Besides dealing with the most complex conditions in vulnerable older people in inpatient and outpatient settings, we promote health and reduce disability in the community through health screening and healthy ageing initiatives such as exercise, nutrition and vaccination programmes. In addition to improving population-based healthcare which enables older adults to age well in the community, we are actively involved in planning Age-Friendly Health Systems and work closely with our community partners.
Apart from clinical work, many of our team members are actively involved in research, undergraduate and postgraduate education, designing curriculum that enable healthcare professionals to manage the ageing population, and collaborating with both local and international organisations to promote healthy ageing.
We provide person-centric quality care and devise personalised care plans for healthy and active ageing through a whole suite of services. All patients referred to our service undergo a Comprehensive Geriatric Assessment (CGA) which includes their medical, functional and psychosocial assessments. We provide value-based care and focus on outcomes which are important for our patients – enabling them to age in place, preventing functional decline and extending healthspan.
Our Expertise:
Head of Division & Senior Consultant
Senior Consultant
Consultants
Associate Consultant
Outpatient Care
Emergency Department
The Geriatric Emergency Medicine (GEM) Nurse service aims to provide the best geriatric care possible right from the start of a patient's journey in NUH. Patients with a Clinical Frailty Scale (CFS) score of 4 or more are referred to a Geriatric Emergency Medicine (GEM) nurse for screening upon discharge. GEM nurses are trained to perform CGAs, which allow them to identify specific care needs, reinforce patient family education, and provide appropriate discharge referrals. This ensures the safe transition of care from the tertiary hospital to the community and decreases the re-attendance of older adults to the Emergency Department.
Inpatient Care and Elderly Care Bundle
Our Geriatric interdisciplinary team members are actively pushing boundaries and improving the overall care of older adults admitted to the hospital. This is achieved through hospital-wide initiatives such as Nurses Improving Care for Healthsystem Elders (NICHE) programme and Elderly Care Bundle implementation, and active participation in the Multidisciplinary Inpatient Falls Prevention Workgroup.
NICHE is an international nursing education and consultation programme designed to improve geriatric care. Foundation to NICHE is the Geriatric Resource Nurse Model in which Registered Nurses are trained to become unit-based resource persons with regards to geriatric nursing care issues, geriatric care standards and practices. Through this programme, we have groomed and equipped Geriatric Resource Nurses (GRNs) with knowledge and skills in these vital areas, with the aim of improving patient outcomes and experiences. They are now present in most adult wards, where they can perform CGAs and provide advice on nursing care management for older patients with complex issues. Through their leadership role in individual wards, geriatric care nursing standards are maintained. They also participate in right siting huddles of care within the ward.
For all older adults admitted to the wards, they are placed on the Elderly Care Bundle, which is a set of common care protocols developed from established and/or evidence-based practices with the aim of preventing functional decline, falls prevention, prevention and management of delirium, continence management, and other hospital acquired complications in the older adult patients. It empowers nurses to initiate the interventions based on identified or potential problems.
For patients who are confused and agitated, a separate nurse-led care service called Elderly Behavioural Support (EBS) service is available. The EBS service provides ongoing advice and education for healthcare professionals and caregivers on managing behavioural issues in older patients with cognitive impairment. It incorporates the principles of Montessori-based Dementia Programming with the aim of reducing restraints, caregiver stress and falls in older patients with confusion.
The Geriatric team also provides guidance and leadership for the Multidisciplinary Inpatient Falls Prevention Workgroup. Over the years, we have seen an overall decline in inpatient falls rates.
In addition to the Elderly Care bundle, we have implemented the Acute Care of the Elderly (ACE) model of care for those admitted to the Geriatric ward and under the care of the Geriatric team. Every older patient in the ward receives reality orientation, adequate hydration through scheduled feeding, bowel management and early mobilisation, all with the intention to prevent delirium and functional decline. Each patient also has an individualised Activities of Daily Living (ADLs) Board which will be updated by the rehabilitation therapists, so that healthcare providers can engage the patients in recommended activities and assist them in ambulation with the appropriate assistive aids. Patients with very high falls risk are cohorted and those who are confused and agitated are allocated a cubicle to ensure they receive specialised care and attention. Patients, especially those with cognitive impairment, will be engaged in structured cognitive therapy for mental stimulation. There is also an increasing shift towards prevention and health promotion where every patient is advised on healthy ageing initiatives including having vaccinations for influenza and pneumonia.
• The SILVER Unit
Our acute geriatric ward features a SILVER Unit (Specialized Innovative LongeVity and Elderly Recovery), which is designed to care for older adults who exhibit confusion and have been admitted for delirium. Staff in the unit undergo special training and provide a comprehensive multidisciplinary patient care programme that ensures early resolution of delirium and prevents functional decline. The unit has a restraint-free environment and focuses on individualised and person-centred care, empowering and educating families to be involved in the care journey. In addition to activities, daily orientation and music therapy, our patients are encouraged to dine and socialise in a communal area with other patients. Our en-suite activity room meant for physiotherapy and occupational therapy also features a reminiscence corner which is especially suitable for older adults with memory issues.
The unit was honoured to host Mdm President Halimah Yacob during her official visit to the hospital on 19 September 2017. Read more about the President’s visit and her interaction with our patients here.
For more information about our SILVER Unit, please click here.
OrthoGeriatric Service
The NUH OrthoGeriatric service is an evidence-based co-management model between Geriatric Medicine and Orthopaedic Surgery. It comprises a dedicated and highly skilled multidisciplinary team to provide holistic care to patients aged 65 years and above who are admitted with a fragility fracture. Comprehensive geriatric assessment and care delivered through a collaborative and multidisciplinary approach has been shown to reduce in-hospital complications, length of stay, functional disability and mortality especially in older adults with hip fractures. This is essential in ensuring an older patient has a smooth transition through preparing for surgery to rehabilitation and recovery. Our fast track hip fracture pathway to our partner community hospital, St Luke’s Hospital, will allow for specialised and expedited rehabilitation and better recovery.
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 gives continuation of care for homebound patients discharged from the hospital to allow for smooth transition from hospital to home. This includes clinical, nursing, rehabilitation and psychosocial support for patients, their family members and/or caregivers.
Our doctors also work closely with community partners to enable ageing in place. For further details, please click here.
Outpatient Care
Geriatric Assessment Clinic
The clinic provides a comprehensive geriatric assessment to address the complex care needs of the older adult. This service will benefit older adults who:
• Are 75 years old and above
• Have complex health problems and atypical presentations e.g. functional decline, memory decline, weight loss, urinary incontinence and overall decline in personal well-being
During the first visit:
• Comprehensive geriatric assessment, which is the gold standard in the care of older adults, will be performed
• If necessary, the Geriatrician will request for investigations to be done and/or refer to relevant allied health professionals for further management
• The Geriatric team will also provide advice and counselling on healthy ageing including the recommended vaccinations for flu and pneumonia.
Subsequent visits will depend on the nature and complexity of the problems.
Our outpatient services are provided at 13b Medicine Clinic. For contact details, operating hours and directions, click here.
Geriatric Oncology (GOLDEN)
Geriatric oncology is a sub-specialty committed to the provision of appropriate cancer treatment to older patients. It comprises of a specialised multi-disciplinary team of doctors, nurses, therapists, pharmacists and social workers and provides individualised holistic cancer management plans and interventions to support older adults along their cancer journey.
The clinic is located at Level 8 and 10 Cancer Centre. Click here to learn more.
Rapid Access Care for Elders (RACE) clinic
The Rapid Access Care for Elders (RACE) clinic is a fast-track clinic providing early medical review for stable older adults seeking medical attention at the emergency department. Patients who are deemed stable enough for a trial of outpatient treatment can be referred by the emergency doctors to be seen in the RACE clinic, with the aim of reducing ward admissions.
Successful Ageing and Fitness Evaluation (SAFE) Clinic
The SAFE clinic is a multidisciplinary and multi-specialty one-stop clinic specialising in preventing frailty, falls, and sarcopenia among adults aged 75 years and above. The aim of the assessment is to understand how we can help you be stronger and steadier on your feet and lower your risks for falls and frailty. Our experienced team of physiotherapist, occupational therapist, dietitian and geriatrician are ready to assist you with a comprehensive and personalised assessment.
The team will guide you through optimising your chronic medical conditions, provide individualised nutrition advice and work with you to enhance your physical and functional abilities.
Faculty members from the Division of Geriatric Medicine are involved in numerous educational initiatives targeted at undergraduate, postgraduate, healthcare professionals, ILTC sectors and the community at large. We also offer short attachments for clinical experience and fellowship programmes.
Undergraduate Education Programme
We are vested in the education of our future doctors, and we make sure that medical students are adequately exposed to geriatric medicine training during both pre-clinical and clinical years.
Students from the Yong Loo Lin School of Medicine, National University of Singapore, undergo a Foundation module in Geriatric Medicine, including Clinical Skills Foundation Programme (CSFP) at the end of their second year, which provides a bridging transition from the didacticism of basic science lectures to clinical learning. With the use of experiential learning, students will begin to grasp the basics of geriatric assessment which they will continue to hone for the rest of their medical education.
Over the five years in medical school, the learning objectives and exposure to Geriatric Medicine are reinforced in many other postings including Medicine, Psychiatry, Family Medicine and Surgery. In the final year, all students will do a 3-week structured internship in geriatric medicine, where students will gain experience in inpatient and outpatient geriatric care, as well as sub-acute, rehabilitation and community care in a community hospital. They will develop core competencies in comprehensive geriatric assessment, formulating differential diagnoses for an older patient, and creating an initial patient-centred management plan for geriatric syndromes. In addition, they will gain knowledge and experience in counselling patients and families on geriatric syndromes, initiating advanced care planning and end-of-life discussions with patients and/or families, working with interdisciplinary team members, as well as become aware of the safe transitions of care into the community.
Geriatric Medicine Senior Residency Programme
The NUHS Geriatric Medicine Senior Residency Programme is a 3-year training programme (2-year ACGME-I accredited and a 1-year Residency Advisory Committee approved) for highly motivated and driven Internal Medicine residents.
We offer diverse clinical experiences both in the acute and community care settings, a comprehensive didactic curriculum and career development programmes in medical education, research and/or hospital administration provided by committed faculty.
The Senior Residency Programme is an integrated experience providing both rotational clinical blocks and longitudinal clinical care based at several sites across the country.
Senior Residents will gain skills through a combination of supervised clinical experiences and formal national didactic teaching. In addition to the essential medical knowledge, each Senior Resident will develop leadership and teaching skills, professional attitudes, and practical experiences to fully prepare them to provide evidence-based patient-centred care to older patients in acute hospital, clinic and intermediate and long-term care settings.
Learn more about our Senior Residency Programme here.
Advanced Practice Nurse (APN) Teaching
The APN in Geriatric care embraces a vital role in the healthcare community by imparting knowledge and expertise to junior nurses and APN interns. Our focus on caring for older patients is of utmost importance, given the unique challenges and needs they may encounter in healthcare settings. Through specialized education and hands-on experience, we strive to equip our fellow nurses with the necessary skills and compassion to provide exceptional care for this vulnerable population.
Additionally, our commitment to evidence-based teaching and presentations allows us to share the latest advancements in nursing care and treatment modalities. By staying up-to-date with the most current research and best practices, we empower our nursing peers to deliver a high quality of care and make informed decisions in their clinical practice.
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
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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Falls
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Functional decline can create a cyclical pattern where causes and effects perpetuate each other (see diagram below). This highlights the importance of early identification, treatment and prevention.
What can loved ones do?
Support is crucial for family members experiencing functional decline. It’s important not to attribute these changes solely to ageing. Seeking a consultation with a geriatrician or physician specialising in geriatric care is advisable. The presence and support of loved ones can be incredibly comforting and motivating for older adults. A CGA conducted by geriatricians and a trained team can help identify the causes of functional decline, focus on the patient's strengths and find solutions to enhance their quality of life. Treatment may involve addressing acute medical conditions, improving function, memory, environment and/or mood.
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.
