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Geriatrics Orientation

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Geriatrics Orientation GERIATRICS The Panacea? Geriatricians are the happiest of all physician groups surveyed Physician Career Satisfaction Across Specialties, Arch ... – PowerPoint PPT presentation

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Title: Geriatrics Orientation


1
Geriatrics Orientation
2
GERIATRICS The Panacea?
  • Geriatricians are the happiest of all physician
    groups surveyed
  • Physician Career Satisfaction Across Specialties,
    Arch Intern Med. 20021621577-1584.
  • Why?

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

4
Usual Care
  • HbA1C lt7
  • Echo
  • Betablocker
  • ASA
  • ACE-I
  • Diuretic
  • Statin
  • Creatinine and labs every 3 months

5
GERIATRICS IS
6
Internal Medicine PLUS
  • FUNCTION

7
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

8
Your Goals
9
Our Goals
  • Functional status evaluation
  • Geriatric Syndromes
  • Venues of Care
  • ULTIMATELY
  • Change your practice caring for the frail elderly

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

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
  • 118 or 160 (night) vs hospital 15
  • 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
  • 745 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 730 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 gt65yo
  • 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 HP 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 230PM
  • 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 915-300
  • 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
  1. Who pays?
  2. How is hospitalization handled?
  3. How are costs curtailed?
  4. What services does TLC provide that other
    programs do not?
  5. Which patients receive rehab services and how is
    this decided?
  6. How are behavioral problems handled?
  7. How are active problems handled during weekend
    hours?
  8. Are hearing aides, visual aides and dental care
    provided?

41
Total Longterm Care Questions to ponder (2)
  1. Are various consultants available and how are
    they employed?
  2. Are there any special policies regarding
    resuscitation, tube feedings, etc?
  3. Is the TLC project one that will work on a large
    scale?
  4. How does your case mix compare to visiting
    nurse/home health programs or nursing homes?
  5. How are you different from other day care
    programs?
  6. What do you do if a client gets sick?
  7. What does it mean when you take risk contracts?
  8. 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 100PM
  • 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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