msh orientation geriatric medicine dr. shabbir alibhai | dr. arielle berger | dr. vicky chau dr....
TRANSCRIPT
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MSH OrientationGeriatric Medicine
Dr. Shabbir Alibhai | Dr. Arielle Berger | Dr. Vicky ChauDr. 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
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Outline
• Existence for Geriatric Medicine
• Hazards of Hospitalization
• Continuum of Geriatric Models of Care
• Housekeeping
• Education & Teaching
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GERIATRIC MEDICINE & THEHAZARDS OF HOSPITALIZATION
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Ageing and Hospital Utilization in Central Toronto LHIN, 2005
Number Age <65 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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Functional Older
Person
Acute Illness + Possible
Impairment
Depressed Mood Negative Expectations
Physical Impairmentand Deconditioning
Dysfunctional Older Person
The Hazards of Hospitalization
Hostile EnvironmentDepersonalization
Bedrest / ImmobiltyMalnutrition / Dehydration
Cognitive DysfunctionMedicines / Polypharmacy
Procedures
Palmer et al., 1998 (Modified)
Conceptualizing Functional Decline
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Baseline DischargeAdmission
70+ PtsN=2293
57% StableN=1311
45% StableN=1039
20% RecoveryN=455
43% DeclineN=982
12% Hospital DeclineN=272
18% Fail to RecoverPre-Hospital Decline
N=402
5% Pre-Hospital and Hospital Decline
N=125
65% Discharged with Baseline Function
N=1494
35% Discharged with Worse than Baseline
FunctionN=799
Covinksy et al., J Am Geriatr Soc 2003
Trajectories of Functional Decline
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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
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CONTINUUM OF GERIATRIC MODELS OF CARE
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COMMUNITY
INPATIENT
ER
AMBULATORYMSH/UHN Geri Med ConsultsMSH Geri Psych ConsultsMSH/TWH OrthogeriatricsMSH ACE Unit
MSH/TRI Geri Med ClinicsMSH Geri Psych Clinic
TWH Memory ClinicTGH Osteoporosis Clinic
TRI Falls Prevention ProgramTRI Geriatric Day Hospital
MSH/UHN GEM NursesMSH ER Geri Mental Health Prog
Home Based Primary/Geri CareMSH Reitman Centre
Temmy Latner Home Palliative CareCCAC ICCP Partnership
Mount Sinai / UHN Geriatrics Continuum
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ERMSH/UHN GEM NursesMSH ER Geri Mental Health
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ISAR (Identification of Seniors at Risk) Tool
Score > 2, at risk for functional decline, ED Visits, and hospitalization
McCusker et al, 1999
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• 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
INPATIENTMSH/UHN Geri Med ConsultsMSH Geri Psych ConsultsMSH/TWH OrthogeriatricsMSH ACE Unit
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Automatic geriatric consultation for
ALL fractured hip patients ≥65 years old
• Referrals– Jeanette, x8419– 11S, x4580
INPATIENTMSH/UHN Geri Med ConsultsMSH Geri Psych ConsultsMSH/TWH OrthogeriatricsMSH ACE Unit
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• Delirium prevention (NNT = 6) & management
• Functional recovery
• Pain management
• Falls prevention & bone health
• Disposition planning
A Proactive Strategy
Marcantonio et al, 2001; Siddiqi et al., 2009
Reactive
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Fractured Hip Patients
Geriatrics
• Mental status– Delirium– Pre-admission cognition– Mood
• Falls• Bone Health• Pain and nausea• Constipation• Medication rationalization• Disposition planning
Med Consults
• Perioperative risk assessment• Respiratory issues requiring
close frequent monitoring• Management of
– Anticoagulation– Blood glucose– Electrolyte abnormalities– Acute kidney injury
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INPATIENTMSH/UHN Geri Med ConsultsMSH Geri Psych ConsultsMSH/TWH OrthogeriatricsMSH ACE Unit
Ben and Hilda Katz ACE Unit Built around Core Principles
1) Care is patient-centered2) Frequent medical review3) Early rehabilitation4) Planning for discharge is part of care5) 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-unitFox 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.
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• 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
ACE Unit Model
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• Shared care for complicated:– Mental health illnesses– Delirium– Behavioural & psychological symptoms of dementia
INPATIENTMSH/UHN Geri Med ConsultsMSH Geri Psych ConsultsMSH/TWH OrthogeriatricsMSH ACE Unit
Weekly Conjoint Geri Med – Geri Psych Rounds
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AMBULATORYMSH/TRI Geri Med Clinics
MSH Geri Psych ClinicTWH Memory Clinic
TGH Osteoporosis ClinicTRI 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
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AMBULATORYMSH/TRI Geri Med Clinics
MSH Geri Psych ClinicTWH Memory Clinic
TGH Osteoporosis ClinicTRI Falls Prevention Program
TRI Geriatric Day Hospital
Toronto Western HospitalWest Wing 5th Floor
Collaborative Multidisciplinary Clinic
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
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AMBULATORYMSH/TRI Geri Med Clinics
MSH Geri Psych ClinicTWH Memory Clinic
TGH Osteoporosis ClinicTRI Falls Prevention Program
TRI Geriatric Day Hospital
Toronto General Hospital, North Wing 7th Floor
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AMBULATORYMSH/TRI Geri Med Clinics
MSH Geri Psych ClinicTWH Memory Clinic
TGH Osteoporosis ClinicTRI Falls Prevention Program
TRI Geriatric Day Hospital
TRI Elm Street Entrance 1st Floor12 Week Falls Prevention Program
TRI 2nd Floor12 Week Geriatric Day Hospital
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COMMUNITYHome Based Primary/Geri Care
MSH Reitman CentreTemmy Latner Home Palliative Care
CCAC ICCP Partnership
http://www.seniorshousecalls.ca
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Catchment Area
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COMMUNITYHome Based Primary/Geri Care
MSH Reitman CentreTemmy Latner Home Palliative Care
CCAC ICCP Partnership
http://www.ccac-ont.ca/icc
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
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HOUSEKEEPING
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ConsultationsPlease send e-mail of new referrals to the
interprofessional geriatric medicine team
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Weekly Rounds
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Sign-out Lists
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“geriatrics”
Please update the sign-out list daily
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EDUCATION & TEACHING
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Education & Teaching
• Educational opportunities• Resident schedules and resources
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Educational Opportunities• Informal/bedside teaching• Geriatric giant seminars, journal club• Specialty seminars• Allied health professional teaching• General medicine rounds
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http://www.mountsinai.on.ca/education/geriatrics/resident-resources-and-schedules/
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Questions