Care of the Elderly
Description
The goal of care of the elderly horizontal experience or geriatrics rotation is to provide learning
opportunities that will enable residents to develop skills required for the provision of
comprehensive care for the elderly.
Objectives
By the completion of this horizontal experience or block experience, residents will be able to:
Family Medicine Expert
COE1. Provide periodic health assessments and preventative care adapted to the needs of the
elderly
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1.1 Common changes of aging: Demonstrate an understanding of the physiological and
psychosocial changes associated with aging, and how they relate to the importance of a
comprehensive approach to care.
1.2 Health promotion in elderly: Counsel elderly patients about lifestyle factors that promote
healthy living, such as smoking cessation, moderation of alcohol consumption, eating a balanced
diet, aerobic and resistance exercise, immunization and optimizing socialization opportunities.
1.3 Prevention and early detection in elderly: Identify conditions that are appropriate for
screening in the older patient, including assessment of falls, vision, hearing, and blood pressure
screening, immunizations, cancer screening (in select groups)
1.4 Adapted Periodic Health Exam: Selectively adapt the periodic health exam to suit a given
patient’s circumstances (personal health goals, age, gender, medical comorbidities and family
history)
COE2. Provide comprehensive care to elderly and geriatric patients using a functional approach
that is adapted to the patients’ physical and cognitive capacity
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2.1 History taking in the elderly, with a focus on functional assessment: In the course of
history taking, physical exam, and treatment planning, assess the impact on problems on a
patient’s independence and ability to function.
2.2 Physical examination of the elderly: Perform an appropriate and adapted physical
examination of elderly patients.
COE3. Perform a patient-centred clinical assessments, manage and follow-up patients presenting
with common (key) conditions in the care of the elderly.
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3.1 Cognitive decline and dementia: Demonstrate an approach to diagnosing declining cognition
(develop a differential diagnosis for cognitive impairments). Use appropriate cognitive assessment
tests (and screening tests where appropriate), and initiate appropriate investigation, management,
supports and care plans for patients with cognitive decline.
3.2 Delirium: Promptly diagnose and manage delirium in the elderly.
3.3 Mood Disorders in the elderly: Recognize the manifestations of depression in the elderly, the
potential for suicide, and diagnose and manage mood disorders in the elderly.
3.4 Falls and Mobility Difficulty: Screen for falls appropriately. Implement rehabilitation and other
resources to improve mobility and prevent falls.
3.5 Fracture Risk in the Elderly: Assess risk factors for increased risk of fractures, including
osteoporosis related fractures, and reduced bone mineral density (BMD). Prevent and treat
fractures (including rehabilitation) where indicated.
3.6 Urinary Incontinence in the elderly: Identify, classify (i.e. stress, urge, mixed, overflow,
functional) and manage different types of urinary incontinence.
3.7 Malnutrition and Depleted Nutritional Status: Identify and manage risk factors for weight
loss and malnutrition in the elderly.
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3.8 Pain in the elderly: Develop an approach to the diagnosis and management plan for pain in
the elderly, which takes, into consideration issues relevant to the elderly.
 3.9 Constipation in the elderly: Describe constipation risk factors, manifestations, and diagnosis
and management in the elderly.
 3.10 Fitness to drive in the elderly: Assess an elderly patient's fitness to drive and complete
mandatory reporting requirements.
 3.11 Capacity issues in the elderly: Assess a patient’s capacity to make informed decisions
about health and planning for the future.
 3.12 Advanced directives: Initiate a discussion about advanced directives and specific wishes
with regard to decisions around health and health care. Describe the differences between a Power
of Attorney for Personal Care and Power of Attorney for Finances. Assist patients in establishing a
Power of Attorney (POA) and seek additional supports (eg social work) if required.
 3.13 Elder abuse and neglect: Identify risk factors for elder abuse. List signs of elder abuse and
neglect, and list avenues for reporting.
COE4. Understand key issues in drug therapy for the elderly, demonstrating an appropriate use
of medications
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4.1 Safe prescribing in the elderly: Demonstrate awareness of medications to be used with
caution and use a safe approach to drug dosing, including required adjustments in renal
impairment. Safely stop commonly used drugs and monitor for signs of withdrawal (e.g. SSRIs,
benzodiazepines)
 4.2 Polypharmacy in the elderly: Recognize polypharmacy and effectively monitor for hazardous
drug-drug interactions, prescribing cascades, drug-disease interactions.
 4.3 Use non-pharmacological alternatives in the elderly: Use non-pharmacological alternatives
to drug therapy wherever appropriate.
 4.4 Treatment adherence in the elderly: Recognize potential barriers to medication adherence
(such as low literacy, poor vision, poverty, poor executive functions) and adapt approach to
prescribing to accommodate for these. Recognize the importance of monitoring and optimizing
adherence to treatment, using strategies such as collaborating with the community pharmacist on
dosette or bubble pack systems and medication home delivery.
 4.5 Medication cessation: Demonstrate awareness of when cessation of medications may be
appropriate (i.e. primary prevention in the very elderly, or other medications near end-of-life).
ADU2. Diagnose and manage acute, urgent, emergent and chronic conditions presenting as
undifferentiated symptoms using a patient-centered family medicine approach
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2.1 Patient centered approach for undifferentiated complaints: Recognize the importance of
using patient centered interviewing for all patients, but especially in those with common
undifferentiated complaints
2.2 Approach to chest pain: Describe an appropriate primary care approach to chest pain that
incorporates a system-based approach and rules out red flags of serious pathologies such as
myocardial ischemia or infarction, pulmonary embolism, dissecting aneurysm, pericarditis,
pneumothorax.
2.3 Approach to fatigue: Demonstrate an appropriate approach to the diagnosis and management
of fatigue.
2.4 Approach to dizziness and vertigo: Demonstrate an appropriate approach to the diagnosis
and management of dizziness and vertigo.
2.5 Approach to cough: Demonstrate an appropriate approach to the diagnosis and management
of cough.
2.6 Approach to unexplained weight loss: Demonstrate an appropriate approach to the
diagnosis and management of unexplained weight loss.
2.7 Approach to abdominal pain: Demonstrate an appropriate approach to the diagnosis and
management of abdominal pain.
ADU3. Distinguish, investigate and respond appropriately to serious, acute, urgent and emergent
conditions in adults
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3.6 Dehydration: Recognize the signs and symptoms of dehydration, and be able to assess the
degree of dehydration and manage appropriately.
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3.13 Prepare for transport: Recognize signs or symptoms when a patient should be transported
to another facility (by land, or air), manage patients with advice from specialists at a distance, and
where appropriate coordinate transfer and adequately stabilize and prepare the patient for
transport.
PAL1. Identify patients who might benefit from a palliative approach and initiate this early in the
disease trajectory
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1.1 Identification: Identify opportunities for advance care planning discussions, whether or not a
patient has a life-threatening or life-limiting illness.
1.2 Initiate a “palliative care approach”: Initiate a “palliative care approach” early in the illness
trajectory).
PAL2. Demonstrate an effective approach to advance care planning
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2.1 Discussion of advance care plans: Initiate advance care planning discussions with patients and
families and participates in the development of highly specific and detailed advance care plan
documents that clearly outline the patient’s wishes that will serve to direct care in the event of certain
clinical conditions.
2.2 Quality of life: Identify the elements that define “quality of life” for an individual patient living with
advanced disease. Understand that family members may differ in opinion from the patient when
prioritizing these elements.
2.3 Differing opinion: Appreciate that family members may differ in opinion form the patient when
prioritizing elements of quality of life.
2.4 Legal definitions: Describe the elements of substitute decision-making, power of attorney, and
living wills.
2.5 Consultation: Refer for consultation (specialty or ethics) those patient with complex issues.
PAL5. Assess and manage pain by multiple modalities and delivery systems
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5.1 Comprehensive pain assessment: Perform a comprehensive assessment of pain and nonpain symptoms
5.2 Approach to pain: Develop an approach to pain management using key principles including a
consideration of pain patho-physiology, the World Health Organization pain ladder, and includes a
role for opioids, adjuvant medications and non-pharmacological tools.
5.3 Opioid prescribing: Prescribe opioids effectively including proper initiation, dosage, titration,
rotation, breakthrough dosing, side effect prevention and use of oral and parenteral routes.
5.4 Adjuvant therapy: Integrate adjuvant therapy in the management of pain.
PAL6. Assess and manage common symptoms in the last year of life
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6.1 Common End-of-life symptoms: Prevent, identify and manage (non pharmacological and
complementary approaches) common EOL symptoms including: nausea, vomiting, constipation
and bowel obstruction, dyspnea, delirium, anxiety, fatigue, anorexia, cachexia.
PAL8. Provide end-of-life care in multiple environments: hospital, hospice, care facility, home
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8.1 Last hours: Plan and manage for the care of the dying patient during the last hours of life.
a) Impending death: Recognize signs and symptoms of impending death
8.2 Setting: Recognize and access the differing resources in different palliative care setting:
patients' homes, hospice, nursing / retirement/ long-term care home, specialized palliative care
environment or in the hospital.
8.3 Death certification: Pronounce death and conduct death certification. Identify situations in
which the coroner must be contacted.
Communicator
FAM8. Establish effective professional relationships with patients and their families
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8.1 Patient centered approach: Communicate using a patient-centered approach that encourages
patient trust and autonomy and is characterized by empathy, respect, and compassion
8.2 Environment: Optimize the physical environment for patient comfort, dignity, privacy,
engagement, and safety
8.3 Patient perspectives: Recognize when the values, biases, or perspectives of patients,
physicians, or other health care professionals may have an impact on the quality of care, and
modify the approach to the patient accordingly
8.4 Non-verbal communication: Respond to a patient’s non-verbal behaviors to enhance
communication
8.5 Disagreements: Manage disagreements and emotionally charged conversations
8.6 Adapting communication: Adapt to the unique preferences of each patient and to his or her
clinical condition and circumstances.
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Elderly: Adapt interviews with elderly patients by adapting personal communication style,
interview environment, and visit content.
FAM9. Elicit and synthesize accurate and relevant information, incorporating the perspectives of
patients and their families
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9.1 Patient-centered interviewing: Use patient-centered interviewing skills to effectively gather
relevant biomedical and psychosocial information
9.2 Structure of interview: Provide a clear structure for and manage the flow of an entire patient
encounter
9.3 Corroborating information: Seek and synthesize relevant information from other sources,
including the patient’s family or caregivers, with the patient’s consent
FAM10. Share health care information and plans with patients and their families
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10.1 Sharing information: Share information and explanations that are clear, accurate, and timely,
while checking for patient and family understanding
10.2 Disclosure: Disclose harmful patient safety incidents to patients and their families accurately
and appropriately
PAL10. Communicate with patient, families and care team about palliative and end-of-life care
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10.1 Communicating with families: Identify situations that may benefit from a family meeting and
facilitate these meetings.
10.2. Supporting families: Support patients and families coping with loss and bereavement, grief
(including anticipatory grief), risk factors for atypical grief and develop an awareness of local
resources to assist families through this process.
FAM14. Document and share written and electronic information about the medical encounter to
optimize clinical decision-making, patient safety, confidentiality, and privacy
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14.1 Documentation requirements: Document clinical encounters in an accurate, complete,
timely, and accessible manner, in compliance with regulatory and legal requirements
14.2 Documentation format: Communicate effectively using a written health record, electronic
medical record, or other digital technology
Collaborator
FAM13. Work effectively with physicians and other colleagues in the health care professions
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13.1 Relationship: Establish and maintain positive relationships with physicians and other
colleagues in the health care professions to support relationship-centered collaborative care
13.2 Team communication: Demonstrate clear and effective communication (both written and
verbal) with physicians and other colleagues in the healthcare professions.
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13.3 Shared decision-making: Negotiate overlapping and shared responsibilities with physicians
and other colleagues in the health care professions.
13.4 Positive work environment: Implement strategies to promote understanding, manage
differences, and resolve conflicts in a manner that supports a collaborative culture
FAM14. Hand over the care of a patient to another health care professional to facilitate continuity
of safe patient care
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14.1 Timing of transfers: Determine when care should be transferred to another physician or
health care professional
14.2 Safe transfers: Demonstrate safe handover of care, using both verbal and written
communication, during a patient transition to a different health care professional, setting, or stage
of care
Leader/Manager
FAM17. Engage in the stewardship of health care resources
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17.1 Resource allocation: Allocate health care resources for optimal patient care, including
referral to other health care professionals and community resources
17.2 Cost-appropriate: Apply evidence and management processes to achieve cost-appropriate
care
Health Advocate
FAM21. Respond to an individual patient’s health needs by advocating with the patient within
and beyond the clinical environment
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21.1 Determinants of health: Work with patients to address determinants of health that affect
them and their access to needed health services or resources
Scholar
FAM24. Integrate best available evidence, contextualized to specific situations, into real-time
decision-making
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24.1 Identifying knowledge gap: Recognize practice uncertainty and knowledge gaps in clinical
encounters and generate focused questions that can address them.
24.4 Integrating evidence: Integrate evidence into decision-making in their practice by reviewing
and appropriately applying guidelines from organizations such as Health Canada, the College of
Family Physicians of Canada, and Canadian Geriatric Society.
Professional
FAM27. Demonstrate a commitment to patients
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27.1 Professional behaviors: Exhibit appropriate professional behaviors and relationship in all
aspects of professional practice, reflecting honesty, integrity, commitment, compassion, respect,
altruism, respect for diversity, and for maintenance of confidentiality.
27.2 Excellence: Demonstrate a commitment to excellence in all aspects of practice.
27.3 Ethical issues: Recognize and respond to ethical issues encountered in practice.
Entrustable Professional Activities
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Assess, manage, and follow-up adults presenting with common (key) conditions.
Diagnose and manage the patient with common chronic conditions and multiple comorbidities.
Manage the elderly patient with multiple co-morbidities.
Evaluation
Field Notes
In-training Assessment Report (ITAR)