1. TWH Orientation Geriatric Medicine

2. Why Geriatrics? The MSH-UHN Continuum of Geriatrics Housekeeping Educational Opportunities

3. Ageing and Hospital Utilization in Central Toronto LHIN, 2005 NumberAge <65Seniors 65 +% Seniors 75+ 2005 Population1,142,46987%13%49% Emergency Room Visits321,04479%21%62% Acute Hospitalizations78,02563%37%64% w/ Alternate Level of Care Days4,26317%83%76% w/ Circulatory Diseases10,36132%68%65% w/ Respiratory Diseases5,92843%57%73% w/ Cancer6,74353%47%54% w/ Injuries5,80958%42%71% w/ Mental Health6,16187%13%59% Inpatient Rehabilitation3,36825%75%66% Toronto Central LHIN, 2006

4. 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

5. Conceptualizing Functional Decline Functional Older Person Acute Illness + Possible Impairment Depressed Mood Negative Expectations Physical Impairment and Deconditioning Dysfunctional Older Person The Hazards of Hospitalization Hostile Environment Depersonalization Bedrest / Immobilty Malnutrition / Dehydration Cognitive Dysfunction Medicines / Polypharmacy Procedures Palmer et al., 1998 (Modified)

6. Trajectories of Functional Decline BaselineDischargeAdmission 70+ Pts N=2293 57% Stable N=1311 45% Stable N=1039 20% Recovery N=455 43% Decline N=982 12% Hospital Decline N=272 18% Fail to Recover Pre-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 Function N=799 Covinksy et al., J Am Geriatr Soc 2003

7. 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

8. COMMUNITY INPATIENT ER AMBULATORY 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 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 Mount Sinai / UHN Geriatrics Continuum

9. 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, 8 th Floor Room 410

10. 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

11. INPATIENT MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit “On-Call” person is paged Add to signout + email to group Email to group Referral Process (Sometimes you will be the “on-call” person even if you are assigned to be in clinic…)

12. 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

13. 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)

15. Fractured Hip Patients: Geri vs. Med Consults Geriatrics Mental status –delirium –pre-admission cognition –mood 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

16. 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 4 th floor Dr. Goldlist, Dr. Ng, Dr. Sinha Jacqueline (416) 586-4800 x 8563

17. 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 5 th Floor OTCognitive testing GeriatricianMedical history, Rx, non-neuro physical exam Behavioural NeurologistNeuro exam Geriatric PsychiatristPsychiatric history One of the aboveFamily gives collateral Multidisciplinary Team Meeting

18. 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 7 th Floor

19. 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 Elm Street Entrance 1 st Floor Intake Assessment to 12 Week Falls Prevention Program TRI 2 nd Floor 12 Week Geriatric Day Hospital RNHPI, Past Medical History, Orthostatic vitals, Weight PharmacistRx PTSocial History, Cognitive Ax, MSK + Power Exam, Gait Assessment GeriatricsPhysical Examination Other Than MSK, Power and Gait Ax Multidisciplinary Team Meeting

20. AMBULATORY MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory Clinic TGH Osteoporosis Clinic TRI Falls Prevention Program TRI Geriatric Day Hospital RNHPI, Past Medical History, Orthostatic vitals, Weight PharmacistRx PTSocial History, Cognitive Ax, MSK + Power Exam, Gait Assessment GeriatricsPhysical Examination Other Than MSK, Power and Gait Ax Multidisciplinary Team Meeting

21. COMMUNITY Home Based Primary/Geri Care MSH Reitman Centre Temmy Latner Home Palliative Care CCAC ICCP Partnership http://www.seniorshousecalls.ca

22. COMMUNITY Home Based Primary/Geri Care MSH Reitman Centre Temmy Latner Home Palliative Care CCAC ICCP Partnership http://www.seniorshousecalls.ca

23. COMMUNITY Home Based Primary/Geri Care MSH Reitman Centre Temmy Latner Home Palliative Care CCAC ICCP Partnership

24. ER MSH/UHN GEM Nurses MSH ER Geri Mental Health Prog

25. House Keeping: Rounds UHN Rounds

26. House Keeping: Sign-out Lists

28. Educational Opportunities

29. http://www.mountsinai.on.ca/education/ geriatrics/resident-resources-and- schedules/

30. Questions?