Early Intervention the Key to Geriatric Assessment: Geriatric Assessment Outreach Teams
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1 Early Intervention the Key to Geriatric Assessment: Geriatric Assessment Outreach Teams
2 Regional Geriatric Program of Eastern Ontario Outpatient Clinics Geriatric Rehabilitation Unit Community Referrals Hospital Referrals Outreach Assessment Teams Geriatric Assessment & Treatment Consultation Services Day Hospitals Geriatric Assessment Units
3 Geriatric Assessment Outreach Teams East GAOT: East of Bronson West GAOT: West of Bronson
4 Who we are Healthcare Professionals We visit people 65 and over in their home for a comprehensive assessment. (Bilingual/Cultural Interpretation) We accept referrals from physicians, relatives, healthcare professionals (GEM, CCAC ) and individuals themselves. Only one team member visits the person in their home.
5 Geriatric Assessment Outreach Teams Referral sources (April 2010 March 2011) combined East West MD sp CCAC other GEM Tot.
6 Geriatric Outreach Assessment Team Members Office Support Ø Intake Co-ordinator Assessors: Ø Nurses Ø Occupational Therapists Ø Physiotherapists Ø Social Workers Clinical Consultant Ø Geriatrician
7 Major Functions Entry point for referrals from the community to access Specialized Geriatric Services. Clinical teaching/training Education (Seniors and caregivers) Evaluation and research
8 Our Goal To help improve quality of life and to promote health, independence and safety in order to help seniors to remain in their own surroundings as comfortably and as long as possible.
9 What we Do Provide comprehensive multidimensional screening assessment Work with other health services, community agencies and Family Physician to help keep seniors as independent as possible in the community for as long as possible. Refer client for further assessment and treatment.
10 When to refer 1. Recent onset of one or more of the Geriatric Giants Cognitive Impairment Falls Incontinence Impaired mobility Decreased function Polypharmacy 2. Major changes in support needs 3. Safety concerns 4. Frequent use of the health care system 5. Multiple complex medical problems
11 What to expect from the visit Multi-dimensional screening assessment incorporating aspects of physical, cognitive, psychosocial factors, functional abilities and environment. Consultation with Family Physician, Community Services, Family Members/Caregivers and others as needed. Case Conference with Geriatricians and Team Members Written Summary and Recommendations
12 Top 10 Health Concerns n=1,540 patients Percent Cognitive Change* Mobility Falls Caregiver Stress IADLs Future Planning ADL Mood ** Pain Nutrition/Wght Loss
13 Geriatric Assessment Outreach Teams Post recommendations (April 2010 March 2011): combined Bruyere DH QCH DH Civic D.H Clinic GPCSO ROH CCAC G.P. other
14 Age Distribution Today, clients seen by Outreach are older. The average age has increased from 80.3 years in to 82.7 years in The percentage of patients 85 yrs+ rose from 27.8 to 40.2 during this same period , n= , n= % 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% < 70 yrs Age Group
15 Case study #1 Mr. M. Referral from Family Physician
16 Situation at time of referral 85 y.o. gentleman living with wife Supportive children in area Referred by family physician for assessment of function Client s concerns: Mobility and balance Tremors Difficulty swallowing Wife and son s concerns: 2 year decline in STM Increased appetite and strong craving for sweets
17 Medical history: CVA & MI - previous year Bipolar disorder AAA Hip fractures Peptic ulcer disease Irregular heart beat
18 Medications: Lithium carbonate Vitamin B1 ASA Calcium with Vit D
19 Issues identified during GAOT assessment: Cognition Behaviour Mobility Falls Tremors Swallowing difficulty Function
20 Recommendation from case conference: Geriatric Day Hospital
21 Geriatric Day Hospital Seen by : Geriatrician Nurse Occupational therapist Physiotherapist Speech therapist Social Worker Family conference prior to being discharged from Day Hospital.
22 Geriatric issues addressed: Cognition: New diagnosis Stroke dementia Mobility and Fall risk: Severe gait and balance changes ADP papers completed walker Exercise program provided Fall prevention strategies given Paratranspo application completed
23 Geriatric issues addressed (cont) ADLs: Found to have fine motor strength and control issues Recommendations given re: equipment needs and cueing for hygiene routine and consistent, structured daily and weekly routines. Swallowing changes: Swallowing assessment done/videofluoroscopy Found to have mild to moderate dysphagia New upper dentures recommended Softer chewable foods and regular liquids recommended
24 Geriatric issues addressed (cont) Community Support and Future planning CCAC referral for weekly bathing and Day Program application Telephone number for Abbotsford House Recommendation for relocation List of retirement homes given to family Referral to Alzheimer Society s First Link Program Safety Blister pack with monitoring Assistance with financial activities Post 911 by all phones Have upper denture replaced Follow swallowing guidelines
25 Case study #2 Mrs. D. Referral from CCAC
26 Situation at time of referral 72 y.o. married woman Husband in hospital awaiting placement Son lives on 2 nd floor of home in a separate apartment First language is Portuguese Referred by CCAC case manager for assessment of cognition, multiple medical problems, caregiver stress and risk Services in place: Help with bathing once per week She denied any problems. Focused on her husband. Son concerned about her mood.
27 Medical history Breast cancer Osteoarthritis Osteoporosis Right total hip replacement Fractured foot
28 Medication: Calcium Femara Zoplicone Lenoltec No. 1 Lorazepam
29 Issues identified during GAOT assessment: Mood Cognition
30 Recommendations from case conference: Psychiatric consultation. Geriatrician suggested blood work and CT of head for family physician to consider.
31 Outcome Psychiatric consultation: Diagnosed with Major depressive disorder with prominent anxiety symptoms. She was enrolled in the ROMHC day hospital A trial of Mirtazapine was started Follow up appointment was booked Geriatric psychiatrist planned to follow Mrs. D. until she had a good response to her antidepressant and her depression was in remission.
32 Case study #3 Mrs. X Referral from Director of Care of a retirement home
33 Situation at time of referral 84 y.o. widowed woman Supportive brother and sister-in-law Living at a retirement home x2 months Referred by Director of care for assessment of Behaviour, Cognition, Mood, Function and Medication review. Need for Long term care Brother and s-i-l s concerns: Mood and Cognition Mrs. X. s concerns: Unable to identify
34 Medical history: Stroke Atrial fibrillation CAD with chest pain at night when off the Nitro patch Hypertension Dementia Recent UTIs OA OP GERD Diverticulosis Zenker s diverticulum Left mastectomy
35 Medication Haloperidol Lorazepam Trazodone (PRN) Aricept ASA Norvasc Metropolol Nitro-Dur patch Nitro spray (PRN) Omeprazole Domperidone Acetaminophen (PRN) Ibuprofen (PRN)
36 Issues identified during GAOT assessment Behaviour Mood Function Cognition Weight loss Tremor Pain Falls/mobility Fatigue Future planning
37 Recommendation from case conference Geriatric Day Hospital for assessment of possible delirium, possible depression and medication review.
38 Geriatric Day Hospital At first visit to the Day Hospital it was determined that her presentation was too complex to sort out on an outpatient basis therefore an admission to the In-Patient geriatric assessment unit was arranged within the next week.
39 Issues addressed by GAU (Inpatient) Cognition Mood Cardiac status Mobility Plan at discharge: Follow up with Geriatric Psychiatry as out-patient
40 Other Important Changes in the Outreach Client Profile Client is: (%) (%) Living alone Living in a retirement home/ residence Referred by GEM
41 Summary Key Messages: Ask WHY? Early identification leads to early intervention/ treatment (reversibility) Potential delay/avoidance of placement (LTC) or relocation. Decrease in hospital utilization (ED visits and hospital admissions). Ensuring that caregivers know what they are dealing with (facing) and what to expect in the future so that they know where to get the necessary supports for themselves and their loved ones preventing crisis situations. Preventing the preventable
42 Lisa Murphy Geriatric Assessor West Geriatric Assessment Outreach Team Louise MacDonald Geriatric Assessor East Geriatric Assessment Outreach Team , ext
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