TWH Orientation Geriatric Medicine

TWH Orientation Geriatric Medicine

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

Ageing and Hospital Utilization in Central Toronto LHIN, 2005 Number Age <65 Seniors 65 + % Seniors 75+ 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% 2005 Population 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 The Hazards of Hospitalization Functional Older Person Acute Illness + Possible Impairment Hostile Environment Depersonalization Bedrest / Immobilty Malnutrition / Dehydration Cognitive Dysfunction Medicines / Polypharmacy Procedures Depressed Mood Negative Expectations Palmer et al. , 1998 (Modified) Physical Impairment and Deconditioning Dysfunctional Older Person

Trajectories of Functional Decline Baseline Admission Discharge 70+ Pts 57% Stable 45% Stable N=2293 N=1311 N=1039 20% Recovery N=455 65% Discharged with Baseline Function N=1494 12% Hospital Decline N=272 43% Decline N=982 18% Fail to Recover Pre-Hospital Decline N=402 5% Pre-Hospital and Hospital Decline Covinksy et al. , J Am Geriatr Soc 2003 N=125 35% Discharged with Worse than Baseline Function N=799

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

INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital Mount Sinai / UHN Geriatrics Continuum COMMUNITY Home Based Primary/Geri Care ER MSH Reitman Centre MSH/UHN GEM Nurses Temmy Latner Home Palliative Care MSH ER Geri Mental Health Prog CCAC ICCP Partnership

INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH 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 Levin PT – Nadia Ianetti OT – Oriana Medeiros Geri Advanced Practice RN & Wound Care RN – Sandra Tully Geri Advanced Practice RN & GEM RN – Petal Samuel RD – Brenda Wilson SLP – Hayley Herman MD – YOU! RGP (Regional Geri Program) Office East Wing, 8 th Floor Room 410

INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit Common RFR: - Delirium & dementia - Functional decline, falls - Diagnostic/treatment challenge - Goals of care and disposition

INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit Referral Process “On-Call” person is paged Add to signout + email to group Email to group (Sometimes you will be the “on-call” person even if you are assigned to be in clinic…)

INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH 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 delirium Optimize pain management Address the issues of “falls” & bone health Enhance functional recovery Increase chances of discharge home

n=126 admitted hip# patients ≥ 65 yo Geri Consult pre-op or <24 h 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

AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI 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 4 th floor Dr. Goldlist, Dr. Ng, Dr. Sinha Jacqueline (416) 586 -4800 x 8563

AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital OT Geriatrician Behavioural Neurologist Geriatric Psychiatrist One of the above Cognitive testing Medical history, Rx, non-neuro physical exam Neuro exam Psychiatric history Family gives collateral Multidisciplinary Team Meeting Toronto Western Hospital, West Wing 5 th Floor

AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital Toronto General Hospital, North Wing 7 th Floor

AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital RN Pharmacist PT Geriatrics HPI, Past Medical History, Orthostatic vitals, Weight Rx Social History, Cognitive Ax, MSK + Power Exam, Gait Assessment Physical Examination Other Than MSK, Power and Gait Ax Multidisciplinary Team Meeting TRI Elm Street Entrance 1 st Floor Intake Assessment to 12 Week Falls Prevention Program TRI 2 nd Floor 12 Week Geriatric Day Hospital

AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital RN Pharmacist PT Geriatrics HPI, Past Medical History, Orthostatic vitals, Weight Rx Social History, Cognitive Ax, MSK + Power Exam, Gait Assessment Physical Examination Other Than MSK, Power and Gait Ax Multidisciplinary Team Meeting

COMMUNITY Home Based Primary/Geri Care MSH Reitman Centre Temmy Latner Home Palliative Care CCAC ICCP Partnership http: //www. seniorshousecalls. ca

COMMUNITY Home Based Primary/Geri Care MSH Reitman Centre Temmy Latner Home Palliative Care CCAC ICCP Partnership http: //www. seniorshousecalls. ca

COMMUNITY Home Based Primary/Geri Care MSH Reitman Centre Temmy Latner Home Palliative Care CCAC ICCP Partnership

ER MSH/UHN GEM Nurses MSH 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-andschedules/

Questions?