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TWH Orientation Geriatric Medicine. Why Geriatrics? The MSH-UHN Continuum of Geriatrics Housekeeping Educational Opportunities. Ageing and Hospital Utilization in Central Toronto LHIN, 2005. Toronto Central LHIN, 2006. The Hazards of Hospitalization. - PowerPoint PPT Presentation
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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?
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