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Care of Older Adults 

Thomas Defer, MD (Preclerkship Collaborative Workgroup), Janice Nevin, MD and Alexander Chessman, MD (Family Medicine Clerkship/Post Clerkship Workgroup), and Ardis Davis, MSW (FMCR Project Manager) with input from the STFM Group on Geriatric Education.  

Contributing Author and Consultant: Harry Strothers, MD

OVERVIEW

It is estimated that by the year 2030, the proportion of U.S. citizens 65 years old and older will be greater than 20%. Indeed, the most rapid rate of growth is among the very oldest group - those over age 85. Not only are people living longer, but also the elderly population is becoming increasingly diverse. In addition, the prevalence of individuals living with chronic diseases that have the potential to affect function and quality of life is also on the rise. These changing demographics will have a significant impact on the practice of medicine and make it imperative that gerontology and geriatric medicine be addressed in medical education.

Medical school curricula must help students understand how to manage geriatric populations with an emphasis on health promotion, disease prevention, and optimizing functional ability. Students must understand the normal changes related to aging, the impact of changing physiology on pharmacologic interventions, the effect of chronic disease on daily living, and the range of community services that are available to support the aging patient. They must also be well versed in the preventive health care needs of the large majority of well elderly.

LEARNING GOALS & OBJECTIVES
(Organized by ACGME competencies)

The starred (*) objectives are ones that are most appropriately addressed during the latter stages of medical education (i.e., more suitable for more experienced students and clinical rotations.)

Patient Care

GOAL: Students will demonstrate care that is compassionate, age appropriate, and effective for the treatment of health problems and the promotion of health in the elderly.

OBJECTIVES: The student will:

  • * Perform the components of a comprehensive geriatric assessment (history and physical examination), including mobility and gait and balance assessments, mini-mental status examination, and pre-operative assessment. (Beginning students should be able to do history, including mini-mental status examination.)
  • * Discuss preventive services with patients, taking into consideration national guidelines, the patient's goals and plans, and the patient's medical condition.
  • * Identify and work effectively with the older patient's caregivers, including demonstrating compassion for the challenges they face in their day-to-day care of the frail elderly.
  • * Provide palliative care, pain management, and end-of-life care in the context of family and individual values.
  • * Manage patients in transition between settings, e.g., between ambulatory/hospital settings and long-term care, including the nursing home/home care.
  • * Take a sexual history from an elderly patient and be able to assess sexual health (beginning students should be able to do the history part).

Medical Knowledge

GOAL: Students will demonstrate the application of evidence-based knowledge about established and evolving bio-medical clinical and cognate (epidemiology and socio-behavioral) sciences in the care of the elderly patient.

OBJECTIVES: Students will:

  • Explain the normal physiologic, psychological, social, and environmental changes of aging, including theories of aging such as biochemical/molecular, cellular, genetic, and bio-psychosocial, and recognize the pathology associated with normal aging and age-associated processes.
  • Describe a typical, healthy, active, and productive elderly person.
  • Explain the pharmacological issues (including issues regarding poly-pharmacy) in aging and describe relevance to therapeutic decisions, including demonstrating adjustment of dosing based on the knowledge of changes in pharmacokinetics that occur as a normal process of aging.
  • * Demonstrate a commitment to maintaining and improving the older patients' functional abilities and independence, including recognition of the under-reporting of symptoms and illnesses (sexuality, substance abuse, elder abuse and neglect, and home safety).
  • Explain other issues related to the psychosocial health of elderly patients, including under reporting of symptoms and illnesses (sexuality and substance abuse).
  • * Detail syndromes associated with aging: dementia/delirium, depression, incontinence, falls/mobility/balance, immobility, pressure ulcers, sensory impairment (including visual and hearing impairment, elder abuse, polypharmacy, malnutrition, sleep disorders, and nonspecific presentations of disease.
  • * Describe diseases that occur more commonly in the older adult such as heart disease, osteoarthritis, and forms of cancer.

Practice-Based Learning and Improvement

GOAL: Students will be able to evaluate practice-based systems of patient care using available evidence to improve the health of elderly patients

OBJECTIVES: The student will:

  • * Develop age-appropriate preventive care strategies in the elderly at all levels (primary - exercise, nutrition; secondary - age-appropriate screening; tertiary - post MI rehab and chemoprophylaxis).
  • Develop systems to manage care that is delivered to an elderly patient across a variety of settings such as office, hospital, home, sub-acute rehabilitation, and nursing home.
  • * Demonstrate an approach to reducing the tendency of elderly to experience iatrogenic illness (e.g., adverse effects of medications, institutionalization, and diagnostic tests).

Interpersonal communication skills

GOAL: Students will demonstrate interpersonal and communication skills with elderly patients, their families and caregivers, and other health professionals that result in the exchange of information to care effectively for elderly patients.

OBJECTIVES: The student will:

  • * Demonstrate interpersonal and communication skills that result in effective information exchange between older patients, their families, and professionals from other disciplines and other specialties.
  • Demonstrate sensitivity and responsiveness to an individual patient's culture, age, gender, and disabilities.

Professionalism

GOAL: Students will demonstrate a commitment to carrying out the professional responsibilities, adherence to ethical principles, and sensitivity required to provide culturally effective care to the elderly.

OBJECTIVES: The student will:

  • Describe the various myths and stereotypes related to older people, recognizing their impact can adversely affect optimal care of elderly patients and be aware of their own attitudes about aging, disability, and death.
  • * Demonstrate application of ethical principles pertaining to the provision of withholding clinical care for the elderly.
  • * Demonstrate awareness of the cultural aspects of aging, including being familiar with the influence of culture and ethnicity on the aging process, health and disease perception, and medical care.

Systems-Based Practice

GOAL: Students will demonstrate both an awareness of the larger context and systems of care that affect elderly patients and an ability to effectively call on system and community resources to provide care that is of optimal value.

OBJECTIVE: The student will:

  • Describe the demography and epidemiology of aging, including the growth in numbers of elder people and heterogeneity of the older population.
  • Describe financial aspects of health care of the elderly, including Medicare, Medicaid, managed care, and regulations governing practice in the home and nursing home.
  • Demonstrate application to patient care of the community resources available for the elderly (including those used to prevent institutionalization).
  • * List community resources generally available for elderly patients (at the clinical level, this list might be reflective of the community within which their care is located).

EDUCATIONAL METHODS and RESOURCES

Teaching strategies:

Lecture/Workshop:

  • Attend multidisciplinary geriatrics rounds in hospital, nursing home
  • Geriatrics elective
  • Home visits with Home Health Agencies and/or faculty member
  • Standardized geriatric patient (patient presents to geriatric assessment center)
  • Direct patient care - office, hospital, nursing home, etc - with preceptor

Integration strategies:

Clinical Experience:

  • Office Practice
  • Acute Care Hospital (e.g. Multidisciplinary Geriatric Rounds)
  • Geriatric Assessment Center
  • Nursing Home
  • Sub-Acute Rehabilitation Unit
  • Home Visit with Home Health Agencies and/or with faculty member

Electives:

  • AAFP has a catalogue of elective rotations around the country. This may have listed opportunities for students in geriatrics rotations.

Other:

EDUCATIONAL RESOURCES

Search Strategy: combining the terms *Education, Medical , Undergraduate / & * Geriatrics returned the most specific references.   Other MeSH terms include Academic Medical Centers. Aged. * Education , Medical / td [Trends]. * Elder Abuse. / ed [ Education ]. Human. Internship and Residency. * Models , Education al

Aimed at students:

Curricular resources:

  • As of June 2001, the Association of American Medical Colleges (AAMC), in collaboration with the John A. Hartford Foundation in New York City, had awarded 40 grants to U.S. medical schools to enhance the gerontology and geriatric curricula. For more information, visit:
    http://www.aamc.org/meded/start.htm
    Click on The AAMC-Hartford Geriatrics Curriculum Program
  • Sealy Center on Aging University of Texas Medical Branch Galveston, TX http://aging.utmb.edu/education/scoa   UTMB has a variety of curricular materials from their Sealy Center on Aging.
  • GERIATRICS RESOURCES from the Society of General Internal Medicine (SGIM)
    http://www.sgim.org/GeriatricsTeachingResources.cfm   SGIM's Geriatrics Teaching Resources provide Web sites and organizations useful for teaching clinical geriatrics. The site was developed by Beth O'Toole, Marilyn Schapira, and Brent Williams, with support from the SGIM-Hartford Collaborative Centers in General Medicine and Geriatrics Project. Now available on SGIM's Web site is the Annotated Bibliography to the SGIM/Hartford Paper, "Integrating Geriatrics into Internal Medicine Residency Programs" (published in an supplement to Annals of Internal Medicine). Categorized in topics including Conceptual Papers, Geriatrics in IM Training, Curricula, Residents' "Baseline" knowledge, Prepared by David Thomas, Eileen Callahan, et al.
  • The American Geriatric Society (AGS) (http://www.americangeriatrics.org/) has multiple resources including; Geriatrics at Your Fingertips in both paper and PDA formats, Geriatric Review Syllabus 5 (GRS5) Teaching Slides, Volume I (1 hour PowerPoint presentations on Assessment of the Older Adult, Hearing Impairment, Delirium, Nutrition, Malnutrition, and Feeding Issues, Dementia, Osteoporosis, Depression and Other Mode Disorders, Palliative Care, Dermatologic Diseases and Disorders, Pharmacotherapy, Diseases and Disorders of the Foot, Preventive Care, Dizziness and Syncope, Pressure Ulcers, Gait Disturbances and Falls, Sexual Function and Dysfunction, Geriatric Health Care: Principles and Statistics, Visual Impairment, Gynecology, Urinary Incontinence were available ($39 for a two year subscription http://www.frycomm.com/ags/teachingslides/ ) as of 9/04.
  • John A. Hartford Foundation consortium for Geriatrics in Residency Training distributed by Stanford University Geriatric Education Resource Center   http://sugerc.stanford.edu/index0a.html

Published material for Clerkship and Course Directors/Developers

  • Heath JM, Dyer CB, Kerzner LJ, Mosqueda L, Murphy C. Four models of medical education about elder mistreatment. Acad Med. 77(11):1101-6, 2002 Nov. The authors describe four models of incorporating elder-mistreatment curricular content and collaboration with adult protective service (APS) community service agencies into geriatrics medical education.
  • Karani R, Callahan EH, Thomas DC. An unfolding case with a linked OSCE: a curriculum in inpatient geriatric medicine. Acad Med. 77(9): 938, 2002 Sep.: This study sought to design, implement, and evaluate a unique educational curriculum in inpatient geriatrics for internal medicine housestaff.
  • Supiano MA, Fantone JC, Grum C. A Web-based geriatrics portfolio to document medical students' learning outcomes. Acad Med. 77(9): 937-8, 2002 Sep.: The University of Michigan Medical School is integrating into its curriculum the attitudes, knowledge, and skills that pertain to the care of older individuals using a defined set of core learning outcomes encompassing all four years. Students demonstrate proficiency in these outcomes as a graduation requirement. The school developed an individualized, interactive, Web-based geriatrics portfolio to track the acquisition and mastery of these outcomes for students.
  • Thornhill J, Richeson N, Roberts E. Senior mentor program: a geriatrics focused curriculum. Acad Med. 77(9): 934-5, 2002 Sep. Introducing medical students to a healthy elderly population and presenting the health care challenges in this population. This program provides a longitudinal experience for undergraduate students with local elders and will provide multiple opportunities for students to follow their same senior mentors over a four-year period both in the home and in the clinical setting. In partnership with the division of geriatrics, healthy patients over 65 were recruited to serve as senior mentors.
  • Arnold L, Shue CK, Jones D. Implementation of geriatric education into the first and second years of a baccalaureate-MD degree program. Acad Med. 77(9): 933-4, 2002 Sep.: The UM-KC School of Medicine seeks to help first and second students view aging as a multidimensional process, challenge stereotypes about aging, learn about factors in healthy aging, and explore medical conditions of older patients by pairing them with a mentor on aging. The mentor is an older adult living independently and experiencing normal psychosocial issues of aging without major medical problems.
  • Cleary LM, Lesky L, Schultz HJ, Smith L. Geriatrics in internal medicine clerkships and residencies: current status and opportunities. Am J Med. 111(9): 738-41, 2001 Dec 15.
  • Marcdante KW. Simpson D, Duthie E. Threading geriatrics content through a four-year curriculum. Acad Med. 76(5): 526-7, 2001 May. A key feature of weaving such a curriculum is to provide materials that support, not replace, key concepts in existing course and clerkships.
  • Anonymous. Core competencies for the care of older patients: recommendations of the American Geriatrics Society. The Education Committee Writing Group of the American Geriatrics Society. Academic Medicine. 75(3): 252-5, 2000 Mar. The aging of the U.S. population has led many organizations to call for an increase in the amount of clinical geriatrics training in medical education. A subcommittee of the American Geriatrics Society's Education Committee was assigned the task of defining core competencies for geriatrics education in medical schools. The subcommittee reviewed the available literature, surveyed selected programs in geriatrics education, and sought input from experts in geriatrics education. They then defined the core knowledge, attitudes, and skills students must develop to care for older people. This article summarizes these core competencies, which medical educators may find useful in developing new curricula on aging or in evaluating existing curricula.
  • Summer AM, Donahue JB, Kaplan K. Introducing home visits and interdisciplinary learning to an existing geriatrics practicum for medical students. Acad Med. 74(5): 602, 1999 May.
  • Westmoreland GR, Litzelman DK. A geriatric medicine program in the internal medicine clerkship. Acad Med. 74(5): 592-3, 1999 May.
  • Stiles N, Haist S. A four-year longitudinal gerontology curriculum for medical students. Acad Med. 74(5): 584-5, 1999 May.
  • Huber P, Gold G, Michel JP. Innovation in an undergraduate geriatrics program. Acad Med. 73(5): 579-80, 1998 May.
  • Hall NK, Riesenberg LA, Stein LK, Biddle WB. Longitudinal effectiveness of a medical school geriatrics clerkship. Acad Med. 72(10 Suppl 1): S28-30, 1997 Oct.
  • Wener S, Foley C, Jaffe A. Three years of a required geriatrics module for third-year medical students. Acad Med. 66(5): 292-4, 1991 May. The Parker Jewish Geriatric Institute, a teaching nursing home at which an accredited internal medicine geriatrics fellowship is based, co-developed with the Department of Family Practice of the medical school at the State University of New York at Stony Brook a mandatory geriatrics module for third-year medical students. The module's implementation over a three-year period (1985-1987) with 278 medical students is described.
  • Wieland D, Rubenstein LZ, Ouslander JG, Martin SE. Organizing an academic nursing home. Impacts on institutionalized elderly. JAMA. 255(19): 2622-7, 1986 May 16. In March 1984, a program for an academic nursing home was established at the Sepulveda Veterans Administration Medical Center. The program was designed to improve care of nursing home patients, provide interdisciplinary training for medical house staff and allied health students, and stimulate research. Overall, the costs of nursing home care were only minimally increased by the program. Results suggest that programs like the academic nursing home can lead to improved process and outcomes of nursing home care.
  • Powers JS, Burger C, Manian FA, Kuhn K, Lichtenstein MJ, Billings FT. A teaching nursing home: the Vanderbilt experience. South Med. J. 79(3): 267-71, 1986 Mar. A program to provide exposure to geriatrics as a teaching nursing home project was initiated at a large urban university medical center. Positive experiences, changes of attitude, and personal growth were noted among those involved in teaching, learning, and care of patients. A description of the program, its expansion, and plans for the future are detailed.
  • Woolliscroft JO, Calhoun JG, Maxim BR, Wolf FM. Medical education in facilities for the elderly. Impact on medical students, facility staff, and residents. JAMA. 252(24): 3382-5, 1984 Dec 28. The development of positive attitudes toward elderly patients has been identified as being an important factor in providing quality geriatric care. This study shows that students' attitudes toward the elderly can be positively changed through incorporation of training at appropriate community facilities for the elderly into existing curricula.
  • Powers CS, Savidge MA, Allen RM, Cooper-Witt CM. Implementing a mandatory geriatrics clerkship. J Am Geriatr Soc. 50(2): 369-73, 2002 Feb. This paper reports the experience of creating a 4-week, mandatory geriatrics clerkship for junior medical students at the University of Arkansas for Medical Sciences Hospital, the Central Arkansas Veterans Healthcare System Hospital, community nursing homes, and community hospice programs in Little Rock, Arkansas. This paper demonstrates that students acquired sufficient cognitive knowledge to complete satisfactorily the clerkship but did not highly value the experience.
  • Alford CL, Miles T, Palmer R, Espino D. An introduction to geriatrics for first-year medical students. J Am Geriatr Soc. 49(6): 782-7, 2001 Jun. This study was to determine the impact of a new educational program. Attitudinal assessments were administered to the group before and after participation in the program and to a comparison group of nonintervention students at the University of Texas Health Science Center, San Antonio. The impact of the program was mixed. Although awareness of geriatrics and comfort with older people was increased, there was little change in career aspirations. Students in the program increased their awareness of physical decline in old age, setting the stage for teaching them about the physician's role with regard to function, and learned that geriatrics is a low-status specialty.
  • Education in geriatric medicine. AGS Education Committee and Public Policy Advisory Group (PPAG). J Am Geriatr Soc. 49(2): 223-4, 2001 Feb. Positions: 1. Gerontology and geriatric medicine should be integrated into the curriculum for each year of medical school, and clinical experiences in geriatrics should be required. 2. Residency and fellowship training programs that involve primary or consultative care of elderly patients should be required to have scheduled clinical and didactic experience in geriatrics. The full spectrum of health care settings should be utilized for training. 3. Future faculty responsible for geriatric education within family medicine, internal medicine, and psychiatry should have academic geriatric fellowship training that includes instruction in clinical care, teaching, research, and administration. Faculty in other specialties who are responsible for geriatric education should have specific advanced training in gerontology and geriatric medicine, especially as it relates to their discipline. 4. Formal recognition of expertise in geriatric medicine should be considered by all specialties that provide care to older adults. 5. Practicing physicians who provide substantial care to older adults should be strongly encouraged to gain continuing medical education in geriatrics. All sectors of the health care market place, including both the for-profit and not-for-profit arenas should be penetrated. 6. Continued increased funding is needed for the support of medical student, residency, and fellowship training programs in geriatric medicine. This must be available for training in acute inpatient, outpatient, and long-term care settings. Additional funding is necessary to support the development of geriatrics faculty and a sufficient number of faculty to direct clinical research and educational programs.
  • Landefeld CS, Callahan CM, Woolard N. 2003 Supplement to Annals of Internal Medicine General Internal Medicine and Geriatrics: Building a Foundation To Improve the Training of General Internists in the Care of Older Adults. Ann Intern Med. 2003; 139 609-614
    http://www.annals.org/cgi/content/abstract/139/7/609?etoc
  • Rubin CD, Stieglitz H, Vicoso B, Kirk L. Development of geriatrics-oriented faculty in general internal medicine. Ann Intern Med. 2003;139 615-620
    http://www.annals.org/cgi/content/abstract/139/7/615?etoc
  • Simon SR, Fabiny AR, Kotch J. Geriatrics training in general internal medicine fellowship programs: current practice, barriers, and strategies for improvement. Ann Intern Med. 2003;139 621-627
    http://www.annals.org/cgi/content/abstract/139/7/621?etoc
  • Thomas DC, Leipzig RM, Smith LG, Dunn K, Sullivan G, Callahan, E. Improving geriatrics training in internal medicine residency programs: best practices and sustainable solutions. Ann Intern Med. 2003;139 628-634 http://www.annals.org/cgi/content/abstract/139/7/628?etoc

Websites:

  • American Federation for Aging Research (AFAR) - http://www.afar.org 1414 Sixth Avenue, 18th Floor New York, NY 100 19 (212) 752-2327 The Federation's main objective is to support basic and clinical biomedical research in the field of aging. AFAR grants are awarded to investigators based on competitive proposals. There are also funds available for student research projects.
  • American Medical Student Association (AMSA) - http://www.amsa.org 1902 Association Drive Reston, VA 20191 (703) 620-6600 AMSA is made up of 30,000 students with local chapters in 140 allopathic and osteopathic schools throughout the country. It is dedicated to the improvement of medical education, health care, and health care delivery. Areas of interest are organized into action committees and interest groups on critical health issues. The Geriatrics Interest Group maintains a Web page on AMSA's Web site with information for students, including interviews with physicians specializing in geriatric care and student chapter project ideas. The interest group also coordinates a listserve that acts as a forum among medical students to exchange ideas and concerns regarding geriatric medicine and to share information relevant to geriatric practice.
  • Association for Gerontology in Higher Education (AGHE) - http://www.aghe.org 1001 Connecticut Avenue, NW, Suite 410 Washington, DC 20036 202/429-9277 AGHE serves as an advocate for gerontology in higher education. Membership comprises over 300 institutions of higher education throughout the United States and Canada. The Association has various publications, including a newsletter and a National Directory of Educational Programs in Gerontology
  • American Society on Aging (ASA) - http://www.asaging.org 833 Market Street, Suite 516 San Francisco, CA 94103 (415) 543-2617 ASA sponsors a wide array of educational activities across the country. Its constituency is largely composed of caregivers from a number of professional disciplines, including nursing, social work, medicine, psychology, and gerontology. Special activities for students are sponsored.
  • Gerontological Society of America (GSA) - http://www.geron.org 1411 K Street, NW, Suite 300 Washington, DC 20005 (202) 393-1411 Also one of the largest professional associations in the United States, the GSA has major interest sections for Biological Sciences, Social Research, Planning and Practice, Clinical Medicine, and Behavioral and Social Science. GSA conducts a large annual meeting and supports a number of student activities.
  • The National Council on the Aging, Inc (NCOA) - http://www.ncoa.org 600 Maryland Avenue, SW West Wing 100 Washington, DC 20024 (202) 479-1200 The Council sponsors a Geriatric Fellowship for Medical Students (GFMS) program. Fellowships are granted to undergraduates who submit successful proposals to carry out specific projects.
  • The American Geriatric Society (AGS) (http://www.americangeriatrics.org/) with over 6,500 physicians and other health care professional members, the AGS has multiple resources including; Geriatrics at Your Fingertips in both paper and PDA formats, GRS5 Teaching Slides, Volume I.
  • http://sugerc.stanford.edu/index0.html   Stanford University Geriatric Education Resource Center (SUGERC) The John A. Hartford Foundation Consortium for Geriatrics in Residency Training
  • http://www.eperc.mcw.edu/   End of Life/Palliative Care Education Resource Center
  • http://www.pogoe.org/px/   Portal of Online Geriatric Education (POGOe) is an online clearinghouse that provides those interested in geriatrics education with a single source for high-quality educational materials primarily designed for physicians in training and practicing physicians.

Family Medicine Curriculum Resource Project (HRSA Contract No. 240-00-0107) Preclerkship Collaborative Workgroup and Family Medicine Clerkship Post Clerkship Workgroup GERIATRICS Special Topic Outline.
September 24, 2004 Revision.
 

For questions or comments, please contact Webmaster or Ardis Davis

This page last updated October 15, 2005