GEM Competency Grid – Eve Losman, MD
SAEM Task Force
GEM Competency Grid: A more extensive list of resources available as well.
A “tool box” was created in 2009 to assist residency directors who wanted to improve their resident’s training in Geriatric Emergency Medicine. In
the past 2 years, there has been an explosion of material available on the Web. The curricula, lectures, and simulations have largely been collected
in one place, POGOe. Although much of this material is intended for medical students and internal medicine residents, much is focused on
emergency care or is applicable to our discipline. The site is increasingly easy to use and the material is of very high quality. Many of the resources
listed below were gleaned from the site.
POGOe – Portal for Online Geriatric Education - http://www.pogoe.org/
Currently has >125 educational products related to emergency medicine.
Page 1 of 9
GEM Competency Grid – Eve Losman, MD
SAEM Task Force
GEM Competency
Educational Tools & Resources
Assessment Tools & Behavior
to be Evaluated
ACGME Core
Competency
Atypical Presentation of Disease:
1. Generate an age-specific
differential diagnosis for elder
patients presenting to the ED
with general weakness,
dizziness, falls, or altered
mental status.
Web-Based:
1. COMET: Cleveland Clinic’s Geriatric Emergency Medicine Online
Curriculum.
The course is designed to improve knowledge of the basic principles of
geriatric emergency care with an emphasis on quality of care issues. The
content is presented through questions, most of which are case-based.
Questions include a brief discussion in the feedback for each answer
chosen as well as suggested readings.
2. POGOe: High fidelity simulations to teach key concepts in emergency
department care of the elderly; University of North Carolina at
Chapel Hill School of Medicine.
Seven simulations instruct EM residents the ED key concepts of geriatric
care. The cases include gastrointestinal bleeding, myocardial infarction,
altered mental status, toxicology, sepsis, abdominal aortic aneurysm,
and mesenteric ischemia. Core concepts taught include medication
interactions, transitions of care, delirium, suicide risks and depression in
the elderly, atypical presentations of disease, and iatrogenic injuries.
Evaluate in the clinical arena.
 Follow-up Log: Require log
to contain a certain
percentage of older adults;
have faculty confirm that
MDM reflects geriatric
considerations.




2. Generate a differential
diagnosis recognizing that
signs and symptoms such as
pain and fever may be absent
or less prominent in elders
with acute coronary
syndromes, acute abdomens,
or infectious processes.
3. Document consideration of
adverse reactions to
medications, including drugdrug and drug-disease
interactions, as part of the
initial differential diagnosis.
PowerPoint Lectures:
1. Atypical Presentations of Disease in the Older Adult; Lisa Mack, MD
(Emory)
2. Assessing the Frail Elderly; John Puxty, MD (Queens Univ.)
3. Geriatric Assessment in a Time Dependent Practice; C. Bree
Johnston, MD MPH (UCSF)
4. The Grey Tsunami: Older Adults in the ED; Eve D. Losman, MD (Univ.
Michigan)
5. Infection in Older Adults; Eve D. Losman, MD (Univ. Michigan)

Perform “x” number of ADE
searches for older adults
with more than 5
medications on their triage
sheet.

Encourage Residency
Programs to specifically
include geriatric patients in
their EM-RRC mandated
“chief complaint
competency”
PC
MK
SBP
PBLI
Articles:
(see master document)
Other:
GEM Resident Manual; Eve D. Losman, MD (Univ. Michigan)
Page 2 of 9
GEM Competency Grid – Eve Losman, MD
SAEM Task Force
GEM Competency
Educational Tools & Resources
Assessment Tools & Behavior
to be Evaluated
ACGME Core
Competency
Trauma including Falls:
4. In patients who have fallen,
evaluate for precipitating
causes of falls such as
medications; alcohol
use/abuse, gait or balance
instability; medical illness
and/or deterioration of
medical condition.
Web-Based:
1. FALLS - CHAMP: University of Chicago
Teaching materials available on the CHAMP webpage link include: a slide
presentation with speaker's notes; a bedside teaching trigger; a pocket
teaching card; references; a sample session evaluation form; CHAMP
overview / user's guide; and access to the entire CHAMP course and all
resources.
2. POGOe: Assessing Falls and ADLs; University of California, Irvine,
School of Medicine
This is Module requires learners to review and analyze patient
information, interpersonal interactions, laboratory and imaging results,
diagnoses and treatment plans.
3. Elder Abuse: an on line module – Carolina Geriatric Education Center
 Define elder mistreatment
 Describe the types of elder mistreatment and its signs and
consequences.
 Screen for and recognize cases of elder mistreatment in the
acute care setting.
 Take appropriate action to report cases of elder mistreatment.
4. A Model Intervention for Elder Abuse and Dementia – Northeastern
Ohio Universities College of Medicine
 The manual is complete with faculty guides, participant
workbooks and additional references. It includes learning
objectives, value statements, interactive exercises and case
discussion guides.
Evaluate in the clinical arena.
 Describe and perform the
Timed Up and Go Test;
Discuss grading and
potential appropriate
follow-up of an abnormal
test.



5. Assess for gait instability in all
ambulatory fallers; if present,
ensure appropriate
disposition and follow up
including attempt to reach
primary care provider.
6. Demonstrate ability to
recognize patterns of trauma
(physical/sexual,
psychological,
neglect/abandonment) that
are consistent with elder
abuse. Manage the abused
patient in accordance with the
rules of the state and
institution.
7. Institute appropriate early
monitoring and testing with
the understanding that elders
may present with muted signs
and symptoms, (e.g., absent
pain and neurologic changes)
and are at risk for occult
shock.

Chart review for
consideration of fall
precipitants and gait
assessment in older fallers.


? Elder Abuse
? Elder Trauma
PC
MK
SBP
PowerPoint Lectures:
1. Falls and Mobility Problems in Older Adults – Shelley B.
Bhattacharya, D.O., M.P.H. (Kansas)
2. Geriatric Trauma – Eve D. Losman, MD (Univ. Michigan)
3. Geriatric Falls – multiple lectures
http://www.med.unc.edu/aging/ncfp/providers.htm
Articles:
(see master document)
Page 3 of 9
GEM Competency Grid – Eve Losman, MD
SAEM Task Force
GEM Competency
Cognitive and Behavioral
Disorders:
8. Assess whether an elder is
able to give an accurate
history, participate in
determining the plan of care,
and understands discharge
instructions.
Educational Tools & Resources
Web Based:
1. SAEM: Emergency Care of the Elder Person
Course manual with section on Delirium including teaching materials,
discussion points, and a Power Point Presentation on Delirium.
2. COMET – Griatric Emergency Medicine Interactive Modules
Module on Altered Mental Status in older ED patients is one in a series of
interactive internet modules consisting of 5 courses in geriatric
emergency care. It is aimed at improving knowledge of the basic
principles of geriatric emergency care with an emphasis on quality of
9. Assess and document current care issues. The modules are a series of case based and Socratic
mental status and any change questions, each question providing immediate feedback, explanations of
from baseline in every elder
the answers and links to pertinent references.
with special attention to
3. Geriatric Web. A web-based digital repository containing a variety of
determining if delirium exists
educational materials, screening tools, guidelines, and lectures on
or has been superimposed on delirium, dementia, and a variety of other geriatric topics.
dementia.
 “Do’s and Don’ts” regarding delirium
 University of Washington:
10. Emergently evaluate and
 Altered Mental Status section is particularly good.
formulate an age-specific
4. The University of Iowa: Geriatric Education Resources.
differential diagnosis for
Downloadable screening tools for altered mental status in PDF form
elders with new cognitive or
including:
behavioral impairment,
 Clock Drawing Test
including self neglect, and
 Confusion Assessment Method
initiate a diagnostic work-up
 Digit Repetition Test
to determine the etiology, and
 Short Portable Mental Status Questionnaire
initiate treatment.
 Trail Making Test
11. Assess and correct (if
appropriate) causative factors PowerPoint:
1. Delirium in the Elderly; Bree Johnston, MD, MPH (UCSF)
in agitated elders such as
2. Delirium; Eve D Losman, MD (Univ. Michigan)
untreated pain, hypoxia,
hypoglycemia and use of
Articles:
irritating tethers (defined as
monitor leads, blood pressure (see master document)
cuff, pulse ox, IV and Foley),
environmental factors (light,
temperature), disorientation.
Assessment Tools & Behavior
to be Evaluated
ACGME Core
Competency
Evaluate in the clinical arena.
 Perform a Mini-Cog and
discuss results with regards
to case finding.






Correctly identify delirium
and initiate work-up.

Determine and document
decision making capacity.
PC
MK
ICS
PBLI
SBP
Page 4 of 9
GEM Competency Grid – Eve Losman, MD
SAEM Task Force
GEM Competency
Educational Tools & Resources
Assessment Tools & Behavior
to be Evaluated
ACGME Core
Competency
Emergent Intervention
Modifications:
12. Recommend therapy based on
the actual benefit to risk ratio,
including but not limited to
acute myocardial infarction,
stroke and sepsis, so that age
alone does not exclude elders
from any therapy.
Web Based:
1. UCSF Academic Geriatric Resource Center
Online Curriculum in Geriatrics and Gerontology: The case-based
curriculum contains five core modules that were developed by a
multidisciplinary team of faculty in the disciplines of dentistry, medicine,
nursing, pharmacy, physical therapy, and social and behavioral sciences
at UCSF.
The core module topics include:
 Demography and Epidemiology of Aging;
 Biology and Physiology of Aging,
 Socio-cultural and Psychological Aspects of Aging,
 Assessment of the Geriatric Patient, and
 Health Care Policies.
2. University of Maryland: This module about Geriatric Assessment is a
part of a 12-module curriculum at the University of Maryland. The
information presented in a text only format but the content is useful.
EBM exercise looking at a
geriatric condition.




13. Identify and implement
measures that protect elders
from developing iatrogenic
complications common to the
Emergency Department
including invasive bladder
catheterization, spinal
immobilization and central line
placement.
CQI exercise focused on a
geriatric condition.
PC
MK
PBLI
SBP
Articles:
(see master document)
Page 5 of 9
GEM Competency Grid – Eve Losman, MD
SAEM Task Force
GEM Competency
Educational Tools & Resources
Assessment Tools & Behavior
to be Evaluated
ACGME Core
Competency
Medication Management
14. Prescribe appropriate drugs
and dosages considering the
current medication, acute and
chronic diagnoses, functional
status, and knowledge of age
related physiologic changes
(renal function, CNS
sensitivity).
Web Based:
1. CHAMP – University of Chicago
 Teaching materials on "Drugs and Aging" include: slide
presentation with speaker's notes and references; bedside
teaching triggers on adverse drug reactions, polypharmacy,
pharmacokinetics, the aging liver, the aging kidney, and
pharmacodynamics; sample session evaluation form; and course
overview/program user's guide.
 "Pain Control" module is part of the CHAMP faculty development
program, which aims to improve inpatient, geriatric medical care
through a "teach the teacher" approach. It is central to one of
CHAMP's themes, improving palliative and end of life care.
Teaching materials include: a slide presentation with speaker's
notes; bedside teaching triggers on assessing and treating pain
and opiate conversions; a pocket teaching card; references; a
sample session evaluation form; and the "CHAMP Overview and
User's Guide."
2. University of Michigan – A Pocket Card on Approach to Older
Patients and Common Drug Side Effects
 Provides a 6-step "checklist" of domains and assessment
methods to guide assessment of older patients. The back of this
card is a "reverse" list of medication side effects, categorized by
side effects and lists of widely used medications associated with
them.
Evaluate in the clinical arena.
 Perform “x” number of ADE
searches for older adults
with more than 5
medications on their triage
sheet.
 Chart review for appropriate
/ inappropriate prescribing
patterns.




15. Search for interactions and
document reasons for use
when prescribing drugs which
present high risk either alone,
or in drug-drug or drugdisease interactions (e.g.
benzodiazapines, digoxin,
insulin, NSAID's, opioids, and
warfarin).
16. Explain all newly prescribed
drugs to elders and caregivers
at discharge assuring they
understand how and why the
drug should be taken, the
possible side effects, and how
and when the drug should be
stopped.
PC
MK
ICS
SBP
CQI exercise focused on
medications prescribed in the ED
/ medication reconciliation /
adverse drug events requiring
revisit to the ED.
PowerPoint Lecture:
None
Articles:
(see master document)
Page 6 of 9
GEM Competency Grid – Eve Losman, MD
SAEM Task Force
GEM Competency
Educational Tools & Resources
Assessment Tools & Behavior
to be Evaluated
ACGME Core
Competency
Transitions of Care:
17. Document history obtained
from ECF of the acute events
necessitating ED transfer
including goals of visit,
medical history, medications,
cognitive and functional
status, advance care plan and
responsible PCP.
Web Based:
1. POGOe: Interdisciplinary Teaching Safe Transitions Case-Based
Session; University of Pennsylvania School of Medicine
This is an introduction to the goals of safe discharge from the hospital
and the role of the interdisciplinary team in facilitating transitions of
care.
Evaluate in the clinical arena.
 Contact ECF / family for
additional information.





Contact ECF / PCP at time of
disposition.
PowerPojnt Lectures:
1. Transitions of Care; Eve D Losman, MD (Univ. Michigan)

18. Provide extended care
facilities and/or PCP with ED
visit summary and plan of
care, including follow-up.
Articles:
(see master document)
Discharge assessment and
documentation (ability to
ambulate, resources at
home to assist as needed,
etc.)
PC
MK
ICS
SBP
19. With recognition of unique
vulnerabilities in elders;
assess and document
suitability for discharge
considering the ED diagnosis,
including cognitive function,
the ability in ambulatory
patients to ambulate safely,
availability of appropriate
nutrition/social support, and
the availability of access to
appropriate follow-up
therapies.
20. Select and document the
rationale for the most
appropriate available
disposition with the least risk
of the many complications
commonly occurring in elders
during inpatient
hospitalization.
Page 7 of 9
GEM Competency Grid – Eve Losman, MD
SAEM Task Force
GEM Competency
Educational Tools & Resources
Assessment Tools & Behavior
to be Evaluated
ACGME Core
Competency
Pain Management / Palliative
Care:
21. Rapidly establish and
document elder’s goals of
care for those with a serious
or life threatening condition
and manage accordingly.
Web Based:
1. CHAMP – University of Chicago
The "Pain Control" module is central to one of CHAMP's themes,
improving palliative and end of life care. Teaching materials include: a
slide presentation with speaker's notes; bedside teaching triggers on
assessing and treating pain and opiate conversions; a pocket teaching
card; references; a sample session evaluation form; and the "CHAMP
Overview and User's Guide."
2. Assessing and treating pain in older adults – AMA (a CME module)
3. Acute pain management in older adults – National Guideline
Clearinghouse
4. EPERC: End of Life/Palliative Education Resource Center – Medical
College of Wisconsin
 The web pages are designed for use by medical school
course/clerkship directors, residency and continuing education
program directors, medical faculty, community preceptors, or
other professionals who are (or will be) involved in providing EOL
instruction to health care professionals in training. Includes
lectures, modules, standardize patient scenarios, sample
evaluation forms, and MCQ exams.
Evaluate in the clinical arena.
 Address pain promptly with
appropriate medications.




22. Assess and provide ED
management for pain and key
non pain symptoms based on
the patient's goals of care.
23. Know how to access hospice
care and how to manage
elders in hospice care while in
the ED.

Document pain level,
intervention under taken,
and response.

Address end-of-life goals of
care.

Access hospice as per your
institution’s practices.
PC
MK
ICS
SBP
Simulation:
 Address end-of-life goals of
care with a standardized
patient / family.
Articles:
(see master document)
Page 8 of 9
GEM Competency Grid – Eve Losman, MD
SAEM Task Force
GEM Competency
Educational Tools & Resources
Assessment Tools & Behavior
to be Evaluated
ACGME Core
Competency
Effect of Co-Morbid Conditions:
24. Assess and document the
presence of co-morbid
conditions ( e.g. pressure
ulcers, cognitive status, falls in
the past year, ability to walk
and transfer, renal function,
and social support) and
include them in your medical
decision making and plan of
care.
Web Based:
1. On-Line Training Modules – Stanford Geriatric Education Center
 Title: Test Your Ethnogeriatric IQ
Description: This module provides eight questions with multiple
choice answers related to commonly held conceptions of ethnic
elders. Test your knowledge.
 Title: Improving Communication With Elders of Different
Cultures
Description: This module provides information on how to
recognize barriers to communication with elders who are
culturally or ethnically different than your own, and some
culturally sensitive approaches to elicit information and promote
shared decision-making and mutual respect.
 Title: Diversity, Healing, and Healthcare
Description: This module contains information about
communication and healthcare beliefs related to 15 cultures, 11
religions, and 8 American immigrant cohorts.
Evaluate in the clinical arena.
 Assess and document the
presence of co-morbid
conditions that impact
decision making for the
patient.




25. Develop plans of care that
anticipate and monitor for
predictable complications in
the patients' condition (e.g.,
GI bleed causing ischemia).
26. Communicate with patients
with hearing/sight
impairments, speech
difficulties, aphasia and
cognitive disorders (e.g. using
family/friend, writing).

PC
MK
ICS
PBLI
Direct observation of
communication skills.
Articles:
(see master document)
Page 9 of 9