as much energy. So like giving them caloric supplements isn't necessarily the solution. And then finally, polypharmacy, right? Like look at the medications. Did they really need to be on those? What are their goals of care? Are they making them, you know, are they giving them delirium, are they, is it making their mouth dry? So they're having trouble swallowing their meals. And if there's side effects, so they don't need them, get rid of them, right? You may not be needing to treat their cholesterol if they're 95 and frail. And so just sort of rational prescribing, give them things that are safe, lower the dose, change medications. And then finally, the concept of prehabilitation. And this, again, this is really in the like oncology, cardiology, orthopedics literature. So if you're going to get chemotherapy or radiation for cancer, maybe two weeks of like a prehab intensive, come in, exercise, get a little stronger, then you'll tolerate it. If you're going to need an elective cardiac procedure, again, get them stronger before their hip replacement, get them stronger, right? So get them, bump them back up that scale towards robust, and then their complications go way down. And so really sort of trying to sell that. And again, I think that the literature shows that these specialty groups have figured that out. It's just a matter of bringing them in for prehabilitation. And in the VA, I'm blessed, I can do that. It's a little bit harder in the private sector where insurance may or may not pay for prehabilitation. And so that's it. So frailty is an age-related syndrome. It's vulnerability to stressors. It precedes disability, but can cause disability. And it's a continuum, and you can go backwards from frail to robust. That's probably the most important thing. Lots of tools. You can pick a couple that are your favorite, it really doesn't matter. The ideal thing is something for that phenotype and something to measure the deficits as they accumulate. And then exercise, exercise, exercise, nutrition, try to keep them healthy and active. And that is the end. Let's see if I can unshare here. Hmm. There's unshare. All right. And that's it. And do you all see the correct slides? Perfect. Yes, we do. Can you hear me Dr. Garstang? Yes. Thank you very much for the wonderful overview of frailty. We learned a lot from you about the, not only the etiology, the consequences and how to fix it. I think that's the key for learning objectives in terms of how can we fix it, not just identifying it. Thank you so much for your wonderful lecture. And now we move on to the last lecture by Dr. O'Park. Dr. Mui-Yan O'Park is a Senior Vice President and Chief Medical Officer, Berkeley Rehabilitation Hospital, White Plains in New York. Dr., I've known Dr. Park for many years and she is a great role model for PM&R physicians. Role model for PM&R physicians. She is a professor in the Department of Rehabilitation Medicine and the Department of Neurology at Albert Einstein College of Medicine. She's Berkeley Rehabilitation Hospital's Senior Vice President and Chief Medical Officer. And she oversees the Berg's operations in patient care, education and research. She plays a key role in the strategic planning and expansion of Berg's programs and rehabilitation services within Montefiore Health System for post-acute care sector for the value-based practice and population health. She melded her academic background with healthcare operation, improving the hospital quality metrics, expanding graduate medical education programs and creating innovative programs. Dr. O'Park received 15 teaching awards with more than 50 peer-reviewed publications at hand. She serves on the editorial board of American Journal of PM&R, Board of American Medical Rehabilitation Providers Association and as a chair of Global Academic Physiatrist Association of Academic Physiatrists. She is an expert in rehabilitation of older individuals from master athletes to frail older adults. Dr. O'Park, it's a pleasure to have you to speak on frailty and the financial impact for the patients and the institutions. Thank you for joining us to give us a fantastic talk and please go ahead. Thank you. Can you see my slide? Yes. Okay. Thank you very much, Dr. Kuduri and thank you for all the speakers before me for the excellent talk. So today I'm gonna talk a little bit about the financial aspect of our interventions for patients who has frailty or at risk for becoming frail. So I'm a physician and I never really thought about thinking about financial aspect of anything, but I do. But this came when I was working on the delirium project in my previous institution and my administrative supervisor came to me and ask, okay, so what you are proposing is very excellent. It's good for the patients, it looks like it, but where is the business plan? So I said, okay, well, I'll figure out. So as soon as I went back to my office, I Googled what is how to make a business plan and that's how my interest in finance in healthcare started. So thank you just to sharing that. So in terms of learning objectives and I think that the natural history of outcomes, which was beautifully elaborated by Dr. Susan Garstang before, but I will really highlight a few touch-ups how those things are taken into account when you are actually calculating the healthcare cost and how we can communicate this with the people who really speaking a different language other than the physicians and the clinicians. And then also in terms of the interventions, I would like to focus the talk, my talk on the hospitalized patients because the previous speaker already covered the outpatient setting and a few things for the future directions in terms of how we come up with the cost effective model of intervention as well as new development, innovative technology. So why are we talking about frailty? This is a very valuable time, Friday morning, but we are dedicating three hours talking about frailty and delirium. The reason is it's really the heating the all three points of priority, how we decide what topics we are gonna tackle in terms of healthcare improvement. So it's number one is highly prevalent. Number two, the impact on the patient outcome is such a great degree. And thirdly, it's modifiable. And these three things also apply to the delirium. So I know the prevalence was already reviewed by Dr. Garstown. So what I wanna emphasize in this slide is that whenever we think about any kind of business plan or thinking about an intervention, the context is specific, specific disease knowledge is important. So what is the frailty in this population? So for example, heart failure, it's a 44%. It's almost half of them. Then it's gonna be easier to speak to the cardiologist and then anybody else, listen, this is the number. And also globally, it will be very different, depends on different countries. So interestingly, the Latin America, the prevalence of frailty is almost 50% higher than what is reported in the United States. What about stroke survivors? It's expected to be high. So frailty 22% and pre-frailty 49, almost 50%. What is important here is that frailty is independent predictor for the post-thrombectomy outcome. So we do a lot of things in the healthcare system or individual doctor's office. We do injections, we do surgery, many different oncology, chemo. With the goal of making the patients better, but what are the true predictors for this interventions? The outcome is really the frailty. And this is stroke patients say the same thing. And also knowing how picking up the frailty as early as possible. So the first presenting symptom of the frailty is weakness. And this is preceding the other category, the exhaustion or weight loss. Having said that, I don't want to depress anybody, but we all know the muscle mass reduction and weakness starts in the mid-life, mid-life, not really until like they hit the 70s. And the other important distinction here, I would like to emphasize is exhaustion or weight loss, which are the criteria of the frailty. If they show as an initial presenting symptoms, which is rare, then it's three to five times more likely that this individual become frail. So this is just showing the individual level progression and trajectory of either healthy person or someone who is pre-frail and becoming frail. And then the dotted red line is unfortunate patient who may be hospitalized or going through some surgery or injuries. Then they, obviously they were in the pre-frail category, but they can easily go down to dependent. And this green line, green arrows are indicating the opportunities where we can intervene and affect the trajectory of the patients. So just in this busy table, I want to draw your attention to only the green circles. So pre-frail patients, the first one showing, this is a study actually followed five years or community living older individuals. And the initially pre-frail patients, actually they can be out of the frailty 20% of the time in three years. And however, when the person is already frail and coming out of frailty is only 0.8%. So that when do we have to do the intervention is very clear from this table. And then I mentioned earlier, a lot of interventions we do really look at the frailty impact. So the last square here is that this is about a study of patients hospitalization and mortality in patients with heart failure. And ultimately they do ventricular assistive devices, but those patients outcome is drastically different depending on their presence, having a frailty or not. So this is another interesting study. We see the patients before the transcatheter aortic valve replacement. So this particular study did a self-investigated self-report of the patients. Okay, so how many activities do you do and how often? And basically this is a showing that the vast majority of the patients who is going through this particular procedure had less than 1,000 calories of consumption activities they do. And then they divided this group into the people who has a high activity, physical activity versus low activity based on the median value. There was absolutely no difference in terms of their cardiac function, ejection fraction or the severity of aortic stenosis. Having said that, when they followed up post-surgical post-procedure, there was a dramatic difference in one month, one year mortality, discharged to nursing home, readmissions, length of stay and depression. And more importantly, why do we do this procedure? There is a hypothesis, okay, you're not very active, probably maybe you have a heart disease, you have aortic stenosis, that's preventing you from moving. So let's fix your valve and see what happens. And this was not a true assumption. It turned out to be that the people who actually after the procedure, the net decrease, net actually physical activity was decreased. So meaning these people after the procedure, they're after one year later, their activity actually went down further. And you can see that the red represents those people with decreased activity versus the green. So how we interpret this kind of findings. So there are greater patients and surgery is a stressor. And if you operate on that person, you're gonna get poor outcomes. So we really have to reverse this frailty, deep frailing, and then the chance of having an optimum outcome is high. So this serves as a framework, whenever we calculate or doing a business plan for our supervisors or business partner. So what is in the literature in terms of the financial impact? So there are a lot of actually studies about what is the financial impact of the frailty compared to whether the intervention is saving money. That's a very two different thing. And it's a lot easier. We say that the frailty actually is costly. And just that there is a study I highlighted in red is, if you're preventing 1% of the pre-frail patients to go to frailty, then you can save 4.4 million pound annually. So this is a very astronomical numbers theoretically. This is a cost comparison among robust versus pre-frail versus frail older people. So in a nutshell, the pre-frail people will cost about double of a robust people and frail people will cost almost triple. More specifically, when you are looking at the low-limb amputation patients, and this was very large study, you can see the N, the frail population, 45,000, and then non-frail was 250,000 people. And when you look at the 90-day outcome, healthcare cost was 1.4 times higher in the people who had a frailty compared to non-frail population. So healthcare cost is not the only cost. There are tremendous amount of out-of-pocket expense for the people who has frailty. So for example, the caregiving cost was estimated at $4,500 per year. Incontinence care can be 1,100 per year, et cetera. So that there is a whole expense, which is beyond the payer health plan is bearing and lots of things are actually transferred to the patients and the family. So too much thinking and we need a doers, right? Okay, so I intentionally inserted this slide, although Dr. Garstang already showed, because especially for the hospitalized patients, they are in the tertiary prevention category. And it's very important to communicate that, what is the goal of doing an intervention in this population? So patient is already frail. It is all about quality of life. Yes, they can be out of the frailty, but as you saw previous study by Dr. Gill, it's only 0.8% of those being frail will be able to reverse back to the non-frail status. So why do we need the justification of additional cost of interventions? It's two reasons. One is public funding, any kind of program, PACE program to be continued, sustained. We absolutely have to prove this is a cost of saving. And the second reason is in a more parochial, in our healthcare system or in our rehab hospital, how we can do the interventions is really incentivize those healthcare systems to support us clinicians to be able to roll out great programs. So then what is the literature saying in terms of frailty interventions, cost effectiveness? So it's kind of a diverging report. And there are some things that are reporting, well, it's actually cost more. And although there was improvement in function, but actually this is costing more. And all those things I showed previously was actually for the community program, community dwelling order others target. But what about the hospitalized patients? So this is a classic study, a Sentinel study, I have to say, that healthy elderly people, they put them in 10 days in bed and what's happening to their muscles and the bones. So they lost 1.5 kilogram, that's almost four pound muscles. And also their muscle strength went down by 15%. And this is a healthy elderly person. So you can imagine what will happen to the people who are already pre-frail or frail status state. So this is a very well done study and done by researchers in Spain. So what they did is that while the patient was in the hospital and they just did a simple exercises. And I'm gonna show you the video of what kind of exercise they did. So they had 421 people and divided into two groups, randomized. So one group got health education, which was control. And the other group actually got this exercise. So what they exercised, they did it twice a day, morning and in evening. So the exercise was two to three sets of eight to 10 reps with, here is the key, 60% of one repetition maximum. It was not two pound. It was quite a challenge. And also they told them, listen, you move as fast as possible. So here, I'm gonna stop the sharing. And if you don't mind, I'm gonna just show you the video. Can you see it? Yes. Okay. So this was a morning exercise. Now after a couple of times, she's doing well. Okay. So I'm gonna show you also the evening exercise. Well, this was another gentleman doing the leg press. And I'm gonna show you the evening exercise. And I'm gonna show you the evening exercise. Can you see the video? Yes, we can. Right. So this cute, very cute Spaniard, older gentleman doing exercise, body exercise, nine pounds. Okay. So I'm gonna back to my slide. It looks good. It's okay? Okay, thank you. So, what did they find was that this is a short physical performance battery. You can see the intervention group versus the control group. So, the intervention group really did so much and how much of an exercise they did. So, their median length of stay was eight days. Remember, this is not U.S. If it's in U.S., it's probably 3.5 days or something. And this is a acute care hospital. They had eight days, and then intervention days was 5.3 days. And their adherence to exercise was 96% for morning exercise and 83% for evening exercises. Well, I'm so impressed by this, but anyway. So, what they found was not only they improved the intervention group in the physical capability, their even MMSE score went up, depression score went down, and quality of life, and the hand grip strength improved. Actually, when you watch this video all the way, they actually have a very tiny small board. They have it in the hand, and they are doing exercises on it. Very nice work. So, what are the other studies, actually, are available for the hospitalized patients' intervention? And I have to tell you, it's really variable. And there were meta-analyses of the same study, and it really didn't improve much length of stay, rehospitalization, and things like that. So, but I was thinking that what is the goal? If you want to, you're not going to shorten the length of stay by doing a few days of exercise. And especially, we are governed by many things, by the insurance or other stuff. Okay. The other thing I want you to think about is many patients who are going through a procedure or surgery are NPO. And how much that cost us? So, this was a very interesting study called the Child Now study. Can we safely have our patients eat with a cardiac catheterization? And it turned out that the people who had a fasting here, the total cost, of course, the patient satisfaction score will be higher when you allow the patient to eat. And then the cost was actually $4,000 higher if you are keeping this paper fasting versus allow the patient to eat. And you can just imagine. So, instead of oral hydration, they may need more IVs and other stuff. So, it's not just the physical exercise we have to think about. There are a lot of other things, opportunities we can save expense and do a lot of good things for the patients. So, what is the issue then? The current cost-effective analysis of the intervention? Number one is really the analysis was only limited to the follow-up time. And as we know so well, as rehab doctors, the frailty is really evolving over many years. And then these current studies didn't have any extrapolating cost or outcomes beyond the follow-up period, very short time. And then the other structure may not incorporate all the relevant health outcomes. Rather, they were relying on the data what was available. So, what can we do about it? And this is not somebody's job. This is our job. We should fix it. So, high-quality cost-effective model. Based on the research that we will pitch for. And then frailty intervention studies, research in translating the improvement in economically meaningful health outcomes. If it's inpatient stay or programs, the length of stay is really important. And adjusted, quality adjusted life years or indirect costs, those things we have to think about as an outcome. Also, knowing what matters to each stakeholders. When we are putting some intervention together and trying to implement, then there are many stakeholders. And then it's really through the communication and requiring lots of negotiation skills. So, who are the stakeholders in making changes in healthcare? Somebody will say, it's like a jeopardy now. Okay. So, you have to choose one. You may say pair. But these are all the important stakeholders. And in my opinion, as a clinician, even we are doctors, we don't always think about the patient and caregiver's perspective. I think that they can be on our side and really, really propel whatever we think we believe is the best for them. But is it really the best for them? And listening and continuously the intervention is patient and caregiver centers. It is so, so important. So, I want to say a few things about the technology and what is the future. So, you know, we have an epic and I'm sure you have some kind of EHR in your facility or, you know, working places. And a ton of information is already collected. So, instead of adding another priority assessment, there is an effort that machine learning using all this information in the already in healthcare system, care EMR, EHR, and predicting the priority in advance. So, that's in the way. And also, instead of performance-based measures, like we measure gait speed, I think it's still important, but using aware of errors and really what is happening in their own environment. And this particular graph is showing that the mean steps per day is a nicely predicting the hazard ratio of all-cause mortalities in patients in cardiac disease. And on the right side, this is an interesting study. And we are always trying to measure the muscle mass. So, instead of doing another measure, they are using an existing MRI or CT scan. And this is a free online tool called the Core Slicer. And you can extract the muscles, for example, the psoas muscle or abdominal muscles and calculate, give us important information. So, this is one thing we just started. So, we know that the muscle strength and physical component is very important part of frailty. Having said that, the frailty, there are actually increasing more evidence. And also, the frailty is a multi-system phenotype. And the multi-sensory integration, the ability to integrate multiple sensory input for an individual, maybe also important aspect of frailty and predicting force, for example. So, this picture is Dr. Mahoney, who is a researcher in Albert Einstein College of Medicine. So, this particular tool is an app in the phone. It's called Catch You. It's readily available in the Apple Store. And you download it, and you will be testing yourself. So, there is a visual cue, and you click there. And then the phone vibrates, and you click there. And then you give a simultaneous stimulation of the visual cue and the vibration and click there. So, how much of a reduction in reaction time actually predicts hope? That's actually the study predicting the poor. So, this is a trial we just started doing it. So, in summary, the frailty is a major population health issue, and it's a huge challenge to healthcare system. And also, there is an emergence of frailty interventions to hold or reverse the frailty, and needs for the cost-effective modeling, capturing the clinical understanding. Really, it's not just a three-month thing. It's a many-year, multi-year outcome needs to be tracked. And to make intervention implemented and be a real thing in clinical practice, we must get a buy-in from all the stakeholders. It was listed before. And focusing on what matters to each stakeholders, which means that when I'm talking to a finance team, what they are most concerned about will be the focus of that. And then I need to speak some operational KPI language. On the other hand, if I'm talking to the family or caregivers, it could be something different, right? So, there is a need for developing different skill sets for the physician leaders to be able to get a buy-in and be a patient advocate and implementing what is published in the literature and evidence supports. Thank you so much for listening. And this is my contact information. And I love this picture. So, I was covering New York Marathon in the medical team, medical tent, and this was the banner outside. So, I took a picture, and then I love it. You can, this picture speaks everything what we are wishing to have. So, thank you. Thank you, Dr. Park. Your message was so clear. Being isolated is not a good thing. It also emphasizes the fact that geriatric rehabilitation has to partner with geriatricians. With that in mind, I had Dr. Caprio come today, leaving his clinic. And last year, we had two geriatricians from the University of Rochester. One of them so emphatically told me that, I told the audience, that reflects your last slide, Dr. Park. She said, she learned at the AGS meetings, one of the speakers said, I believe, when you see a geriatric patient, whether in any setting, outpatient, inpatient, whatever, you say, what's the matter? Don't say, what's the matter? Ask the patient what matters to you. There's a clear message, and that's what you said in your last slide. And basically, if they are not as partners in the care, we are not going to get any outcome. If they say it's important for me to go to my granddaughter's graduation walking on my own, that matters to her. That gives a clear message to us her functional status has to be improved. That's what should matter to us to implement the care for that particular patient. I think partnering with geriatricians gives us a lot of information that we need to learn from them and they can also take our approaches to improve the delirium, be it frailty or be it overall health of the geriatric population. With that, I think I'll open up for questions to all the speakers as a question answer session or even like a panel discussion. Please, the speakers, unmute yourselves and then respond to the questions. Thank you, Dr. Caprio, Dr. Goldstein, Dr. Strasser, although remotely, and Dr. O'Park. Thank you all very much for taking part in this pre-conference session for geriatric rehab community. All right, can we start the questions if the audience have any questions? I was afraid that we may not finish in our timeframe, but I was pleasantly surprised that we were able to give our message in a timely fashion. And yet we accomplished our goals of meeting our objectives. We met our objectives and we delivered the message that people need to learn. Unfortunately, this is a working day, so a lot of people could not participate, but I think the record and message should give them an opportunity to learn from what the speakers have to say today. And it's a very, very important topic about delirium and equally important frailty, they're interconnected. And I think they're reversible, they're preventable, and we can take advantage of the growing population's health by giving the message that we gave today. Thank you, and if there are no questions in the audience, that means they're all digesting it. I'm gonna ask a question. How do you guys motivate your older patients? I see a lot of patients in clinic, mid to late 80s, and I try to encourage them to exercise at home or even to come in and do some therapy with us. And a lot of times they're like, oh, I'm not interested or I'm too tired or I don't have transportation or they don't want people in their house. And I'm just curious how, if you guys have any good strategies on, I mean, this is true for all ages, right? But I think as people get older and tireder, like how do you help people start exercising? I think it's a great question. Maybe I'll just go first and give you a couple of my thoughts. One of the things that I notice with a lot of the patients that I see is that they don't necessarily identify with the word exercise, right? Or even think about therapy or think about, it sounds too challenging to them, particularly like what you just said, you feel too tired, it's just not something that kind of resonates with them. And oftentimes they think about exercise as pumping iron, it's Jack LaLanne, it's doing all these sorts of things. I'm like, I can't do that, right? So I try to reframe it for them of really just talking about, so what do you do to keep active? Like what is your, and kind of walk through, what's your daily activity like? Well, how much time are you sitting watching television with that? And I have a great nurse that I work with that really talks about every time a commercial comes on, do you get up out of your chair and move around or do you, and have kind of strategies about just literally moving more. And I think that we really became very cognizant of this during the first part of COVID as well with so much isolation that people weren't gonna be going out to gyms or to PT appointments and those sorts of things. So it was really about what can you do with your own home? And even going out to your front porch and those sorts of things, just to kind of have some daily activities. I've had some patients that are very tech savvy and they really, they do like having the pedometers or their watch or those kinds of things that count steps and they try to hit a goal. And we kind of have this like arbitrary 10,000 step or whatever, and we don't, they don't need that. If you're beyond 3000, that's great. So, it's kind of some of those strategies, whatever works for them, I think is key with that. What we've also done, like with our home care agency, we partnered with one of our community kind of aging services network organizations that has been doing virtual exercise programs and things that they can do, join or even kind of that's recorded on YouTube. So some of those kinds of things, people if they're motivated can do that as well. I've suggested, if folks aren't that savvy to be able to do Zoom and those kinds of things, if they have internet access, at least at all, I've been sending them to the National Institute on Aging YouTube channel because they have exercise programs and things on that as well. And so that they could do that as part of a routine. So I think it's really just using the strategy of whatever is gonna kind of motivate them, just like with any of us, right? So I can go next. And that's actually you're hitting the head of the nail, it's the hardest thing. And I'm actually struggling with my own mother who became very frail. I haven't seen her for three years because of the pandemic, I didn't go back and I went to Korea this time and I didn't recognize her, like she's young. So, you know, try to get her out of there. And so one thing is I do short physical performance battery in every visit and they become very curious about the numbers. So, oh, what was my number? And then we have, you know, the resident or fellow will have a little bit of expression too. So we have a agreement before we go to the room and listen, if this person is not the best, then we are gonna give a little bit of a stress, not a stress, but you know, you are a little worse than before. And people are naturally competitive, you know, once, yeah, what is gonna be your walking speed? And then can I do it again? They say, can I do the thing again? No, you can't do it again. So then it sets up, okay, so what we can do, you're a little worse, maybe you lost some weight and then these are the things you can do. And what you can do is not a huge thing as Tom just mentioned. It's just something like a 10 times a chair rise and you watch that video. These are not even considered as exercise. You're standing and bring your legs sideways. I mean, so I think that that's really the key. So it doesn't take a lot to be staying out of a being, becoming frail. It doesn't take a lot, but you know, when this inactivity is just off the roof, they really don't do much, yeah. All right, can I add a couple of things to this? In terms of asking them to do exercise, just tell them, be active like Dr. Caprio said. And what I tell them, no matter where you live, be it a house, be it an apartment, you have a little dining area, a little kitchen and a little living area. Why don't you go two times in the beginning, going round and round for 10 minutes, just put a clock there, but don't do other things like answering the phone or anything, just go around at your own pace. If you can do it two times, increase it to three times. And then add something else to it. If your daughter or your daughter-in-law or any family member takes you shopping, walk in the mall and don't take your wallet, but go before the stores open so that you won't run into busy shoppers and don't spend your money, just do that. And that's exercise too, even if you go once a week, or once in two weeks you go shopping and do that. And then if you need to get a few things from the store, don't ask your family to do it. Tell them to drive you there and you go around with the cart. That's being active too. So incorporate what you do in your daily life and be mobile, but don't use scientific words, exercise, mobility, this and that. And speak their daily language. That's what I've been doing with my older adults. It works sometimes, it doesn't work sometimes. So the other thing I was practicing, but I don't know how good it is. Why don't you write it down what you did from today till you come back next time. And if you forget to bring that, don't see me. And if it's important for you to see me, just bring that piece of paper that you jot it down. It doesn't have to be methodical. I think those tips do help a little bit. I'm not saying it will undo delirium, undo frailty. And then I also wanted to give you a personal story. My mother died a year ago to date. All right, October last year. She was 94, never had a hospital admission, never had any illness. She maintained, she was reading till the day she died. She was there on a Sunday night. I was just calling her routinely and she sounded very different. And I said, what's going on with you? And I video, switched to video call. And I didn't see, she didn't look good. I said, something's wrong with you. She said, no, I just got up from my nap. I said, 6 p.m., you don't take a nap, I know that. The next thing you know, that evening, my niece went there, she's an ophthalmologist. She went to visit her and then she put her in the hospital because she didn't look good. And she had the classic signs of hypoactive delirium. Delirium. She was sleeping a lot and she didn't want anybody to talk to her. She said, this is my time to rest, leave me alone. This was Sunday night, she went to the hospital. Tuesday morning at 3 a.m., she passed away. So it's unrecognized, untreated, and she just lost. She was 94, so they said she lived a very good life, but she could have lived two more years. But so this is what happens, unregulated delirium, untreated delirium, and we lose loved ones. And it really takes a lot from those of us who know things that can be prevented, but I was not there. And there was no way I could talk to the physicians there because they were busy with other things. So anyway, that's my story. Anybody else have anything to contribute? Audience? Thank you, Dr. Bhaduri, for sharing that personal story. And I think it frames it very, very well about the importance of what we've talked about today. I'm wondering if we can see in the chat there as well, and Dr. Garstang, you've responded to some of it, just about sarcopenia and frailty and steroids, any thoughts on that? Yeah, I don't know if there's study, I think there's studies on testosterone in older men and it can increase muscle mass, but does not necessarily reverse frailty. And in women, I think there isn't data, but I don't know for sure. That's my understanding as well. There's a question in the chat box. I was just thinking of another another mother story, right? So you get to the age where you're you look at your parents and you're like, oh, there's an example of delirium. Look at that. So my mother is 92 and and fairly frail. But one of the things that we did, she was having a lot of trouble like getting up out of like rising from a chair without using her arms. Right. And we moved her into a place where there were five stairs, which I thought for sure was going to be a disaster because she wouldn't be able to go up them. But she sort of struggled her, you know, pulled herself up them every day, probably three or four times a day. And after a couple of months, she was way stronger, walking further, able to go up the five stairs, you know, barely touching the handrail, able to jump up from her chair and walk across the room way more quickly. And I would not have thought that going up five stairs a couple of times a day would have made that much difference. It was really remarkable. And I think some of it's just that proximal strength that makes such a big difference to to people's functional abilities. And you start losing that pretty early, right? If you do strength testing on a 65 year old in clinic, like hip flexors are a little weak. And, you know, we don't think about that, that the ability to stand as maybe like a maybe not a sentinel thing, but you see that really early, right? While people look great once they're up. And maybe if we even just work on that, like in the videos, Dr. O'Park showed with the person doing sit to stand ten times, you know, once a day, like maybe even just that is enough to to make people functional for longer. I think that's a that's a really great point, as I often refer to as the the high investment payoff, you know, with small interventions like that, because I think that if you look at someone's sort of baseline activity or their basal metabolic rate and everything and their sort of day to day lives, just ten minutes, as Dr. Paduri had said, is, you know, just starting out at ten minutes of really intentional activity a day could be a huge benefit. You know, that could be a game changer. And then you could you could progressively increase some of that. But just that's kind of what I negotiate is sometimes just like ten minutes. Just have it very focused of like ten minutes. Like you said, those five steps that getting up off the couch, doing those sorts of things can mean the difference between them being able to get to the bathroom on their own or not. You know, I mean, this is really a game changer. You know, as the population is aging, we all talk about the numbers, but how are they aging is the factor that we need to worry about. Are they, you know, if they are aging, you know, with grace? I think that's important for them. And they're able to live in the community. That's another important factor. And that last thing is, are they dealing with incontinence? If we can deal with those things, I think the quality of life automatically improves. And then their visits to the hospitals and to the outpatient settings will be less. And that will be a reduction in the cost for the health care system. Right. Interconnected. But we need to start from the beginning and saying what is important to them. What matters to them and that should matter to us. Right. And that should be the message that we should give in the geriatric world. And again, you know, we have to partner with geriatricians, primary care physicians. And I have seen several times a patient with hyponatremia untreated. And, you know, and then I see patients who are vitamin D deficient. They're not corrected. As a PM and a doc, I have to correct that. What happened to the PCP? So we need and I corrected, but then I make sure that the PCP is aware. I am doing it. Please do a follow up essay and see what we need to do. Right. I think those are the things that we need to be cognizant. The factors that are causing this frailty are very much in our hands to correct. And I think Dr. Garstang, you had a question, there is sarcopenia requisite for frailty. Have you addressed it? It's in the chat box. I did type an answer in the chat. Yeah. OK, good. So and I think has a question. No. Thanks, Dr. Garstang. So wonderful talk and session. Thank you to all of you. It was really informative. And I think this topic is more and more prevalent and less and not talked about enough as we get into more of a geriatric population. I myself am in a inpatient rehab unit in the Jersey Shore. And our average age of patients is seven is nine years older than the average age of the nation, because it just happens to be an area where a lot of people retire. So my question to you, because you had you all had mentioned a lot of outpatient kind of assessments and interventions and things, but on the inpatient rehab side of things, is there anything that you would add to regular inpatient rehab that maybe we should be doing for our geriatric population, such as should we be doing more of the frailty assessments? Should we be doing is there any kind of intervention that we really should be considering in these patients as opposed to our our other patients? Dr. Gosling, would you like to address this? I'm going to let Dr. O'Park, I think she has more knowledge of the inpatient setting. Okay, so that's actually an excellent point, and I have to tell you, I am also struggling. We are all, I think, on the same page. So are you talking about more the consultation basis in the acute care setting, acute care hospital setting, or in the inpatient rehab setting? The inpatient rehab setting, it's a little bit easier, because you will get, you know, the basic assessment pretty much done from therapy team and other members of the team. And now, actually, with the RPIE 4.0 has also, the CAM is included in there, and a few other things are already in there, so that instead of, you know, I'm all about efficiency, right? So try to see what's already collected, and then pull those items from what's already in the EHR is the better way, instead of adding another assessment. In the inpatient side, it's a little bit difficult, but, you know, there are a couple of things you can put it together. For example, the AM peg, I'm sure you're doing it too, and then the six clicks, that already has quite a lot of information about how much this person is mobile. It's a self-report, yeah. But that can be utilized, and some other things, for example, the frailty assessment being done in the ED setting, that will be really the best way to do it, because that really changes the whole thing, right? The earlier this assessment is being done, that will be the best way of doing it. But if you find any very brilliant way of doing this, then we'll be very happy to hear more. I had an idea while we are listening to you all. Should we add frailty assessment as part of a vital sign, just like we added pain as a vital sign? It's not easy, but I think unless some, we need to start somewhere, right? Maybe we can do a study using this as a vital sign and see how helpful, and the impact of that in functional outcome. I think maybe that's something Dr. Park maybe can initiate as a vital sign. Yes, and then it's absolutely. And actually, we are in the middle of looking at where we can get pooled that data instead of putting on other assessment. Because there is so much information already in the health system. So, yeah, that's the direction. Thank you. Thank you, Dr. Park. Thank you. That's helpful. Actually, I'm a little nervous. I want my whole rehab to hear your talk, your talks, but I'm a little nervous because I'm afraid my therapists are going to say, see, they're all frail. We shouldn't push them as hard as we can. We shouldn't push them as hard as we do. No, you have to push more. Yeah, when you look at that video and the intervention, and this is already shown in actually U.S. nursing home population. You have to challenge the patient with a higher weights, like, you know, 50% of the one repetition maximum. Otherwise, you will not get there. I think that that study made such a big difference was because of the intensity of the exercise. Not a lot of times, but they really, you know, did it. So that's what I'm, at least what I'm trying to do in this place. it is more my micro environment. When I see them and they're moving the legs like this up and down in the gym, then I go there and excuse me. What are you doing? You're blowing airs, right? So we need to really guide them with evidence. Yeah. I think we have another basic problem here. When we do consultation for patients who are, we say rehab is three hours a day. And we forget the fact that sometimes you can improve their ability to tolerate exercise, that bringing them, giving them the rest breaks, maybe instead of doing 45 minutes on it of stretch, give them 20 minutes, give them five minute rest. Somehow we need to modify the way we do inpatient rehab. That might have a long-term impact. Does that make sense? I don't mean that you need to bring somebody who is sitting tall. There was a very interesting study. I just came back from the AMRTA meeting, American Medical Rehabilitation Providers Association. There was one presentation poster by Hartford group and they essentially work with the patient and caregivers when the caregiver visits them. And then they gave a work to do. And that was fascinating. It was such an innovative study and they showed length of stay was shortened. The G.G. score was higher. It was really impressive. And I'd be happy to share that if you can. I took a picture of the poster. So if I can share it. Yes. Thank you, Dr. Paduri. Thank you for setting this up. Thank you all for taking part and giving us excellent times. And I'm truly impressed with your participation and your message that you gave to the audience as well as to me in person. And thank you so much. And we look forward to seeing you again in the future sessions. Thank you. Thank you. Thank you, Devon.

delirium

older adults

changes in consciousness

cognitive function

symptoms

causes

risk factors

early recognition

non-pharmacological interventions

frailty

aging-related syndrome

reduction in function

vulnerability

assessment tools

pathophysiology