Geriatrics OrientationGeriatrics Orientation

GERIATRICSGERIATRICSThe Panacea?The Panacea?

Geriatricians are the happiest of all Geriatricians are the happiest of all physician groups surveyedphysician groups surveyed

Physician Career Satisfaction Across Specialties, Physician Career Satisfaction Across Specialties, Arch Intern Med. 2002;162:1577-1584.Arch Intern Med. 2002;162:1577-1584.

Why?Why?

Case 82 year oldCase 82 year old DiabetesDiabetes CADCAD HTNHTN Chronic kidney failure, EGFR 45Chronic kidney failure, EGFR 45

Usual CareUsual Care HbA1C <7HbA1C <7 EchoEcho BetablockerBetablocker ASAASA ACE-IACE-I DiureticDiuretic StatinStatin Creatinine and labs every 3 monthsCreatinine and labs every 3 months

GERIATRICS IS…GERIATRICS IS…

Internal MedicineInternal MedicinePLUSPLUS

FUNCTIONFUNCTION

+FUNCTION+FUNCTION

Patient #1Patient #1 Works 40 hours/wkWorks 40 hours/wk Walks 3 miles TIWWalks 3 miles TIW Cleans houseCleans house CooksCooks

Patient #2Patient #2 BedboundBedbound Requires Requires

assistance with assistance with ADLs/IADLsADLs/IADLs

Family cares for Family cares for himhim

Cognitive Cognitive impairmentimpairment

Your Goals…Your Goals…

Our GoalsOur Goals Functional status evaluationFunctional status evaluation Geriatric SyndromesGeriatric Syndromes Venues of CareVenues of Care

ULTIMATELYULTIMATELY Change your practice caring for the Change your practice caring for the

frail elderlyfrail elderly

Functional StatusFunctional Status ADLsADLs

• BathingBathing• DressingDressing• ToiletingToileting• Transfer/walkingTransfer/walking• FeedingFeeding

IADLsIADLs• CookingCooking• CleaningCleaning• Shopping Shopping • DrivingDriving• TelephoneTelephone• FinancesFinances• MedicationsMedications

Geriatric SyndromesGeriatric Syndromes FallsFalls Dementia/DeliriumDementia/Delirium PolypharmacyPolypharmacy Urinary IncontinenceUrinary Incontinence Weight lossWeight loss DepressionDepression Pressure SoresPressure Sores Sensory ImpairmentSensory Impairment End of lifeEnd of life

Care SettingsCare Settings Hospital ConsultsHospital Consults

• DeliriumDelirium• PolypharmacyPolypharmacy• Goals of careGoals of care• Discharge assistanceDischarge assistance

Care Settings (2)Care Settings (2) ClinicClinic

• Ambulatory patientsAmbulatory patients• Present with family oftenPresent with family often• How did you get here?How did you get here?• Primary carePrimary care

Internal Medicine Internal Medicine with need to consider risks with need to consider risks and benefits.and benefits.

Care Settings (3)Care Settings (3) Skilled Nursing FacilitySkilled Nursing Facility

• Subacute rehabSubacute rehab• Short term staysShort term stays• Medically complexMedically complex• Full team evaluation and managementFull team evaluation and management• Technology/testing readily availableTechnology/testing readily available

Nursing Home-Long Term CareNursing Home-Long Term Care• Custodial care needsCustodial care needs• Interdisciplinary teamInterdisciplinary team• Quality of Life focusQuality of Life focus

Challenges in NH careChallenges in NH care Nursing home patient to nurse ratioNursing home patient to nurse ratio

• 1:18 or 1:60 (night) vs hospital 1:51:18 or 1:60 (night) vs hospital 1:5 No respiratory therapyNo respiratory therapy Scarcity of RNs makes central lines, Scarcity of RNs makes central lines,

IV push meds, TPN, NOW labs not IV push meds, TPN, NOW labs not feasiblefeasible

Frequent monitoring (post procedure Frequent monitoring (post procedure or dramatic change in condition) may or dramatic change in condition) may require return to hospitalrequire return to hospital

Might take 2 days for labs to returnMight take 2 days for labs to return

Care Setting (4)Care Setting (4) Home CareHome Care

• Pt seen in natural settingPt seen in natural setting• Complete pharmacy evaluationComplete pharmacy evaluation• Functional evaluationFunctional evaluation• Less technology readily availableLess technology readily available

Day CareDay Care

Why is Geriatrics Exciting?Why is Geriatrics Exciting? Functional evaluationFunctional evaluation Quality of LifeQuality of Life Risks/Benefits of treatments or Risks/Benefits of treatments or

evaluationsevaluations Transitions in lifeTransitions in life

How are we going to How are we going to teach this to you?teach this to you?

Nuts and BoltsNuts and Bolts

Didactic SeriesDidactic Series Core Geriatric issuesCore Geriatric issues 7:45 AM (follow schedule)7:45 AM (follow schedule)

• Generally Monday & Wednesday at Generally Monday & Wednesday at State Veterans HomeState Veterans Home

• Generally Tuesday & Friday at VAGenerally Tuesday & Friday at VA Remember to do an evaluation after Remember to do an evaluation after

each lectureeach lecture

Geriatric Grand RoundsGeriatric Grand Rounds Thursday 7:30 AM Thursday 7:30 AM

• Academic Office building 7 floorAcademic Office building 7 floor• 11stst and 3 and 3rdrd

Journal Club 2Journal Club 2ndnd Thursday Thursday• VA auditoriumVA auditorium

ConsultsConsults One person designated as consult One person designated as consult

personperson Responsible for VA consults, SVH Responsible for VA consults, SVH

admissions, inpatient issuesadmissions, inpatient issues Primary pt responsibility may be Primary pt responsibility may be

redistributedredistributed

Types of care/practiceTypes of care/practice Nursing home careNursing home care

• VAVA• State Veterans Home (SVH)State Veterans Home (SVH)

ClinicsClinics Home CareHome Care Day Care-Total Longterm CareDay Care-Total Longterm Care Geriatric ResearchGeriatric Research Palliative CarePalliative Care

State Veteran HomeState Veteran Home Subacute Rehabilitation through Subacute Rehabilitation through

MedicareMedicare Veterans or dependentsVeterans or dependents Many from AIPMany from AIP

• May consult on pt prior to hospital d/cMay consult on pt prior to hospital d/c

Skilled Nursing Patients (SNF)Skilled Nursing Patients (SNF) See patients and write notes twice See patients and write notes twice

per week or with significant changeper week or with significant change Interdisciplinary team-informal Interdisciplinary team-informal

meetingsmeetings Learn from other members of the Learn from other members of the

teamteam

Geriatric Evaluation and Geriatric Evaluation and Management (GEM)Management (GEM)

Screening tool [templates/geriatrics]Screening tool [templates/geriatrics]• Includes completed MMSEIncludes completed MMSE• Functional assessmentFunctional assessment• Contact made to caregiverContact made to caregiver

Consult type at VAConsult type at VA• Geriatric syndromesGeriatric syndromes

e.g. Surgical patient is delirious in the ICUe.g. Surgical patient is delirious in the ICU Elderly woman admitted with fallsElderly woman admitted with falls

• DispositionDisposition Will you take this person for rehab?Will you take this person for rehab? Where is the optimal place for this pt to go? Can you Where is the optimal place for this pt to go? Can you

help with the transition?help with the transition?

GEM Inpatient (VA)GEM Inpatient (VA) Patient characteristics:Patient characteristics:

• Ideally 2-3 weeks of rehabIdeally 2-3 weeks of rehab Debility from illness/hospitalizationDebility from illness/hospitalization PolypharmacyPolypharmacy Potentially reversible physical frailtyPotentially reversible physical frailty Potentially reversible cognitive declinePotentially reversible cognitive decline Wound careWound care

• Hospice (variable)Hospice (variable)• Pt goal is to go back to home or ALF (not NH)Pt goal is to go back to home or ALF (not NH)• Prefer patients >65yoPrefer patients >65yo• PT/OT set goals for pt prior to Geri consultPT/OT set goals for pt prior to Geri consult• Preference for pt with additional medical issue Preference for pt with additional medical issue

and geriatric syndromeand geriatric syndrome• Pt motivatedPt motivated• Pt agrees to transfer to NHPt agrees to transfer to NH

Transfer to GEMTransfer to GEM Needs Needs new H&Pnew H&P on transfer on transfer

• NHCU MD/NP Admission templateNHCU MD/NP Admission template• Admit for 14-90 days, alwaysAdmit for 14-90 days, always

Hospital should do d/c summaryHospital should do d/c summary Need delayed admission ordersNeed delayed admission orders

• Admission to NHCU short termAdmission to NHCU short term Higher intensity care only done for 24 Higher intensity care only done for 24

hours (vitals…)hours (vitals…)• No TPN, IV narcoticsNo TPN, IV narcotics

May set up an appt on d/c in Geri clinic if May set up an appt on d/c in Geri clinic if no available PCP f/uno available PCP f/u

GEM InpatientGEM Inpatient See patients 2-3 days per weekSee patients 2-3 days per week Write notes about twice per weekWrite notes about twice per week

• more if changesmore if changes Manage medical problemsManage medical problems Focus on function planning for Focus on function planning for

dischargedischarge Interdisciplinary team meetingInterdisciplinary team meeting

• Tuesday 11AM at VATuesday 11AM at VA Discharge summary to be dictated on Discharge summary to be dictated on

discharge date (or day before) discharge date (or day before)

Nursing Home Care Unit (VA)Nursing Home Care Unit (VA) GEM (purple)-subacute rehab; short termGEM (purple)-subacute rehab; short term Rehab (green)-subacute rehab; longer term; Rehab (green)-subacute rehab; longer term;

less educationless education Long Term Care (brown/yellow)-custodial Long Term Care (brown/yellow)-custodial

care; live in NHCUcare; live in NHCU Comfort Care (blue)-inpatient hospice careComfort Care (blue)-inpatient hospice care Respite (orange)-short term caregiver breakRespite (orange)-short term caregiver break

Dr. Bourg is NHCU medical directorDr. Bourg is NHCU medical director

Team meetings-Team meetings-things to think aboutthings to think about

Does this group have goals that direct them (program/ Does this group have goals that direct them (program/ client goals?client goals?

Aside from the professional roles, what other roles did Aside from the professional roles, what other roles did people assume (facilitator, time keeper, clarifier, problem people assume (facilitator, time keeper, clarifier, problem solver, attentive listener)?solver, attentive listener)?

How long did the meeting take? Was it efficient? Why?How long did the meeting take? Was it efficient? Why? Was the meeting structured in any way?Was the meeting structured in any way? How did this group make decisions (consensus, voting, How did this group make decisions (consensus, voting,

default)?default)? Did you observe conflict in the group? How was it handled?Did you observe conflict in the group? How was it handled? Who was the leader of the group?Who was the leader of the group? Did you note examples of leadership shifting in the group?Did you note examples of leadership shifting in the group? What did you observe about communication?What did you observe about communication? How were the tasks assigned in the group?How were the tasks assigned in the group? What were your overall impressions of the group?What were your overall impressions of the group?

ClinicsClinics VA VA UniversityUniversity CommunityCommunity Denver HealthDenver Health

Most clinics start at 1PM; communicate Most clinics start at 1PM; communicate with attending if schedule issues! with attending if schedule issues!

VA ClinicVA Clinic New patients at 1PM and 2:30PMNew patients at 1PM and 2:30PM Full Geriatric evaluationFull Geriatric evaluation Patients are scheduled for residentsPatients are scheduled for residents Use Geriatric template on the shared Use Geriatric template on the shared

drivedrive

University ClinicUniversity Clinic AOP 5AOP 5thth floor floor Different attendingsDifferent attendings Goals:Goals:

• Learn to manage geriatric issueLearn to manage geriatric issue• Experience varying attending stylesExperience varying attending styles• Appreciate demographic differences Appreciate demographic differences • Observe/compare clinic management & Observe/compare clinic management &

setupsetup

Centura Senior Life CenterCentura Senior Life Center Drs. Price, VerMiller, Cain, LazaroffDrs. Price, VerMiller, Cain, Lazaroff Location: 1601 Lowell Location: 1601 Lowell GoalsGoals

• Learn to manage geriatric issueLearn to manage geriatric issue• Experience varying attending stylesExperience varying attending styles• Appreciate demographic differences Appreciate demographic differences • Observe/compare clinic management & Observe/compare clinic management &

setupsetup

Denver Health Senior ClinicDenver Health Senior Clinic Dr. YasuiDr. Yasui Location: Location:

• Wellington Webb Primary Care bldgWellington Webb Primary Care bldg Goals:Goals:

• Learn to manage geriatric issueLearn to manage geriatric issue• Appreciate Cultural differencesAppreciate Cultural differences

Centura Senior Health Center at Centura Senior Health Center at Range VistaRange Vista

Dr. MartauDr. Martau Location: 8300 N Alcott, Ste #101Location: 8300 N Alcott, Ste #101 Goals:Goals:

• Learn to manage geriatric issueLearn to manage geriatric issue• Appreciate demographic differences Appreciate demographic differences • Observe/compare clinic management & Observe/compare clinic management &

setupsetup

Home Based Primary CareHome Based Primary Care Afternoon visit with Dr. Bray-HallAfternoon visit with Dr. Bray-Hall Logistics: meet at 1PM at VA bldg 4Logistics: meet at 1PM at VA bldg 4 Goals:Goals:

• Identify functional needs at homeIdentify functional needs at home• Review meds pt is actually takingReview meds pt is actually taking• Find out how pt LIVES despite medical Find out how pt LIVES despite medical

issuesissues• Evaluate caregiver issuesEvaluate caregiver issues

Total Longterm CareTotal Longterm Care Adult DaycareAdult Daycare Program of All-Inclusive Care for the Program of All-Inclusive Care for the

Elderly (PACE)Elderly (PACE) 6 clinic sites in Denver6 clinic sites in Denver Go after morning lecture 9:15-3:00Go after morning lecture 9:15-3:00 ASK QUESTIONS!!!ASK QUESTIONS!!! PARTICIPATE!!!PARTICIPATE!!! Focus: Non-medical, learn about Focus: Non-medical, learn about

program and additional services.program and additional services.

Total Longterm CareTotal Longterm Care

Goals:Goals:• See alternative management of frailSee alternative management of frail• Appreciate complexity of enrollees Appreciate complexity of enrollees

needsneeds• Learn about pay sourceLearn about pay source

Total Longterm Care: Total Longterm Care: Questions to ponder Questions to ponder

1.1. Who pays?Who pays?2.2. How is hospitalization handled?How is hospitalization handled?3.3. How are costs curtailed?How are costs curtailed?4.4. What services does TLC provide that other What services does TLC provide that other

programs do not?programs do not?5.5. Which patients receive rehab services and Which patients receive rehab services and

how is this decided?how is this decided?6.6. How are behavioral problems handled?How are behavioral problems handled?7.7. How are active problems handled during How are active problems handled during

weekend hours?weekend hours?8.8. Are hearing aides, visual aides and dental Are hearing aides, visual aides and dental

care provided?care provided?

Total Longterm Care: Total Longterm Care: Questions to ponder (2)Questions to ponder (2)

9.9. Are various consultants available and how are Are various consultants available and how are they employed?they employed?

10.10. Are there any special policies regarding Are there any special policies regarding resuscitation, tube feedings, etc?resuscitation, tube feedings, etc?

11.11. Is the TLC project one that will work on a large Is the TLC project one that will work on a large scale?scale?

12.12. How does your “case mix” compare to visiting How does your “case mix” compare to visiting nurse/home health programs or nursing homes?nurse/home health programs or nursing homes?

13.13. How are you different from other day care How are you different from other day care programs?programs?

14.14. What do you do if a client gets sick?What do you do if a client gets sick?15.15. What does it mean when you take “risk What does it mean when you take “risk

contracts?”contracts?”16.16. How do you save money?How do you save money?

Geriatric Research-Geriatric Research-Testing procedures in exercise and Testing procedures in exercise and

aging researchaging research Meet with Catherine Jankowski, PhD Meet with Catherine Jankowski, PhD Research in Exercise, Metabolism, Research in Exercise, Metabolism,

Hormone changes in elderlyHormone changes in elderly UCDHSC Exercise Research Laboratory UCDHSC Exercise Research Laboratory

(ERL)(ERL) Leprino Office Building (LOB), 3rd floor Leprino Office Building (LOB), 3rd floor

Room 360Room 360 Volunteer needed for Volunteer needed for

• DXA (non-pregnant, do not wear metal or DXA (non-pregnant, do not wear metal or plastic)plastic)

• VO2 max (exercise clothing, prefer not highly VO2 max (exercise clothing, prefer not highly trained)trained)

Testing procedures in exercise Testing procedures in exercise research: Objectivesresearch: Objectives

To observe a graded treadmill exercise test with To observe a graded treadmill exercise test with ECG and respiratory gas collectionECG and respiratory gas collection

To recognize the expected changes in oxygen To recognize the expected changes in oxygen consumption, carbon dioxide production, and consumption, carbon dioxide production, and ventilation during graded exerciseventilation during graded exercise

To interpret test results and determine if a To interpret test results and determine if a maximal cardiovascular effort has been achievedmaximal cardiovascular effort has been achieved

To observe bone densitometry scans (DXA; total To observe bone densitometry scans (DXA; total body, hip, and spine) to measure bone mineral body, hip, and spine) to measure bone mineral density and body compositiondensity and body composition

To interpret the bone mineral density and body To interpret the bone mineral density and body composition data composition data

Palliative CarePalliative Care Dr. Levy and the palliative care teamDr. Levy and the palliative care team Inpatient rounds at VA; 1:00PMInpatient rounds at VA; 1:00PM Call Dr. LevyCall Dr. Levy Goals:Goals:

• Appreciate input from interdisciplinary Appreciate input from interdisciplinary team consultation in palliative careteam consultation in palliative care

• Learn components of symptom Learn components of symptom assessment (physical, emotional, social, assessment (physical, emotional, social, spiritual)spiritual)

• Identify ways to manage and palliate Identify ways to manage and palliate symptomssymptoms

Case PresentationCase Presentation Near end of the monthNear end of the month 20-30 minute discussion of a patient 20-30 minute discussion of a patient

and geriatric issue you saw this and geriatric issue you saw this monthmonth

Examples: Examples: • Screening guidelinesScreening guidelines• Weight loss/gainWeight loss/gain• Visual/hearing changesVisual/hearing changes• Prognosis Prognosis

Make handoutMake handout

LogisticsLogistics WeekendsWeekends

• Each takes one weekend, Each takes one weekend, • round Saturday at VA, round Saturday at VA, • call 303-393-2865 Sundaycall 303-393-2865 Sunday

Nights-leave consult pager onNights-leave consult pager on VacationVacation Switching/Commitments-Notification by 1Switching/Commitments-Notification by 1stst

week of rotation requiredweek of rotation required

TEAM FOCUSTEAM FOCUS

GeriatricsGeriatrics

FunctionFunction

TeamTeam