Geriatrics
I.
Rationale
By the year 2030 the current geriatric population will have doubled and represent close to 25% of our
total population within the US. At present more than 40% of hospital days and 36% of our national
healthcare dollars are consumed by our geriatric patients while they currently compose less than 15% of
our total present population. With the graying of America, the Family Practice resident must cultivate
knowledge and skills that can maximize both function and quality existence, as well as treat conditions
and diseases common to the elderly.
II.
Goals
Patient care/Medical knowledge
A. Acquire the knowledge base and skills to provide care to the elderly.
B. Learn appropriate incorporation of health promotion and disease prevention into elder care.
Interpersonal Skills/Communication Skills
A. Develop patient sensitive skills for interviewing that provide accurate, complete collection of
information regarding symptoms, family, and environment that affect the patient’s health and
well-being.
B. Develop skills in communicating findings, educating both patients and their families, discussing
sensitive issues, including end-of-life issues and negotiating a plan of action.
C. Develop a therapeutic relationship with both the patient and family.
D. Develop experience in planning and coordinating multiple healthcare providers to accomplish
comprehensive care for elderly patients.
Practice-Based Learning and Improvement
A. Residents must be able to investigate and evaluate their patient care practices, appraise and
assimilate scientific evidence, and improve their patient care practices.
B. Develop resources for life-long learning in geriatrics.
Systems Based Practice
A. Communicate verbally and document within the patient’s record clearly and completely both to
facilitate care and meet the documentation billing requirements of Medicare.
B. Develop an understanding of the high cost of modern medicine both in monetary and human
terms and apply principles of cost containment.
C. Understand the elements of various support systems of the older patient, including geriatric
medical services, community services, family support systems, respite care.
Professionalism
A. Develop a personal ethic within the framework of modern medicine that will permit
appropriate elder care and assessment of decision-making and end-of-life decisions.
Last Updated April 19, 2013
III.
Objectives
Patient care/Medical knowledge
A. To acquire the knowledge base and skills to provide care to the elder patient. Core knowledge areas to
include diagnosis, natural course and management of common complaints in the elderly including:
1. Abuse: psychological, physical; and neglect
2. Abdominal pain: missed perforation, aneurysm, diverticulitis, malignancies, etc.
3. Aging physiology and pharmacokinetic changes
4. Alcoholism and substance abuse
5. Altered mental status and non-specific disease presentations
6. Anorexia, dehydration, dentition, nutritional disorders and malnutrition
7. CVA, TIA, RIND and Lacunae
8. CHF
9. Chest pain: angina, MI, aneurysm
10. Constipation, impaction, & anorectal disorders
11. DJD
12. Delirium, Dementia
13. Depression
14. Diabetes
15. Dizziness, syncope and orthostatic hypotension
16. Falls and gait disorders
17. Femoral and other common fractures
18. Hearing and visual changes/losses
19. Hypertension
20. Hypothermia
21. Hypothyroidism
22. Iatrogenic illnesses
23. Incontinence, use of catheterization and alternatives
24. Life cycle changes of retirement, bereavement, relocation, loss of healthy self- image and
institutionalization, etc.
25. Osteoporosis/Osteopenia
26. Respiratory infections and prevention
27. Perioperative evaluation and preparation
28. Podiatric problems
29. Prostatic disorders
30. Sores, ulcers and decubitus
31. Sexual dysfunction/modifications
32. Skin cancers and actinic/keratotic changes
33. Speech and swallowing disorders
34. Stroke and TIA
35. Tremors, Parkinsonism and pseudo-Parkinsonism
36. UTI vs asymptomatic bacteria
B. Competencies necessary for the management of the frail elderly, especially in the long-term care
setting:
1. Concepts of rehabilitation and/or maximizing function
2. Consequences of institutionalization, immobilization and incontinence
3. Alternatives to ECF’s (Extended care facilities)
4. Optimal use of problem lists and medication lists
5. Polypharmacy Last Updated September 26, 2006
Last Updated April 19, 2013
C. Completely utilize assessment tools:
1. MMSE
2. ADL
3. Nutritional assessment
4. Depression inventory
5. Home visit and Safety evaluation
D. Learn appropriate incorporation of health promotion and disease prevention into the care of the elder
patient.
1. Immunizations
2. Screening guidelines
3. Exercise, nutrition and counseling to promote quality of life
4. Environmental safety and risk reduction
5. Proactive discussion/planning for end-of-life decisions
E. Learn elements of support services and systems
1. Interview patient including financial, family, and community support systems.
2. Evaluate the patient’s home or physical environment as it promotes or detracts from the
patient’s health.
3. Identify isolating factors for the patient.
Learning Activities
X
Attending Rounds
X
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty
Conference
Morning Report
X
Didactics
Other
Evaluation Methods
X
Attending Evaluation
Program Director
Review
360 ᵒ evaluation
Other
X
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
X
X
Faculty Supervision
Procedures
X
X
Directly Supervised
Procedures
In-Training Exam
Videotape Review
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
X
Faculty Supervision
and Feedback
Quarterly Review
Interpersonal Skills/Communication
A. Develop patient sensitive skills for interviewing that allow accurate, complete collection of information
regarding the patient’s symptoms, family or care giver issues, environmental concerns or supports,
especially modifying techniques to allow for slowed spontaneity, disabilities or dementia.
1. Direct the history taking process in such a fashion that accurate data is collected and the
spontaneity of the patient is not stifled.
2. Gather information from the demented person and/or the family/patient advocate.
3. Knowledge and appreciation of the developmental tasks of the older person.
4. Use varied methods of communication and data collection for speech-impaired persons.
B. Develop skills in communicating results, educating patients and their families, dealing with sensitive
issues for patients and families, and negotiating a plan of treatment with the patient.
Last Updated April 19, 2013
1.
2.
3.
4.
Negotiate care options, plan of work-up, and management with the patient and family,
discussing possible outcomes, risks, and benefits.
Clearly communicate follow-up plan and desire to take care of the patient.
Counsel patient regarding life cycle changes and retirement planning.
C. Develop therapeutic doctor-patient and doctor-family relationships.
1. Educate the patient and family to set achievable goals for improvement or maintenance of
health.
2. Recognize that chronic disease is managed and that the emphasis is on care not cure, and
effectively communicate that to the patient and/or family.
3. Make contact with family of nursing home patients as appropriate and as needed to notify
family of change in condition or needs for change in the care plan.
4. 4. Encourage continued independence and maintenance of self care and self determination
for the patient.
D. The resident will have experience planning care and collaborating with multiple health care
professionals in providing comprehensive health care to older persons.
1. Utilizes family practice center faculty and staff or staff in long term care facilities to organize
community or facility resources needed for the patient’s care.
2. Utilizes skills of long term care nursing staff to learn patient care plan construction.
3. Assists the patient in negotiating a changing health care system and environment.
4. Critically evaluates and select consultant advice for integration into patient management.
Learning Activities
X
Attending Rounds
X
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty
Conference
Morning Report
X
Didactics
Other
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
X
Evaluation Methods
X
Attending Evaluation
Program Director
Review
360 ᵒ evaluation
Other
Faculty Supervision
Procedures
X
Directly Supervised
Procedures
In-Training Exam
X
Videotape Review
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
X
Faculty Supervision
and Feedback
Quarterly Review
Practice-Based Learning and Improvement
A. Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate
scientific evidence, and improve their patient care practices. Residents are expected to:
1. Analyze practice experience and perform practice-based improvement activities using a
systematic methodology.
2. Locate, appraise, and assimilate evidence from scientific studies related to their patients'
health problems.
3. Obtain and use information about their own population of patients and the larger population
from which their patients are drawn.
Last Updated April 19, 2013
4. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies
and other information on diagnostic and therapeutic effectiveness.
5. Use information technology to manage information, access on-line medical information; and
support their own education.
6. Learn to incorporate health promotion and disease prevention into patient care.
7. Use evidence-based medicine, evaluation of available evidence, and use of best-available
evidence at morning report meetings and during routine clinical care.
Learning Activities
X
Attending Rounds
X
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty
Conference
Morning Report
X
Didactics
Other
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
X
Evaluation Methods
X
Attending Evaluation
Program Director
Review
360 ᵒ evaluation
Other
Faculty Supervision
Procedures
X
Directly Supervised
Procedures
In-Training Exam
X
Videotape Review
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
X
Faculty Supervision
and Feedback
Quarterly Review
Systems-Based Practice
A. Develop understanding of components of Medicare, the impact of these components on access to
medical services for the elderly patient.
B. Develop understanding of the physicians obligations and responsibilities under Medicare contract;
become familiar with information sources which can inform the physician regarding these
obligations and responsibilities.
C. Communicate and document clearly and completely by written and verbal methods.
1. Document thoroughly to meet Medicare guidelines for patient care and billing
classification.
2. Appropriately prescreen patients needing hospitalization according to Medicare or
secondary insurer guidelines.
3. Keep problem and medication list up-to-date.
D. Understand the high cost of medical care and applies principles of cost containment to decision
making.
E. Understand the elements of various support systems of the older patient, including geriatric
medical services, community services, family support systems, respite care
Learning Activities
X
Attending Rounds
X
Multidisciplinary Rounds
Last Updated April 19, 2013
Research Conference
Ethics/Comm Conference
Outpatient Clinics
Direct Patient care
X
Grand Rounds
Sub-Specialty
Conference
Morning Report
Didactics
Other
Specialty Conference
Noon Conference
X
Evaluation Methods
X
Attending Evaluation
Program Director
Review
360 ᵒ evaluation
Other
Faculty Supervision
Procedures
X
Directly Supervised
Procedures
In-Training Exam
X
Videotape Review
Resident Seminar
Journal Club
X
Readings
Morning Report
X
Faculty Supervision
and Feedback
Quarterly Review
Professionalism
A. Develop interview skills, communication skills and a personal ethic for patient care and care decisionmaking.
1. Assist the patient and family in weighing decisions about patient care with integration of
basic bioethical concepts.
2. Guide patients and their families in using legal resources including advanced directives as
living wills, guardianship, and evaluation of competence. Do not resuscitate, CPR,
intubation, ER transfer, surgery, I.V.’s, lab tests, tube feedings and medical interventions.
3. Respect patient privacy by guarding medical information that the patient does not wish
to share with their family.
4. Identify personal attitudes to aging, disability, and death as distinguished from the
patient’s attitude. Last Updated September 26, 2006
B. Develop a base of resources for personal education and develop a plan for ongoing education.
1. Identify CME materials and meetings for continued information gathering.
2. Set goals for future practice environment and direct learning to those goals.
C. Teach others
1. Participate in teaching geriatric care principles to medical students, nurse practitioner
students, and physician assistant students.
Learning Activities
X
Attending Rounds
X
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty
Conference
Morning Report
X
Didactics
Other
Research Conference
Ethics/Comm Conference
Specialty Conference
Noon Conference
X
Evaluation Methods
X
Attending Evaluation
Program Director
Last Updated April 19, 2013
X
Faculty Supervision
Procedures
Directly Supervised
Procedures
In-Training Exam
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
X
Readings
Morning Report
X
Faculty Supervision
Review
and Feedback
360 ᵒ evaluation
X
Videotape Review
Quarterly Review
Other:1) Topic presentation (longitudinal rotation) 2) research project presentation
(block rotation)
IV.
Instructional Strategies (see above
A. Provide continuity of care in the out-patient setting by following elders assigned in the FPC.
B. Participate in the in-patient service, focusing on the management of acute exacerbation of chronic
disease and the management of chronically ill patients who have higher levels of acuity or more comorbid conditions. Includes a minimum of two pre-op evaluations, at least one over the age of 80.
C. Geriatric home visits / environmental safety evaluations, as specified in Behavioral Medicine
curriculum.
D. Monthly nursing home visits with assigned continuity patients and didactic rounds with Dr Darradji
E. Associated rotations for additional experience: ER, Inpatient FMS, FP center, ICU, medical
subspecialties, dermatology and General surgery.
F. Core series of readings. See Reading list below
V.
Evaluation Strategies (see above)
Block Rotation/VA Nursing Home
A. Direct observation of patient care by precepting faculty.
B. Direct observation of communication skills, teamwork ability and professionalism
C. Ongoing review of resident’s documentation by precepting faculty
D. Complete geriatric medicine knowledge pre and post test
E. Complete geriatric medicine computer based learning modules as assigned by the course coordinator
F. Evaluation of case presentations on rounds
G. Evaluation of topic presentation
H. Faculty evaluation of resident upon completion of rotation.
I. Resident evaluation of rotation and faculty.
J. Performance on the geriatrics section of the in-training exam and mini-quizzes.
Longitudinal Rotation/Monthly Nursing home visits
A. Direct observation of patient care by precepting faculty.
B. Ongoing review of resident’s documentation by precepting faculty
C. Evaluation of case presentations
D. Evaluation of topic presentation
E. Faculty evaluation of resident upon completion of rotation.
F. Resident evaluation of rotation and faculty.
G. Performance on the geriatrics section of the in-training exam and mini-quizzes.
VI.
Implementation Methods
A. Four week block rotation during second year of residency which will include:
Eight half-days of participation per week in the nursing home at The Veteran’s Administration
Hospital in Atlanta, GA.
Liaison: Anna Mirk, MD
contact: Felicia Williams fax
Geriatrics & Extended Care
Felicia.williams@va.gov
Atlanta VA Hospital
(404) 321-6111 x 17867
1670 Clairmont Road
(404) 728-779 fax
Decatur, GA 30033
Last Updated April 19, 2013
B. The above includes one to two half-days per week rotating through several or all of the following
clinics/departments: continence clinic, hospice and pain management, wound clinic, OT/PT, speech
therapy, geriatric outpatient clinic.
C. On remaining half days, the resident will be assigned 10 to 12 patients. The resident will manage
these patients, round on these patients and write a monthly progress note. Residents will present
their assigned patients during formal monthly rounds to Geriatric team at the end of their rotation.
D. Hospice management of a terminal patient(s).
E. Weekly wound care rounds with Dr Kim House.
F. Admission and management of respite care patients, not to exceed two per week.
G. Formal geriatric topic presentation to Dr. Mirk and other care team members, assigned by rotation
coordinator.
H. Didactic meetings with Dr. Mirk every other week.
I. Daily Internal Medicine Noon conference as duties allow.
J. Attend Thursday morning Geriatrics didactic sessions and resident roundtable sessions
K. During this block, weekend calls are taken as upper level on the FMS at EUHM.
L. One half day of Family Practice Continuity Clinic per week at Emory Dunwoody.
Reading List:
Recommended Readings: Last Updated April 25, 2012
AAFP
AAFP
AAFP
AAFP
AAFP
AAFP
Monograph #389, Dementia, 2011.
monograph #344, Healthy Older Adult, 2008.
monograph #336, End of Life Care, 2007.
monograph #315, The Patient in The Long term Care Facility, 2005.
monograph #297, Caring for Elderly Individuals, 2004.
monograph #315, Arthritis, 2010.
Websites:
Geriatrics journal: http://www.geri.com
The American Geriatrics Society: http://www.americangeriatrics.org
_ American Geriatrics Society’s Clinical Geriatrics journal:
http://www.clinicalgeriatrics.com
Geriatrics & Aging journal: http://www.geriatricsandaging.com
British Geriatrics Society: http://www.bgs.org.uk
E-books at the Emory Library,
http://health.library.emory.edu/collections/etextbooks
search “geriatrics”. Search results on 4-25-2012:
Drugs for the Geriatric Patient, edited by R.I. Shorr et al, 2007
MD Consult
Primary Care Geriatrics: a Case-Based Approach, 5th ed, edited by R.J. Ham et al, 2006
MD Consult
Brocklehurst's Textbook of Geriatric Medicine and Gerontology, 7th ed, edited by H.M. Fillit
et al, 2010
MD Consult
Evidence-Based Geriatric Nursing Protocols for Best Practice, 3rd ed, edited by E. Capezuti et
al, 2008
R2 Library
Last Updated April 19, 2013
Hazzard's Geriatric Medicine and Gerontology, 6e ed., edited by J.B. Halter et al, 2009
AccessMedicine
American Psychiatric Publishing Textbook of Geriatric Psychiatry, 4th Ed., edited by D.G.
Blazer and D.C. Steffens, 2009
Psychiatry Online
Practice of Geriatrics, 4th ed, edited by E.H. Duthie et al, 2007
MD Consult
Geriatric Medicine: an Evidence Based Approach, 4th ed, edited by C.K. Cassel, 2003
STAT!Ref
A Practical Guide to Heart Failure in Older People, 1st ed, edited by C. Ward and M. Witham,
2009
R2 Library
Art of Dementia Care, by J. Verity and D. Kuhn, 2008
R2 Library
Last Updated April 19, 2013