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MSH Orientation Geriatric 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 Outline • Why Geriatrics? • Continuum of Geriatric Models of Care • Geriatric Medicine Consultation Service & Clinics • Orientation Package • Orthopedic & Physiatry Residents WHY GERIATRICS? 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 / Immobility Malnutrition / Dehydration Cognitive Dysfunction Medicines / Polypharmacy Procedures Depressed Mood Negative Expectations Physical Impairment and Deconditioning Dysfunctional Older Person Palmer et al., 1998 (Modified) Trajectories of Functional Decline Baseline 70+ Pts Admission 57% Stable Discharge 45% Stable N=2293 20% Recovery 65% Discharged with Baseline Function 12% Hospital Decline 43% Decline 18% Fail to Recover Pre-Hospital Decline 5% Pre-Hospital and Hospital Decline Covinksy et al., J Am Geriatr Soc 2003 35% Discharged with Worse than Baseline Function Costs of Functional Decline • The loss of independent functioning during hospitalization has been associated with: – – – – Prolonged lengths of hospital stay Increased readmission A greater risk of institutionalization Higher mortality rates Palmer et al., 1998 Comprehensive Geriatrics Assessment (CGA) “ … a multidisciplinary diagnostic process intended to determine a frail elderly person’s medical, psychosocial, and functional capabilities and limitations in order to develop an overall plan for treatment and long term follow up” Rubenstein, 1982 Components of a CGA ID/RFR Labs & Investigations PMHx Confusion Assessment Method (CAM) Mini Mental Status Exam (MMSE) Montreal Cognitive Assessment (MoCA) Physical HPI Examination S hopping Activities of Daily Living (ADLs) Rowland Universal Dementia Assessment D ressing H ousekeeping Scale (RUDAS) Mood & Weight loss CGA E ating A ccounting Geriatric Depression Scale (GDS) cognition Bladder & bowel A mbulating F ood Prep/Meds • Current living situation Vision & hearing incontinence Cognitive Tcommunity oileting/transfer T Medications Assessment • Family & supports Falls Pain ygiene • AdvanceHcare directives ransportation/Tele Dysphagia Sleep phone • Powers of attorney Geriatric • GeneralFunctional financial situation Review of History Systems Social History MSH & UHN GERIATRIC CARE CONTINUUM AMBULATORY INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit TRI Geriatric Rehabilitation Unit MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital Mount Sinai / UHN Geriatrics Continuum COMMUNITY ER MSH/UHN GEM Nurses MSH ER Geri Mental Health Prog Home Based Primary/Geri Care MSH Reitman Centre Temmy Latner Home Palliative Care CCAC ICCP Partnership GERIATRIC CONSULTATION SERVICE Inpatient Geriatric Medicine • Interprofessional team – Carm Marziliano, SW – Natasha Bhesania, PT – Chris Fan-Lun, Pharm • Common Referrals from MSH, TGH, & PMH Delirium & dementia Functional decline, falls Diagnostic/treatment challenge Transition to outpatient & home-based services (House Calls) – Goals of care & disposition – – – – Other Common Referrals • Automatic consultations – Orthogeriatrics hip fracture patients – House Calls – ICCP • GEM Flags • Geriatric Psychiatry Orthogeriatrics Automatic geriatric consultation for ALL fractured hip patients ≥65 years old * * Orthopedic residents focus on low trauma (fragility) hip fractures (NOT high trauma, periprosthestic, or pathological) but can be involved in medical & surgical cases for further learning • Orthopedic, Hospitalist, & Geriatric Medicine Co-Management Model • Referrals – Staff automatic e-mail notification – Jeanette Villapando/Tammy Mok, x8419 – 11S, x4580 A Reactive Proactive Strategy • Delirium prevention & management • Functional recovery • Pain management • Falls prevention & bone health • Disposition planning Marcantonio et al, 2001; Siddiqi et al., 2009 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 Geriatrics • Mental status – Delirium – Pre-admission cognition – Mood • • • • • • Falls Bone Health Pain and nausea Constipation Medication rationalization Disposition planning Hospitalist & Med Consults • Perioperative risk assessment • Respiratory issues requiring close frequent monitoring • Management of – – – – Anticoagulation Blood glucose Electrolyte abnormalities Acute kidney injury House Calls (HC) • Home based primary care for homebound seniors living within the central LHIN catchment area • Types of consultations: – New Patient Referral to HC • Complete & fax HC’s referral form (including geriatrics consultation note & discharge summary) – Existing HC patients who are admitted to MSH • Staff e-mail notification when HC patient arrives to ER • Automatic but limited consultation for MRP co-management and support • Upon discharge, fax discharge summary and geriatric notes to HC http://www.seniorshousecalls.ca Integrated Client Care Project (ICCP) • Intensive CCAC case management for the most complicated patients living in the community • Close collaboration with Primary Care, Psychiatry, Geriatrics • Referrals – Staff e-mail notification when ICCP patient arrives in ER – Automatic consultation for MRP co-management and support http://www.ccac-ont.ca/icc GEM Flags • Check GEM flags daily • Review GEM nursing notes in Powerchart for GEM flagged patients – Open patient chart Clinical Notes GEM Nursing notes • Liaise with admitting team and offer geriatric support if needed Geriatric Psychiatry Consult Service • Shared care for complicated: – Mental health illnesses – Delirium management – Behavioural & psychological symptoms of dementia Consultations E-mail new referrals to the interprofessional geriatric medicine team at MSH & TGH respectively Consultations • Always record consult date, start, and stop time on your consult note • Store carbon copy of completed consults in the filing cabinet (middle drawer) in alphabetical order Consult Recommendations • AVOID consult SUGGEST orders – Miscommunication – Delays in patient care • Always best to communicate recommendations directly to referring team • Direct order entry for geriatric related issues on fractured hip patients Sign-out Lists “geriatrics” *** ALWAYS UPDATE THE SIGN-OUT LIST *** OUTPATIENT GERIATRIC & SPECIALTY CLINICS Clinic • Please check your schedules & be on time for your clinic, as patients have been scheduled for you in advance Geriatric Medicine Clinics TRI Outpatient Clinics Ground Floor (Elm Street Entrance) Drs. Alibhai, Berger, Chau, Liberman Ramona Gheorghe, NP, & Katie Stock, SW UC Outpatient Physician Clinics Admin (416) 597-3422 x 4200 MSH AIMGP Area 4th floor Drs. Goldlist, Ng, Sinha Chris Fan-Lun, Pharmacist Stephanie (416) 586-4800 x 8563 * Please ensure you obtain an MSH and/or UHN dictation code at the beginning of your rotation * TWH Memory Clinic • Collaborative multidisciplinary assessment of memory disorders beyond the MMSE/MoCA Collaborative Multidisciplinary Clinic Neuropyschologist/OT/SW 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 • Arrive at 1:00 pm sharp in the West Wing on the 5th Floor TRI Falls Prevention Clinic • Focused assessment of falls in older adults – Multidisciplinary intake assessment for consideration of a 12 Week Falls Prevention Program • Arrive at 1:00pm sharp for clinic orientation • Located in the outpatient clinic area on the ground floor (Elm Street entrance) ORIENTATION PACKAGE Orientation Package • Personalized schedule (review daily) – – – – Clinical activity (e.g. clinics) Weekly Rounds Education & Teaching opportunities End of Rotation Debrief & Feedback • On Call Schedules * Reminder: new consult e-mail notifications • Orientation manual – Includes Falls & Memory Clinic orientation materials • References & Resources Weekly Rounds Attended by: • House Calls (Emma) • ICCP (Debbie) • ACE (Rebecca) Attended by: • Hospitalist Educational Opportunities • • • • • Informal/bedside teaching Geriatric giant seminars, Geriatric Psychiatry, Journal club Specialty seminars Allied health professional teaching General medicine, grand, & osteoporosis rounds Resident Geriatric Office • Office workspace for you and others during your rotation, so please keep it clean and tidy • Obtain an office key from Phoebe Tian – $20 deposit - - returned at the end of rotation • Always lock the door and turn off the lights if you are the last one in the office http://www.mountsinai.on.ca/education/ geriatrics/resident-resources-andschedules/ ADDITIONAL NOTES FOR ORTHOPEDIC & PHYSIATRY RESIDENTS Orthogeriatric Resident Schedule • 2 weeks hospitalist then 2 weeks geriatric medicine • Mandatory clinics & programs during your rotation – Falls Prevention Clinic – Geriatric Day Hospital • Additional medical consults teaching • 1 Weekend Home Call shift (see next slides) Physiatry Resident Schedule • 8 Week block – 2 Weeks acute care geriatrics at MSH/UHN – 3 Weeks rehabilitation at TRI • Separate TRI Orientation upon start at TRI – 3 Weeks outpatient clinics & community experiences • 1 Weekend Home Call shift Weekend Home Call • Geriatric medicine staff receives e-mail notification of new orthogeriatrics (and surgical) referrals and will divvy consults to the orthopedic resident on call • Contact your on-call staff prior to the weekend to exchange contacts Thank You & Enjoy Your Rotation! • Questions?