Transcript MSH Orientation - Mount Sinai Hospital

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
• Existence for Geriatric Medicine
• Hazards of Hospitalization
• Continuum of Geriatric Models of Care
• Housekeeping
• Education & Teaching
GERIATRIC MEDICINE & THE
HAZARDS OF HOSPITALIZATION
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 / Immobilty
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
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
N=125
Covinksy et al., J Am Geriatr Soc 2003
35% Discharged
with Worse than
Baseline Function
N=799
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
CONTINUUM OF GERIATRIC
MODELS OF CARE
AMBULATORY
INPATIENT
MSH/UHN Geri Med Consults
MSH Geri Psych Consults
MSH/TWH Orthogeriatrics
MSH ACE Unit
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
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
ER
MSH/UHN GEM Nurses
MSH ER Geri Mental Health
ISAR (Identification of Seniors at Risk) Tool
Score > 2, at risk for functional decline, ED Visits, and hospitalization
McCusker et al, 1999
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
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
A Reactive Proactive Strategy
• Delirium prevention (NNT = 6) & management
• Functional recovery
• Pain management
• Falls prevention & bone health
• Disposition planning
Marcantonio et al, 2001; Siddiqi et al., 2009
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
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)
2)
3)
4)
5)
Care is patient-centered
Frequent medical review
Early rehabilitation
Planning for discharge is part of care
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.
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
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
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 floor
Dr. Goldlist, Dr. Ng, Dr. Sinha
Jacqueline (416) 586-4800 x 8563
Memory Clinic Initial Assessment
AMBULATORY
Reason for Referral:
MSH/TRI Geri Med Clinics
MSH Geri Psych Clinic
A.
History of Presenting Illness
TWH Memory Clinic
1.
What was the first sign that raised your concerns?
TGH Osteoporosis Clinic
TRI Falls Prevention Program
TRI Geriatric Day Hospital
Toronto Western Hospital
West Wing 5th Floor
When were memory difficulties first suspected?
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
Collaborative Multidisciplinary Clinic
OT
Geriatrician
·
Forget appointments
·
Forget events
·
Forget recent conversations
·
Misplace objects
·
Forget where parked car
·
Forget to pay bills
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
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
Falls Prevention Program Intake Assessment
Date:
Age:
TRI Falls Prevention Program
TRI Geriatric Day Hospital
RN
Addressograph
Falls History / History of Present Illness:
TRI Elm Street Entrance 1st Floor
12 Week Falls Prevention Program
Coping with Falling:
Past Medical & Surgical History:
TRI 2nd Floor
12 Week Geriatric Day Hospital
M | F
COMMUNITY
Home Based Primary/Geri Care
MSH Reitman Centre
Temmy Latner Home Palliative Care
CCAC ICCP Partnership
http://www.seniorshousecalls.ca
Catchment Area
COMMUNITY
Home Based Primary/Geri Care
MSH Reitman Centre
Temmy 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
HOUSEKEEPING
Consultations
Please send e-mail of new referrals to the
interprofessional geriatric medicine team
Weekly Rounds
Sign-out Lists
“geriatrics”
Please update the sign-out list daily
EDUCATION & TEACHING
Education & Teaching
• Educational opportunities
• Resident schedules and resources
Educational Opportunities
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•
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•
•
Informal/bedside teaching
Geriatric giant seminars, journal club
Specialty seminars
Allied health professional teaching
General medicine rounds
http://www.mountsinai.on.ca/education/
geriatrics/resident-resources-andschedules/
Questions