Making strides in health-care approaches for seniors

Teresa Kowalczyk, pictured above with her grandchildren, spent six weeks in Sunnybrook’s Intensive Care Unit after contracting bacterial meningitis. “[Staff] paid attention to my needs. After a few visits, I felt like I was at home,” she says. (Photography by Tim Fraser)

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For Teresa Kowalczyk, Sunnybrook’s approach to caring for seniors is not an abstract concept. It’s something that helped save her life.

In April 2009, she was rushed to the emergency department of her local hospital where she was diagnosed with bacterial meningitis, a disease that affects the membranes surrounding the brain and spinal cord. Left untreated, the disease can be fatal in a matter of hours. Patients can suffer damage to the brain after recovery, and speech and mobility can be permanently affected.

Teresa, now 79, was in the Intensive Care Unit (ICU) for six weeks, either unconscious or sedated. She then spent four months recovering at another facility before she entered Sunnybrook’s W. P. Scott Geriatric Day Hospital.

“When I came to Sunnybrook, I was shaking. I didn’t know what to expect, but they were very friendly and had patience with my disability,” says Teresa, who is still relearning some speech skills following her illness. “They paid attention to my needs. After a few visits, I felt like I was at home. There were many activities like physiotherapy and painting. Everyone has a smile on their faces, and they treated me with respect, as a normal person.”

For Teresa’s husband, Victor, it was a turning point. “Sunnybrook’s Day Hospital was the missing link,” he says. “That’s where Teresa started to be an independent person again. She can take Wheel-Trans by herself. She is gardening, she can walk to the hairdresser. I couldn’t imagine it when she could only move one finger [in the ICU]. The program is tremendous.”

As a senior citizen who spent many months under Sunnybrook’s care, Teresa’s case is typical of the demographic shift that is happening at hospitals across Canada.

Senior citizens are the fastest-growing age group in Canada, which means health-care professionals have to pay attention to the unique needs, opportunities and challenges presented by this bulging population cohort.

How significant is the greying of Canada? According to Statistics Canada, about five million Canadians were aged 65 or older in 2011. This number is now expected to double in the next 20 years, reaching 10.4 million seniors by 2036. From a health-care perspective, the aging of the baby boom generation, combined with an increase in life expectancy, means taking a different approach to patient care.

[mks_pullquote align=”left” width=”300″ size=”24″ bg_color=”#2f56a5″ txt_color=”#ffffff”]
“Sunnybrook’s Day Hospital was the missing link. That’s where Teresa started to be an independent person again.”
– Victor, Teresa Kowalczyk’s husband [/mks_pullquote]

In 2011, the most recent date for which statistics are available, 52 per cent of the patients served by Sunnybrook’s programs (excluding women and babies, and veterans) were over 65 years of age. Although seniors made up 14 per cent of the population in 2011, they accounted for 63 per cent of all in-patient days in Ontario.

Sunnybrook, which has a distinguished history of caring for seniors, recognized the population shift early and made senior-friendly care a priority almost a decade ago.

“It’s not just about being nice to older people,” says Dr. Barbara Liu, a geriatrician at Sunnybrook and executive director of the Regional Geriatric Program of Toronto. “Senior-friendly care requires a comprehensive approach to implementing best practices, providing an accessible environment, overcoming systemic barriers and addressing all aspects of care delivery, from attitudes to the emotional and behavioural side. Seniors often have the greatest needs, yet they are the most reluctant to ask for help.”

One of the challenging areas where Sunnybrook and other hospitals are making strides is with elderly patients who have delirium, an acute and fluctuating state of confusion characterized by inattention, disorganized thinking and changes to level of consciousness. New ways of treating delirium and reassessing current methods with an eye toward less reliance on drugs are aimed at improving outcomes for patients. This grew out of a concern that seniors, particularly those in long-term care facilities, are being overprescribed powerful medications that can have major side effects. A February 2016 report from the Canadian Institute for Health Information found that 39 per cent of long-term care residents were prescribed an anti-psychotic drug at least once in 2014.

The Sunnybrook senior-friendly team addressed the problem with a grant from the hospital’s Alternate Funding Plan (AFP) Innovation Fund to start its Anti-psychotic Stewardship Program.

“The program is a second look at elderly patients who are prescribed anti-psychotic medications, a class of drugs used to reduce or relieve symptoms of psychosis such as delusions or hallucinations,” says Deborah Brown, a nurse practitioner. “We’re piloting an anti-psychotic stewardship program which is the first of its kind in an acute care setting.”

Brown says delirium is preventable, but barriers persist, including gaps in understanding its root causes. She says simple things like speaking to community care providers and engaging more with family members of patients are critical to more person-centred care, rather than seeing someone solely as a patient.

“Using validated screening tools such as the Confusion Assessment Method [CAM], we can get a better idea if there has been changes to a patient’s baseline, which is how they were before they came to the hospital,” says Brown. CAM is a screening tool that allows clinicians to efficiently assess for the presence of delirium.

Another key area of focus is mobilizing patients early in their hospital stay. The act of walking or even moving from a hospital bed to a chair is better than bed rest and this has shown to reduce the incidence of delirium, as well as a reduced length of stay.

Keeping patients moving is especially important considering up to one-third of older patients experience a decline in their function as a result of being immobile during their hospital stay.

“Patients can lose 5 per cent of their muscle strength per day of bed rest, so the early mobilization strategy is critical, whether it’s a simple exercise or walking. It gets patients moving three times a day,” says Jocelyn Denomme, a physiotherapist and mobility lead for the Senior Friendly Strategy at Sunnybrook.

One of the keys to mobilizing elderly patients at Sunnybrook was the introduction of Healthy Stay Volunteers five years ago. Young people accompany patients on walks and help them navigate the hospital’s often busy corridors or help elderly patients stay oriented by paying friendly visits. What started out as a small program of about 40 to 50 people has grown into a major network of more than 600 volunteers.

Sunnybrook is also the co-lead site for Mobilization of Vulnerable Elders in Ontario (MOVE ON). The program promotes early and consistent mobilization of hospital patients throughout their hospital stay. MOVE ON grew from a joint initiative of Sunnybrook and St. Michael’s Hospital, to a 14-site provincial collaboration funded by the Council of Academic Hospitals of Ontario (CAHO). It has now reached beyond these 14 hospitals to include over 40 hospitals in Ontario.

Outside the hospital, Sunnybrook has formed partnerships with Emergency Medical Services (EMS) services in Toronto, and Halton and Peel regions to have hospital clinicians shadow paramedics during their calls in the community.

“This is a collaborative effort, to determine how we can better understand the person and how they were functioning prior to hospitalization, which is essential information for  care providers,” says Beth O’Leary, program manager, Senior Friendly Strategy & Best Practice Implementation. “This helps to guide the delivery of appropriate care and best practice.”

Dr. Liu says one of the keys to changing how health-care professionals deliver care to an aging population is changing our language and attitudes. “Ageism is one of the last accepted forms of discrimination, but I’m hopeful this will change because of the progress in other domains for example, how we talk about and view mental health and disability,” she says. “Hopefully, society will catch up on this issue, too.”

Looking after the health-care needs of seniors is a complex process with many challenges. Through innovative best practices, knowledge sharing and a return to some basic care approaches, Sunnybrook is helping to make an aging population’s golden years live up to their promise.

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Growing old gracefully

Veterans have fought in war, now they are facing new battles of deteriorating health and dementia.

That’s where Sunnybrook’s Veterans Centre plays an important role. Nestled on the hospital’s leafy grounds, it is the largest veterans’ care facility in Canada. Working in partnership with Veterans Affairs Canada, the Veterans Centre provides long-term care to 475 veterans from the Second World War and Korea.

Opened in 1948 by Prime Minister William Lyon Mackenzie King, Sunnybrook was originally founded as a hospital for war veterans, a place for the courageous men and women who served our country to heal and readjust to life at home.

Sunnybrook pioneered new procedures in the diagnosis of musculoskeletal problems, spinal cord injuries, cardiovascular conditions, plastic surgery and rehabilitation medicine for soldiers returning home with devastating injuries.

Today, residents live as independently as possible in the Kilgour wing, George Hees wing and the Dorothy Macham Home. Care is divided into four main categories: physical support, cognitive support, mental health support and palliative care (for veterans, as well as community patients). With the generous support of Veterans Affairs Canada, myriad unique recreation, music and art therapy programs and outings are an integral part of daily life and are designed to maximize quality of life for the residents.

Along with specialized cognitive support care units, the Dorothy Macham Home provides a therapeutic, home-like setting for 10 veteran residents who have aggressive behaviours related to dementia, and sometimes complicated by post-traumatic stress disorder. The unique design of the home was the result of extensive consultation with both national and international experts in dementia care.

Sunnybrook is committed to the welfare of Canada’s war veterans. If you would like more information about the Veterans Centre, visit sunnybrook.ca/veterans.

For eligibility and admission inquiries, please contact Veterans Affairs Canada directly at 1-866-522-2122.

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