Transcript Fourth Year Medical Students* Required Written Patient Care

Fourth Year Medical Students’ Required
Patient Care Reflections in Patients with
Advanced Illness and Complete Functional
Assessment. Are They Including Nutritional
Status?
John Agens, M.D. Associate Professor in Geriatrics
Florida State University College of Medicine
John Agens, M.D. Associate
Professor in Geriatrics
Florida State University College
of Medicine
I have no conflicts of interest to disclose!
Objectives
• Discuss very briefly results of a survey of awareness of vitamin D
deficiency states and treatment among faculty at a medical school.
• Know how often our community faculty prescribe vitamin D using the
window of our 4th year geriatrics medical students’ written
medication review assignments on frail older patients.
• Know how often students address nutrition using the window of our
4th year geriatrics medical students’ written functional assessment
and advanced illness assignments on frail older patients.
• Compare your performance on seven final exam questions with our
students’ performance on those questions.
Mission and Vision of our Medical School
• The Florida State University College of Medicine will educate and develop
exemplary physicians who practice patient-centered health care, discover
and advance knowledge, and are responsive to community needs,
especially through service to elder, rural, minority, and underserved
populations.
• The FSU College of Medicine will lead the nation in preparing
compassionate physicians to deliver the highest quality 21st Century
patient-centered medicine to communities of greatest need.
• Florida has the highest proportion of older persons in the US and the
lowest per capita number of geriatricians. Geriatric education is mandated
by law in the founding of our school.
• Among a handful of medical schools with a department of geriatrics.
Fall prevention with supplemental vitamin and active forms of
vitamin D: a meta-analysis of randomized controlled trials
Bischoff-Ferrai, et al; BMJ 2009;339:b3692
• A dose of 700 IU -1000 IU supplemental vitamin D a day reduced falls
by 19%, and by up to 26% with vitamin D3, within 2-5 months of
treatment initiation.
• Vitamin D may not reduce falls at doses of less than 700 IU per day.
• In the introduction and literature review for this study it was pointed
out that vitamin D has a direct beneficial effect on muscle, and
improved strength and balance in several trials in older persons
Bishoff-Ferrari, et al. J Bone Miner Res 2003:18343-51
Pfeifer M, et. al. Osteporosis Int 2009; 20:315-22
Pfeifer M, et. al. J Bone Miner Res 2000; 15: 1113-8
American Geriatrics Society Consensus Statement
on Vitamin D for Prevention of Falls and Their
Consequences JAGS 2013
• Clinicians are strongly advised to recommend vitamin D
supplementation of at least 1000 IU/d with calcium to older adults
residing in institutional settings to reduce the risk of fracture and falls.
• There are insufficient data at this time to support a recommendation
for increased vitamin D without calcium for older persons residing in
the community or institutional settings.
• Clinicians should review older adults vitamin D intake form all sources
and discuss strategies to achieve a total vitamin D input associated
with fall and fracture prevention.
• Routine laboratory testing for 25(OH)D serum concentrations is not
necessary.
Awareness of vitamin D deficiency states and recommended
supplementation doses: survey of faculty and staff at a medical
school Agens JE, Galasko GT, Purandare AV, Lin J ESPEN December 2012 Volume 7, Issue 6
• Anonymous survey of faculty at Florida State College of Medicine
• 209 respondents approximately half were physicians
• 1800 faculty across six campuses across Florida, low response rate
• Geographically distributed, community based medical school model
• 3rd and 4th year student do their clinical years in physician practices
• Purpose of this survey was to determine the level of awareness of
vitamin D deficiency states, physician awareness of their own vitamin
D status, and recommendation of vitamin D supplementation and
treatment for their patients
Survey: Vitamin D Deficiency Categorical
Variables of Responders
• Are you personally taking vitamin D yourself? (yes/no)
• Are you personally taking calcium? (yes/no)
• Your age?
• Sunlight exposure (less than 20 minutes a day?)
• Have you ever had your vitamin D level checked? (yes/no)
• If your vitamin D level has ever been checked, was it low? (yes/no)
• If you are a physician, what dose of vitamin D do you recommended
for prevention of vitamin D deficiency? Treatment? 200 IU, 400 IU,
800 IU, 1000 IU, or greater than 1000 IU
Vitamin D survey: Key Findings
• Osteomalacia and rickets were widely recognized as associated with
vitamin D deficiency. Osteoporosis as well, but significantly less so.
• Few surveyed listed fractures or falls as associated with vitamin D
deficiency.
• 70% of the female physicians were taking vitamin D, 43% of males
• Only 23% of the physicians had ever had their vitamin D level checked
• Older age, less than 20 minutes of sun exposure, and taking calcium
was associated with having a vitamin D level checked.
• Two thirds who knew their vitamin D level said it was low.
Prevention
Treatment
Response (Percentage)
58
31
25
22
12
2
2
16
10
10
10
2
200
400
800
1000
>1000
Unsure
Figure 3. MD Recommended Daily Dose Vitamin D International
Units
Vitamin D survey: Additional findings
• Physicians who had their own vitamin D level checked were 4.5 times
more likely to recommend greater than or equal to 800 IU per day for
supplementation for their patients.
Fourth Year Medical Students’ Required Written
Patient Care Assignments on Geriatrics Clerkship
• Perform a medication review including a patient-centered analysis of
general efficacy, specific risk/benefit analysis, calculation of remaining life
expectancy and comparison with time to benefit for each medication,
reasoning out a person-centered therapeutic plan.
• Demonstrate proficiency in detecting and describing functional
impairment detailing the patient's premorbid status, the events leading
to the observed functional changes and a brief description of the
functional changes, exam, and proposed plans for rehabilitation including
nutrition. The goals of the patient must be included.
• Submit 'reflections at the end of life' using a patient summary, patient
goals, plan of care, efficacy of existing care plan, recommendations for
proposed changes including nutrition, critique of the healthcare delivery
system and description of any ethical issues.
Fourth Year Medical Students’ Competencies
Assessed by Observation and Case Discussion
• Demonstrate to Clerkship Director or designated faculty the ability to
perform fall risk assessment with correct interpretation of results, including
gait assessment.
• Demonstrate to Clerkship Director or designated faculty the ability to
assess for cognitive impairment using the appropriate screening tools
(CAM, Minicog, MMSE or MoCA observation) with correct interpretation of
results (case discussion).
• Demonstrate knowledge and understanding of the key components of a
safe and comprehensive discharge/admission plan for an older adult. A
case presentation to Clerkship Director that includes plans to assist the
patient in maintaining or improving function including nutrition.
Fourth Year Medical Students’ Competencies
Required Procedures
• Calculate Creatinine Clearance
• Depression Screening Tool
• Incontinence Assessment
• Nutritional Assessment
• Perform Therapeutic Review
• Functional Assessment Complete
• Confusion Assessment Method
• Cognitive Assessment with MoCA/ MMSE, or Mini-Cog
• Get up and Go/ Gait Assessment
How frequently is vitamin D supplementation used
in a cross section of a frail older population?
• Subjects: consenting medical student’s medication review
assignments- one patient per student, 82 assignments about one out
of four students taking the required clerkship in geriatrics
• Three consecutive academic years of data: 2013, 2014, 2015
• Patient age range 55-102 years of age, average age 81 years old
• Patients on 6-17 medications including OTC and dietary supplements
• 57% of the patients in rehabilitation settings, nursing homes, or ALFs
• Almost all patients had functional impairment
• Students are required to include all non-prescription and dietary
supplements in their medication review written assignments.
Answer: Vitamin D was used in < 1 of 3 frail patients
• 2012-13: 26% of patients on 800-2000 IU, one patient on < 800 IU
and student recommended increase, and in two patients student
recommended vitamin D be added.
• 2013-14: 27% of patients, most on 400 IU with 1200mg calcium/ day;
but two patients without dose specified, one on 50,000IU noted
deficient (level 22ng/ml), one patient noted deficient but not on D,
and in one case the student recommended D should be added.
• 2014-15: 30% of patients, ranging 400 IU to 2000 IU/ daily, in one
case student recommended a decrease from 50,000 IU weekly to
1000- 2000 IU daily after reviewing records for deficiency, and one
student recommended starting 1000 IU of D daily.
Word search finds on students’ assignments
representing 73 frail older persons
Functional Assessment search ‘diet’
2014-15
53 %
2013-14
2.5%
2012-13
18%
Advanced Illness word search ‘diet’
2014-15
57%
2013-14
45.8%
2012-13
46.4%
nutrition
50%
24%
13%
nutrition
56%
39%
52%
A 76-yr-old male comes to the office for follow-up and medication refills.
His examination is unchanged since his last visit 3 months ago, except
that his weight has decreased from 99.8 kg (220 lb.) to 92.5 kg (204 lb.).
He expresses surprise about the weight loss, “Since my daughter and
grandchildren moved out, all I do is sit and read with the TV on”.
Which one of the following is most appropriate?
a. Administer the Simplified Nutritional Assessment Questionnaire
b. Conduct a motivational interview about intentional weight loss
c. Discuss the weight loss and evaluate him for causes
d. Encourage him to continue to lose weight
e. Set exercise and diet goals, and schedule follow-up in 2 months
f. Suggest a nutritional supplement to help him regain the lost weight
Answer c. Discuss the weight loss and
evaluate him for causes
• p-Bis statistic 0.32 (desired value 0.20 – 0.80)
• 80% {82% high performers 74% low performers}
• 20% choose answer a. Administer the Simplified Nutritional
Assessment Questionnaire
A 68-year-old male has severe vascular dementia and lives in a nursing
home. A gastrostomy was placed 1 year ago because of severe dysphagia
following a stroke. Recently, the patient has become increasingly agitated
and pulled out the feeding tube several times.
Efforts to conceal and anchor the tube have been unsuccessful.
Changes in environment and judicious use of medications also have
been ineffective. Which of the following is most appropriate action?
a. Increase medication dosage to sedate the patient.
b. Place mitts on the patient’s hands.
c. Place restraints on the patient’s wrists.
d. Reevaluate the need for the gastrostomy.
e. Replace the gastrostomy with jejunostomy
Answer d. Reevaluate the need for the
gastrostomy.
• p-Bis statistic 0.23 (desired value 0.20 – 0.80)
• 86% {100% high performers 92% low performers}
• 4% choose answer a. Increase medication dosage to sedate the
patient.
An 84-year-old female moved to a nursing home 6 months ago, following
her husband's death. She has severe dementia and requires considerable
assistance with eating. Since admission, she has lost 5 kg (11 lb), which is
20% below her ideal weight.
No aspiration is noted on swallowing evaluation. The patient eats very
slowly. The staff confirm that a long period of time is required to feed
the patient. Her dentures fit well, and a psychiatric evaluation reveals
no evidence of depression. The patient never made any statements
about artificial feeding and does not have the capacity to understand
that option now. Which of the following is the most appropriate
action?
a. Arrange for a temporary nasogastric feeding tube
b. Begin donepezil therapy
c. Develop interdisciplinary strategies to improve feeding
d. Order nutritional supplements to be placed at her bedside
e. Place a percutaneous endoscopic gastrostomy
Answer c. Develop interdisciplinary strategies
to improve feeding
• p-Bis statistic 0.01
• 88% {92% high performers 85% low performers}
• 8% choose answer d, Order nutritional supplements to be placed at
her bedside
• 4% e, Place a percutaneous endoscopic gastrostomy
A 74-year-old female who had a stroke 1 week ago is reported by her
caregiver to be coughing at mealtimes, drooling intermittently, requiring a
prolonged period of time to eat, and failing to finish more than half of her
food.
The patient's recent stroke was her second stroke in 1 year,
and there is clinical evidence that both hemispheres are now
involved. Concerning her mealtime behavior, what is the most
appropriate test for establishing a diagnosis?
a. Esophageal manometry
b. Esophagography
c. Esophagoscopy
d. Ultrasound evaluation of swallowing
e. Video fluroscopy evaluation of swallowing
Answer e. Video evaluation of swallowing
• p-Bis statistic 0.52 (desired value 0.20 – 0.80)
• 79% {93% high performers 65% low performers}
• 4% choose answer c, Esophagoscopy
• 3% a, Esophageal manometry
Which of the following statements regarding the use of
tube feeding in patients with severe dementia is correct?
a. It does not improve survival.
b. It improves functional status.
c. It improves patient comfort.
d. It protects against aspiration pneumonia.
e. It promotes the healing of pressure ulcers.
Answer a. It does not improve survival.
• p-Bis statistic 0.41
• 80% {86% high performers 71% low performers}
• 13% choose answer d, It protects against aspiration pneumonia.
• 2% b, It improves functional status.
A 78-year-old female who lives alone comes for an office visit as a new
patient. She has osteoarthritis, macular degeneration, hypertension, and
mild hearing loss. She has no symptoms except knee pain when she
walks. On examination, she is thin (body mass index [kg/m2] of 19.2).
On examination, crepitus is present in both knees. The rest of the
examination is within normal limits. Hemoglobin and hematocrit
are normal, as was a colonoscopy approximately 10 years ago.
What is the most appropriate next step in evaluating her
nutritional status?
a. Check lymphocyte count
b. Check serum albumin
c. Check serum cholesterol
d. Inquire about recent weight loss
Answer d, Inquire about recent weight loss
• p-Bis statistic 0.52
• 96% {100% high performers 87% low performers}
• 4% choose b, Check serum albumin.
An 84-year-old female of Middle-Eastern descent has been in your
nursing home for 3 years following a hemi-plegic stroke. She is tube fed
due to dysphagia. She rarely leaves the facility and shares a room with
another resident who has the bed by the only window.
Nursing staff reports a general decline in her strength and balance in
recent months, and report that she moans in non-specific discomfort
when moved. Exam confirms the above observations. There is
tenderness when putting pressure tibial bones bilaterally.
• Which of the following tests are likely to show the problem?
a. 25 hydroxy vitamin D
b. CPK
c. ESR
d. LDH
e. SGOT
Answer a. 25 hydroxy vitamin D
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You!