CPM-II


Goals | Intro/Key Principles | Psychosocial | Function | Medical History
Pharmacotherapeutics | Advance Directives | Physical Exam | Wrap-up
Online Senior Health Assessment (for use with your patient)


Goals and Objectives
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The goal of this curriculum is to provide all medical students exposure to the full range of medical and functional issues that occur commonly among chronically-ill older persons. The program will provide students the opportunity to work closely with older adults who are recovering from acute illness. This exposure will highlight a) interaction of multiple comorbidities; b) the interaction between illness and functional status; c) the role of medication in health and illness d) course of functional recovery for ill older adult; and e) the interaction between health and social resources and their consequences for older adults. In order to accomplish all of this, students will be asked to systematically assess an older adult’s medical, functional, social, and psychiatric condition. Our goal is to give students a longitudinal experience so that this assessment will occur over the semester and may involve the evaluation of more than one patient over that time. Faculty support and direction are important elements of the experience. During the semester students will become more facile and comfortable with the assessment process and with older adults.

A COMPOSITE WRITE-UP WILL BE DUE AT THE END OF THE SEMESTER


Session 1 – Intro, Key Principles of Geriatrics
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SHA homework

Meet with preceptor and be introduced to the patient
Review procedures for accessing patient charts
Meet key nursing staff
Review confidentiality standards and policy on charting
Determine meeting location within the facility
Review grading standards
Review background for following session
View DVD with group discussion to follow

Discussed:

A Story to Remember
Expectations for Older Adults
Key Principles of Geriatrics
Session notes by Kelly Noble (semester 1)
Session notes by Melissa Hoffman (semester 2)


Session 2 – Psychosocial History
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SHA homework

Introduce yourself to the patient
Review reasons for student activity and plans for the student visits
Events that precipitated admission to current domicile or program
Current social resources or those in place two weeks prior to precipitating hospitalization
– Where did they live
– With whom
– Ability to go out of home
– Transportation resources
– How were instrumental activities of daily living done
– Assist with activities of daily living
Perform Geriatric Depression Scale Senior Health Assessment | iPhone app
Perform Mini Mental Exam
Perform Six Item Screener

Faculty session: Discuss social factors that underlie skilled nursing admission
Discuss depression/Dementia/Delirium.

Faculty resource
http://www.pogoe.org/productid/18816

Prepare students for next session: functional status assessment, review Tinetti Fall risk index (see NEJM article).

Assigned reading:

http://www.pogoe.org/sites/default/files/mediasite/depression_and_grief/Player.html

Discussed:

Session notes 2012
Session notes 2013-01-28 | Student presentation | pdf


Session 3 – Understanding Functional Status
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SHA homework

Review with patient the activities planned for the sessions
Administer FIM scales for Self care, mobility, locomotion, sphincter control using self report, observation, and nursing reports
– Obtain history of patients ability 2 weeks prior to index hospitalization
– Review with patient and nursing staff patient’s current capacity in long term care
Observe and score:
– Bed mobility
Turning to side (left and right)
Supine to upright and return to supine
Supine to sit on edge of bed
– Transfer from bed to chair and back
– Ambulation – score by Tinetti Scale. If patient is non-ambulatory do not score
– Dressing – ask patient to put on shirt or blouse (over gown) and button the garment
– Administer 10 cc swallow test – unless patient is not allowed to take anything by mouth.

Functional status video:
http://www.pogoe.org/node/3456

Table 1. Performance Levels for Functional Independence Measure Items

When a helper is not required
7. Complete independence
6. Independent with the use of a device

When a helper is required
5. Supervision or prior preparation
4. Minimal assistance (with the patient providing three quarters or more of the combined effort)
3. Moderate assistance (with the patient providing one half to three quarters of the combined effort)
In complete dependence the helper provides
2. Maximal assistance (with the patient providing one quarter to less than one half of the
combined effort)
1. Total assistance (with the patient providing less that one quarter of effort)

Stineman: Medical Care, 35(6). June 1997 JS90-JS105

The respondent is asked, “During the past months, have you experienced any of the following? If so, how often did it occur?”
Frequency
Pain/Discomfort
Every Day Less than daily Not at all
Aches/pains in joints or muscles
Chest pain
Shortness of breath
Dizziness
Itching/burning
Headaches

Classify the pain as nociceptive, neuropathic, or mixed

Faculty session: Review functional status assessment, discuss functional status and disability.

Review bedside assessments. Review pain assessment and management.

Assigned reading:

http://umconnect.umn.edu/p82129657 (video slideshow)
Management of Persistent Pain in Older Persons (first page). Jour Am Geri Soc. 2002 50(6):S205-S224

Discussed:

Older Patient Interview form
Session notes


Session 4 – The Medical History
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SHA homework

Review planned activities with the patient
Obtain medical history
History of present illness
Pain
Evaluate the patient’s pain:
Take a history of the patient’s pain
Intensity, location
Impact on ADLs and IADLs
Analgesic history
Patient beliefs about pain
Patient’s satisfaction with current treatment
Administer visual analog scale for pain
Recent interim illnesses.
Past medical history
Allergies
Vaccinations
Employment, education history
Use of Alcohol and cigarettes
Review of systems – review current pain status
Present patient centered history – see Tinetti article

Assigned reading:

Clinical Implications of Aging Physiology (abstract). Williams ME.  Am Jour Med. 1984;76:1049-54.
The End of the Disease Era (article). Tinetti ME, Fried T.  Am Jour Med; 2004;116(3):179-85.

Discussed:

Previsit questionnaire
Session notes


Session 5 – Pharmacotherapeutics
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SHA homework

Review medications
Match each medication to a diagnosis
Identify common side effects and potential drug interactions/side effects
Identify potential areas to improve medication profile

Faculty session: Review medication profiles, discuss polypharmacy, discuss common
medications that are inappropriate medications for older adults.

Assigned reading:

Beers Criteria Pocket Card
Prescribing for older people. [Review] [38 refs] Milton JC. Hill-Smith I. Jackson SH. BMJ. 336(7644):606-9, 2008 Mar 15
Risk of adverse drug events by patient destination after hospital discharge.  Triller DM. Clause SL. Hamilton RA. American Journal of Health-System Pharmacy. 62(18):1883-9, 2005 Sep 15

Discussed:

Drugs Can Make You Sick! medication-symptom analyzer
Key Principles of Geriatrics
Session notes


Session 6 – Advance Directives
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SHA homework

Discussion of patient diagnoses/prognosis
Discussion of patient’s current advance directives:
Who can make decisions?
What is an ethics consult?
Guardianship/POA’s
DNR/DNI
Health Care Proxy
Feeding tubes and artificial hydration

Faculty session:
Review common ethical issues, review terms and implementation of health care proxy

Assigned Reading:

CPR

Myths and Truths of CPR

Feeding tubes

Feeding tubes benefits and burden grid
Guidelines for Long Term Feeding Tube Placement
Tube Feeding in Patients with Advanced Dementia: A Review of the Evidence
Finucane, TE, Christmas, C, Travis, K.  JAMA. 1999;282(14):1365-1370. [article pdf]
Video

Discussed:

NYS Health Care Proxy | form
NYS MOLST | form
NYS Nonhospital DNR | form
Death After Discharge – What Would You Do? article


Session 7 – Physical Examination
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Vital signs, focus on skin, cardiac, respiratory and mental status

Faculty session: Review pertinent physical findings.

Discussed:

Physical exam grid
Session notes


Wrap-up – Attendance, Participation, and Write-Up
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Evaluation of student performance: Attendance and participation in faculty conferences Composite patient write-up at end of semester.

Completing the CPM-II geriatric longitudinal block.
Students are expected to provide a write-up of their patient experience. The write-up is due via e-mail at your faculty leader’s address by Friday, April 20, 2012.
For this block experience students may submit a joint write-up. That is, student pairs may submit one write-up.

The format for the write-up is:
History – follow patient centered format as described in Tinetti’s paper on the end of the disease era.
Major co-morbidities
Current functional status using the Functional Independence Measure
Medication profile including diagnosis, possible drug-drug interactions, and current symptomatology that may be related to medication side-effects.
Mental status score
Pain scale
Depression scale
Pertinent Physical findings
Advanced directives

A summary statement of at least one substantive paragraph should be included. The student should comment on key concepts learned from the patient experience.

Discussed:

Final writeup instructions

*****

Online Senior Health Assessment items

1 Demographics – Basic Information Your Doctor Needs to Know  
2 Overall Health – How Is Your Overall Health?  
3 Activities  – Are You Staying Active? 
4 Advance Directives   
5 Alcohol Use – Could Alcohol Be a Problem for You?  
6 Andropause – Is Your Testosterone Low?   
7 Balance – Are You Taking Medications That Might Make You Fall?   
8 Balance – Do You Feel Unsteady or Afraid You’ll Fall? 
9 Caregiving – Are You Helping to Care for a Loved One?   
10 Daily Function – Do You Have Problems Managing In Everyday Life? 
11 Diabetes Risk Test – Are You at Risk for Diabetes?  
12 Dizziness – Is It Keeping You From Doing What You Want to Do?    
13 Driving – Are You a Danger to Yourself or Others?  
14 End of Life Values and Beliefs – What Kind of Death Do You Want?    
15 Feelings & Attitudes – Are Your Feelings and Emotions Keeping You From Living Life to the Fullest? 
16 Grief – How Are You Dealing With It?    
17 Hearing – Are You Going Deaf?  
18 Medical Problems – What Medical Problems are Holding You Back?  
19 Medications – Are Medications Making You Sick?     
20 Memory – Is Your Memory Slipping?   
21 Mood – Are You Depressed?  
22 Nutrition – Do You Eat Properly?    
23 Pain – Is Pain Making Life Miserable?    
24 Physical Activity Readiness Questionnaire – Is It Safe For You to Exercise?   
25 Prevention – Are You Doing Everything You Can to Stay Healthy?  
26 Quality of Life – How Do You Rate Your Quality of Life? What Could Make It Better?     
27 Safety – Is Your Living Environment Unsafe?      
28 Significant Events – What Major Events Have You Experienced Recently? 
29 Sleep – Do You Have Sleep Apnea? 
30 Symptoms – What Troublesome Symptoms are You Experiencing?  
31 Urine Function – Do Urination Problems Keep You from Doing What You Want or Embarrass You?  
32 Vision – Is Your Eyesight Failing?
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