m3 seminar december 2004 1 “geriatrics” in a nutshell karen e. hall, m.d., ph.d. clinical...
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M3 SeminarDecember 2004 1
“Geriatrics”in a Nutshell
Karen E. Hall, M.D., Ph.D.
Clinical Assistant Professor of Internal MedicineUniversity of Michigan and VA Ann Arbor Health
SystemsResearch Scientist,
Geriatric Research, Education and Clinical Center
M3 SeminarDecember 2004 2
Geriatric DemographicPopulation aged >65 years
0
25
50
75
1900 1925 1950 1975 2000 2025
Mil
lio
ns
10 x Increase
20 x Increase!
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U.S. Centenarian Population
2000 2010 2020 2030 2040 20500
250
500
750
1000
17 x Increase!
Tho
usan
ds
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All physicians need to All physicians need to understand “Geriatrics”understand “Geriatrics”
• Geriatrics Portfolio Activities highlighted by the “Geriatrics
Center M-Tree”
Cumulative record of Geriatric teaching activities throughout medical school
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UM Geriatrics PortfolioUM Geriatrics Portfolio• All UMMS graduates will be
competent in providing care for older individuals.
• no “Geriatrics” course.
• learning outcomes – established as minimum competency standards in geriatrics – presented in multiple courses and clinical experiences throughout all four years .
• portfolio provides an accessible, convenient mechanism to highlight the geriatrics content.
M3 SeminarDecember 2004 6
M3 SeminarDecember 2004 7
Learning OutcomesLearning Outcomes
• Review M3 Clinical Competencies In Coursetools htps://ctools.umich.edu/portal
• Geriatrics Portfolio H and P writeups, track your geriatrics content
• Physical Examination Skills Documentation of impairments
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M3 Clinical CompetenciesM3 Clinical Competencies(from CourseTools)(from CourseTools)
• Geriatric syndromes and conditions
• Diseases more common in older patients
• Psychosocial issues
• Disease prevention
• Ethical Issues
• Health Care Financing (Medicare)
• Cultural aspects of aging
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Geriatric Syndromes (hospital)Geriatric Syndromes (hospital)
• Dementia, delerium, depression common, not documented
• Inappropriate medications anticholinergic
• Gait and mobility impairment not documented
• Incontinence
• Iatrogenic impairment bed rest, constipation, pressure ulcers
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Geriatric Syndromes Geriatric Syndromes (outpatient)(outpatient)
• Dementia, Depression
• Incontinence
• Osteoporosis
• Falls
• Hearing and vision impairment
• Sleep disorders
• Failure to thrive
• Iatrogenic (medications)
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Documentation/SkillsDocumentation/Skills
First rule of history and physical exam
“To treat the problem, you have to
document the problem”
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DocumentationDocumentation
First rule of geriatrics (similar to first rule of
real estate sales)
“Function, Function, Function”
Patients don’t care about their diagnoses,
they care about their function
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Ask about….
• ADLs (Activities of Daily Living)
• IADLs (Independent Activities of Daily Living)
• Mobility
• Incontinence
• Affect/Mood
• Cognition (Memory)
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These items go into the historyThese items go into the history
Either “Social History” or
“Functional History”
Or
In the HPI!
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Physical ExamPhysical ExamTest the following:
Mobility – Timed Up and Go test- stand, walk, turn, sit
Cognition – Mini-Cog (3 item recall) or MMSE (Mini Mental Status Exam)
Affect – Two question Depression screen
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The results go in the Physical The results go in the Physical ExamExam
“Timed Up and Go was 15 seconds, patient walked slowly, unsteady, had to hold rail for support”
“Two question depression screen positive”
“Patient only remembered 2 of 3 items on Mini-Cog”
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Documentation does not Documentation does not necessarily mean “Diagnosis”necessarily mean “Diagnosis”Diagnosis belongs in the “Impression/Plan” section
BUT….
Rule #1: Avoid the trap of “premature labeling”
Problem 1. “Falls” – (list the differential here)
Not Problem 1. “Probable spinal stenosis”
Or Problem 1. “Musculoskeletal System”
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Develop a Plan rather than a Develop a Plan rather than a DiagnosisDiagnosis
Rule #2:You can start addressing functional impairments without having a specific diagnosis
Patients appreciate a practical plan
Home safety, mobility aids, social supports
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Prevention = “Screening”Prevention = “Screening”Back to First rule of History and Physical
Examination ….
“To prevent it, you have to document it”
Learn about primary and secondary prevention screening that maximizes function and minimizes future impairment
Keep current about age-associated recommendations for tertiary prevention (“treatment”)
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Social, Ethical, CulturalSocial, Ethical, CulturalLearn about cultural influences on health behavior
•DNR, family involvement
Learn about stressors that affect patients and families
•Caregiver stress, finances
Know what resources are out there to help
•Social work (Turner clinic + other), types of assisted living, medication assistance, Area Agency on Aging, 3 day inpatient requirement for Medicare payment of CNH!
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Social, Ethical, CulturalSocial, Ethical, CulturalAsk the patient what THEY WANT TO DO about their problem
“Do not assume your preference is their preference!”
This will avoid more lawsuits than any other intervention!