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Core Competencies for Family Medicine Residents attending Home Care GCT
1. Medical Assessment of a homebound older person
a. History
i. Take an appropriately thorough history in a timely manner,
suggest using the GCT CGA template.
ii. Demonstrate ability to effectively and selectively identify and
prioritize main presenting symptoms.
iii. Take an appropriate social history that identifies social
supports, activities, education, employment history, family
function and caregiver stress.
iv. Take a functional history identifying ADLs and IADLs.
v. Be aware of driving safety and how to screen for it. Includes
knowledge of community resources for driver evaluation,
CMA Driver’s Guide and/or the Canadian Consensus
Conference on Dementia Guidelines as a resource to
evaluating the older driver.
vi. Identify and take a history of the main geriatric syndromes:
Pain, Mood, Sleep, Nutrition, Bowel/Bladder function,
Mobility/Falls.
b. Cognitive Assessment
i. Recognize signs of declining cognitive function in elderly
individuals, such as poor hygiene, memory complaints from
patients of their family members and difficulty with IADL’s
such as banking and meal preparation.
ii. Assess cognition through a defined set of questions targeted
to evaluate degree of cognitive impairment.
iii. Be familiar with cognitive assessment tools such as MMSE
and MoCA.
c. Mental Status Examination
i. Recognize signs of apathy, depression, grief, anxiety,
delusions and hallucinations.
ii. Be prepared to recognize the signs and symptoms of
delirium and if necessary use a screening tool such as the
CAM to screen for delirium.
iii. Learn to recognize signs and symptoms of depression in the
elderly by utilizing screening tools such as the Geriatric
Depression Scale, SIGECAPS. Be aware of the risks and be
able to screen for suicidal ideation.
iv. Know the fundamental aspects of a competency assessment
(e.g. medical competence, financial competence, housing
competence).
v. Be aware of the laws pertaining to competence (e.g. POA,
Public Guardian and Trusteeship, the Mental Health Act).
vi. Identify impaired and intact decision making abilities as
some may be retained in a given individual.
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d. Physical Exam
i. Perform an appropriately thorough physical examination in a
timely manner we suggest you use the exam format outlined
on the GCT CGA template.
ii. Exhibit an awareness of the role of the physical examination
in making certain diagnoses more or less likely.
iii. Be familiar with the normal signs of aging and dementia as
they present on physical assessment.
iv. Perform a detailed neurologic exam that screens for the
signs of dementia.
v. Understand the important screening tools to assess balance
and gait such as: 4-point balance test, Berg, TUG.
2. Differential Diagnosis
a. Formulate a differential diagnosis based on the history, physical
and cognitive evaluation of an older person.
b. Understand the different types of dementia including Alzheimer’s
Disease, Lewy Body Dementia, Fronto temporal Dementia and
Vascular Dementia.
c. Understand how chronic medical conditions can affect the overall
health and well being of an older person and how these conditions
can be mediated.
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3. Medication Management
a. Complete a comprehensive medication review, including taking a
history for allergies and evaluating appropriate dosing based on
declining renal function.
b. Recognize the importance of drug monitoring, as well as strategies
for enhancing treatment adherence (e.g. blister packaging,
medication reminders, assistance).
c. Have the ability to safely stop commonly used drugs and monitor
for signs of withdrawal (e.g. SSRI's, benzodiazepines).
d. Be familiar with the BEERs criteria for medications that can cause
harm.
e. Choose drugs within a class that offer the best balance between
therapeutic benefit and adverse effects.
f. Use non-pharmacological alternatives to drug therapy in the elderly
wherever appropriate.
4. Formulate an Impression and Plan
a. Impression should highlight the major medical diagnoses that are
impacting patient well being. Be able to recommend medication and
management changes that can improve overall comfort and
function.
b. Specify type and stage of cognitive impairment. Recommend
treatment if indicated. Be aware of the current recommendations
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for treatment, medication contraindications, side effects and
evaluation of effectiveness. Develop skill in counselling family on
expectations of medical treatment.
c. Be familiar with the levels of community and facility care available
and be able to recommend appropriate level of care.
d. Be able to discuss anticipatory care and acknowledge the role of
patient values, attitudes and beliefs towards medical interventions
and devise an appropriate care plan with the patient and family.
e. Understand the inherent risks for the older patient in transitioning
from home to a care setting and between care settings.
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