TWH Orientation Geriatric Medicine

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

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Ageing and Hospital Utilization in Central
Toronto LHIN, 2005
Number Age lt65 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
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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

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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)
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Trajectories of Functional Decline
Baseline
Discharge
Admission
70 Pts N2293
57 Stable N1311
45 Stable N1039
65 Discharged with Baseline Function N1494
20 Recovery N455
12 Hospital Decline N272
35 Discharged with Worse than Baseline
Function N799
18 Fail to Recover Pre-Hospital Decline N402
43 Decline N982
5 Pre-Hospital and Hospital Decline N125
Covinksy et al., J Am Geriatr Soc 2003
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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

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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
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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 LevinPT Nadia IanettiOT Oriana
MedeirosGeri Advanced Practice RN Wound Care
RN Sandra TullyGeri Advanced Practice RN GEM
RN Petal SamuelRD Brenda WilsonSLP Hayley
Herman MD YOU!
RGP (Regional Geri Program) OfficeEast Wing, 8th
Floor Room 410
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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

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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)
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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
WHY? Reduce incident delirium Optimize pain
management Address the issues of falls
bone health Enhance functional
recovery Increase chances of discharge home
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n126 admitted hip patients 65 yo Geri Consult
pre-op or lt24h post-op Daily visits to follow 10
parameters Incident delirium 50 vs. 32 (ARR
18 NNT6)
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Fractured Hip Patients Geri vs. Med Consults

• Geriatrics

• Med Consults

• Mental status
• delirium
• pre-admission cognition
• mood
• Falls
• Bone Health
• Pain nausea
• Constipation
• Medication rationalization
• Disposition planning

• Perioperative risk assessment
• Resp issues requiring close frequent monitoring
• Management of
• anticoagulation
• blood glucose
• electrolyte abnormalities
• acute kidney injury

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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 floorDr.
Goldlist, Dr. Ng, Dr. Sinha Jacqueline (416)
586-4800 x 8563
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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 Multidisciplinary Team Meeting
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
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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
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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 Multidisciplinary Team Meeting
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 2nd Floor 12 Week Geriatric Day Hospital
TRI Elm Street Entrance 1st Floor Intake
Assessment to 12 Week Falls Prevention Program
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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 Multidisciplinary Team Meeting
AMBULATORY
MSH/TRI Geri Med Clinics MSH Geri Psych
Clinic TWH Memory Clinic TGH Osteoporosis
Clinic TRI Falls Prevention Program TRI Geriatric
Day Hospital
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COMMUNITY
Home Based Primary/Geri CareMSH Reitman
CentreTemmy Latner Home Palliative Care CCAC
ICCP Partnership
http//www.seniorshousecalls.ca
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COMMUNITY
Home Based Primary/Geri CareMSH Reitman
CentreTemmy Latner Home Palliative Care CCAC
ICCP Partnership
http//www.seniorshousecalls.ca
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COMMUNITY
Home Based Primary/Geri CareMSH Reitman
CentreTemmy Latner Home Palliative Care CCAC
ICCP Partnership
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ER
MSH/UHN GEM Nurses MSH ER Geri Mental Health Prog
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House Keeping Rounds
UHN Rounds
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House Keeping Sign-out Lists
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Educational Opportunities
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http//www.mountsinai.on.ca/education/geriatrics/r
esident-resources-and-schedules/
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Questions?