1. M3 Seminar December 2004 1 “Geriatrics” in a Nutshell Karen E. Hall, M.D., Ph.D. Clinical Assistant Professor of Internal Medicine University of Michigan and VA Ann Arbor Health Systems Research Scientist, Geriatric Research, Education and Clinical Center

2. M3 Seminar December 2004 2 Geriatric Demographic Population aged >65 years 10 x Increase 20 x Increase!

3. M3 Seminar December 2004 3 17 x Increase! Thousands

4. M3 Seminar December 2004 4 All physicians need to understand “Geriatrics” Geriatrics Portfolio m Activities highlighted by the “Geriatrics Center M-Tree” m Cumulative record of Geriatric teaching activities throughout medical school

5. M3 Seminar December 2004 5 UM Geriatrics Portfolio All UMMS graduates will be competent in providing care for older individuals. no “Geriatrics” course. learning outcomes – established as minimum competency standards in geriatrics – presented in multiple courses and clinical experiences throughout all four years. portfolio provides an accessible, convenient mechanism to highlight the geriatrics content.

6. M3 Seminar December 2004 6

7. M3 Seminar December 2004 7 Learning Outcomes Review M3 Clinical Competencies In Coursetools htps://ctools.umich.edu/portal Geriatrics Portfolio m H and P writeups, track your geriatrics content Physical Examination Skills m Documentation of impairments

8. M3 Seminar December 2004 8 M3 Clinical Competencies (from CourseTools) Geriatric syndromes and conditions Diseases more common in older patients Psychosocial issues Disease prevention Ethical Issues Health Care Financing (Medicare) Cultural aspects of aging

9. M3 Seminar December 2004 9 Geriatric Syndromes (hospital) Dementia, delerium, depression m common, not documented Inappropriate medications m anticholinergic Gait and mobility impairment m not documented Incontinence Iatrogenic impairment m bed rest, constipation, pressure ulcers

10. M3 Seminar December 2004 10 Geriatric Syndromes (outpatient) Dementia, Depression Incontinence Osteoporosis Falls Hearing and vision impairment Sleep disorders Failure to thrive Iatrogenic (medications)

11. M3 Seminar December 2004 11 Documentation/Skills First rule of history and physical exam “To treat the problem, you have to document the problem”

12. M3 Seminar December 2004 12 Documentation First rule of geriatrics (similar to first rule of real estate sales) “Function, Function, Function” Patients don’t care about their diagnoses, they care about their function

13. M3 Seminar December 2004 13 Ask about…. ADLs (Activities of Daily Living) IADLs (Independent Activities of Daily Living) Mobility Incontinence Affect/Mood Cognition (Memory)

14. M3 Seminar December 2004 14 These items go into the history Either “Social History” or “Functional History” Or In the HPI!

15. M3 Seminar December 2004 15 Physical Exam Test the following: Mobility – Timed Up and Go test- stand, walk, turn, sit Cognition – Mini-Cog (3 item recall) or MMSE (Mini Mental Status Exam) Affect – Two question Depression screen

16. M3 Seminar December 2004 16 The results go in the Physical Exam “Timed Up and Go was 15 seconds, patient walked slowly, unsteady, had to hold rail for support” “Two question depression screen positive” “Patient only remembered 2 of 3 items on Mini- Cog”

17. M3 Seminar December 2004 17 Documentation does not necessarily mean “Diagnosis” Diagnosis belongs in the “Impression/Plan” section BUT…. Rule #1: Avoid the trap of “premature labeling” Problem 1. “Falls” – (list the differential here) Not Problem 1. “Probable spinal stenosis” Or Problem 1. “Musculoskeletal System”

18. M3 Seminar December 2004 18 Develop a Plan rather than a Diagnosis Rule #2: You can start addressing functional impairments without having a specific diagnosis Patients appreciate a practical plan Home safety, mobility aids, social supports

19. M3 Seminar December 2004 19 Prevention = “Screening” Back to First rule of History and Physical Examination …. “To prevent it, you have to document it” Learn about primary and secondary prevention screening that maximizes function and minimizes future impairment Keep current about age-associated recommendations for tertiary prevention (“treatment”)

20. M3 Seminar December 2004 20 Social, Ethical, Cultural Learn about cultural influences on health behavior DNR, family involvement Learn about stressors that affect patients and families Caregiver stress, finances Know what resources are out there to help Social work (Turner clinic + other), types of assisted living, medication assistance, Area Agency on Aging, 3 day inpatient requirement for Medicare payment of CNH!

21. M3 Seminar December 2004 21 Social, Ethical, Cultural Ask the patient what THEY WANT TO DO about their problem “Do not assume your preference is their preference!” This will avoid more lawsuits than any other intervention!