1. 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

2. Outline Why Geriatrics? Continuum of Geriatric Models of Care Geriatric Medicine Consultation Service & Clinics Orientation Package Orthopedic & Physiatry Residents

3. WHY GERIATRICS?

4. 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

5. 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

6. 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 / Immobility Malnutrition / Dehydration Cognitive Dysfunction Medicines / Polypharmacy Procedures Palmer et al., 1998 (Modified) Conceptualizing Functional Decline

7. BaselineDischargeAdmission 70+ Pts N=2293 57% Stable45% Stable 20% Recovery 43% Decline 12% Hospital Decline 18% Fail to Recover Pre-Hospital Decline 5% Pre-Hospital and Hospital Decline 65% Discharged with Baseline Function 35% Discharged with Worse than Baseline Function Covinksy et al., J Am Geriatr Soc 2003 Trajectories of Functional Decline

8. Costs of Functional Decline The loss of independent functioning during hospitalization has been associated with: – Prolonged lengths of hospital stay – Increased readmission – A greater risk of institutionalization – Higher mortality rates Palmer et al., 1998

9. Comprehensive Geriatrics Assessment (CGA) “ … a multidisciplinary diagnostic process intended to determine a frail elderly person’s medical, psychosocial, and functional capabilities and limitations in order to develop an overall plan for treatment and long term follow up ” Rubenstein, 1982

10. CGA ID/RFRPMHxHPIMedications Functional History Social History Geriatric Review of Systems Cognitive Assessment Physical Examination Labs & Investigations Components of a CGA Confusion Assessment Method (CAM) Mini Mental Status Exam (MMSE) Montreal Cognitive Assessment (MoCA) Rowland Universal Dementia Assessment Scale (RUDAS) Geriatric Depression Scale (GDS) Mood & cognition Vision & hearing Falls Dysphagia Weight loss Bladder & bowel incontinence Pain Sleep Current living situation Family & community supports Advance care directives Powers of attorney General financial situation D ressing E ating A mbulating T oileting/transfer H ygiene S hopping H ousekeeping A ccounting F ood Prep/Meds T ransportation/Tele phone Activities of Daily Living (ADLs)

11. MSH & UHN GERIATRIC CARE CONTINUUM

12. COMMUNITY INPATIENT ER AMBULATORY MSH/UHN Geri Med Consults MSH Geri Psych Consults MSH/TWH Orthogeriatrics MSH ACE Unit TRI Geriatric Rehabilitation Unit MSH/TRI Geri Med Clinics MSH Geri Psych Clinic TWH Memory 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

13. GERIATRIC CONSULTATION SERVICE

14. Inpatient Geriatric Medicine Interprofessional team – Carm Marziliano, SW – Natasha Bhesania, PT – Chris Fan-Lun, Pharm Common Referrals from MSH, TGH, & PMH – Delirium & dementia – Functional decline, falls – Diagnostic/treatment challenge – Transition to outpatient & home-based services (House Calls) – Goals of care & disposition

15. Other Common Referrals Automatic consultations – Orthogeriatrics hip fracture patients – House Calls – ICCP GEM Flags Geriatric Psychiatry

16. Orthogeriatrics Automatic geriatric consultation for ALL fractured hip patients ≥65 years old * Orthopedic, Hospitalist, & Geriatric Medicine Co-Management Model Referrals – Staff automatic e-mail notification – Jeanette Villapando/Tammy Mok, x8419 – 11S, x4580 * Orthopedic residents focus on low trauma ( fragility ) hip fractures ( NOT high trauma, periprosthestic, or pathological ) but can be involved in medical & surgical cases for further learning

17. Delirium prevention & management Functional recovery Pain management Falls prevention & bone health Disposition planning A Proactive Strategy Marcantonio et al, 2001; Siddiqi et al., 2009 Reactive

18. 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)

19. Fractured Hip Patients Geriatrics Mental status – Delirium – Pre-admission cognition – Mood Falls Bone Health Pain and nausea Constipation Medication rationalization Disposition planning Hospitalist & Med Consults Perioperative risk assessment Respiratory issues requiring close frequent monitoring Management of – Anticoagulation – Blood glucose – Electrolyte abnormalities – Acute kidney injury

20. http://www.seniorshousecalls.ca House Calls (HC) Home based primary care for homebound seniors living within the central LHIN catchment area Types of consultations: – New Patient Referral to HC Complete & fax HC’s referral form (including geriatrics consultation note & discharge summary ) – Existing HC patients who are admitted to MSH Staff e-mail notification when HC patient arrives to ER Automatic but limited consultation for MRP co-management and support Upon discharge, fax discharge summary and geriatric notes to HC

21. http://www.ccac-ont.ca/icc Integrated Client Care Project (ICCP) Intensive CCAC case management for the most complicated patients living in the community Close collaboration with Primary Care, Psychiatry, Geriatrics Referrals – Staff e-mail notification when ICCP patient arrives in ER – Automatic consultation for MRP co-management and support

22. Check GEM flags daily Review GEM nursing notes in Powerchart for GEM flagged patients – Open patient chart  Clinical Notes  GEM Nursing notes Liaise with admitting team and offer geriatric support if needed GEM Flags

23. Geriatric Psychiatry Consult Service Shared care for complicated: – Mental health illnesses – Delirium management – Behavioural & psychological symptoms of dementia

24. Consultations E-mail new referrals to the interprofessional geriatric medicine team at MSH & TGH respectively

25. Consultations Always record consult date, start, and stop time on your consult note Store carbon copy of completed consults in the filing cabinet (middle drawer) in alphabetical order

26. Consult Recommendations AVOID consult SUGGEST orders – Miscommunication – Delays in patient care Always best to communicate recommendations directly to referring team Direct order entry for geriatric related issues on fractured hip patients

27. Sign-out Lists

28. “geriatrics” *** ALWAYS UPDATE THE SIGN-OUT LIST ***

29. OUTPATIENT GERIATRIC & SPECIALTY CLINICS

30. Clinic Please check your schedules & be on time for your clinic, as patients have been scheduled for you in advance

31. Geriatric Medicine Clinics TRI Outpatient Clinics Ground Floor (Elm Street Entrance) Drs. Alibhai, Berger, Chau, Liberman Ramona Gheorghe, NP, & Katie Stock, SW UC Outpatient Physician Clinics Admin (416) 597-3422 x 4200 MSH AIMGP Area 4 th floor Drs. Goldlist, Ng, Sinha Chris Fan-Lun, Pharmacist Stephanie (416) 586-4800 x 8563 * Please ensure you obtain an MSH and/or UHN dictation code at the beginning of your rotation *

32. Collaborative multidisciplinary assessment of memory disorders beyond the MMSE/MoCA Arrive at 1:00 pm sharp in the West Wing on the 5 th Floor Collaborative Multidisciplinary Clinic Neuropyschologist/OT/SWCognitive testing GeriatricianMedical history, Rx, non-neuro physical exam Behavioural NeurologistNeuro exam Geriatric PsychiatristPsychiatric history One of the aboveFamily gives collateral Multidisciplinary Team Meeting TWH Memory Clinic

33. Focused assessment of falls in older adults – Multidisciplinary intake assessment for consideration of a 12 Week Falls Prevention Program Arrive at 1:00pm sharp for clinic orientation Located in the outpatient clinic area on the ground floor (Elm Street entrance) TRI Falls Prevention Clinic

34. ORIENTATION PACKAGE

35. Orientation Package Personalized schedule ( review daily ) – Clinical activity (e.g. clinics) – Weekly Rounds – Education & Teaching opportunities – End of Rotation Debrief & Feedback On Call Schedules * Reminder: new consult e-mail notifications Orientation manual – Includes Falls & Memory Clinic orientation materials References & Resources

36. Weekly Rounds Attended by: House Calls (Emma) ICCP (Debbie) ACE (Rebecca) Attended by: Hospitalist

37. Educational Opportunities Informal/bedside teaching Geriatric giant seminars, Geriatric Psychiatry, Journal club Specialty seminars Allied health professional teaching General medicine, grand, & osteoporosis rounds

38. Resident Geriatric Office Office workspace for you and others during your rotation, so please keep it clean and tidy Obtain an office key from Phoebe Tian – $20 deposit - - returned at the end of rotation Always lock the door and turn off the lights if you are the last one in the office

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

40. ADDITIONAL NOTES FOR ORTHOPEDIC & PHYSIATRY RESIDENTS

41. Orthogeriatric Resident Schedule 2 weeks hospitalist then 2 weeks geriatric medicine Mandatory clinics & programs during your rotation – Falls Prevention Clinic – Geriatric Day Hospital Additional medical consults teaching 1 Weekend Home Call shift (see next slides)

42. Physiatry Resident Schedule 8 Week block – 2 Weeks acute care geriatrics at MSH/UHN – 3 Weeks rehabilitation at TRI Separate TRI Orientation upon start at TRI – 3 Weeks outpatient clinics & community experiences 1 Weekend Home Call shift

43. Weekend Home Call Geriatric medicine staff receives e-mail notification of new orthogeriatrics (and surgical) referrals and will divvy consults to the orthopedic resident on call Contact your on-call staff prior to the weekend to exchange contacts

44. Thank You & Enjoy Your Rotation! Questions?