PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
SECTION 12: GERIATRICS
This section has been reviewed and approved by the Chief, Division of Geriatrics as well as
the Program Director, Internal Medicine Residency Program at Prince George’s Hospital
Center.
________________________
Chief, Division. Of Geriatrics
______________________________
Program Director, Residency Program
I. Overview
The care of older adults is a substantial and growing component health care services.
The number of elderly, with their burden of chronic disease, is increasing competency in
clinical geriatrics involves recognizing the difference in presentation of disease and the
importance of maintaining functional independence in elderly patients. With increasing
age, presentations of disease become less classic and are often muted, and timely
recognition requires attentiveness to subtle signs. Appropriate management requires a
balance of patient observation, judicious diagnostic intervention and acceptance of limits
as defined by the patient. Effective management of problems may be complex and may
necessitate an interdisciplinary approach that takes social support into account. Medical
and psychological problems, acute and chronic, frequently co-exist.
Many competencies of geriatrics are included within lists for other disciplines. They are
repeated here to reflect the unique set of skills required to manage specific problems
when they occur in the elderly.
II. Principle Teaching Methods
This consists of direct patient care in both inpatient and outpatient settings in area
nursing homes and Geriatrician offices as well as a multidisciplinary view of care of the
elderly:
1. . Issues related to end of life and hospice are taught in an area Hospice Center
through lectures and patient care including home visits.
2. The residents also follow a Physiatrist and observe several evaluation techniques
including swallow evaluations, cognitive evaluation, gait and balance evaluation etc.
3. In the inpatient nursing home setting the goal is to emphasize the multiple health
care needs of the elderly and learn management of acute and chronic disease
processes. Skilled care includes rehabilitation services (physical, occupational, and
speech therapy), wound and ostomy care, patient education, certain types of
intravenous and injection therapy, pain control, and medical observation. The
nursing and social work staff serves a pivotal role by continually reassessing patient
status and initiating appropriate changes in the treatment and discharge plans.
4. Psychiatric illnesses in the elderly can present atypically and often misdiagnosed.
For example patients with depression may be diagnosed as dementia and patients
with thyroid problems may be diagnosed with depression or dementia. Internists
must also be aware of risk factors that cause depression in elderly like loneliness or
loss of a loved one. The residents therefore round with a staff psychiatrist and learn
interviewing and screening techniques for psychiatric illnesses as well as
management of psychiatric disorders.
5. Ophthalmologic issues are important in the elderly. Loss of vision, its evaluation and
impact on the elderly are discussed during the encounters in the area
ophthalmologists office.
6. Endocrine issues related to metabolic bone disease and other endocrine
abnormalities in the elderly are discussed while shadowing an area endocrinologist.
The residents must make a double sided copy of their geriatrics attendance sheet at the
beginning of the rotation. This sheet must be signed by the attending physician for each
encounter. Topics discussed during the encounter must be marked. A completed sheet
must be submitted to the program coordinator at the end of the rotation to obtain credit
for the rotation. Attendance > 75% in each part of the rotation is required for satisfactory
completion of the rotation. Any missed encounters must be explained in writing at the
end of the month.
Residents will also learn regarding the field throughout the year by taking care of
geriatric patients admitted to the hospital or being followed up at the Glenridge Medical
center and from a series of lectures scheduled throughout the year, conducted by
geriatrician and focusing on issues like:
 Dementia
 Delirium
 Incontinence
 Decubutis Ulcers
III. Strengths and Limitations
Residents learn from direct interaction with the multiple subspecialties involved in the
care of the elderly.
At the nursing home and outpatient rehabilitation center resident learns management of
multiple medical problems, polypharmacy, nutritional assessment, wound care, urinary
incontinence. They also learn about a multidisciplinary approach to patient care
especially with respect to nutrition, patient safety and functional ability.
IV. Goals and Objectives for Geriatrics Rotation
Legend for Learning Activities
Learning Venues:
1. Direct patient care: supervised by attending physician
2. Management rounds at Nursing Home
3. Didactic Lectures including Core Lecture Series
4. Self Study
Evaluation Methods:
A. Attending evaluation
B. Direct Clinical Observation
C. Nursing Evaluation
D. In-Training Examination
Learning Venues*
Evaluation
Methods
1,2
A, B
1,2
A, B
1,2
A,B
1,2
A,B,D
ALL
A,B,D
Learning Venues*
Evaluation
Methods
ALL
A,B,D
ALL
A,B
Learning Venues*
Evaluation
Methods
ALL
A, B
Meet with Program
Director
A, B, D
Learning Venues
Evaluation
Methods
1,2
A,B,C
ALL
ALL
1,2,3
A, B, C
Learning Venues*
Evaluation
Methods
1,2,3
A,B,C
1,2,3
A,B,C
Competency: Systems-Based Practice
Learning Venues
Evaluation
Methods
Understand and utilize the multidisciplinary resources
necessary to care optimally for hospitalized and out
1,2
A,B,C
Competency: Patient Care
Interview patients more skillfully, gathers accurate and
essential information with emphasis on geriatric
illness
Examine patients more skillfully with competent and
complete observation of normal and abnormal signs,
particularly in the elderly population
Define and prioritize patient’s medical problems,
recognizing the special presentation of illness in the
elderly
Generate and prioritize differential diagnoses with
appropriate testing and therapeusis
Develop rational, evidence-based management
strategies
Competency: Medical Knowledge
Expand clinically applicable knowledge base of the
basic and clinical sciences underlying the care of
medical service patients, both out and inpatients.
Access and critically evaluate current medical
information and scientific evidence relevant to geratric
care
Competency: Practice-Based Learning and
Improvement
Identify and acknowledge gaps in personal knowledge
and skills in the care of hospitalized and out patients,
paticularly the elderly
Develop and implement strategies for filling gaps in
knowledge and skills and minimize errors
Competency: Interpersonal and Communication
Skills
Communicate effectively with patients and families,
with particular emphasis on explanation of complex
and multi-system illness and the testing required to
confirm diagnostic possibilities
Communicate effectively with physician colleagues at
all levels with appropriate consultation when needed
Present patient information concisely and clearly,
verbally and in writing. Adhere to confidentiality.
Competency: Professionalism
Demonstrate respect, compassion, integrity and
altruism towards patients, families, colleagues, and all
members of the health care team
Demonstrate sensitivity to confidentiality, gender, age,
cultural differences and disabilities
patients and the limitations of various practice
environments.
Collaborate with other members of the health care
team to assure comprehensive patient care
Use evidence-based, cost-conscious strategies in the
care of hospitalized and outpatients
1,2
A,B,C
ALL
A,B,D
V. Educational Content
A. Physical Medicine and Rehabilitation
When possible, patient’s rehabilitation sessions are schedule so that the resident can be
present. Physical, occupational, and speech therapists teach the resident their
assessment and treatment approaches to patient problems, both general (e.g., gait
instability, cognitive impairment) and particular (e.g., hip fracture, stroke). Residents
should develop an understanding of the components of a Rehabilitation Prescription,
and the indications of Rehabilitation Team Referrals. They will also gain familiarity of
Physical Medicine methods for management of:
1) Falls
2) Gait disorders: Understand impairment, disability and handicap terms
3) Poor safety awareness
4) Sundowning
5) :Low back pain, Radiculopathy
1) Electrodiagnostic Evaluation of the Peripheral Nervous System: Understand
basics of test and its clinical indications
6) Contractures, Degenerative joint diseases
7) Cognitive dysfunction and its evaluation
8) Functional assessment
 Comprehensive Rehabilitation Evaluation of Function
 Familiarity with Quantitative Methods of Patient Functional Evaluation
9) Gait assessment
10) Home safety assessment
 Motor vehicle driving assessment
 Needs assessment on hospital discharge, including rehabilitation
 Audiology
 Neuropsychiatric testing
 Videofluoroscopy for swallowing problems
B. Ophthalmology
Eye problems are common in the elderly population. They could result as a
consequence of systemic illnesses (like diabetic retinopathy) or as a result of aging itself
(cataract). They are important issues that impact their ability to live and /or function
independently.
1) Vision loss: acute and chronic
 Cataracts
 Glaucoma
 Macular degeneration
 Optic atrophy
 Visual field and acuity testing
2) Common disorders of the eyelid
 Blepharitis
 Chalazion
3) Floaters and visual phenomenon and fundoscopic evaluation (where appropriate)
of:
 Retinal/ vitreous detachment
 Diabetic retinopathy
 Subconjunctival hemorrhage
4) Injuries
 Foreign bodies, external and superficial
 Orbital fracture
5) Infections and inflammation
 Conjunctivitis
 Uveitis
 Schleritis
 Keratitis
 Optic neuritis
 Eye involvement in giant cell arteritis
 Orbital or periorbital cellulitis
6) Eye pain/photophobia and work up
 Increased intraocular pressure
 Retinal artery or vein occlusion
 Corneal abrasion with fluorescein stain and slit lamp
7) Systemic effects of ophthalmic medications
8) Dry eye syndromes
C. Psychiatry
Psychiatric illnesses in the elderly can present atypically and often misdiagnosed. For
example patients with depression may be diagnosed as dementia and patients with
thyroid problems may be diagnosed with depression or dementia. Internists must also be
aware of risk factors that cause depression in elderly like loneliness or loss of a loved
one.
The residents therefore round with a staff psychiatrist and learn interviewing and
screening techniques for psychiatric illnesses as well as management of psychiatric
disorders.
1) Substance Abuse and Related Disorders
2) Delirium
3) Delusions, Hallucinations
4) Dementia, Cognitive disorders
5) Depression, Bipolar disorder, dysthymia, Suicide risk
6) Fatigue
7) Late-onset psychotic disorders
8) Neurobehavioral disorders
 Agitation
 Psychosis
 Anxiety
 Confusion
9) Social isolation
 Adjustment disorders (grief, life-cycle changes)
 Poor hygiene or self-care
10) Personality disorders
11) Schizophrenia
12) Insomnia and other Sleep disorders
13) Humanistic Approach of Patient Care/Social Issues
14) Mental status examination, including standardized cognitive examinations (e.g.
Mini Mental State Exam) when indicated.
15) Neuropsychologic evaluation
D. Endocrine / metabolic
Endocrine issues are common in elderly. Residents learn about special issues in
management of chronic medical problems (like brittle diabetes) and issues related to
problems with memory and mobility (uncontrolled blood sugars, dehydration). Wellness
is also an important aspect of elder care and residents learn about important issues like
osteoporosis by shadowing an endocrinologist one half day a week.
1) Dehydration
 Hypernatremia
 Hyponatremia
2) Diabetes mellitus, type 2
3) Disorders of temperature regulation
4) Thyroid Disorder
 Hyperthyroidism
 Hypothyroidism
 Multinodular goiter
 Sick euthyroid state
5) Failure to Thrive
6) Metabolic bone disease, Osteoporosis
E. End of Life Care (Hospice Care)
An important aspect of general internist practice is care at end of life. Resident learn how
to compassionately manage patients and deal with issues related to end of life by
shadowing at an area Hospice Center with a focus on:
1) Death and Dying
2) Bereavement
3) Bowel obstruction
4) Dyspnea
5) Pain Management
6) Nutrition
7) Treating the caregiver
8) Medico-legal and Ethical Issues may also be discussed like
 Elder Abuse
 Advance directives
 Health care proxy
 Unrealistic expectations of family and patient
 Evaluating decision making capacity
The following issues will be addressed on a case by case basis by discussions with the
supervising Geriatrician in the Nursing Home, Rehabilitation Center and Outpatient
Offices:
F. Cardiovascular
1) Angina/Myocardial infarction
2) Atrial fibrillation
3) Congestive heart failure
4) Hypertension
5) Lower-extremity edema
6) Orthostatic hypotension
7) Peripheral vascular disease
G. Gastroenterology
1) Colon Cancer
2) GI bleed
3) Constipation, obstipation
4) Diverticular disease
5) Fecal incontinence
6) GERD
7) Ischemic bowel
8) Swallowing disorders
H. Hematology
1) Anemia of chronic disease
2) Iron deficiency anemia
3) Leukemias and lymphproliferative disorders
4) Multiple myeloma
I.
Iatrogenic Disease
1) Adverse drug reactions
2) Nosocomial complications
3) Polypharmacy, drug interactions
4) Procedure complications
J. Neurologic/ sensory
2) Carotid artery disease
3) Normal pressure hyprocephalus
4) Parkinson’s disease
5) Spinal stenosis
6) Stroke
7) Transient ischemic attack
8) Dementia
 Alzheimers
 Multi-infarct
 Thyroid disease related
 Infectious disease related (neurosyphilis etc.)
9) Hearing loss
 Cerumen impaction
 Presbycusis
10) Peripheral neuropathy
11) Syncope
12) Dizziness
13) Vestibular disorders
14) Sleep disorders
K. Nutrition
1) Aspiration
2) Feeding disorders
3) Malnutrition, under nutrition
4) Oral health problems
L. Renal/Urologic
1) Age related changes in renal function
 Adjusting medication dose for patient’s GFR
2) Prostate disease
 Benign Prostatic Hypertrophy
 Prostate Cancer
 Role of PSA
3) Sexual dysfunction
4) Urinary incontinence
5) Urinary retention
 Evaluating results of urodynamic studies
6) Urinary tract infection
 Catheter related infections
M. Rheumatologic/Musculoskeletal
1) Contractures
2) Crystal diseases (gout, pseudogout)
3) Deconditioning
4) Degenerative joint disease
5) Fractures
 Hip
 Vertebral compression fracture
 Wrist
6) Giant cell arteritis
7) Immobility
8) Low back pain
9) Osteoporosis
10) Polymyalgia rheumatica
11) Spinal stenosis
12) Subacromial bursitis
13) Trochanteric bursitis
N. Skin
1)
2)
3)
4)
5)
Pressure ulcers
Cancers
Pruritis
Seborrhic keratosis
Xerosis
O. Tuberculosis
1) Interpreting PPD results in nursing home patients
2) INH prophylaxis: indications, monitoring, duration
3) Treatment
VI.
Recommended Reading
All residents are encouraged to read the Geriatrics section from the MKSAP during their
month long rotation as well as read on topics on a case-by-case basis. Other resources
are as follows:
1) Bentley DW, Bradley S, High K, et al. Practice guideline for evaluation of fever and
infection in long-term care facilities. Clin Infect Dis. 2000; 31:640-53
2) Chang JT, Morton SC, Rubenstein LZ et al. Interventions for the prevention of falls
in older adults: systematic review and meta-analysis of randomised clinical
trials. BMJ. 328(7441):680, 2004 Mar 20
3) Fick DM, Cooper JW, Wade WE, et al. Updating the Beers Criteria for Potentially
Inappropriate Medication Use in Older Adults. Arch Intern Med. 2003;163:2716-2724
4) Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced
dementia: A review of the evidence. JAMA 1999;282(14):1365-70.
5) Matulonis UA. End of life issues in older patients. Seminars in Oncology. 31(2):27481, 2004 Apr.
6) Mui AC. The Program of All-Inclusive Care for the Elderly (PACE): an innovative
long-term care model in the United States. Journal of Aging & Social Policy. 13(23):53-67, 2001.
7) Scientific Committee of the First International Consultation on Incontinence.
Assessment and treatment of urinary incontinence. Lancet 355(9221):2153-2158.
8) Small GW, Rabins PV, Barry PP, et al. Diagnosis and treatment of Alzheimer
disease and related disorders. Consensus statement of the American Association for
Geriatric Psychiatry, the Alzheimer’s Association, and the American Geriatrics
Society. JAMA 1997;278:1363-71
9) Wrenn K. Fecal Impaction. NEJM 1989;321(10):658-662
10) Practical Functional Assessment of the Elderly Person: A Primary Care Approach.
Fleming KC. Mayo Clin Proc 1995.890-910.
11) Preventive Services in the Adult Aged 65 and Older. HuffmanGB. Clinics in Family
Practice.June 2000.
12) The Geriatric Patient: A Systematic Approach to Maintaining Health. Miller KE.
American Family Physician. February 2000.1089-1104.
13) Preventing Falls in Elderly Persons. Tinetti ME. N Engl J Med. January 2003. 42-49.
14) Falls in the Elderly. FullerGF. American Family Physician.2000.2159-68.
15) Inappropriate Medications for Elderly Patients. Chutka D Mayo Clin Proc 2004.122139.
16) The Medicare Program. www.medicare.gov
17) Constipation and Fecal Incontinence in the Elderly Population. Romero Y. Mayo Clin
Proc 1996.81-92.
18) The Pathophysiology of Urinary incontinence Among Institutionalized Elderly
Persons. Resnick N. N Engl J Med 1989.1-7.
19) Urinary Incontinence in the Elderly Population. Chutka D. Mayo Clin Proc 1996.93101.
20) Cancer Screening in Elderly Patients. Walter LC. JAMA. 2001.2750-56.
21) Pressure Ulcers: Prevention and Management. Evans JM. Mayo Clin Proc 1995.789799.
22) Depression in the elderly: Tailoring medical therapy to their special needs. Raj A.
Postgraduate Medicine, June 2004; 115(6)
23) Delirium in Elderly Patients: Evaluation and Management. Rumnans TA. Mayo Clin
Proc 1995. 989-998.
24) Alzheimer Disease. Cummings JL. JAMA 2002.2335-38.
25) Physician Evaluation and Management of Nursing Home Residents. Ouslander JG.
Ann Intern Med 1994. 584-592.
26) Hazards of Hospitalization of the Elderly. Creditor MC. Ann intern Med 1993.219223.
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
GERIATRICS ROTATION SCHEDULE SHEET
Monday
8:00am
9:00am-12:00am
Morning Report
Psychiatry Rounds
12:00-1:00 pm
1:00pm-5:00pm
Noon Conference
Physical medicine
8:00am
St. Thomas More
Nursing & Rehab
Center
OAO Maryland Trade
Center
Tuesday
1:00pm
Wednesday
Thursday
7:30am
Ophthalmology
PGHC Conference Rm.
Dr Bangura
301-437-7992
PGHC Conference Rm
Dr. Kulkarni
Dr. Devore
Dr. Turkewitz
(301) 345-5857
Dr. Malouf
(301) 423-5252
1:30pm
Nursing home
Dr. Husain, Saadia
301-580-6732
8am-12:00 N
Endocrinology
Dr. Sotoudeh
301-474-0400
Multidisciplinary rounds
with Dr Devore and write
notes
Friday
1:30pm
Gladys Spellman
9:00am
Urology
Dr. Ajrawat, Harbhajan
301-772-3434
12:00-1:00 pm
Noon Conference
PGHC Conference Rm
1:30pm
Glenridge clinic
Weekly clinic
St. Thomas More Nursing & Rehab Center
Gladys Spellman Speciality Hospital
4922 LaSalle Road
2900 Mercy Lane
Hyattsville, MD 20782
Cheverly, Maryland 20785
301-864-2333
301-618-2010
Dr. Turkewitz’s Office
Dr F. Sotoudeh
OAO Maryland Trade Center 4th Fl
7525 Greenway Center Drive, Ste 209
7500 Greenway Center Drive
Greenbelt, MD 20770
Greenbelt, MD 20770
301-474-0400
301-345-5857
Dr. H. Ajrawat
6126 Landover Road
Cheverly, MD 20785
301-772-3434
Dr. George Malouf
5210 Auth Road
Camp Springs, MD 20746
301-423-5252
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
GERIATRICS ROTATION ATTENDANCE SHEET
RESIDENT NAME________________________________________________________
PGY LEVEL_______________
ROTATION MONTH_____________
Psychiatry: Please discuss topics listed under the subsection of Psychiatry in the Geriatrics Curriculum.
MUST DISCUSS THE MINI MENTAL EXAM
Date
Topic
Discussed
Signature
Gladys Spellman Nursing Home: Please discuss topics listed under the Educational Content of the
Geriatrics Curriculum
Date
Topics
Discussed
Signature
St Thomas More Nursing And Rehab Center: Please discuss topics listed under the Educational
Content of the Geriatrics Curriculum
Date
Topics
Discussed
Signature
Dr. Turkevitz office: Please discuss topics listed under the Educational Content of the Geriatrics
Curriculum
Date
Topic
Discussed
Signature
RESIDENT NAME______________________________________
Dr. Malouf’s Office: Please discuss one of the topics listed under the subsection of Ophthalmology in
the Geriatrics Curriculum .
Date
Topics
Discussed
Signature
Dr Sotoudeh’s office: Please discuss one of the topics listed under the subsection of Endocrinology in
the Geriatrics curriculum
Date
Topics
Discussed
Signature
Physical Medicine: Please discuss one of the topics listed under the subsection of physical medicine
in the Geriatrics curriculum. MUST DISCUSS COGNITIVE EVALUATION
Date
Topics
Discussed
Signature
Urology: Please discuss some topics in urology. Especially discuss about urinary incontinence and
erectile dysfuction, and prostate cancer.
Date
Topics
Discussed
Signature