Division of Geriatric Medicine

Head of Division & Senior Consultant 

• Associate Professor Reshma Merchant  

Senior Consultant 

• Dr Ng Shu Ee  

Consultants 

• Dr Wong Ling Ling Beatrix
• Dr Chen Zhixuan Matthew 
• Dr Ling Mun Wai Natalie 
• Dr Lim Zhiying 

Associate Consultant 

• Dr Ho Wen Teng Vanda  

Senior Residents 

• Dr Anandraj Selva Rajoo 
• Dr Michelle Chan 
• Dr S Nachammai Vidhya 
• Dr Xavier Tay 

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• Emergency Department 
• Inpatient Care and Elderly Care Bundle 
• The SILVER Unit 
• OrthoGeriatric Service 
  

Outpatient Care

• Geriatric Assessment Clinic 
• Geriatric Oncology (GOLDEN) 
• Rapid Access Care for Elders (RACE) Clinic 
• Successful Ageing and Fitness Evaluation (SAFE) Clinic

Emergency Department

Geriatric Emergency Medicine (GEM) Nurse service at NUH aims to provide exceptional geriatric care from the onset of a patient's journey. Patients with a Clinical Frailty Scale (CFS) score of 4 or higher are referred to a GEM nurse for screening prior to discharge. GEM nurses, skilled in conducting CGAs, are adept at identifying specific care needs, reinforcing patient and family education and arranging appropriate discharge referrals. This approach ensures a safe transition of care from the hospital to the community and helps reduce frequency of older adults re-attending the Emergency Department. 

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Inpatient Care and Elderly Care Bundle 
Our Geriatric interdisciplinary team is dedicated to advancing the care of older adults admitted to the hospital. This is achieved through hospital-wide initiatives, such as the Nurses Improving Care for Healthsystem Elders (NICHE) programme and the implementation of the Elderly Care Bundle, along with active participation in the Multidisciplinary Inpatient Falls Prevention Workgroup.  

The NICHE programme, an international nursing education and consultation initiative, is designed to improve geriatric care. Central to this programme is the Geriatric Resource Nurse Model, which empowers Registered Nurses to serve as unit-based resources for geriatric nursing care issues and standards. Through NICHE, we have developed Geriatric Resource Nurses (GRNs) who are now present in most adult wards. They conduct CGAs, advise on nursing care management for older patients with complex needs, and uphold geriatric care nursing standards. Additionally, they play a key role in coordinating care within the ward. 

For older adults admitted to the wards, the Elderly Care Bundle is implemented. This bundle comprises a set of care protocols derived from established and/or evidence-based practices. It aims to prevent functional decline, falls, delirium, and manage continence and other hospital-acquired complications in older patients. It enables nurses to initiate interventions based on identified or potential issues. 

TheElderly Behavioural Support (EBS) service, a nurse-led initiative, offers ongoing advice and education for healthcare professionals and caregivers on managing behavioural issues in older patients with cognitive impairment. Incorporating the principles of Montessori-based Dementia Programming, the EBS service strives to reduce restraints, caregiver stress and falls in confused older patients. The Geriatric team also leads the Multidisciplinary Inpatient Falls Prevention Workgroup. Over the years, we have observed a decline in inpatient falls rates. 

Additionally, the Acute Care of the Elderly (ACE) model of care is implemented for patients admitted to the Geriatric ward under our team's care. Every older patient receives reality orientation, adequate hydration, bowel management and early mobilisation, all aimed at preventing delirium and functional decline. Each patient's Activities of Daily Living (ADLs) Board is updated by rehabilitation therapists to guide healthcare providers in engaging patients in recommended activities and assisting them with appropriate assistive aids. Patients with high falls risk are closely monitored, and those who are confused and agitated receive specialised care in designated cubicles. For cognitive stimulation, patients, especially those with cognitive impairment, participate in structured cognitive therapy. All patients are informed about healthy ageing initiatives, including vaccinations for influenza and pneumonia. 

The SILVER Unit  
Our acute geriatric ward features a SILVER Unit (Specialized Innovative LongeVity and Elderly Recovery), specifically designed to care for older adults experiencing confusion and admitted for delirium. The staff in this unit receive specialised training and implement a comprehensive, multidisciplinary patient care programme that ensures the early resolution of delirium and prevents functional decline. Emphasising a restraint-free environment, the unit prioritises individualised and person-centred care, actively involving and educating families in the care process. Patients benefit from daily activities, orientation sessions, and music therapy, and are encouraged to dine and socialise in a communal area. The unit also includes an en-suite activity room, complete with a reminiscence corner, catering specifically to patients with memory issues. 

The unit was honoured to host Mdm President Halimah Yacob during her official visit to the hospital on 19 September 2017. For more details about the President’s visit and her interaction with our patients, click here. 

For more information about our SILVER Unit, please click here. 

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OrthoGeriatric Service 

The NUH OrthoGeriatrics service is a co-management model between Geriatric Medicine and Orthopaedic Surgery, based on evidence-based practices. It comprises a dedicated and expert multidisciplinary team providing holistic care to patients aged 65 years and above with fragility fractures. Our approach, integrating comprehensive geriatric assessment and collaborative care, has proven effective in reducing in-hospital complications, length of stay and mortality, particularly in older adults with hip fractures. This service is essential for ensuring a seamless transition from pre-surgery preparation through to rehabilitation and recovery. Our fast-track hip fracture pathway to our partner community hospital, St Luke's Hospital, facilitates specialised and expedited rehabilitation for better recovery outcomes. 

Care in the Community  
Our team actively provides support and consultation to the NUHS Regional Health System's Community Care Team - Hospital to Home programme, which provides continued care for homebound patients discharged from the hospital, ensuring a smooth transition to home. It encompasses clinical, nursing, rehabilitation and psychosocial support for patients, their family members and caregivers. 

Our doctors also work closely with community partners to facilitate ageing in place for older adults. 

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Outpatient Care 
Geriatric Assessment Clinic  
The clinic offers comprehensive geriatric assessments to address the complex care needs of older adults. This service is beneficial for individuals who: 

Are aged 75 years and above 
Experience complex health problems and atypical symptoms, such as functional decline, memory loss, weight loss, urinary incontinence and overall decline in personal well-being 

 During the initial visit: 

A comprehensive geriatric assessment, considered the gold standard in older adult care, will be conducted 

If necessary, the Geriatrician may request further investigations and/or refer patients to relevant allied health professionals for additional management 

The Geriatric team will provide advice and counselling on healthy ageing, including recommended vaccinations for flu and pneumonia. 

Subsequent visits will be tailored based on the nature and complexity of the individual's problems. 

For information on our outpatient services, including contact details, operating hours and directions to 13b Medicine Clinic, click hhere to learn more. 

Rapid Access Care for Elders (RACE) clinic 
The RACE clinic offers a fast-track service for early medical review of stable older adults who seek medical attention at the Emergency Department. Patients deemed stable enough for outpatient treatment may be referred by emergency doctors to the RACE clinic, with the aim of reducing unnecessary ward admissions.   

Successful Ageing and Fitness Evaluation (SAFE) Clinic 

The SAFE clinic, catering to adults aged 75 years and above, specialises in preventing frailty, falls, and sarcopenia. Our multidisciplinary and multi-specialty team, including physiotherapists, occupational therapists, dietitians and geriatricians, focuses on strengthening patients and reducing their risk of falls and frailty. 

The team provides comprehensive and personalised assessments, optimises chronic medical conditions, offers individualised nutrition advice and works to enhance patients’ physical and functional abilities. Click here to learn more. 

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The Division of Geriatric Medicine at NUH focuses its research efforts on extending the healthspan, preventing frailty and disability, and enhancing the quality of life for older adults. Our research encompasses a wide range, from prevention to end-of-life care, and from basic science to translational research and population health improvement. Our team is actively engaged in clinical research on value-based care and oncogeriatric and orthogeriatric subspecialties, with a strong emphasis on early access, holistic clinical management and the right siting of care. To achieve this, we work closely with basic scientists, clinical and community partners, maintaining a translational perspective to achieve tangible benefits for older adults. Our research focuses on two main areas: 

1)     Physical frailty
Physical frailty, characterised by weight loss, low grip strength, exhaustion, slow gait speed and low physical activity, is a common issue among older adults and a significant contributor to functional decline and early mortality. Our approach to addressing this geriatric syndrome is multi-pronged: 

(A)   Detection 
We have developed an innovative web-based application for use in primary care and community settings to facilitate the timely identification of older adults living with pre-frailty1. This early detection allows for preventive and proactive care, enabling older adults to age in place without disability. This research project is a collaboration with the National University Polyclinic (NUP), Jurong Community Hospital (JCH), NUS’s Saw Swee Hock School of Public Health (SSHSPH) and NUS Engineering. 

(B)   Exercise 
Physical exercise and memory training have been found beneficial in preventing and delaying dementia and frailty. Our HAPPY (Healthy Aging Promotion Programme for you) community programme combines physical exercise (stretching, aerobic, resistance and balance), cognitive training and self-empowerment (www.straitstimes.com/singapore/programme-launched-to-help-frail-senior-citizens-maintain-mental-and-physical-health ). It is currently implemented in over 15 sites island-wide, in collaboration with community partners, and includes an ongoing volunteer training programme. During the COVID-19 pandemic, we successfully transitioned to an online platform to maintain the continuity of the programme. Participation in this programme has been shown to reduce the risk of depression and improve physical and cognitive function, as well as quality of life2. 

Credit: todayonline 

(C)  Nutrition 
Healthy ageing, as defined by the World Health Organisation in 2015, involves maintaining functional abilities for well-being in old age. Nutrition, particularly a high-protein diet, plays a crucial role in longevity and health span, stimulating muscle protein synthesis and helping delay the onset of frailty and/or sarcopenia. The Healthy Older People Everyday (HOPE) - Role of High Protein Diet in Reduction of Frailty and Sarcopenia project evaluates the acceptability and effectiveness of a high-protein diet in improving function and reducing disability among community-dwelling seniors. This research project is in collaboration with the Health Promotion Board (HPB) and SSHSPH. 

2)     Immunosenescence
Immunosenescence, the age-related decline in the immune system characterised by chronic inflammation throughout the body, increases the risk of infection and severity of infections in older adults and diminishes responses to vaccination. This area of study has become particularly crucial during the COVID-19 pandemic. We are conducting an in-depth basic science study examining the local older population’s response to COVID-19 mRNA vaccination. The findings of this study will help us understand the mechanisms behind poorer vaccination responses in older adults and identify potential targets for intervention. 

References 

1. Merchant et al. Rapid Geriatric Assessment Using Mobile App in Primary Care: Prevalence of Geriatric Syndromes and Review of Its Feasibility. Front Med (Lausanne). 2020 Jul 8;7:261. 
2. Merchant et al. Community-Based Peer-Led Intervention for Healthy Ageing and Evaluation of the "HAPPY" Program. J Nutr Health Aging. 2021;25(4):520-527. 

Selected List of Publications 
Publications 
1.     Merchant RA, Ho VWT, Chen MZ, Wong BLL, Lim Z, Chan YH, Ling N, Ng SE, Santosa A, Murphy D, Vathsala A. Outcomes of Care by Geriatricians and Non-geriatricians in an Academic Hospital. Front Med (Lausanne). 2022 Jun 6;9:908100. doi: 10.3389/fmed.2022.908100. PMID: 35733862; PMCID: PMC9208654. 

2.     Merchant RA, Aprahamian I, Woo J, Vellas B, Morley JE. Editorial: Resilience And Successful Aging. J Nutr Health Aging. 2022;26(7):652-656. doi: 10.1007/s12603-022-1818-4. PMID: 35842754; PMCID: PMC9209635. 

3.     Chen MZ, Chan YH, Wong MWK, Merchant RA. Comparison of Rapid Cognitive Screen against Montreal Cognitive Assessment in screening for cognitive impairment in the old and old-old. Psychogeriatrics. 2022 Jul;22(4):460-468. doi: 10.1111/psyg.12841. Epub 2022 May 16. PMID: 35577347; PMCID: PMC9325369. 

4.     Ho V, Merchant RA. The Acceptability of Digital Technology and Tele-Exercise in the Age of COVID-19: Cross-sectional Study. JMIR Aging. 2022 Apr 13;5(2):e33165. doi: 10.2196/33165. PMID: 35294921; PMCID: PMC9009381. 

5.     Merchant RA, Seetharaman S, Au L, Wong MWK, Wong BLL, Tan LF, Chen MZ, Ng SE, Soong JTY, Hui RJY, Kwek SC, Morley JE. Relationship of Fat Mass Index and Fat Free Mass Index With Body Mass Index and Association With Function, Cognition and Sarcopenia in Pre-Frail Older Adults. Front Endocrinol (Lausanne). 2021 Dec 24;12:765415. doi: 10.3389/fendo.2021.765415. PMID: 35002957; PMCID: PMC8741276. 

6.     Ng ZX, Zheng H, Chen MZ, Soon YY, Ho F. Comprehensive Geriatric Assessment guided treatment versus usual care for older adults aged 60 years and above with cancer. Cohrane Database of Systematic Reviews. 2021(10). doi: 10.1002/14651858.cd014875 

7.     Izquierdo M, Merchant RA, Morley JE, et al. International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines. J Nutr Health Aging. 2021;25(7):824-853. doi: 10.1007/s12603-021-1665-8. PMID: 34409961. 

8.     Merchant RA, Chan YH, Hui RJY, Tsoi CT, Kwek SC, Tan WM, Lim JY, Sandrasageran S, Wong BLL, Chen MZ, Ng SE, Morley JE. Motoric cognitive risk syndrome, physio-cognitive decline syndrome, cognitive frailty and reversibility with dual-task exercise. Exp Gerontol. 2021 Jul 15;150:111362. doi: 10.1016/j.exger.2021.111362. Epub 2021 Apr 19. PMID: 33887381. 

9.     Merchant RA, Tsoi CT, Tan WM, Lau W, Sandrasageran S, Arai H. Community-Based Peer-Led Intervention for Healthy Ageing and Evaluation of the 'HAPPY' Program. J Nutr Health Aging. 2021;25(4):520-527. doi: 10.1007/s12603-021-1606-6. PMID: 33786571; PMCID: PMC7883995. 

10.  Ho V, Chen C, Ho S, Hooi B, Chin LS, Merchant RA. Healthcare utilisation in the last year of life in internal medicine, young-old versus old-old. BMC Geriatr. 2020 Nov 23;20(1):495. doi: 10.1186/s12877-020-01894-0. PMID: 33228566; PMCID: PMC7685638. 

11.  Merchant RA, Chen MZ, Wong BLL, Ng SE, Shirooka H, Lim JY, Sandrasageran S, Morley JE. Relationship Between Fear of Falling, Fear-Related Activity Restriction, Frailty, and Sarcopenia. J Am Geriatr Soc. 2020 Nov;68(11):2602-2608. doi: 10.1111/jgs.16719. Epub 2020 Aug 17. PMID: 32804411. 

12.  Ho VWT, Chen C, Merchant RA. Cumulative Effect of Visual Impairment, Multimorbidity, and Frailty on Intrinsic Capacity in Community-Dwelling Older Adults. J Aging Health. 2020 Aug-Sep;32(7-8):670-676. doi: 10.1177/0898264319847818. Epub 2019 May 8. PMID: 31068051. 

13.  Merchant RA, Hui RJY, Kwek SC, Sundram M, Tay A, Jayasundram J, Chen MZ, Ng SE, Tan LF, Morley JE. Rapid Geriatric Assessment Using Mobile App in Primary Care: Prevalence of Geriatric Syndromes and Review of Its Feasibility. Front Med (Lausanne). 2020 Jul 8;7:261. doi: 10.3389/fmed.2020.00261. PMID: 32733901; PMCID: PMC7360669. 

14.  Merchant RA, Chen MZ, Ng SE, Sandrasageran S, Wong BLL. Letter to the Editor: The Role of a Geriatrician Has Become Even More Important in an Academic Institution during COVID-19. J Nutr Health Aging. 2020;24(6):681-682. doi: 10.1007/s12603-020-1387-3. PMID: 32510123; PMCID: PMC7220849. 

15.  Merchant RA, Chen MZ, Tan LWL, Lim MY, Ho HK, van Dam RM. Singapore Healthy Older People Everyday (HOPE) Study: Prevalence of Frailty and Associated Factors in Older Adults. J Am Med Dir Assoc. 2017 Aug 1;18(8):734.e9-734.e14. doi: 10.1016/j.jamda.2017.04.020. Epub 2017 Jun 13. PMID: 28623152. 

16. Wong BLL, Chan YH, O'Neill GK, Murphy D, Merchant RA. Frailty, length of stay and cost in hip fracture patients. Osteoporos Int. 2023 Jan;34(1):59-68. Doi: 10.1007/s00198-022-06553-1. Epub 2022 Oct 5.  

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• Alzheimer’s dementia 

• Infections (senior may not always exhibit a fever but rather a change in mental status)
• Medications, especially those with a high anticholinergic load
• Pain 
• Dehydration
• Constipation 

• Environmental changes, such as hospitalisation
• Use of multiple medications 
• Existing underlying dementia
• Poor eyesight or hearing  

• Addressing the underlying cause. Alongside acute treatment, we support patients by maintaining a calm environment, orienting them to their surroundings and explaining the reason for their hospital stay
• Alleviating pain and minimising discomfort
• Encouraging a regular sleep-wake cycle when possible
• Making hearing aids and eyeglasses available if the patient uses them at home
• Removing barriers and restraints, including urinary catheters, where possible
• Promoting mobility and cognitive activities 

• Balance problems and muscle weakness 
• Poor vision
• Impaired sensation or foot pain 
• Long-term health conditions, such as heart disease, dementia or low blood pressure
• Vitamin D deficiency 
• Medications affecting attention (e.g. opioid analgesics, antianxiety drugs, and some anti-depressant drugs) or lowering blood pressure (e.g. antihypertensive, diuretic, and some heart drugs), including some over-the-counter medicines
• Poor safety awareness  

• the floor is wet or has been recently polished, such as in the bathroom
• the lighting in the room is dim
• rugs or carpets aren't properly secured
• the person is reaching for storage areas, such as a cupboard, or is going down stairs
• the person is rushing to get to the toilet
• there are electrical or extension cords or objects that are in the way of walking
• there are uneven sidewalks and broken curbs
• the person is unfamiliar with his/her surroundings 

• Discuss fall risks and medication reviews with your doctor.
• Engage in strength and balance exercises.
• Ensure appropriate clothing and footwear.
• Regularly check your eyesight and update eyeglasses.
• Make your home safer with grab bars, non-slip mats, good lighting and removing tripping hazards.
• Limit alcohol consumption to avoid coordination and balance issues.

• evaluate your risk for falling and talk with them about specific things you can do
• review your medicines to see if any might make you dizzy or sleepy. This should include prescription medicines and over-the-counter medicines. Your doctor may recommend alternative medication or lower doses if they feel the side effects increase your chances of having a fall. In some cases, it may be possible for the medication to be stopped.
• Do strength and balance exercises
• Do exercises that make your legs stronger and improve your balance. This can take the form of simple activities such as walking and dancing, or training programmes. Tai Chi is a good example of such an exercise.
• Have proper clothes and footwear
• Avoid loose-fitting, trailing clothes that might trip you
• Wear well-fitting shoes that are in good condition and support the ankle
• Take care of your feet by trimming your toenails regularly and seeing a doctor about any foot problems 

• Add grab bars inside and outside your bathroom 
• Use non-slip mats in the bathroom
• Mop up spills to prevent wet, slippery floors
• Get help lifting or moving items that are heavy or difficult to lift
• Remove clutter that you could trip over 
• Ensure all areas of the home are well lit 
• Avoid alcohol 

International Day of Older Persons 
Our team organises annual events to celebrate the International Day of Older Persons on 1st October. Past events have included public and GP forums on topics relevant to older people and public performances to promote healthy ageing. 

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