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Outpatient Geriatrics Rotation for
Family Medicine and Internal Medicine Residents

Welcome to the outpatient geriatrics rotation for family medicine and internal medicine residents. We sincerely hope the next month is an enjoyable and beneficial experience for you. Our main goal is to prepare you for the unique issues in geriatric medicine which you will encounter in your careers as primary care physicians. Overall, we want you to have fun while gaining insight into one of the most dynamic and rapidly growing segments of the population who you will be caring for in the future.

We are all well aware of the expected dramatic increase in the number of elderly patients in the United States as the baby-boomers become 65. As noted by the DW Reynolds Foundation on Aging and Quality of Life, by 2030 the number of Americans age 65 and over will reach 70 million, 20% of the population and more than double the size of that group in 1995.  Those 85 and older are our fastest growing age group.  Their numbers will at least double within 30 years, to 8.5 million. Preparing physicians to provide better care for them when they become ill is vital but only one part of the equation. With today’s rapid technological advances, elderly patients and their families are expecting an improved quality of life in their later years.  Often, this necessitates that physicians practice medicine in a variety of environments outside of the hospital or clinic and in a manner that focuses on comfort, dignity to the patient, and minimizes stress on caregivers and their resources.

Most physicians today lack adequate training to meet the needs of the frail elderly patient.  Such patients typically suffer from interacting physical, social and psychological conditions –both acute and chronic – that limit their independence and threaten their capacity to function in daily life. The physician must now be adept at interacting with an interdisciplinary care team in order to effectively manage these challenging cases. Our goal is to help you to become aware of the full spectrum of issues relating to this population and to learn some of the techniques to better deal with them.

 

Overview

The purpose of this rotation is to provide formal training in geriatric medicine to the internal medicine/family medicine resident, and to introduce him/her to the skills needed to provide high quality acute, chronic, and preventive care to older adults.

Goals

  1. Incorporate a basic working knowledge of aging physiology and pharmacotherapy to evaluate and manage syndromes or diseases unique to or more common in older persons.
  2. Improve skills in taking sensitive and focused history and physical examinations in older patients, and learn how to use the observations of patients' families and significant others in patient care and management.
  3. Develop an understanding of and facility in geriatric assessment of older patients including screening instruments and an awareness of the importance of patient function in medical care.
  4. Recognize the importance of working collaboratively with an interdisciplinary health care team.
  5. Develop physician skills in working effectively with other community resources dedicated to the care of older patients in all settings.
  6. Practice the use of evidence-based medicine in the evaluation and management of complex older patients (see supplemental material).
    • The residents will be able to develop a clinical problem into an answerable clinical question.
    • The residents will understand the principles of applying evidence to the care of very old, medically complex, functionally disabled, and cognitively impaired patients.

Proposed Objectives

Knowledge

  1. Demonstrate an understanding of the diagnosis, treatment, rehabilitation and convalescence from common geriatric diseases and syndromes such as cognitive impairment, delirium, depression, urinary and fecal incontinence, syncope, balance disorders, falls, fractures, immobility, pressure ulcers, Parkinson’s disease and movement disorders, iatrogenesis and sensory impairment.
  2. Interpret findings based on an understanding that disease presentation in older patients may differ from younger patients.
  3. Recognize the need to modify the history and physical based on knowledge of sensory deficits and functional limitations.
  4. Distinguish normal from pathological aging.
  5. Distinguish the roles and responsibilities of other team members, e.g., nursing, social work, physical therapy, nutrition, pharmacy.
  6. Understand the roles and responsibilities of resources available through community agencies such as visiting nurses, home health aides, home care corporation case managers, home delivered meals, and adult day care.
  7. Know cost/reimbursement issues related to #6.

Skills

  1. Effectively manage a variety of common geriatric syndromes/diseases.
  2. Evaluate and incorporate cognitive, phychosocial, and functional status into the overall assessment of the older patient.
  3. Recognize problems related to pharmacotherapy such as adverse drug reactions, polypharmacy, and non-compliance.
  4. Acquire effective exam skills targeted at the diagnosis and management of common geriatric syndromes (as described in Knowledge Objective #1).
  5. Adapt management techniques to the preferences and capabilities of older patients and their families.
  6. Utilize appropriate technology while encompassing an awareness of the limits of these interventions on light of individual patient values.
  7. Communicate with older patients and their families utilizing effective, compassionate, and respectful interpersonal skills. Recognize the prevelance of caregiver stress and know the techniques/interventions necessary to manage this crucial aspect of geriatric care.
  8. Collaborate with other health care team members in the assessment, implementation, and evaluation of care.
  9. Make appropriate referrals to community resources.
  10. Maintain effective communication with community resources on behalf of the patient and his/her family.

Attitudes

  1. View the elderly as physically, psychologically, functionally, culturally, and socially diverse.
  2. Appreciate the heterogeneity and atypical presentation of and response to illness in older patients.
  3. Appreciate the non-medical issues in caring for the older patient e.g., psychosocial, ethical, legal, and cost-benefit.
  4. Appreciate the roles of all elements of an interdisciplinary team.
  5. Appreciate the value of community resources in provided care to older people living at home.

Questions, concerns, issues?

Contact: Mary Ann Forciea, MD