MSH Orientation Geriatric Medicine

1. MSH OrientationGeriatric Medicine Dr. Shabbir Alibhai | Dr. Arielle Berger | Dr. Vicky Chau Dr. 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

2. Outline • Existence for Geriatric Medicine • Hazards of Hospitalization • Continuum of Geriatric Models of Care • Housekeeping • Education & Teaching

3. Geriatric medicine & thehazards of hospitalization

4. Ageing and Hospital Utilization in Central Toronto LHIN, 2005 Toronto Central LHIN, 2006

5. 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

6. Conceptualizing Functional Decline The Hazards of Hospitalization Hostile Environment Depersonalization Bedrest / Immobilty Malnutrition / Dehydration Cognitive Dysfunction Medicines / Polypharmacy Procedures Functional Older Person Acute Illness + Possible Impairment Depressed Mood Negative Expectations Physical Impairment and Deconditioning Dysfunctional Older Person Palmer et al., 1998 (Modified)

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

8. 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

9. Continuum of geriatric models of care

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

11. ER MSH/UHN GEM Nurses MSH ER Geri Mental Health

12. ISAR (Identification of Seniors at Risk) Tool Score > 2, at risk for functional decline, ED Visits, and hospitalization McCusker et al, 1999

13. INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit • 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

14. 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 • Referrals • Jeanette, x8419 • 11S, x4580

15. A Proactive Strategy Reactive • Delirium prevention (NNT = 6) & management • Functional recovery • Pain management • Falls prevention & bone health • Disposition planning Marcantonio et al, 2001; Siddiqi et al., 2009

18. Fractured Hip Patients Geriatrics Med Consults Perioperative risk assessment Respiratory issues requiring close frequent monitoring Management of Anticoagulation Blood glucose Electrolyte abnormalities Acute kidney injury • Mental status • Delirium • Pre-admission cognition • Mood • Falls • Bone Health • Pain and nausea • Constipation • Medication rationalization • Disposition planning

19. INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit Ben and Hilda Katz ACE Unit Built around Core Principles 1) Care is patient-centered 2) Frequent medical review 3) Early rehabilitation 4) Planning for discharge is part of care 5) 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-unit Fox 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.

20. ACE Unit Model • 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

21. INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit • Shared care for complicated: • Mental health illnesses • Delirium • Behavioural & psychological symptoms of dementia Weekly Conjoint Geri Med – Geri Psych Rounds

22. 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/Urooj (416) 597-3422 x 3047 MSH AIMGP Area 4th floorDr. Goldlist, Dr. Ng, Dr. Sinha Jacqueline (416) 586-4800 x 8563

23. 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 Western Hospital West Wing 5th Floor

24. 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 7th Floor

25. AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital TRI Elm Street Entrance 1st Floor 12 Week Falls Prevention Program TRI 2nd Floor 12 Week Geriatric Day Hospital

26. COMMUNITY Home Based Primary/Geri CareMSH Reitman CentreTemmy Latner Home Palliative Care CCAC ICCP Partnership http://www.seniorshousecalls.ca

27. Catchment Area

28. COMMUNITY Home Based Primary/Geri CareMSH Reitman CentreTemmy Latner Home Palliative Care CCAC ICCP Partnership 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 http://www.ccac-ont.ca/icc

29. Housekeeping

30. Consultations Please send e-mail of new referrals to the interprofessional geriatric medicine team

31. Weekly Rounds

32. Sign-out Lists

33. “geriatrics” Please update the sign-out list daily

34. Education & Teaching

35. Education & Teaching • Educational opportunities • Resident schedules and resources

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

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

38. Questions