The purpose of this rotation is to provide formal training in geriatric medicine to the internal medicine/family medicine resident, and to introduce him/her to the skills needed to provide high quality acute, chronic, and preventive care to older adults.

Goals

1. Incorporate a basic working knowledge of aging physiology and pharmacotherapy to evaluate and manage syndromes or diseases unique to or more common in older persons.
2. Improve skills in taking sensitive and focused history and physical examinations in older patients, and learn how to use the observations of patients' families and significant others in patient care and management.
3. Develop an understanding of and facility in geriatric assessment of older patients including screening instruments and an awareness of the importance of patient function in medical care.
4. Recognize the importance of working collaboratively with an interdisciplinary health care team.
5. Develop physician skills in working effectively with other community resources dedicated to the care of older patients in all settings.
6. Practice the use of evidence-based medicine in the evaluation and management of complex older patients (see supplemental material).
• The residents will be able to develop a clinical problem into an answerable clinical question.
• The residents will understand the principles of applying evidence to the care of very old, medically complex, functionally disabled, and cognitively impaired patients.

Proposed Objectives

Knowledge

1. Demonstrate an understanding of the diagnosis, treatment, rehabilitation and convalescence from common geriatric diseases and syndromes such as cognitive impairment, delirium, depression, urinary and fecal incontinence, syncope, balance disorders, falls, fractures, immobility, pressure ulcers, Parkinson’s disease and movement disorders, iatrogenesis and sensory impairment.
2. Interpret findings based on an understanding that disease presentation in older patients may differ from younger patients.
3. Recognize the need to modify the history and physical based on knowledge of sensory deficits and functional limitations.
4. Distinguish normal from pathological aging.
5. Distinguish the roles and responsibilities of other team members, e.g., nursing, social work, physical therapy, nutrition, pharmacy.
6. Understand the roles and responsibilities of resources available through community agencies such as visiting nurses, home health aides, home care corporation case managers, home delivered meals, and adult day care.
7. Know cost/reimbursement issues related to #6.

Skills

1. Effectively manage a variety of common geriatric syndromes/diseases.
2. Evaluate and incorporate cognitive, phychosocial, and functional status into the overall assessment of the older patient.
3. Recognize problems related to pharmacotherapy such as adverse drug reactions, polypharmacy, and non-compliance.
4. Acquire effective exam skills targeted at the diagnosis and management of common geriatric syndromes (as described in Knowledge Objective #1).
5. Adapt management techniques to the preferences and capabilities of older patients and their families.
6. Utilize appropriate technology while encompassing an awareness of the limits of these interventions on light of individual patient values.
7. Communicate with older patients and their families utilizing effective, compassionate, and respectful interpersonal skills. Recognize the prevelance of caregiver stress and know the techniques/interventions necessary to manage this crucial aspect of geriatric care.
8. Collaborate with other health care team members in the assessment, implementation, and evaluation of care.
9. Make appropriate referrals to community resources.
10. Maintain effective communication with community resources on behalf of the patient and his/her family.

Attitudes

1. View the elderly as physically, psychologically, functionally, culturally, and socially diverse.
2. Appreciate the heterogeneity and atypical presentation of and response to illness in older patients.
3. Appreciate the non-medical issues in caring for the older patient e.g., psychosocial, ethical, legal, and cost-benefit.
4. Appreciate the roles of all elements of an interdisciplinary team.
5. Appreciate the value of community resources in provided care to older people living at home.

Perelman Center for Advanced Medicine
3400 Civic Center Blvd
Philadelphia, PA 19104
Phone: 215-662-7810
Penn Memory Center

Physician education at the Alzheimer’s Disease Center involves in-clinic “hands-on” training, reading and formal didactics. Physicians will learn how to:

• Perform and interpret the tests of cognition, affect and health.
• Perform a focused history and physical.
• Diagnose, stage and treat dementia.

The following are course topics with the goals of each topic. To achieve these goals, the student is expected to review the assigned readings and lectures, and participate in the Penn Memory Center.

Course Topics

1. The epidemiology, differential diagnosis and clinical course of dementia
• Describe the pathology, clinical presentation and course of dementia
• Understand the controversies and changing concepts in the nosology of dementia
2. The work up of cognitive complaints
• Have the skills to perform an office-based assessment of the patient with cognitive complaints
• Understand the domains of cognitive function
• Understand the instruments available to measure the domains of cognitive function
• Understand the tests available and that may become available to diagnose dementia
3. The treatment of patients with dementia: primary treatment
• Understand the difference between disease slowing and symptomatic treatments for dementia
• Be able to describe the symptoms of dementia
• Be able to identify effective treatments for dementia
4. The treatment of patients with dementia: management of neuropsychiatric symptoms
• Understand the spectrum of common neuropsychiatric symptoms
• Understand the role of medications and non-medication strategy in the treatment of neuropsychiatric symptoms
5. The treatment of patients with dementia: bioethical issues and caregiving
• Describe the four roles of the caregiver of the patient with dementia
• Understand the impact of dementia on each of the caregivers’ roles
• Understand the standards for assessing a patient’s decision-making capacity
• Develop strategies to practice effective decision-making with caregivers and patients: focus on decisions about treatment, research, end-of-life care and driving.

Methods to Activate Course Topics

1. Participation in Penn Memory Center:
   Week 1: Observe psychometric testing and assessment of patient and review test scoring and interpretation and physical exam
   Week 2: Observe follow-up and initial patient visits, and review the structure of an interview with a knowledgeable informant
   Week 3: Perform and dictate a patient assessment
   Week 4: Perform and dictate a patient assessment

   Students will provide Carol Edwards with their contact information so they can receive results of the diagnostic work-up of their patients that become available after they complete their clinic rotation.

2. The following are the instructional materials organized by topic. The student is responsible for reading and viewing these materials in their off-clinic time. The papers and lectures are available via the ADC Web site. The links for these papers and the PowerPoint lecture on staging are “causes,” “diagnosis,” and “treatment and disease management” under the heading “Understanding Alzheimer's Disease and related dementias.”

Readings

• Clark CM, Karlawish, JHT. Alzheimer disease: Current concepts and emerging diagnostic and therapeutic strategies. Annals of Internal Medicine. 2003; 138: 400-410.
• Karlawish JHT, & Clark CM. Diagnostic evaluation of elderly patients with mild memory problems. Annals of Internal Medicine. 2003; 138: 411-419.

Course Director
Soumya Bollampally, MD
Division of Geriatric Medicine
Ralston House
3615 Chestnut Street
Soumya.Bollampally@uphs.upenn.edu
Fax: 215-573-8684

Course Description

Both the In-Home Primary Care Program of the Ralston Center and the VA Home Based Primary Care Program follow panels of frail older patients who can no longer leave their homes to receive primary care. Both programs use interdisciplinary team care in the management of these patients. During the elective, residents will make home visits with staff of both programs, attend team meetings, and present one 10 minute discussion about an issue arising from a patient chosen from those seen. Residents will also be given the opportunity to choose one patient from their own panel of clinic patients; the resident and housecalls staff will visit that patient together to provide a “home care consultation” on the environment of care for that patient.

Goals

1. Development of a treatment plan for a homebound older patient.
2. Utilization of community support services.
3. Home modification.
4. Appropriate medication management.
5. Diagnosis and management of common medical problems seen in older homebound patients.
6. Differences in management at home from:
• Hospital
• Office
• Nursing Home

Readings

Loengard AU, Boal J. Home Care of the Frail Elderly. Clinics in Geriatric Med 20:795-807. 2004

Restore Health is a 124-bed skilled nursing facility offering long- and short-term care. Team members include nurses, social workers, dietitians, physical, occupational and speech therapists, and a recreation therapist.

I. Criteria for Nursing Home Placement

• Medical
• Functional
• Psychosocial

II. Geriatric syndromes, disorders and issues in the long-term care setting choice of individual appropriate course of action, use of standardized assessments, methods to utilize multidisciplinary care/evaluation, differential diagnosis, therapeutic intervention via a specific case approach

• Rehabilitation
• Palliative Care
• Health care maintenance
• Neuropsychiatric and behavioral disturbances
• Incontinence both urinary and fecal
• Pressure Ulcers
• Malnutrition with eating problems
• Sensory deficits especially visual and audiologic
• Syncope and dizziness
• Falls/gait instability
• Cardiovascular disease including hypertension and coronary artery disease/confusion with gastrointestinal disorders
• Infection including UTI and pneumonia
• Neurological disorders including stroke, movement disorder, seizures
• Endocrinologic disorders

III. Criteria for determination of acute hospitalization

• Level of aggressiveness
• Complicating issues
• Nursing home capabilities

General Nursing Home Objectives

• Learn skills necessary to perform a new patient admission or readmission and appreciate the importance of acquiring complete and facilitating adequate medical record transfers from various institutions.
• Appreciate the importance of the intra-agency transfer form.
• Appreciate the complexities of long-term care and the importance of the compete geriatric assessment in nursing home settings.
• Gain a better understanding of issues specific to nursing home care including but not limited to wound care, fall prevention, monitoring complications related to polypharmacy and iatrogenesis, and prevention of weight loss.
• Appreciate the roles of the multiple ancillary services involved in nursing home patient care and the unique care model that exists in which a limited number of caregivers (RNs, NPs, LPNs, CNAs, MDs, etc.) provide care to a large number of frail patients.

Contact Information

Renaissance Nursing Home

Joshua Uy, MD
4712 Chester Ave
Philadelphia, PA 19143
Email: Joshua.Uy@uphs.upenn.edu or Vimmi.Panchal@uphs.upenn.edu

St Ignatius Nursing Home

Vimmi Panchal, MD
4401 Haverford Ave
Philadelphia, PA 19104
Email: Vimmi.Panchal@uphs.upenn.edu