Geriatrics
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Care of Older Adults

This document was developed by representatives of, and has been endorsed by, the American Academy of Family Physicians and the Society of Teachers of Family Medicine. Additions were made to this document to explain the Competency Based Geriatrics Curriculum at the Altoona Family Physician Residency Program.
Preamble

The ultimate concern of all physicians is the welfare of the patient. The acquisition of appropriate skills and knowledge in history taking, physical examination, and clinical and psychosocial diagnosis and management of each type of patient the family physician will encounter must be an integral part of residency training. The patient's age and background often require different approaches to care.

The percentage and number of older adults in our society is steadily increasing. Elderly persons occupy a large number of acute-care hospital beds, comprise the largest percentage of nursing home residents and make more visits to physicians' offices than any other segment of the population. Yet the health care system has become geared to acute and episodic rather than preventative, chronic and comprehensive care.

Although people do not suddenly acquire different characteristics at an arbitrarily predetermined age, there are, nonetheless, many subtle and significant differences in the approach to diagnosis and management of older as opposed to younger adults. Also, the philosophy of comprehensive, continuing care incorporates the belief that health in later years is vitally affected by lifestyle and health care patterns established throughout life. One goal of family physicians is to prepare younger adult and middle-aged patients for the changes of increasing age. Another overall goal is to assist elderly persons to function independently with self-respect, preserving lifestyle as much as possible. Thus, the curriculum implies a comprehensive approach to the psychosocial and economic factors affecting the aging patient as well as the patient's family.

This curriculum guideline provides an outline of the attitudes, knowledge and skills that should be among the objectives of training programs in family medicine and which will lead to optimal care of elderly patients by future family physicians.

 

 Altoona Family Physicians Rotation Description: The Family Practice Geriatrics curriculum is longitudinal. The resident will see patients in their own continuity panel at AFP or WFP through all three years of residency and under the guidance of the preceptor provide age appropriate, compassionate, and evidence based care to his or her geriatric patients.

 

The third year resident will also see patients under faculty supervision at the Altoona Center for Nursing Care and Amber Terrace Assisted living.

 

Residents will also follow two of their own continuity patients in the nursing home during their PGY2 and PGY3 years.

 

Competency Based Curriculum Goals

 

 Patient Care

 Goal 1.The resident will provide patient care to the elderly that if compassionate, appropriate and effective for the treatment of health problems and promotes longevity and vigor.

 

Objectives

  1. The PGY1 and OME1 resident will care for elderly patients in the AFP and WFP office site and his or her ability to fulfill rotation goals will be measured by the preceptors both at the time of visit and through precepting of patient records after visits and 360 degree evaluations by preceptors, office staff and patients via patient satisfaction survey   .
  2. The PGY2 and PGY3 resident will be responsible for the care of the minimum of two geriatric continuity patients at ______________ Nursing Facility. The resident will visit the patient as required by Medicare and facility policies under the supervision of ____________. Patient care will be evaluated and measured by 360 degree evaluation of preceptor and nursing home staff.

 

Goal 2.

Medical Knowledge Medical Knowledge

 

Goal1. The resident will acquire the knowledge, skills and attitudes to effectively and compassionately care for elderly patients.

 

Objective 1. The resident will complete pre and post tests as assigned in Geriatrics in Medical Knowledge Curriculum. They will read the assigned monographs to assist in completing these tests. When the resident masters 100% on these tests, all answer sheets will be handed in to Administrative Assistant Cindy Fickes. The assigned monographs are to be completed on the Rural Rotation in the PGY3 and OGME 3 year. They are as follows:

 

297. Care for elderly individuals

315. The Patient in the Long Term Care Facility

344. Healthy older adults

 

Objective 2. The resident will also attend Geriatric lectures as scheduled in didactic conference schedule. Progress will be measured by conference attendance records. Residents that immediately score 100% on pre and post tests will seek out guidance from their advisor for further reading and study.

 

Attitudes

The resident should develop attitudes that encompass:

  1. An awareness of the importance of the physician's own attitudes to aging, disability and death.
  2. Compassion and humanism, balancing realism and practicality in the consideration of inevitable decline and loss.
  3. The promotion of dignity through self-care and self-determination.
  4. Recognition of the importance of family and home in the overall life and health of patients.
  5. An understanding of appropriate limitation of investigation and treatment for the benefit of the patient.
  6. Lifelong learning and contributing to the body of knowledge about aging, health and the medical management of aging patients.
  7. An awareness of the importance of a multi-disciplinary approach to the enhancement of individualized care.
  8. Continuing accessibility to and accountability for his or her patients.
  9. An awareness of the importance of cost containment.
  10. An awareness of the benefits and limitations of advanced directives, living wills and durable powers of attorney.

Knowledge

The resident should develop knowledge of:

  1. The underlying physiologic "normal aging" changes in the various body systems, including diminished homeostatic abilities, altered metabolism and effects of drugs, and other changes relating to the assessment and treatment of elderly patients.
  2. The normal psychologic, social and environmental changes of aging, including reactions to common stresses such as retirement, bereavement, relocation and ill health, and the changes in family relationships that affect health care of the elderly.
  3. The unique modes of presentation of elderly patients for care, including altered and nonspecific presentations of specific diseases.
  4. The risks and adverse outcomes in geriatric care of polypharmacy, iatrogenic illness, immobilization and its consequences, over-dependency, inappropriate institutionalization, non-recognition of treatable illness, over-treatment, inappropriate use of high technology and the unsupported family.
  5. The means for promoting health and health maintenance through the screening for and the assessment of risk factors.
  6. The range of services available to promote rehabilitation or maintenance of an independent lifestyle for elderly people, increasing their ability to function as long as possible in their existing family, home and social environments.
  7. The indications and benefits of the house call in the assessment and management of elderly patients.
  8. The characteristics of the various types of long-term care facilities and alternative housing available to the elderly.
  9. The specific regulations for the care of patients in long-term facilities.
  10. The financial aspects of health care of the elderly and the way these influence health care patterns and decisions.
  11. The means to actively promote health in the elderly through exercise, nutrition and psycho-social counseling.
  12. The evaluation of the functional status of the elderly patient.
  13. The following problems, which are either especially characteristic of older patients, or differ significantly in their presentation and/or management in order adults.
    1. Special senses: hearing and vision loss, speech disorders, decubiti, gait disorders
    2. Respiratory: pneumonia and other respiratory infections
    3. Cardiovascular: hypertension, congestive heart failure, myocardial infarction, thromboembolism, temporal arteritis, cerebral vascular accident, transient ischemic attacks, postural hypotension
    4. Gastrointestinal: dentition problems, acute abdomen, anorexia, constipation, fecal impaction
    5. Geritourinary: incontinence, urinary tract infections, bacteriuria, sexual dysfunction
    6. Musculoskeletal: degenerative joint disease, fractures, contractures, osteopenia/osteoporosis, podiatric problems, falls
    7. Neurological: delirium, dementia (eg. Alzheimers), altered mental status, dizziness, tremor, memory loss, gait disorders
    8. Metabolic: dehydration, diabetes, hypothyroidism, drug-induced illness, malnutrition, anemia, hypothermia, malignancies
    9. Psychosocial: abuse (both physical and psychological), alcoholism and other substance abuse, grief reactions, depression, psychological effects of illness, pain, terminal care, anorexia, failure to thrive

Skills

The resident should develop skills in:

  1. Obtaining a comprehensive history and mental status examination, utilizing all available sources of information.
  2. Conducting an efficient comprehensive physical examination in office, hospital and nursing-home settings, mindful of the patient's modesty and mobility.
  3. Appropriate selection, interpretation and performance of diagnostic procedures.
  4. Performing appropriate house calls and coordinating home care.
  5. Developing problem lists in practical, clinical, functional, psychologic and social terms.
  6. Setting appropriate priorities and limitations for investigation and treatment.
  7. Communicating to the patient and/or caregivers the proposed investigation and treatment plans in such a way as to promote understanding, compliance and appropriate attitudes.
  8. Communicating hope and empathy.
  9. Counseling about psychologic, social and physical stresses and changes of age, dying and death.
  10. Coordinating a range of services appropriate to the patient's needs and support systems.
  11. Integrating factors in the patient's family, home and general lifestyle into the diagnostic and therapeutic process.
  12. Consulting with physicians and other healthcare professionals, including the critical evaluation and selective use of consultant advice and the integration of management in critical care situations.
  13. Dealing with issues of death and dying.

Practice Based Learning and Improvement

Goal 3. The resident must demonstrate the ability to investigate and evaluate their care of elderly patients, to appraise and assimilate the latest scientific evidence in the care of the elderly, and to continuously improve patient care based on constant self evaluation and life-long learning.

Objective 1. The resident will identify his or her strength’s and limits in expertise via pre- and post tests and study of the Home Study Monographs. Progress will be measured via these scores. The resident will also have clinical application of medical knowledge monitored by evaluations by faculty and staff.

Objective 2. The resident will use the Monograph assignments to improve knowledge and seek out faculty advisor if a more individual study plan is needed.

Objective 3. The resident will participate in patient education of the elderly and their families at each encounter. This will be measure by observation and evaluation by attendings and office staff.

Interpersonal and Communication Skills

Goal 4. The resident must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with elderly patients, their families, and health professionals.

Objective 1. The resident will demonstrate effective communication with the elderly and their families as measured by evaluation by faculty and peer evaluation.

Objective 2. The resident will demonstrate effective communications with social workers, nurses, and other professionals involved in the patients care in the inpatient, outpatient, nursing home and assisted living settings. This will be measured by 360 degree evaluation. Will we query staff and our social workers?

Professionalism

Goal 5. The resident will demonstrate an adherence to carrying out professional responsibilities and adherence to ethical principles.

Objective 1. The resident will demonstrate respect for the elderly in the inpatient, outpatient (AFP and WFP offices), nursing home and during home visits. This will be measured by faculty evaluation and patient satisfaction surveys.

Objective 2. The resident will be sensitive the older adults needs for privacy and making their own health care decisions. They will demonstrate conscious efforts to avoid ageism and understand that the elderly should partake in their own healthcare and decision making in fullest possible manner. This will be measured by faculty and staff evaluation and patient satisfaction surveys.

Systems-based Practice

Goal 6. Residents will demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Objective 1. The resident will be able to deliver health care to the elderly in the outpatient, inpatient, home visit, nursing home and assisted living setting. This will be measured by faculty evaluation.

 

. Objective 2. The resident will also care for the elderly on the inpatient medicine service rotation through out all three years of training with emphasis on safe transitions from the home setting to hospital to home again including any nursing or assisted living facilities

Objective 3. The resident will coordinate the elderly patient’s care paying particular attention to transitions in settings of care. This will be measured by faculty evaluation of discharge notes in the AFP electronic health record, effective communication of initial orders and medications to Nursing homes and feedback from adjunct faculty on verbal or written communication to primary care physicians not at AFP and WFP.

Objective 4. The resident will be aware of the costs of various interventions for the elderly and be able to individualize risks and benefits for the individual patient.  This will be measured by faculty evaluation in the inpatient and outpatient (AFP and WFP offices) and via patient satisfaction surveys.

Objective 5. The resident will demonstrate attentiveness to patient safety and the danger in transitions from different facilities and levels of care. This will be evaluated by review of discharge summaries by faculty at the AFP, WFP offices and the receiving supervising attendings at the nursing homes. Readmissions will also be discussed at family medicine rounds. Difficulties and errors will be reported via evaluations to resident advisors.

 

Resources

  1. Reichel, W, ed. Care of the Elderly: Clinical Aspects of Aging. 5th ed. Baltimore: Williams & Wilkins, 1999.
  2. Ham, RJ, Sloane PD, eds. Primary Care Geriatrics: A Case-Based approach. 4th ed. St. Louis: Mosby-Year Book, 2001.
  3. Reuben DB, Yoshikawa TT, Besdine RW, eds. Geriatrics Review Syllabus Supplement: A Core Curriculum in Geriatric Medicine. 5th ed. New York City: American Geriatrics Society, 2002.

Web Sites:

http://www.geri.com
http://www.americangeriatrics.org
http://www.geriatricsandaging.com


Published 9/83
Revised 5/87
Revised 5/94
Resources revised 2/96
Revised 10/01

Adapted by Altoona Family Physicians