Geriatric Psychiatry Inpatient Rotation for
Medical Students
Welcome to the Geriatric Psychiatry Inpatient rotation! Though three weeks is a
short time, we want you to have a great learning experience while you’re here
with us. One of the most unique aspects of this rotation are the varied
opportunities to learn. You’ll see that each member of the treatment team has an
area of expertise—feel free to ask anyone any questions that you have. You’ll be
able to appreciate how aging may be affected by emotional/behavioral issues
and the confluence of both medical and psychiatric problems.
Objectives
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To become familiar with the psychiatric and social difficulties experienced
by the elderly and the differences in the presentations of the various
psychiatric disorders
To understand and participate in the medical workup for acutely ill
psychiatry inpatients and to understand how the combination of medical
and psychiatric illness can complicate the diagnosis and treatment of each
To understand the importance of loss of autonomy and cognitive
dysfunction to the presentation of psychiatric disease, to tension in family
dynamics and to treatment challenges
To learn how to interact with psychiatrically ill elderly patients and to
perform the mental status exam with a particular focus on expanded
cognitive testing.
To appreciate the multidisciplinary approach to diagnosing psychiatric
disorders in the elderly (MD, nursing, social work, occupational therapy,
recreational therapy, and consultative medical assessments)
To appreciate the team approach to the acute inpatient management of
geriatric psychiatric disorders, including pharmacotherapy,
psychotherapies, occupational therapy, recreational therapy,
social/environmental interventions and disposition planning.
To appreciate the importance of the family/support system in the
discharge planning for patients who have been hospitalized.
Competency Building
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Skills in interviewing geriatric patients about sensitive topics such as loss
of autonomy, fear of death, changes in sexuality, substance use/abuse,
ongoing elder abuse and changing roles within the family system.
Mental status exam skills in interviewing and in presentation.
Performing cognitive screening in all patients and more advanced
cognitive testing when indicated.
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Education of patients and family members about topics such as cognitive
impairment, loss of autonomy, disposition needs, lifestyle management,
substance abuse. Psychoeducation re: diagnoses and medications
Communication skills for care-givers in dealing with cognitively limited
relatives
Further development of organizational skills in patient care, including
interview techniques, presentations and progress notes
Expectations
Arrive 30 minutes before scheduled rounds
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Check in with your resident(s)
Review nursing notes (e-chart), get details from nursing staff.
See vital signs, sleep chart, use of prn’s (check MAR) over last 24 hrs.
Check pending labs
Check in briefly with patients re: new problems, side effects from meds
Attend Morning Rounds and Treatment Team
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Briefly present each assigned patient
Facilitate input from treatment team members
Summarize the treatment plan for the day
After Team
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Clarify questions from team with resident/attending, staff, social work.
Work with resident(s) on writing orders (use CPOE), following up on tests,
lab work, making contacts, etc.
Participate in scheduled family meetings involving your patients.
Gather information from referring providers and other health care agents
involved in the patient’s pre-hospital care (with patient permission)
See your patients to work on rapport building, supportive work, goal work,
safety plan, disposition planning, cognitive reassessment and symptom
tracking.
Participate in at least one therapeutic group each for occupational therapy
(OT) and recreational therapy (RT). Attend a Kohlman Living Skills
Assessment on a patient.
Other Expectations
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Document progress notes in WebCIS; have resident review for feedback.
Use time in the afternoons not spent with patients, groups, and families to
look up information on clinical topics of interest related to geriatric issues.
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You will be expected to make a short presentation to the team during the
last week of the rotation.
Complete one history and physical assessment, including differential
diagnoses and preliminary treatment plan; present it to your attending.
Working with your patients
One of the biggest challenges in working with geriatric patients is how easily
we’re reminded of our own family’s aging members (and perhaps of our own
mortality). On the one hand this can lead us to develop a special rapport with
our patients based on experiences we’ve had with our own loved ones, but on
the other can lead to distancing from issues that might remind of us our own or
our loved ones mortality and potential infirmity. Because of rampant ‘ageism’ in
our society and a general disrespect for our aging members (often based on
these fears) it is important to confront these issues through understanding the
experiences of our elders.
A few pointers:
 Reminiscing with your patients is a great way to establish rapport. Be sure
to follow this up with some discussion of your patients’ issues, worries and
goal work. Be sensitive to issues of autonomy, the loss of which is a
major fear of the elderly.
 While empathy is important, minimize sharing your own personal
experiences with your patients.
 Meet with your patients where others can see you.
 Cognitively impaired patients may need frequent reminders of where they
are and what your role is (and even who you are). It often makes sense to
see these patients briefly over multiple visits throughout the day.
 Physical exams should be done in the treatment room with a chaperone of
the same gender of the patient. (Limited physical exams may be done in
the patient’s rooms as necessary).
 If you don’t know the answer to something say so, but reassure the patient
that you will pass on the concern to appropriate staff members.
 If you feel uncomfortable or confused about an interaction with a patient,
don’t hesitate to seek guidance from your resident or attending.
A Note on Confidentiality
Most of what a patient tells us will be confidential, i.e. we do not share with
family members unless given permission. The only exceptions are issues that
involve harm to self and/or others. In the case of our geriatric patients, harm to
self can include incompetency to manage one’s own affairs safely. Please
remember the following:
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A therapeutic goal should always be to encourage communication
amongst family members but the patient’s right to confidentiality
must be respected for all competent patients.
If a patient has a guardian, then that person has the right to all
pertinent patient information.
If a patient has a designated HCPOA (Health Care Power of
Attorney) then we may communicate with that person if we believe
the patient’s competency has been compromised.
Working with families
On occasions there may be a high degree of discord between the patient and
their family members, especially their children (typically regarding issues of
autonomy). Therefore, we try to work with patients and families together as
much as possible. Strategies include:
 Meeting (or talking) with the patient and family separately to get an idea of
the problems(s) from every perspective
 Counseling the patient re: their diagnoses, treatment, disposition needs
and the role of the family in recovery
 Educating the family re: concerns the team may have regarding living
alone, medication management and/or managing finances. Discussing the
issue of guardianship when appropriate
 Counseling the family on appropriate communication techniques based on
the needs of the patient.
Always be sure to discuss any concerns, ambiguities or difficulties in dealing with
families with your resident and/or attending.
A Note on Informed Consent
Given that patients (or guardians/HCPOAs when indicated) must consent
for all psychotropic medications we prescribe, and that the evidence base
for many of the medications is limited and therefore prescribing is
sometimes “off-label,” UNC Hospitals takes informed consent very
seriously.
Document in your progress note that you have discussed:
 Indication(s) for medication/potential benefits
 Potential risks/adverse events
 Treatment alternatives, risks/benefits
 Risks/benefits of not treating
 “Off-label” status if applicable