TWH Orientation Geriatric Medicine. Why Geriatrics? The MSH-UHN Continuum of Geriatrics Housekeeping...

TWH OrientationGeriatric Medicine

• Why Geriatrics?• The MSH-UHN Continuum of Geriatrics• Housekeeping• Educational Opportunities

Ageing and Hospital Utilization

in Central Toronto LHIN, 2005Number Age <65 Seniors 65 + % Seniors 75+

2005 Population 1,142,469 87% 13% 49%

Emergency Room Visits 321,044 79% 21% 62%

Acute Hospitalizations 78,025 63% 37% 64%

w/ Alternate Level of Care Days 4,263 17% 83% 76%

w/ Circulatory Diseases 10,361 32% 68% 65%

w/ Respiratory Diseases 5,928 43% 57% 73%

w/ Cancer 6,743 53% 47% 54%

w/ Injuries 5,809 58% 42% 71%

w/ Mental Health 6,161 87% 13% 59%

Inpatient Rehabilitation 3,368 25% 75% 66%

Toronto Central LHIN, 2006

The Hazards of Hospitalization

• Older people are particularly vulnerable to the risks of iatrogenic illness and functional decline.

• The pathogenesis of functional and cognitive decline is complex and involves an interaction amongst: • the ageing process • comorbid and acute illnesses • the hospitalization process

Conceptualizing Functional Decline

Functional Older

Person

Acute Illness + Possible Impairment

Depressed Mood Negative Expectations

Physical Impairmentand Deconditioning

Dysfunctional Older Person

The Hazards of Hospitalization

Hostile EnvironmentDepersonalizationBedrest / Immobilty

Malnutrition / DehydrationCognitive Dysfunction

Medicines / PolypharmacyProcedures

Palmer et al., 1998 (Modified)

Trajectories of Functional Decline

Baseline DischargeAdmission

70+ PtsN=2293

57% StableN=1311

45% StableN=1039

20% RecoveryN=455

43% DeclineN=982

12% Hospital DeclineN=272

18% Fail to RecoverPre-Hospital Decline

N=402

5% Pre-Hospital and Hospital Decline

N=125

65% Discharged with Baseline

FunctionN=1494

35% Discharged with Worse than

Baseline FunctionN=799

Covinksy et al., J Am Geriatr Soc 2003

The Hazards of Hospitalization

THE COST OF FUNCTIONAL DECLINE (Palmer, 1995)

The loss of independent functioning during hospitalization has been associated with: Prolonged lengths of hospital stay Increased recidivism A greater risk of institutionalization Higher mortality rates

COMMUNITY

INPATIENT

ER

AMBULATORYMSH/UHN Geri Med ConsultsMSH Geri Psych ConsultsMSH/TWH OrthogeriatricsMSH ACE Unit

MSH/TRI Geri Med ClinicsMSH Geri Psych Clinic

TWH Memory ClinicTGH Osteoporosis Clinic

TRI Falls Prevention ProgramTRI Geriatric Day Hospital

MSH/UHN GEM NursesMSH ER Geri Mental Health Prog

Home Based Primary/Geri CareMSH Reitman Centre

Temmy Latner Home Palliative CareCCAC ICCP Partnership

Mount Sinai / UHN Geriatrics Continuum

INPATIENTMSH/UHN Geri Med ConsultsMSH Geri Psych ConsultsMSH/TWH OrthogeriatricsMSH ACE Unit

The TWH Geriatric Medicine Consults Team Is called the “MACE Team”

(Mobile Acute Care of Elders Team)“We bring our multidisciplinary specialized geri services to you –

wherever you are in the hospital”

SW – Helen LevinPT – Nadia Ianetti

OT – Oriana MedeirosGeri Advanced Practice RN & Wound Care RN – Sandra Tully

Geri Advanced Practice RN & GEM RN – Petal SamuelRD – Brenda Wilson

SLP – Hayley HermanMD – YOU!

RGP (Regional Geri Program) OfficeEast Wing, 8th Floor Room 410

INPATIENTMSH/UHN Geri Med ConsultsMSH Geri Psych ConsultsMSH/TWH OrthogeriatricsMSH ACE Unit

Common RFR:-Delirium & dementia-Functional decline, falls-Diagnostic/treatment challenge-Goals of care and disposition

INPATIENTMSH/UHN Geri Med ConsultsMSH Geri Psych ConsultsMSH/TWH OrthogeriatricsMSH ACE Unit

“On-Call” person is paged

Add to signout + email to group

Email to group

Referral Process

(Sometimes you will be the “on-call” person even if you are assigned to be in clinic…)

INPATIENTMSH/UHN Geri Med ConsultsMSH Geri Psych ConsultsMSH/TWH OrthogeriatricsMSH ACE Unit

Automatic geriatric consultation for all fractured hip patients ≥65 years old

Ortho PCC

Email to Geri staff

Email to group

WHY? Reduce incident deliriumOptimize pain managementAddress the issues of “falls” & bone healthEnhance functional recoveryIncrease chances of discharge home

n=126 admitted hip# patients ≥65 yo

Geri Consult pre-op or <24h post-op

Daily visits to follow 10 parameters

Incident delirium 50 vs. 32% (ARR 18% NNT~6)

Fractured Hip Patients: Geri vs. Med Consults

Geriatrics

• Mental status– delirium– pre-admission cognition– mood

• Falls• Bone Health• Pain & nausea• Constipation• Medication rationalization• Disposition planning

Med Consults

• Perioperative risk assessment

• Resp issues requiring close frequent monitoring

• Management of– anticoagulation– blood glucose– electrolyte abnormalities– acute kidney injury

AMBULATORYMSH/TRI Geri Med Clinics

MSH Geri Psych ClinicTWH Memory Clinic

TGH Osteoporosis ClinicTRI Falls Prevention Program

TRI Geriatric Day Hospital

Please phone in to confirm the day before clinic:

TRI Outpatient Clinics Ground Floor (Elm Street Entrance)Dr. Alibhai, Dr. Chau, Dr. Liberman

Angela or Urooj or Gilleanne (416) 597-3422 x 3047

MSH AIMGP Area 4th floorDr. Goldlist, Dr. Ng, Dr. Sinha

Jacqueline (416) 586-4800 x 8563

AMBULATORYMSH/TRI Geri Med Clinics

MSH Geri Psych ClinicTWH Memory Clinic

TGH Osteoporosis ClinicTRI Falls Prevention Program

TRI Geriatric Day Hospital

Toronto Western Hospital, West Wing 5th Floor

OT Cognitive testing

Geriatrician Medical history, Rx,non-neuro physical exam

Behavioural Neurologist Neuro exam

Geriatric Psychiatrist Psychiatric history

One of the above Family gives collateral

Multidisciplinary Team Meeting

AMBULATORYMSH/TRI Geri Med Clinics

MSH Geri Psych ClinicTWH Memory Clinic

TGH Osteoporosis ClinicTRI Falls Prevention Program

TRI Geriatric Day Hospital

Toronto General Hospital, North Wing 7th Floor

AMBULATORYMSH/TRI Geri Med Clinics

MSH Geri Psych ClinicTWH Memory Clinic

TGH Osteoporosis ClinicTRI Falls Prevention Program

TRI Geriatric Day Hospital

TRI Elm Street Entrance 1st FloorIntake Assessment to

12 Week Falls Prevention Program

TRI 2nd Floor12 Week Geriatric Day Hospital

RN HPI, Past Medical History, Orthostatic vitals, Weight

Pharmacist Rx

PT Social History, Cognitive Ax,MSK + Power Exam, Gait Assessment

Geriatrics Physical Examination Other Than MSK, Power and Gait Ax

Multidisciplinary Team Meeting

AMBULATORYMSH/TRI Geri Med Clinics

MSH Geri Psych ClinicTWH Memory Clinic

TGH Osteoporosis ClinicTRI Falls Prevention Program

TRI Geriatric Day Hospital

RN HPI, Past Medical History, Orthostatic vitals, Weight

Pharmacist Rx

PT Social History, Cognitive Ax,MSK + Power Exam, Gait Assessment

Geriatrics Physical Examination Other Than MSK, Power and Gait Ax

Multidisciplinary Team Meeting

COMMUNITYHome Based Primary/Geri Care

MSH Reitman CentreTemmy Latner Home Palliative Care

CCAC ICCP Partnership

http://www.seniorshousecalls.ca

COMMUNITYHome Based Primary/Geri Care

MSH Reitman CentreTemmy Latner Home Palliative Care

CCAC ICCP Partnership

http://www.seniorshousecalls.ca

COMMUNITYHome Based Primary/Geri Care

MSH Reitman CentreTemmy Latner Home Palliative Care

CCAC ICCP Partnership

ERMSH/UHN GEM NursesMSH ER Geri Mental Health Prog

House Keeping: Rounds

UHN Rounds

House Keeping: Sign-out Lists

Educational Opportunities

http://www.mountsinai.on.ca/education/geriatrics/resident-resources-and-schedules/

Questions?