TWH Orientation
Geriatric Medicine
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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
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Older people are particularly vulnerable to the risks of
iatrogenic illness and functional decline.
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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
65% Discharged
with Baseline
Function
N=1494
N=455
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, 8th 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 <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
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•
•
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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 4th floor
Dr. Goldlist, Dr. Ng, Dr. Sinha
Jacqueline (416) 586-4800 x 8563
OT
AMBULATORY
MSH/TRI Geri Med Clinics
MSH Geri Psych Clinic
TWH Memory Clinic
TGH Osteoporosis Clinic
TRI Falls Prevention Program
TRI Geriatric Day Hospital
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
Patient ID:
Memory Clinic Initial Assessment
Reason for Referral:
A.
History of Presenting Illness
1.
What was the first sign that raised your concerns?
When were memory difficulties first suspected?
Toronto Western Hospital, West Wing
5th
Floor
2.
Did the symptoms develop suddenly?
3.
Has there been worsening/progression? Was progression gradual or step wise?
4.
Were there any fluctuations?
B.
Cognitive Domains
I
Memory
a)
Short Term Memory
1.
Does the patient:
·
Repeat himself/herself over and over again
·
Lose track of days/dates/time
·
Forget names of people or objects
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
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 1st Floor
Intake Assessment to
12 Week Falls Prevention Program
TRI 2nd 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?