Geriatrics rotation–Internal Medicine

Geriatrics and Hospice-Palliative Medicine (HPM) often present clinical syndromes with multiple interacting domains that affect the health, function and well-being of the patient and family. Goals of care shift from curing/fixing to improving function (geriatrics) and/or providing safety and comfort (HPM). A key overarching goal of this rotation is to develop this “bigger picture” view of the patient-family situation. The goals and objectives of the rotation are best summarized by the 26 geriatric competencies developed for internal medicine residents – Geriatric Competencies. Please review these competencies making special note of those you feel you can improve in your own practice.

As patients are encountered in a variety of settings (VA ambulatory care, hospice, nursing home, inpatient, your own clinic) please identify patients that exemplify one or more of these competencies. These patient encounters are used to do a comprehensive multi-dimensional assessment and write up (see below). This will engage you in the multiple interacting domains of the patient experience as well as provide an element of active learning into the rotation.

The rotation normally consists of 2 separate blocks, each 2 weeks long. One 2 week block is done at the VA ambulatory clinics. The other 2 week block is done with with Dr. George Martinez doing Hospice Palliative Medicine at the VA (during these 2 weeks you will have Geri clinic on Tues and Thurs mornings at the VA).

comprehensive multi-dimensional assessment and write-up

A specific outcome of the rotation will be one (1) write-up/week that addresses the Geriatric Competencies. The basic format is – 1) brief statement of the clinical case 2) annotated (multi-dimensional) problem list 3) discussion of 1-2 of the key problems (each of which should correspond to one of the 26 geriatric competencies) 4) discussion of a primary research paper of pertinence to these 1-2 key problems. (These write-ups will be reviewed by faculty (gsb) and sent back).

Identify a patient you have seen and evaluated. Review 26 Geriatric Competencies (also below) … the goal is to have addressed each of these 26 items by the end of the rotation.

See example write ups here and here.

1. Briefly summarize pertinent aspects of H&P.

2. Write up – in annotated problem list format – using the ‘dimensions of care’ format (see below) – the key clinical problems, syndromes, issues that are affecting the patient and family … with brief discussion – especially re the interactions of these problems with each other.

3. Pick one or two of these problems, read the pertinent section in UpToDate (or other secondary resource) and write 2-3 paragraphs that apply that information to your patients. (cite your source)

4. Find a primary research paper that addresses a facet of one of these problems and write 1-2 paragraphs that summarizes/applies that information. (cite your source)

5. email to gbrungardt@kumc.edu for feedback

 

dimensions of care – 26 geri competencies – crosswalk

Structure and Processes of Care – interdisciplinary team assessment based on patient/family goals of care; prognosis; disposition (hospice level of care – inpatient unit, home); safety … hospital patient safety (17,18,19,20) … transitions of care (21,22) … 14 …

Physical Aspects of Care – pain, dyspnea, n/v, fatigue, constipation, other; performance status; medical diagnoses; medications (add/wean/titrate) … screening … complex/chronic illness (8,10,11, 12 … meds (1,2,3) … ambulatory care (23,24,25,26)

Psych Aspects of Care – anxiety, depression, delirium, cognitive impairment; stress, anticipatory grief, coping strategies; pharm/non-pharm rx; pt/fam grief/bereavement; … cognitive, affective, behavioral (4,5,6,7) …

Social Aspects of Care – family/friend communication/interaction/support; caregiver crisis

Spiritual Aspects of Care – spiritual/religious/existential; hopes/fears; forgiveness;

Cultural Aspects of Care – language, ritual, dietary, other.

Care of the Imminently Dying – presence; recognition and communication to pt/fam; education/normalization; prognosis (eg hours to days; very few days; etc) … palliative, end-of-life (15,16)

Ethical & Legal Aspects of Care – decision maker; adv dir; and/dnr; manh; abx. … complex/chronic 9, 13,

[italicized summarizes 26 competencies)

misc. …

You should seek to identify their strengths/weaknesses and seek out patients/clinical situations to ‘fill in’ these gaps.

 

Geriatric Competencies

 

MEDICATION MANAGEMENT

1 Prescribe appropriate drugs and dosages considering: age-related changes in renal and hepatic function, body composition, and CNS sensitivity; common side effects in light of patient’s comorbidities, functional status, and other medications; and drug-drug interactions.

 

2 When prescribing drugs which present high risk for adverse events and interactions (these medications include, but are not limited to, coumadin, NSAID’s, opioids, digoxin, insulin, strongly anticholinergic drugs, and psychotropic drugs), discuss and document the rationale for their use, alternatives, and ways to decrease side effects.

 

3 Periodically review patient’s medications (including meds prescribed by other physicians, OTC and CAM) with the patient and/or caregiver to assess adherence, eliminate ineffective, duplicate and unnecessary medications, and assure that all medically indicated pharmacotherapy is prescribed.

 

COGNITIVE, AFFECTIVE, AND BEHAVIORAL HEALTH

4 Appropriately administer and interpret the results of at least one validated screening tool for each of the following: delirium, dementia, depression, and substance abuse.

 

5 Recognize delirium as a medical urgency, promptly evaluate and treat underlying problem.

 

6 Evaluate and formulate a differential diagnosis and workup for patients with changes in affect, cognition, and behavior (agitation, psychosis, anxiety, apathy).

 

7 In patients with dementia and/or depression, initiate treatment and/or refer as appropriate.

 

COMPLEX OR CHRONIC ILLNESS(ES) IN OLDER ADULTS

8 Identify and assess barriers to communication such as hearing and/or sight impairments, speech difficulties, aphasia, limited health literacy, and cognitive disorders. When present, demonstrate ability to use adaptive equipment and alternative methods to communicate (e.g., with the aid of family/friend, caregiver).

 

9 Determine whether an older patient has sufficient capacity to give an accurate history, make decisions and participate in developing the plan of care.

 

10 In evaluating adults with undifferentiated illness, generate differential diagnoses that include diseases that often present atypically in older adults (e.g., acute coronary syndromes, the acute abdomen, urinary tract infection, and pneumonia).

 

11 Consider adverse reactions to medication in the differential diagnosis of new symptoms or geriatric syndromes (e.g., cognitive impairment, constipation, falls, incontinence).

 

12 Demonstrate understanding of the major age-related changes in physical and laboratory findings during diagnostic reasoning (e.g., S4 does not reflect CHF, pulse increase less common with orthostasis, pO2 declines with age, abdominal pain may be less severe).

 

13 Discuss and document advance care planning and goals of care with all patients with chronic or complex illness, and/or their surrogates.

 

14 Develop a treatment plan that incorporates the patient’s and family’s goals of care, preserves function, and relieves symptoms.

 

 

PALLIATIVE AND END OF LIFE CARE

15 In patients with life limiting or severe chronic illness, assess pain and distressing non-pain symptoms (dyspnea, nausea, vomiting, fatigue) at regular intervals and institute appropriate treatment based on their goals of care.

 

16 In patients with life limiting or severe chronic illness, identify with the patient, family and care team when goals of care and management should transition to primarily comfort care.

 

HOSPITAL PATIENT SAFETY

17 As part of the daily physical exam of all hospitalized older patients, assess and document whether delirium is present.

 

18 In hospitalized medical and surgical patients, evaluate – on admission and on a regular basis – for fall risk, immobility, pressure ulcers, adequacy of oral intake, pain, new urinary incontinence, constipation, and inappropriate medication prescribing, and institute appropriate corrective measures.

 

19 In hospitalized patients with an indwelling bladder catheter, discontinue or document indication for use.

 

20 Before using or renewing physical or chemical restraints on geriatric patients, assess for and treat reversible causes of agitation (e.g., use of irritating tethers [including monitor leads, blood pressure cuff, pulse oximeter, intravenous lines and in-dwelling bladder catheters], untreated pain, alcohol withdrawal, delirium, ambient noise). Consider alternatives to restraints such as additional staffing, environmental modifications, and presence of family members.

 

TRANSITIONS OF CARE

21 In planning hospital discharge, work in conjunction with other health care providers (e.g., social work, case management, nursing, physical therapy) to recommend appropriate services based on: the clinical needs, personal values and social and financial resources of the patients and their families (e.g., symptom and functional goals in the context of prognosis, care directives, home circumstances and financial resources); and the patient’s eligibility for community-based services (e.g., home health care, day care, assisted living, nursing home,

rehabilitation, or hospice).

 

22 In transfers between the hospital and skilled nursing or extended care facilities, ensure that: for transfers to the hospital: the caretaking team has correct information on the acute events necessitating transfer, goals of transfer, medical history, medications, allergies, baseline cognitive and functional status, advance care plan and responsible PCP; and for transfers from the hospital: a written summary of hospital course be completed and transmitted to the patient and/or family caregivers as well as the receiving health care providers that accurately and concisely communicates evaluation and management, clinical status, discharge medications, current cognitive and functional status, advance directives, plan of care, scheduled or needed follow-up, and hospital physician contact information.

 

AMBULATORY CARE

23 Yearly screen all ambulatory elders for falls or fear of falling. If positive, assess gait and balance instability, evaluate for potentially precipitating causes (medications, neuromuscular conditions, and medical illness), and implement interventions to decrease risk of falling.

 

24 Detect, evaluate and initiate management of bowel and bladder dysfunction in community dwelling older adults.

 

25 Identify older persons at high safety risk, including unsafe driving or elder abuse/neglect, and develop a plan for assessment or referral.

 

26 Individualize standard recommendations for screening tests and chemoprophylaxis in older patients based on life expectancy, functional status, patient preference and goals of care.