Transcript Geriatrics Orientation

Geriatrics Orientation
GERIATRICS
The Panacea?
Geriatricians are the happiest of all
physician groups surveyed
Physician Career Satisfaction Across Specialties,
Arch Intern Med. 2002;162:1577-1584.
Why?
Case 82 year old
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Diabetes
CAD
HTN
Chronic kidney failure, EGFR 45
Usual Care
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HbA1C <7
Echo
Betablocker
ASA
ACE-I
Diuretic
Statin
Creatinine and labs every 3 months
GERIATRICS IS…
Internal Medicine
PLUS
FUNCTION
+FUNCTION
Patient #1
 Works 40 hours/wk
 Walks 3 miles TIW
 Cleans house
 Cooks
Patient #2
 Bedbound
 Requires
assistance with
ADLs/IADLs
 Family cares for
him
 Cognitive
impairment
Your Goals…
Our Goals
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Functional status evaluation
Geriatric Syndromes
Venues of Care
ULTIMATELY
 Change your practice caring for the
frail elderly
Functional Status
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ADLs
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Bathing
Dressing
Toileting
Transfer/walking
Feeding
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IADLs
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Cooking
Cleaning
Shopping
Driving
Telephone
Finances
Medications
Geriatric Syndromes
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Falls
Dementia/Delirium
Polypharmacy
Urinary Incontinence
Weight loss
Depression
Pressure Sores
Sensory Impairment
End of life
Care Settings
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Hospital Consults
• Delirium
• Polypharmacy
• Goals of care
• Discharge assistance
Care Settings (2)
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Clinic
• Ambulatory patients
• Present with family often
• How did you get here?
• Primary care
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Internal Medicine with need to consider risks
and benefits.
Care Settings (3)
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Skilled Nursing Facility
• Subacute rehab
• Short term stays
• Medically complex
• Full team evaluation and management
• Technology/testing readily available
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Nursing Home-Long Term Care
• Custodial care needs
• Interdisciplinary team
• Quality of Life focus
Challenges in NH care
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Nursing home patient to nurse ratio
• 1:18 or 1:60 (night) vs hospital 1:5
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No respiratory therapy
Scarcity of RNs makes central lines,
IV push meds, TPN, NOW labs not
feasible
Frequent monitoring (post procedure
or dramatic change in condition) may
require return to hospital
Might take 2 days for labs to return
Care Setting (4)
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Home Care
• Pt seen in natural setting
• Complete pharmacy evaluation
• Functional evaluation
• Less technology readily available
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Day Care
Why is Geriatrics Exciting?
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Functional evaluation
Quality of Life
Risks/Benefits of treatments or
evaluations
Transitions in life
How are we going to
teach this to you?
Nuts and Bolts
Didactic Series
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Core Geriatric issues
7:45 AM (follow schedule)
• Generally Monday & Wednesday at State
Veterans Home
• Generally Tuesday & Friday at VA
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Remember to do an evaluation after
each lecture
Geriatric Grand Rounds
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Thursday 7:30 AM
• Academic Office building 7 floor
• 1st and 3rd
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Journal Club 2nd Thursday
• VA auditorium
Consults
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One person designated as consult
person
Responsible for VA consults, SVH
admissions, inpatient issues
Primary pt responsibility may be
redistributed
Types of care/practice
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Nursing home care
• VA
• State Veterans Home (SVH)
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Clinics
Home Care
Day Care-Total Longterm Care
Geriatric Research
Palliative Care
State Veteran Home
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Subacute Rehabilitation through
Medicare
Veterans or dependents
Many from AIP
• May consult on pt prior to hospital d/c
Skilled Nursing Patients (SNF)
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See patients and write notes twice
per week or with significant change
Interdisciplinary team-informal
meetings
Learn from other members of the
team
Geriatric Evaluation and
Management (GEM)
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Screening tool [templates/geriatrics]
• Includes completed MMSE
• Functional assessment
• Contact made to caregiver
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Consult type at VA
• Geriatric syndromes
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e.g. Surgical patient is delirious in the ICU
Elderly woman admitted with falls
• Disposition
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Will you take this person for rehab?
Where is the optimal place for this pt to go? Can you
help with the transition?
GEM Inpatient (VA)
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Patient characteristics:
• Ideally 2-3 weeks of rehab
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Debility from illness/hospitalization
Polypharmacy
Potentially reversible physical frailty
Potentially reversible cognitive decline
Wound care
Hospice (variable)
Pt goal is to go back to home or ALF (not NH)
Prefer patients >65yo
PT/OT set goals for pt prior to Geri consult
Preference for pt with additional medical issue
and geriatric syndrome
• Pt motivated
• Pt agrees to transfer to NH
Transfer to GEM
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Needs new H&P on transfer
• NHCU MD/NP Admission template
• Admit for 14-90 days, always
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Hospital should do d/c summary
Need delayed admission orders
• Admission to NHCU short term
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Higher intensity care only done for 24
hours (vitals…)
• No TPN, IV narcotics
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May set up an appt on d/c in Geri clinic if
no available PCP f/u
GEM Inpatient
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See patients 2-3 days per week
Write notes about twice per week
• more if changes
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Manage medical problems
Focus on function planning for
discharge
Interdisciplinary team meeting
• Tuesday 11AM at VA
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Discharge summary to be dictated on
discharge date (or day before)
Nursing Home Care Unit (VA)
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GEM (purple)-subacute rehab; short term
Rehab (green)-subacute rehab; longer
term; less education
Long Term Care (brown/yellow)-custodial
care; live in NHCU
Comfort Care (blue)-inpatient hospice care
Respite (orange)-short term caregiver
break
Dr. Bourg is NHCU medical director
Team meetingsthings to think about
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Does this group have goals that direct them (program/
client goals?
Aside from the professional roles, what other roles did
people assume (facilitator, time keeper, clarifier, problem
solver, attentive listener)?
How long did the meeting take? Was it efficient? Why?
Was the meeting structured in any way?
How did this group make decisions (consensus, voting,
default)?
Did you observe conflict in the group? How was it handled?
Who was the leader of the group?
Did you note examples of leadership shifting in the group?
What did you observe about communication?
How were the tasks assigned in the group?
What were your overall impressions of the group?
Clinics
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VA
University
Community
Denver Health
Most clinics start at 1PM; communicate
with attending if schedule issues!
VA Clinic
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New patients at 1PM and 2:30PM
Full Geriatric evaluation
Patients are scheduled for residents
Use Geriatric template on the shared
drive
University Clinic
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AOP 5th floor
Different attendings
Goals:
• Learn to manage geriatric issue
• Experience varying attending styles
• Appreciate demographic differences
• Observe/compare clinic management &
setup
Centura Senior Life Center
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Drs. Price, VerMiller, Cain, Lazaroff
Location: 1601 Lowell
Goals
• Learn to manage geriatric issue
• Experience varying attending styles
• Appreciate demographic differences
• Observe/compare clinic management &
setup
Denver Health Senior Clinic
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Dr. Yasui
Location:
• Wellington Webb Primary Care bldg
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Goals:
• Learn to manage geriatric issue
• Appreciate Cultural differences
Centura Senior Health Center at
Range Vista
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Dr. Martau
Location: 8300 N Alcott, Ste #101
Goals:
• Learn to manage geriatric issue
• Appreciate demographic differences
• Observe/compare clinic management &
setup
Home Based Primary Care
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Afternoon visit with Dr. Bray-Hall
Logistics: meet at 1PM at VA bldg 4
Goals:
• Identify functional needs at home
• Review meds pt is actually taking
• Find out how pt LIVES despite medical
issues
• Evaluate caregiver issues
Total Longterm Care
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Adult Daycare
Program of All-Inclusive Care for the
Elderly (PACE)
6 clinic sites in Denver
Go after morning lecture 9:15-3:00
ASK QUESTIONS!!!
PARTICIPATE!!!
Focus: Non-medical, learn about
program and additional services.
Total Longterm Care
Goals:
• See alternative management of frail
• Appreciate complexity of enrollees
needs
• Learn about pay source
Total Longterm Care:
Questions to ponder
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Who pays?
How is hospitalization handled?
How are costs curtailed?
What services does TLC provide that other
programs do not?
Which patients receive rehab services and
how is this decided?
How are behavioral problems handled?
How are active problems handled during
weekend hours?
Are hearing aides, visual aides and dental
care provided?
Total Longterm Care:
Questions to ponder (2)
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Are various consultants available and how are
they employed?
Are there any special policies regarding
resuscitation, tube feedings, etc?
Is the TLC project one that will work on a large
scale?
How does your “case mix” compare to visiting
nurse/home health programs or nursing homes?
How are you different from other day care
programs?
What do you do if a client gets sick?
What does it mean when you take “risk
contracts?”
How do you save money?
Geriatric ResearchTesting procedures in exercise and
aging research
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Meet with Catherine Jankowski, PhD
Research in Exercise, Metabolism,
Hormone changes in elderly
UCDHSC Exercise Research Laboratory
(ERL)
Leprino Office Building (LOB), 3rd floor
Room 360
Volunteer needed for
• DXA (non-pregnant, do not wear metal or
plastic)
• VO2 max (exercise clothing, prefer not highly
trained)
Testing procedures in exercise
research: Objectives
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To observe a graded treadmill exercise test with
ECG and respiratory gas collection
To recognize the expected changes in oxygen
consumption, carbon dioxide production, and
ventilation during graded exercise
To interpret test results and determine if a
maximal cardiovascular effort has been achieved
To observe bone densitometry scans (DXA; total
body, hip, and spine) to measure bone mineral
density and body composition
To interpret the bone mineral density and body
composition data
Palliative Care
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Dr. Levy and the palliative care team
Inpatient rounds at VA; 1:00PM
Call Dr. Levy
Goals:
• Appreciate input from interdisciplinary
team consultation in palliative care
• Learn components of symptom
assessment (physical, emotional, social,
spiritual)
• Identify ways to manage and palliate
symptoms
Case Presentation
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Near end of the month
20-30 minute discussion of a patient
and geriatric issue you saw this
month
Examples:
• Screening guidelines
• Weight loss/gain
• Visual/hearing changes
• Prognosis
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Make handout
Logistics
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Weekends
• Each takes one weekend,
• round Saturday at VA,
• call 303-393-2865 Sunday
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Nights-leave consult pager on
Vacation
Switching/Commitments-Notification by 1st
week of rotation required
TEAM FOCUS
Geriatrics
Function
Team