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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. Diabetes CAD HTN Chronic kidney failure, EGFR 45. Usual Care.

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Geriatrics Orientation

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  1. Geriatrics Orientation

  2. GERIATRICSThe Panacea? Geriatricians are the happiest of all physician groups surveyed Physician Career Satisfaction Across Specialties, Arch Intern Med. 2002;162:1577-1584. Why?

  3. Case 82 year old • Diabetes • CAD • HTN • Chronic kidney failure, EGFR 45

  4. Usual Care • HbA1C <7 • Echo • Betablocker • ASA • ACE-I • Diuretic • Statin • Creatinine and labs every 3 months

  5. GERIATRICS IS…

  6. Internal MedicinePLUS FUNCTION

  7. 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 +FUNCTION

  8. Your Goals…

  9. Our Goals • Functional status evaluation • Geriatric Syndromes • Venues of Care ULTIMATELY • Change your practice caring for the frail elderly

  10. ADLs Bathing Dressing Toileting Transfer/walking Feeding IADLs Cooking Cleaning Shopping Driving Telephone Finances Medications Functional Status

  11. Geriatric Syndromes • Falls • Dementia/Delirium • Polypharmacy • Urinary Incontinence • Weight loss • Depression • Pressure Sores • Sensory Impairment • End of life

  12. Care Settings • Hospital Consults • Delirium • Polypharmacy • Goals of care • Discharge assistance

  13. Care Settings (2) • Clinic • Ambulatory patients • Present with family often • How did you get here? • Primary care • Internal Medicine with need to consider risks and benefits.

  14. Care Settings (3) • Skilled Nursing Facility • Subacute rehab • Short term stays • Medically complex • Full team evaluation and management • Technology/testing readily available • Nursing Home-Long Term Care • Custodial care needs • Interdisciplinary team • Quality of Life focus

  15. Challenges in NH care • Nursing home patient to nurse ratio • 1:18 or 1:60 (night) vs hospital 1:5 • 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

  16. Care Setting (4) • Home Care • Pt seen in natural setting • Complete pharmacy evaluation • Functional evaluation • Less technology readily available • Day Care

  17. Why is Geriatrics Exciting? • Functional evaluation • Quality of Life • Risks/Benefits of treatments or evaluations • Transitions in life

  18. How are we going to teach this to you? Nuts and Bolts

  19. Didactic Series • Core Geriatric issues • 7:45 AM (follow schedule) • Generally Monday & Wednesday at State Veterans Home • Generally Tuesday & Friday at VA • Remember to do an evaluation after each lecture

  20. Geriatric Grand Rounds • Thursday 7:30 AM • Academic Office building 7 floor • 1st and 3rd • Journal Club 2nd Thursday • VA auditorium

  21. Consults • One person designated as consult person • Responsible for VA consults, SVH admissions, inpatient issues • Primary pt responsibility may be redistributed

  22. Types of care/practice • Nursing home care • VA • State Veterans Home (SVH) • Clinics • Home Care • Day Care-Total Longterm Care • Geriatric Research • Palliative Care

  23. State Veteran Home • Subacute Rehabilitation through Medicare • Veterans or dependents • Many from AIP • May consult on pt prior to hospital d/c

  24. Skilled Nursing Patients (SNF) • See patients and write notes twice per week or with significant change • Interdisciplinary team-informal meetings • Learn from other members of the team

  25. Geriatric Evaluation and Management (GEM) • Screening tool [templates/geriatrics] • Includes completed MMSE • Functional assessment • Contact made to caregiver • Consult type at VA • Geriatric syndromes • e.g. Surgical patient is delirious in the ICU • Elderly woman admitted with falls • Disposition • Will you take this person for rehab? • Where is the optimal place for this pt to go? Can you help with the transition?

  26. GEM Inpatient (VA) • Patient characteristics: • Ideally 2-3 weeks of rehab • 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

  27. Transfer to GEM • Needs new H&P on transfer • NHCU MD/NP Admission template • Admit for 14-90 days, always • Hospital should do d/c summary • Need delayed admission orders • Admission to NHCU short term • Higher intensity care only done for 24 hours (vitals…) • No TPN, IV narcotics • May set up an appt on d/c in Geri clinic if no available PCP f/u

  28. GEM Inpatient • See patients 2-3 days per week • Write notes about twice per week • more if changes • Manage medical problems • Focus on function planning for discharge • Interdisciplinary team meeting • Tuesday 11AM at VA • Discharge summary to be dictated on discharge date (or day before)

  29. Nursing Home Care Unit (VA) • 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

  30. Team meetings-things to think about • 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?

  31. Clinics • VA • University • Community • Denver Health Most clinics start at 1PM; communicate with attending if schedule issues!

  32. VA Clinic • New patients at 1PM and 2:30PM • Full Geriatric evaluation • Patients are scheduled for residents • Use Geriatric template on the shared drive

  33. University Clinic • AOP 5th floor • Different attendings • Goals: • Learn to manage geriatric issue • Experience varying attending styles • Appreciate demographic differences • Observe/compare clinic management & setup

  34. Centura Senior Life Center • 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

  35. Denver Health Senior Clinic • Dr. Yasui • Location: • Wellington Webb Primary Care bldg • Goals: • Learn to manage geriatric issue • Appreciate Cultural differences

  36. Centura Senior Health Center at Range Vista • Dr. Martau • Location: 8300 N Alcott, Ste #101 • Goals: • Learn to manage geriatric issue • Appreciate demographic differences • Observe/compare clinic management & setup

  37. Home Based Primary Care • 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

  38. Total Longterm Care • 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.

  39. Total Longterm Care Goals: • See alternative management of frail • Appreciate complexity of enrollees needs • Learn about pay source

  40. Total Longterm Care: Questions to ponder • 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?

  41. Total Longterm Care: Questions to ponder (2) • 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?

  42. Geriatric Research-Testing procedures in exercise and aging research • 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)

  43. Testing procedures in exercise research: Objectives • 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

  44. Palliative Care • 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

  45. Case Presentation • 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 • Make handout

  46. Logistics • Weekends • Each takes one weekend, • round Saturday at VA, • call 303-393-2865 Sunday • Nights-leave consult pager on • Vacation • Switching/Commitments-Notification by 1st week of rotation required TEAM FOCUS

  47. Geriatrics Function Team

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