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!

M3 SeminarDecember 2004 3

U.S. Centenarian Population

2000 2010 2020 2030 2040 20500

250

500

750

1000

17 x Increase!

Tho

usan

ds

M3 SeminarDecember 2004 4

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

M3 SeminarDecember 2004 5

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

M3 SeminarDecember 2004 8

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

M3 SeminarDecember 2004 9

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

M3 SeminarDecember 2004 10

Geriatric Syndromes Geriatric Syndromes (outpatient)(outpatient)

• Dementia, Depression

• Incontinence

• Osteoporosis

• Falls

• Hearing and vision impairment

• Sleep disorders

• Failure to thrive

• Iatrogenic (medications)

M3 SeminarDecember 2004 11

Documentation/SkillsDocumentation/Skills

First rule of history and physical exam

“To treat the problem, you have to

document the problem”

M3 SeminarDecember 2004 12

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

M3 SeminarDecember 2004 13

Ask about….

• ADLs (Activities of Daily Living)

• IADLs (Independent Activities of Daily Living)

• Mobility

• Incontinence

• Affect/Mood

• Cognition (Memory)

M3 SeminarDecember 2004 14

These items go into the historyThese items go into the history

Either “Social History” or

“Functional History”

Or

In the HPI!

M3 SeminarDecember 2004 15

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

M3 SeminarDecember 2004 16

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”

M3 SeminarDecember 2004 17

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”

M3 SeminarDecember 2004 18

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

M3 SeminarDecember 2004 19

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”)

M3 SeminarDecember 2004 20

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!

M3 SeminarDecember 2004 21

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!