MSH Orientation Geriatric Medicine

MSH OrientationGeriatric Medicine

Dr. Shabbir Alibhai | Dr. Arielle Berger | Dr. Vicky ChauDr. Barry Goldlist | Dr. Dan Liberman | Dr. Karen Ng | Dr. Samir Sinha

Mount Sinai Hospital Suite 475, 600 University Avenue

Toronto, Ontario, M5G 1X5(416) 586-4800 x 7859

Outline

• Existence for Geriatric Medicine

• Hazards of Hospitalization

• Continuum of Geriatric Models of Care

• Housekeeping

• Education & Teaching

GERIATRIC MEDICINE & THEHAZARDS OF HOSPITALIZATION

Ageing and Hospital Utilization in Central Toronto LHIN, 2005

Number 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

Functional Older

Person

Acute Illness + Possible

Impairment

Depressed Mood Negative Expectations

Physical Impairmentand Deconditioning

Dysfunctional Older Person

The Hazards of Hospitalization

Hostile EnvironmentDepersonalization

Bedrest / ImmobiltyMalnutrition / Dehydration

Cognitive DysfunctionMedicines / Polypharmacy

Procedures

Palmer et al., 1998 (Modified)

Conceptualizing 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 Function

N=1494

35% Discharged with Worse than Baseline

FunctionN=799

Covinksy et al., J Am Geriatr Soc 2003

Trajectories of Functional Decline

Costs of Functional Decline

• 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

Palmer et al., 1998

CONTINUUM OF GERIATRIC MODELS OF CARE

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

ERMSH/UHN GEM NursesMSH ER Geri Mental Health

ISAR (Identification of Seniors at Risk) Tool

Score > 2, at risk for functional decline, ED Visits, and hospitalization

McCusker et al, 1999

• Common RFR– Diagnostic/treatment challenge– Functional decline, falls– Delirium & dementia– Transition to outpatient & home-based services– Goals of care & disposition

• Interprofessional team– Carm Marziliano, SW– Natasha Behsania, PT– Chris Fan-Lun, Pharm

• Resident Geriatric Office– Rm 475, $20 key deposit

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

Automatic geriatric consultation for

ALL fractured hip patients ≥65 years old

• Referrals– Jeanette, x8419– 11S, x4580

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

• Delirium prevention (NNT = 6) & management

• Functional recovery

• Pain management

• Falls prevention & bone health

• Disposition planning

A Proactive Strategy

Marcantonio et al, 2001; Siddiqi et al., 2009

Reactive

Fractured Hip Patients

Geriatrics

• Mental status– Delirium– Pre-admission cognition– Mood

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

Med Consults

• Perioperative risk assessment• Respiratory issues requiring

close frequent monitoring• Management of

– Anticoagulation– Blood glucose– Electrolyte abnormalities– Acute kidney injury

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

Ben and Hilda Katz ACE Unit Built around Core Principles

1) Care is patient-centered2) Frequent medical review3) Early rehabilitation4) Planning for discharge is part of care5) Hospital environment is elder friendly

http://www.mountsinai.on.ca/about_us/news/2011-news/mount-sinai-opens-ben-and-hilda-katz-acute-care-for-elders-ace-unitFox et al. Effectiveness of Acute Geriatric Unit Care Using Acute Care for Elders Components: A Systematic Review and Meta-analysis. JAGS. 2012; 60: 2237 – 2245.

• 28 internal medicine beds located on 10N/S• Most responsible physician is the GIM attending

• Admission Criteria• Recent decline in functional abilities• Recent change in cognition or behaviour• Geriatric syndromes• Complex social issues• ISAR Score > 2 on ED assessment

http://www.mountsinai.on.ca/about_us/news/2011-news/mount-sinai-opens-ben-and-hilda-katz-acute-care-for-elders-ace-unit

ACE Unit Model

• Shared care for complicated:– Mental health illnesses– Delirium– Behavioural & psychological symptoms of dementia

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

Weekly Conjoint Geri Med – Geri Psych Rounds

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/Urooj (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 HospitalWest Wing 5th Floor

Collaborative Multidisciplinary Clinic

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 Floor12 Week Falls Prevention Program

TRI 2nd Floor12 Week Geriatric Day Hospital

COMMUNITYHome Based Primary/Geri Care

MSH Reitman CentreTemmy Latner Home Palliative Care

CCAC ICCP Partnership

http://www.seniorshousecalls.ca

Catchment Area

COMMUNITYHome Based Primary/Geri Care

MSH Reitman CentreTemmy Latner Home Palliative Care

CCAC ICCP Partnership

http://www.ccac-ont.ca/icc

Integrated Client Care Project (ICCP)

• Pilot project at MSH & TWH

• 1 CCAC coordinator for 40 of its most complicated users

• Intensive case management

• Close collaboration with Primary Care, Psych, Geriatrics – Geriatrics automatically notified when ICCP patient arrives in ER– Geriatrics service to help manage care in conjunction with MRP

HOUSEKEEPING

ConsultationsPlease send e-mail of new referrals to the

interprofessional geriatric medicine team

Weekly Rounds

Sign-out Lists

“geriatrics”

Please update the sign-out list daily

EDUCATION & TEACHING

Education & Teaching

• Educational opportunities• Resident schedules and resources

Educational Opportunities• Informal/bedside teaching• Geriatric giant seminars, journal club• Specialty seminars• Allied health professional teaching• General medicine rounds

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

Questions