1 - E-Ageing: E-Ageing



THE UNIVERSITY OF WESTERN AUSTRALIA

SCHOOL OF MEDICINE & PHARMACOLOGY

4TH YEAR STUDENTS

INTRODUCTION TO GERIATRIC MEDICINE

UNIT GUIDEBOOK

IMED4492/IMED4492

Medicine Specialty – Geriatric Medicine

Updated 2010

_________________________________________________________________________

TABLE OF CONTENTS

1 CURRICULUM 3

2 THE GERIATRIC MEDICINE COURSE 3

2.1 SELF DIRECTED LEARNING MODULES 3

2.2 CLINICAL ATTACHMENTS AND CLINICAL TUTORIALS 3

2.3 SPECIALTY CLINICS 4

2.4 ON-LINE CASE STUDIES 6

2.5 LOG BOOKS 6

2.6 TIME ALLOCATION 6

3 OVERVIEW OF LEARNING OUTCOMES 8

4 Specific Learning Outcomes 9

5 ASSESSMENT 11

5.1 CASE REPORT 11

5.2 STUDENT QUESTIONNAIRES 11

6 ACADEMIC DISHONESTY 12

7 APPEALS AGAINST ACADEMIC ASSESSMENT 12

8 Normal Ageing and Common Health Problems SDLM 15

9 Dementia SDLM 17

10 Residential Care SDLM – Week Three 22

11 An Older Woman with Hip Fracture PBL – Week Four 23

12 ALZHEIMER’S ASSOCATION – MAP 24

13 EXAMPLE OF CASE REPORT 25

THE UNIVERSITY OF WESTERN AUSTRALIA

SCHOOL OF MEDICINE & PHARMACOLOGY

4TH YEAR STUDENTS

INTRODUCTION TO GERIATRIC MEDICINE

UNIT GUIDEBOOK

IMED4492/IMED4492

Medicine Specialty – Geriatric Medicine

_________________________________________________________________________

CURRICULUM

The Medicine 4th Year curriculum includes a four week course in Geriatric Medicine. Self Directed Learning Modules (SDLMs), ward tutorials and activities, and community visits are arranged at each teaching hospital. Students are also expected to attend and take an active part in the postgraduate clinical meetings in geriatric medicine which are usually held at the Sir Charles Gairdner Hospital, Roma Miles Room on Monday afternoons at 5.00 pm. Details are posted on the hospital postgraduate noticeboards.

THE GERIATRIC MEDICINE COURSE

This is hospital based and includes clinical attachments, tutorials, case presentations and problem based/self directed learning activities.

Please be advised that in order to pass IMED 4491/92 Medical Specialties, you must pass both the Geriatrics and Musculoskeletal components of the course.  Each component is worth 50% of your mark.”

1 SELF DIRECTED LEARNING MODULES

Students will be expected to participate in all SDLMs. There will be four SDLMs. Subject to timetabling requirements, there will be one SDLM per week. In the first SDLM the theme will be the changes associated with normal ageing. In the second SDLM the theme will be dementia. In the third SDLM the theme will be residential care. In the final week there will be a Problem Based Learning (PBL) module on hip fracture. Students will be informed in more detail about these activities during the attachment.

2 CLINICAL ATTACHMENTS AND CLINICAL TUTORIALS

The Geriatric Medicine term includes ample time for your clinical work. This is where you will learn most. Usually groups of students will be linked to a Consultant’s clinical team, as well as an Aged Care Assessment Team (ACAT). Students are expected to play an active role in the teams they are attached to. This includes clerking patients admitted to the team (usually at least three per week), participating in ward rounds and presenting at team meetings.

It is only in occasional circumstances that a patient admitted to Geriatric Medicine will not be suitable for a student to be involved in their care. This component of the course is delivered by multiple teams across metropolitan sites so individual experiences will vary and be subject to negotiation between students and the tutors/clinical teams

Students sometimes feed back that they find it difficult to access sufficient numbers of patients at the teaching hospitals. Fortunately in Geriatric Medicine there is a wealth of clinical material to be found at the Restorative Units. The Restorative Units are sub-acute Geriatric Medicine wards at Peel, Joondalup, Mercy, Osborne Park and Bentley Hospitals. There are restorative units at Swan and Armadale, anticipated to provide placements for UNDA students. Students invariably report that seeing patients at the Restorative Units at the Secondary Hospitals is worthwhile.

In addition, each week there will be two clinical tutorials, one of which will cover topics such as rehabilitation for older people, falls, incontinence and geriatric assessment. Every effort will be made to provide students with exposure to community assessments during this attachment. Tutors are clinicians and experience may vary depending on your tutor and site. We have posted references on the main tutorial topics online and other articles are available from the University library (see attached list). Students should prepare for tutorials with reference to their texts and the attached lists of resource materials.

Arrangements are also made for students to visit Alzheimer’s Australia (WA) in Shenton Park and be given an insight into the facilities and services available from this organisation. This normally takes place on the afternoon of the second Tuesday of the term and all students are expected to attend.

3 SPECIALTY CLINICS

Feedback from prior groups has indicated that students find attending the Memory Clinic very worthwhile. This provides first hand experience in the assessment of patients presenting with memory complaints. Details for Memory Clinic Attendance are listed below. In addition there are several clinics in Falls & Osteoporosis, Continence and General Geriatric Medicine across the metropolitan area. Interested students should discuss the possibility of attending these clinics with their tutor.

Students allocated to Royal Perth Hospital

On the first day of term contact your tutors (preferably the advanced trainee) to arrange case allocation and attendance at team meetings, etc.

This can be done via the Dept of Geriatric Medicine Office:

Jenny Peters Ph: 9224 2099

Emma Reany Ph: 9224 2773

Clinicians and Advanced Trainees are happy to teach up to 4 students in the Mercy Memory Clinic.

If the clinics are running and there are no PBLs or tutorials scheduled, 2-4 students can present to the Memory Clinic. It is advisable to ring the day before to confirm that the clinic has not been cancelled.

Mercy Memory Service 9.00am on Wednesdays and Fridays

Mercy Restorative Unit, Thirlmere Road, Mount Lawley. Ph: 9370 9900

Home Visits

Please contact the relevant ACAT team to organise attendance at home visits.

Contact should be made at the beginning of term, as generally only one student per visit will be allowed and clients and families have to agree to student attendance.  When arranging the home visit, please make sure you provide your mobile phone contact, in case visits have to be cancelled or rearranged.

ACAT Teams

Bentley Health Service Alison Morcombe Ph : 9334 3764

Mercy (Inner City) David Easton: Ph: 9370 9900

Please also refer to handout - IV Year Medical Students Allocated to RPH Dept Geriatric Medicine.

Students allocated to Sir Charles Gairdner Hospital

At the orientation session students will receive a handout from the hospital informing them of relevant clinics with contact details. For further information contact the Administrative Supervisor Bob Scullen of the Department of Aged Care & Rehabilitation - Phone: 9346 3721.

Sir Charles Gairdner Clinics:

Contact: Ms Christine Stannard on 9346 2594

Memory Clinic: 0900 Tuesday (PM)

Memory Clinic: 1300 Thursday (CI)

Memory Clinic 0900 Monday (MW)

Continence Clinic: 1300 Tuesday (LTS)

Falls Clinic: 0900 Wednesday (CI / KI)

General: 0900 Monday (SH)

1300 Monday (CI)

0900 Tuesday (PM)

1300 Tuesday (LTS)

1300 Thursday (CI / DG)

Students allocated to Fremantle Hospital

Contact the Department of Geriatric Medicine secretary, phone: 9431 2994 and she will advise students of relevant clinics and contact details. . Dr Clarnette will meet students on the first morning of the term at 8.30 am in Greenslades wing, level V4.

Students allocated to Osborne Park and Joondalup Hospitals

Students will be divided into two groups with one attending OPH and the other Joondalup Health Campus. All students however will return to OPH for combined tutorial sessions.

All the clinics below are located in the Rehabilitation and Aged Care Department,

F Block, Osborne Park Hospital, Osborne Place, Stirling

Parkinson’s Disease Clinic

Ph: 9346 8113

***Students need to confirm suitable date for attendance with Marie Rome, Clinic Nurse***

Day Hospital Outpatient Clinics Run daily. Deal with a variety of cases including falls, memory and general medical.

Ph: 9346 8101

Journal Club / Case Presentations 12.00 pm on Wednesdays

Seminar Room

ACAT Team

In the first instance, please contact either Karen Mabbott (ph: 9346 8105) or Sharon Steyn (ph: 9346 8227) and they will direct you to the appropriate registrars and ward areas.

4 ON-LINE CASE STUDIES

Case studies to support student learning have been developed and are available at . 9 of these should be completed during your geriatric medicine term. There are case studies linking directly to the main tutorial topics (falls, continence, rehabilitation and geriatric assessment). The remaining case studies link to SDLMs:

|SDLM |On-line e-Ageing Case Studies |

|Week 1: Normal Ageing |Healthy Ageing |

|Week 2: Dementia |Dementia, Depression & Delirium |

|Week 3 Residential care |Residential Care |

|Week 4: Hip Fracture |N/A |

The healthy ageing Case Study should be completed in the first week. Other case studies should be completed when students prepare for the relevant tutorial or SDLM.

5 LOG BOOKS

These are provided to facilitate reflective learning. The log book can be accessed on the e-Ageing site (copy also attached). Students are encouraged to use the log book regularly and to discuss cases recorded, as well as reviewing the log book with tutors as part of end of term feedback.

6 TIME ALLOCATION

About half of each student’s week will be spent directly involved in the clinical activities of the service to which the students are attached

• Clinical activities including : )

Small group tutorials ) 50%

Ward work )

• SDLMs, PBLs and Tutorials 25%

(2 - 3 x 1.5 hrs/week)

• Self-directed learning time 25%

Students must have free time for effective involvement in the overall program to prepare for SDLMs

and tutorials and research clinical questions that arise during the attachment.

OVERVIEW OF LEARNING OUTCOMES

|LEARNING OUTCOMES |THEME |TEACHING and LEARNING EXPERIENCES |GRADUATE OUTCOMES |

|At the end of this unit students will be | | | |

|able to: | | | |

|Work in partnership with older people |Doctor and Patient |Ward Attachment |Provide effective and safe patient |

|considering the social and physical | |Clinic Attendance |management |

|determinants of health and illness. | |Visits to RCF | |

| | |Visits to Community Organisations | |

| Identify the evidence available to |Scientific Basis of |Self Directed and problem based learning |Apply the scientific/evidence based |

|assist clinical decision making in |Medicine |modules |approach to medicine and practice |

|Geriatric medicine, and appreciate the | |Tutorial Programme | |

|limitations of the currently available | |Case Write-up | |

|evidence base. | | | |

|3. Explain the ageing process and |Scientific Basis of |Self Directed Learning module |Demonstrate an in depth knowledge of |

|physiology of ageing |Medicine | |normal human structure, function and |

| | | |behaviour |

|4. Explain the aetiology, natural |Scientific Basis of |Ward Attachment |Apply knowledge of pathological and |

|history, pathology and clinical features,|Medicine |Clinic Attendance |clinical features of disease. |

|management and prognosis for the common | |Self Directed and problem based learning | |

|geriatric syndromes and common diseases | |modules | |

|of ageing. | |Tutorial Programme | |

|5. Discuss and demonstrate effective |Doctor and Patient |Ward Attachment |Use effective communication skills and |

|communication skills related to | |Clinic Attendance |styles. |

|interactions with patients, health care | |Visits to RCF |Provide effective and safe patient |

|professional and colleagues | |Visits to Community Organisations |assessment and management. |

| | |SDLM and PBL | |

| | |Tutorial Programme | |

|6. Demonstrate effective history, |Doctor and Patient |Ward Attachment |Provide effective and safe patient |

|examination and presentation skills when | |Clinic Attendance |assessment and management |

|working with older people. | |Tutorial Programme |Perform and practice practical |

| | | |procedures effectively and safely. |

|7. Apply health promotion, maintenance,|Doctor, Health and |Ward Attachment |Apply and evaluate health maintenance, |

|disease prevention approaches to the |Society |Clinic Attendance |promotion and disease prevention |

|health of the ageing | |Tutorial Programme |approaches to clinical practice |

| | |Self Directed and problem based learning | |

| | |modules | |

|8. Discuss and use ethical and legal |Personal and |Self Directed and problem based learning |Apply ethical behaviour to professional |

|standards of practice. |Professional |modules |practice |

| |Development |Ward Attachment | |

| | |Clinic Attendance | |

| | |Tutorial Programme | |

Specific Learning Outcomes

These specific learning outcomes provide detailed description of the knowledge and skills you need to have obtained by the end of this geriatrics attachment.

. Work in partnership with older people, considering the social and physical determinants of health and illness, and the services available to older people in Australia

▪ use a positive approach to old age and illness in old people

▪ explore ageism and negative stereotypes

▪ demonstrate confidence in ability to deal with older people’s problems

▪ apply a holistic approach to patients (people rather than diseases)

▪ discuss roles and function of the multidisciplinary team

▪ discuss the role of the rehabilitation team and consider the role of the doctor

as coordinator in that team

▪ outline how to determine a feasible rehabilitation plan, how to set appropriate

goals for rehabilitation and monitor the progress of patients.

▪ discuss the standards and levels of residential care available for the ageing in

Australia

i. describe methods of assessment required before older people can be placed in residential care.

ii. describe standards required of residential care facilities and some of the problems that have been met in accommodating these.

▪ discuss the need for setting appropriate goals for rehabilitation and monitoring the progress of patients in achieving these goals.

▪ to have knowledge of the role and function of the aged care assessment team and the community support services that these teams access.

. Identify the evidence available to assist clinical decision making in Geriatric Medicine, and appreciate the limitations of the currently available evidence base

Explain the ageing process and physiology of ageing

▪ Understand the demographics of population ageing in Australia

▪ particularly the sensory organs and cognition

▪ differentiate between normal ageing and common diseases of older age.

▪ demonstrate knowledge of the demographics of the ageing population.

. Explain the aetiology, natural history, pathology and clinical features, management and prognosis for the common geriatric syndromes and common diseases of ageing.

▪ Dementia

• identify common types in Australia

• identify behavioural effects that may present throughout the course of illness

• distinguish dementia from other common problems (eg. Delirium and depression)

• discuss medical, social and ethical challenges that result from the care of people with dementia.

• discuss pharmocological treatment of Alzheimer’s Disease

▪ Falls and metabolic bone disease

• prevalence, implications, causes/risk factors (drugs, orthostatic hypotension and multiple pathology

• explain the importance of assessing falls and metabolic bone disease in elderly patients with fractures

• describe the biochemistry, pharmacology and treatment of steroid induced bone loss.

• Explain, with examples, the functional and psychological consequences of hip fracture

▪ Continence

• Urinary Incontinence

▪ prevalence, pathophysiology and classification

▪ assessment and management

▪ use and abuse of catheters

▪ drugs - causing and treating incontinence

• Faecal

▪ causes and management

. Discuss and demonstrate effective communication skills related to interactions with patients, health care professional and colleagues

▪ with older people and their carers

▪ with allied health professionals (the multidisciplinary team)

▪ discuss roles of the carers

. Demonstrate effective history, examination and presentation skills when working with older people (Geriatric Assessment).

▪ assess cognitive and physical function of older people

▪ explain the concepts of impairment (pathologies), disability and handicap and how the assessment of all these domains is important in the management of older people.

▪ to have knowledge of the individual roles of the multidisciplinary team and to appreciate the importance of the multidisciplinary team in the comprehensive assessment of disabled older people.

. Apply health promotion, maintenance, disease prevention approaches to the health of the ageing

▪ explain the concept of iatrogenesis, considering the importance of issues

such as polypharmacy in geriatric medicine

. Discuss and use ethical and legal standards of practice.

▪ discuss principles of medical ethics, eg autonomy, risk-taking etc

ASSESSMENT

Ward ratings will be an important part of continuous assessment. Individual terms will be weighted approximately on the proportion of time that that term occupies compared to the total year of teaching. The ward rating in geriatric medicine will be composed of two components. They are the case report and the overall tutor assessment.

We also expect that you will record patients that you are seeing. As a guide, the required absolute minimum is to clerk, and follow the management of, three new inpatients a week. You must also participate in at least one ACAT domiciliary assessment. Learning experiences can be enhanced by using the logbook to record and reflect.

Your Assessment Forms are attached. It is the responsibility of the student to bring the Assessment Forms to the tutor at the end of the attachment.

1 CASE REPORT

One case report is required from each 4th Year medical student. The requirements for the case report are as follows:

The aim is to produce an assessment of a current inpatient (in either an acute or restorative ward). You should document in not more than 3 pages, the presentation and history, examination, disabilities and pathologies, followed by a summary of their progress in hospital with their final ADLs and discharge arrangements if appropriate. A follow-up home visit on your patient is required.

You must identify suitable patients for the case write up during weeks 1 and 2. Aim to identify 3 to 4 patients in case discharge of your chosen patient does not eventuate within the required time frame.

Finally, we would like you to comment (in not more than 2 pages) on whatever aspects of the patient’s care, either in hospital or otherwise, you feel appropriate. The case report and comments must not exceed four pages and neatly handwritten reports will be acceptable. You should ask your consultant or his/her registrar for allocation of suitable patients and they will help you with any questions that you may have regarding this report.

The reports will be marked out of 20 (see pro forma sheet). These reports must be handed in by Wednesday of week 4 of clerkship to the Secretary or Administrative Officer at the Geriatric Unit to which you are attached. The clinical tutor will endeavour to mark them within 2 days and you will be able to discuss the result with your tutor on the last Friday of the clerkship.

A sample case report is attached. Tutors have asked us to emphasise that this is NOT a model case report.

Overall Tutor Assessment

The tutor assessment will be marked pass/fail and will be based on performance during the term including clerking patients and contribution to tutorials.

2 STUDENT QUESTIONNAIRES

Each student is required to complete a SPOT questionnaire form at the end of term. These will be administered to you by a member of staff.

ACADEMIC DISHONESTY

All forms of cheating, plagiarism and copying are condemned by the University as unacceptable behaviour. The Faculty’s policy is to ensure that no student profits from such behaviour. Generally a failure will be recorded for the subject in which the cheating has occurred. Serious cases shall be referred to the University’s Board of Discipline. All students should note that cases of copying are automatically reported to the Sub-Dean and documentary evidence along with associated correspondence is placed on the student’s permanent record.

APPEALS AGAINST ACADEMIC ASSESSMENT

If students feel they have been unfairly assessed, they have the right to appeal their mark by submitting an Appeal Against Academic Assessment form to the Head of School and Faculty Office. The form must be submitted within twelve working days of the formal despatch of your unit assessment. It is recommended that students contact the Guild Education Officers to aid them in the appeals process. They can be contacted on ph: 6488 2295 or email: education@guild.uwa.edu.au. Full regulations governing appeals procedures are available in the University Handbook, available online at .

7. CONTACTS

Students experiencing problems with the programme should contact the coordinators at each hospital as follows:

Royal Perth Hospital and Overall Convenor

Dr C Beer, Department of Geriatric Medicine Phone: 9224 2750

Fremantle Hospital

Dr Roger Clarnette, Department of Geriatric Medicine Phone: 9431 2673

(email: roger.clarnette@health..au )

Sir Charles Gairdner, Osborne Park, Hollywood & Joondalup Hospitals

Administrative Officer, University Department of Medicine Phone: 9346 3721/3974

If problems remain unsolved contact: School Manager on 9224 0250 in the first instance.

8. REFERENCE READING

Books

➢ Recommended Text: Gray, L et al. Geriatric Medicine, A Pocket Book for Doctors, Nurses, Other Health Professionals and Students. 2nd Edition. Ausmed Publications, 2000.

➢ Evans, JG (Ed). Oxford Textbook of Geriatric Medicine. 2nd Edition. Oxford University Press, 2000.

➢ Coni, N. Lecture Notes on Geriatric Medicine. 6th Edition. Malden, MA: Blackwell Publishing, 2003. (RPH Library)

Web CT

Resources are listed over the page grouped by topic.

Material on Web CT is under IMED 4492

|Objective |Reference |

| | Journal Articles |Web CT – Article or Web Link |

|General | |Student Introductory notes |

| | |Student appraisal and suggested case marking form |

|Court Case |Ryan G A, Legge M and Rosman D (1998). Age related changes in drivers’ crash risk and crash type. Acid. |Age-based testing on older drivers doesn’t work – researchers. Monash Newsline, Monash |

| |Anal. and Prev. 30 (3): 379-387 |University (2005) |

|Dementia and Related |Warne R W and Nicklason F (1999). Aetiology and Management of mental frailty. Is it dementia? Current |Minds Matter Presenter – presentation notes from computer program. |

|Topics |Therapeutics. September: 16-24 |Maher S and Almeida O (2002). Delirium in the elderly – another medical emergency. Current|

| | |Therapeutics. |

| | |March: 39-45 |

| | |Watson J D G (2001). Disorders of memory and intellect. Medical Journal of Australia. |

| | |175: 433-439 |

| | |Australian Society for Geriatric Medicine, Position Statement No. 13. Delirium in Older |

| | |People. |

| | |.au/documents/PositionStatementNo13_001.pdf |

| | |Dementia Tutorial: Diagnosis and Management in Primary Care |

| | |ehr.chime.ucl.ac.uk/demcare/index.html |

| | |Medical care of older persons in residential aged care facilities. The Royal Australian |

| | |College of General Practitioners (2005) |

| | |.au/downloads/pdf/20050501silverbook.pdf |

|Residential Care | |Australian Society for Geriatric Medicine, Position Statement No. 9. Medical care for |

| | |people in residential aged care services |

| | |Australian Society for Geriatric Medicine, Position Statement No. 10. Residential aged |

| | |care from the geriatricians perspective |

|Hip Fracture |Zuckerman J D (2005). Hip fracture. Current concepts. 334 (23): 1519-1525 |Chilov MD, Cameron ID and March LM (2003). Evidence-based guidelines for fixing broken |

| | |hips: an update. Medical Journal of Australia. 179(9): 489-493. |

|Objective | Reference |

| |Electronic Reserve |Web CT – Article or Web Link |

|Incontinence |Resnick, N M (1996). Geriatric incontinence. Geriatric Urology. 23 (1): 55-74 |Tutorial (K Scott). |

| | |McKertich K (2008). Urinary incontinence. Assessment in women: stress, urge or both? |

| | |Australian Family Physician; 27(2); 112-117 |

| | |McKertich K (2008). Urinary incontinence. Procedural & surgical treatments for Women. |

| | |Australian Family Physician; 27(2); 122-131) |

| | |Neumann P. Physiotherapy for urinary incontinence. Australian Family Physician; 27(2); |

| | |118-121 |

| | |Santiago SK. Urinary incontinence. Pathophysiology & management outline. Australian |

| | |Family Physician; 27(2) 106-110 |

|Falls |Tinetti M E (2003). Clinical Practice. Preventing falls in elderly persons. The New England Journal of |Department of Health (2004). The Falls policy for older Western Australians, Department of |

| |Medicine. 348 (1): 42-49 |Health, Perth |

| |American Geriatrics Society et al (2001). Guideline for the prevention of falls in older persons. JAGS. |(accessed at health..au/publications/) |

| |49: 664-672 |Falls in the Elderly handout |

| |Alexander N B (1996). Gait Disorders in Older Adults. JAGS. 44: 434-451 | |

| |Berman P and O’Reilly S C (1995). Clinical Aspects of Gait Disturbance in the Elderly. Reviews in Clinical | |

| |Gerontology. 5: 83-88 | |

|Rehabilitation | |Cameron I D and Kurrle S E (2002). Rehabilitation and older people. Medical Journal of |

| | |Australia. 177: 387-391 |

|Geriatric Assessment |Podsiadlo D and Richardson S (1991). The timed “up & go” : A test of basic functional mobility for frail |Australian Society for Geriatric Medicine, Position Statement No. 8. Geriatric assessment |

| |elderly persons. JAGS. 39: 142-148 |and community practice |

| |Gladstone D J and Black S E (2002). The neurological examination in ageing, dementia and cerebrovascular |Comprehensive Geriatric assessment. American Geriatrics Society (AGS). Comprehensive |

| |disease. Geriatrics and Ageing. 5 (9): 55-60 |geriatric assessment position statement. |

| |Dysch L and Crome P (2003). Using the clock drawing task in primary care. Geriatric Medicine September: |Mini-Mental State Examination Form (RPH) |

| |75-80 |Geriatric Assessment Notes |

| |Editorial (2001). ICF approved as the successor of ICIDH. Journal of Rehabilitation Medicine. 33: 193-194 |RPH Department of Geriatric Medicine sample patient assessment form |

| |Yesavage J A, Brink T L, Rose T L et al (1983). Development and validation of a geriatric depression |Geriatric Depression Scale (short form) |

| |screening scale: a preliminary report. Journal of Psychiatric Research 17: 37-49 |Miller K E, Zylstra R G and Standridge J B (2000). The geriatric patient: a systematic |

| | |approach to maintaining health. Am Fam Physician. 61(4): 1089-104 |

| | |afp/20000215/1089.html |

Normal Ageing and Common Health Problems SDLM

1 Court Case

Problem Description

It is the year 2005 and in the face of continuing concerns about road accident rates the Western Australian Government has passed a new law which bans all people over the age of 78 from driving. Driving licences become invalid on the 78th birthday. There is a massive public outcry and the Western Australia Council on the Ageing (COTA) is challenging the ruling in the Supreme Court.

On Friday morning we will be holding a mock court case. Your group will divide in two and half will be in favour of the new law (government lawyers and expert witnesses) and half against (lawyers for the COTA and expert witnesses). The Judge will make a ruling based on the evidence and arguments presented.

What are the issues involved?

What information would you need to argue this case?

What should the expert witnesses be expert in?

The Court Rules

The judge will be your tutor and often there will be an invited judge as well. They will watch time-keeping, keep order and may ask for clarification of factual information but largely remain quiet. At the end of the court session they will make a ruling on whether the law should be overturned or upheld. Each side needs to appoint a QC (Queen’s counsel) and four expert witnesses.

The QC will provide an opening statement, interrogate their own and the opposite side’s witnesses and then do a summing up. She/he will need to liaise closely with her/his own team members who will have most of the factual information. They must also watch time keeping; there is only 30 mins to put their case across and they must make sure they get through all their witnesses in the allocated time period.

The expert witnesses who will take on a role (eg Professor of Geriatrics or Minister for Transport) will need to be familiar with their own area and make sure that the evidence they give will not overlap too much with other witnesses. Frequently there will be witnesses for and against in the same area of expertise and you should try and anticipate the opposing team’s arguments for cross questioning.

Suggested Timetable (it is important to note that this an example only)

1400 Judges convene court

1405 Opening statement COTA

1410 Opening statement gov

1415 Case for the COTA

Expert witness 1 for COTA 4 mins

Cross-questioning by gov QC 2 mins

Expert witness 2 for COTA 4 mins

Cross-questioning by gov QC 2 mins

Expert witness 3 for COTA 4 mins

Cross-questioning by gov QC 2 mins

Expert witness 4 for COTA 4 mins

Cross-questioning by gov QC 2 mins

1445 Case for the government

Expert witness 1 for gov 4 mins

Cross-questioning by COTA QC 2 mins

Expert witness 2 for gov 4 mins

Cross-questioning by COTA QC 2 mins

Expert witness 3 for gov 4 mins

Cross-questioning by COTA QC 2 mins

Expert witness 4 for gov 4 mins

Cross-questioning by COTA QC 2 mins

1515 Summing up by the government

1520 Summing up by COTA

1525 Judges deliberation and judgement

1530 End - Feedback session

2 Healthy Ageing Interactive Case Study

Complete the Healthy Ageing Interactive Case Study to assist your learning regarding normal and abnormal ageing.

Dementia SDLM

1 Interactive Case Study

In addition to the Dementia, Delirium and Depression Interactive Case Studies ensure that you listen to the Dementia Lecture available via the e-Ageing site.

Many tutors will want to debrief regarding several issues in the case. Prepare your discussion point thoughts here:

What are the challenges taking a history from a person presenting with cognitive complaints?

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How to use collateral history in establishing a diagnosis? What are some of the ethical and management difficulties associated with whether to believe the informant?

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What are the symptoms required to make a clinical diagnosis of dementia?

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What is the differential diagnosis for someone presenting with cognitive impairment.

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What investigations are required?

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How to assess cognition?

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How to communicate the diagnosis?

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Role of advance care planning?

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Competency assessment?

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How to access care services?

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How to support carers?

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2 Work Sheet for ‘Minds Matter’

This activity is based on a computer program called ‘Minds Matter’. Please ensure that you complete the program independently prior to meeting with your tutor at the end of Week 2

This program has been loaded onto computers for use in the following locations :

• GAT computer room, FJ Clark Lecture Theatre complex, T Block, Sir Charles Gairdner Hospital (*students must take their own walkman type headphones to plug into the computer to listen to audio)

Start menu / Programmes / Reference material / ‘Minds Matter’

• Room 4129, Colonial House (2 doors down from Student Common Room). Please see Admin Officer, UWA Geriatric Medicine Unit for access code.

NOTE: Food and drink is NOT to be taken into the computer rooms

Start menu / Programmes / Reference material / ‘Minds Matter’; or

Start menu/programmes/applications link/reference material/mind matter

You will find the program simple to use. At the bottom left hand corner of each screen is an oval shaped navigation pane. Clicking on the video symbol allows you to view the video selection screen. Clicking one of the arrows allows you to go scroll forwards or backwards through the slides. Clicking the bar allows you to view the index. A crossed circle indicates the end of a subsection. Clicking on the figure symbol allows you to exit. A curved arrow indicates the end of a subsection. Clicking the curved arrow returns you to the subsection menu.

Hard copies of the presentation slides are available from Web CT.

Introduction

Read the slides. Note the definitions of dementia and Alzheimer’s disease. Watch the video about Ben and Doris.

What is wrong with Ben?

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Does Ben’s slight facial asymmetry have any significance? What about the use of amlodipine given his history of headaches?

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Who should you believe – Ben or Doris? What are some of the ethical and management difficulties associated with whether to believe the informant (Doris) or Ben?

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Diagnosis

Watch the videos demonstrating use of the MMSE and clock drawing tests and read the slides. Depending on your prior learning you may need to research additional information to complete this section.

We are told ‘this patient has consented to appear in this series of videos’? How do you assess whether a person with dementia has capacity to provide informed consent?

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List the seven hints on how to approach the diagnosis

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What is the ‘head turning’ sign that is referred to in the program?

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What is the program referring to by ‘focal or general loss’? How could this help in diagnosis?

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Are the investigations listed necessary in every case?

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Both delirium and dementia are common causes of impaired cognition in elderly patients. Understanding the difference between delirium and dementia is important. Delirium is an acute confusional state, which may be superimposed on dementia. It is commonly caused by drugs and other forms of iatrogenesis, illness such as sepsis, and metabolic derangements. Delirium is characterized by an altered conscious state (impaired attention and reduced clarity of awareness of the environment) and a fluctuating course. Delirium developing in hospital is associated with increased morbidity and mortality. Thus urgent medical assessment is required. Whilst you are probably familiar with the clinical picture of an agitated delirium (e.g. ‘delirium tremens’) remember that hypoactive delirium is not uncommon in the elderly.

Depression is another important differential diagnosis. It is also important to consider the possibility of depression superimposed on dementia: co-morbid depression is easily unrecognized in people with dementia.

We have listed some features that help to distinguish dementia from delirium and depression.

Delirium Dementia Depression

|Usually acute |Insidious onset and chronic course with |Onset over a few weeks |

| |gradual decline usual | |

|Altered level of consciousness |Clear sensorium. Mood usually flat |Depressed mood |

|Hypoactive and hyperactive forms |Often normal motor function |Psychomotor slowing may occur if severe |

|Usually reversible |Reversible causes sought but uncommonly found|Often responds to treatment. Can be |

| | |treatment resistant |

|Often associated with intercurrent |Patient often otherwise well. |Associated symptoms (Anxiety, insomnia & |

|illness |Depression may be co-morbid |anorexia) common |

|Fluctuating Course |‘Sundowning’ common |Diurnal variation common. Often mood worse in|

| | |mornings |

|Prominent disorientation |Poor STM, relatively preserved LTM, |Claims “don’t know”; equal LTM and STM |

| |disorientation usually late in the disease |problems |

|May complicate hospitalisation for |Brought by family |Self referral |

|another problem | | |

|May have history of cognitive impairment |Usually no prior mental health history. |May have psychiatric history, particularly of|

|or episodes of delirium. | |depression |

What is meant by the term ’pseudodementia’?

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Management

Read the slides and watch the videos on ‘breaking the news’.

Think about the issues raised with respect to legal and financial issues, and driving and occupational issues. How does this information tie in with your knowledge about ethical issues concerning risk taking in older people (discussed last week)?

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Treatment

Read the slides. Research will be required to answer the questions posed in the program.

What is the rationale for cholinergic therapy?

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Do these medications “slow the progression of the disease”?

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What are the side effects of cholinergic therapy?

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What are the contraindications to cholinergic therapy?

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What are some of the ethical issues about symptomatic drug treatment in Alzheimer’s disease? For example, when do you initiate this treatment? When do you cease it? Who makes these decisions and who pays for it?

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Residential Care SDLM – Week Three

Residential Care is an important part of the support services that are available for older Australians. Residential Care provision is allocated throughout Australia on the basis of the number of older people over the age of 70 years. The licensing of beds based on a ratio of 100 beds per thousand people over the age of 70 years. On this basis there are approximately 75,000 nursing home beds and 70,000 hostel beds in Australia in the year 2002.

Over the last three years there has been a considerable amount of negative publicity regarding the standards of care available in residential care. It is important that you, as future doctors, understand about residential care and particularly concerning some of the issues regarding health care.

As part of your resource material for this unit please work through the Interactive Case Study and view the Policy from the Australian Society for Geriatric Medicine in regards to health care for older people in residential care at . It is important to emphasise that this Policy is the opinion of a small group of doctors and may not, in fact, be representative of the widespread views of either the Medical profession as a whole, the health care professions or the Australian community. Nevertheless it does represent the views of a learned part of the profession who seem to be taking these issues seriously.

As part of this learning module, the major basis will be the cases defined by you, the students. An introduction will occur on the first day of this module, where we will explain that you are expected to find somebody that either you or your family were previously acquainted with, such as a neighbour, friend or relative, who has subsequently been placed in residential care. What we would ask you to do is to find out how the process of assessment occurred and why that person was placed in residential care. The perceptions of the person in residential care and the family may be quite different from the health care professionals who assisted in the transfer.

It would be reasonable for you to visit this person in residential care so that you can form some opinion about the quality of care generally provided in the residential care facility where this person now resides. It would also be helpful during your term to visit at least one other nursing home or hostel, preferably a different level of care to the one you have just visited, so as to gain an idea of the different levels of care that can be offered in different facilities. Should you not know anyone living in residential care through personal contacts, organising ACAT visits to care facilities is an acceptable alternative.

On the second session of the SDLM we will be asking each of you to provide the views of these people and your views of the residential care facilities that you have visited. Only if it is completely impossible for you to find an appropriate older person to interview, will the team help you by providing the name and address of somebody you can visit.

The objectives for this Residential Care SDLM

1. To understand the levels of care offered in different forms of residential care facilities within Australia

2. To understand the methods of assessment acquired before all the people can be placed in residential care facilities.

3. To have a knowledge of the standards required in residential care facilities and some of the problems that have been met in accommodating these.

An Older Woman with Hip Fracture PBL – Week Four

This PBL will be taught in the final week of your term.

The PBL abstract, objectives and first trigger are copied below. Please prepare for the PBL by reviewing several patients with hip fracture and completing your background reading on the causes, treatment and prevention of hip fracture. In addition to your reading of texts the review by Chilov 1 (which is available free on the net) may be helpful. We have also included a review paper

Abstract

An older woman suffers a fall and hip fracture. Following successful surgery these problems require assessment during her rehabilitation. She has been taking a number of medications which are implicated in causing or increasing the risk of falls. She has osteoporosis due to age and chronic corticosteroid use. The main focus is on iatrogenic causes of falls and fracture, polypharmacy and drug withdrawal in the elderly. The case also illustrates several psychosocial consequences of acute illness in older people and why rehabilitation needs to be multidisciplinary.

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After this PBL case students should be able to:

1. Explain the importance of assessing falls and metabolic bone disease in elderly patients with fracture.

2. Explain how iatrogenic factors contribute to the burden of falls and fractures.

3. Assess a patient who has fallen.

4. Describe the biochemistry and pharmacology of steroid-induced bone loss.

5. Have a working knowledge of the treatment of steroid-induced osteoporosis.

6. Explain the causes and describe consequences of polypharmacy in the elderly.

7. Describe how to detect orthostatic hypotension.

8. Describe how to how to reduce the hazard associated with the withdrawal of steroids and benzodiazepines.

9. Have a working knowledge of the functional and psychological consequences of hip fracture and the use of multidisciplinary teams in rehabilitation.

|Trigger 1 | |

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Mrs Ingram is a 78 year old widow who has been admitted to hospital after a fall and hip fracture. You are the intern caring for her on the orthopaedic ward. She has had a successful operation and post-operative management went well. It is now 4 days after the admission and she is beginning to be mobilised by the staff. The visiting geriatrician has recommended a transfer to the rehabilitation ward and asked you to consider why she fell and sustained a fracture.

She tells you that she fell in the lounge of her house about 8.30 am. She thinks she tripped over the leg of chair when going towards the kitchen. She does not remember much about it as she had so much pain and she spent many hours on the floor before she was found.

Discussion Questions

1. What are Mrs Ingram’s problems?

2. What do you know about the causes of falls?

3. Is it possible that she fell for some other reason than the one she gave?

4. What do you know about the causes of fractures after a minor fall in a 78 year old woman?

5. What additional information would you need to better understand her problems?

1. Chilov MN, Cameron ID, March LM. Evidence-based guidelines for fixing broken hips: an update. Med J Aust 2003;179(9):489-93.

ALZHEIMER’S ASSOCATION – MAP

[pic]

EXAMPLE OF CASE REPORT

from

GERIATRIC MEDICINE

TUTORS HAVE ASKED US TO EMPHASISE THAT THIS IS A SAMPLE (NOT MODEL) CASE REPORT: ALL CASE HISTORIES (INCLUDING THIS ONE) ARE MARKED ACCORDING TO THE MARKING KEY

REMEMBER:

YOU MUST ATTACH THE APPRAISAL FORMS TO YOUR CASE REPORT

WHEN HANDING IT IN FOR MARKING

PART 1 – INPATIENT CARE

Inpatient history: Mrs H is an 85 year old lady who presented to A&E on the 11th June with acute shortness of breath. She mentioned an increasingly severe non-productive cough in the 2 weeks prior to admission. Subsequent investigations revealed bilateral lower lobe pneumonia. This was treated with antibiotics. An ECG revealed a RBBB, with a ventricular rate of 37 and an atrial rate of 100. She was referred to cardiology and a permanent pacemaker was inserted on the 18th of June. On the 22nd June she was assessed by ACAP, and received physiotherapy. She was transferred to V5 on the 28th June when I had the opportunity to speak with her.

She felt much better than when admitted. She has some exertional dyspnoea, usually coming on after 20 yards of walking. This has been going on for some years, though has been worse in hospital. She also complains of orthopnea, and usually uses 2 cushions at night. Again this has become worse in hospital. She describes some ankle oedema to her knees, prior to admission she had swollen feet. She does not complain of palpitations or haemoptysis. Her cough has improved and does not feel SOB at rest.

|Disabilities |Pathologies |

|Poor mobility |# RNOF/ #LNOF |

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|SOB on exertion |COAD |

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|Difficulty in shower |Hypertension, with an |

| |element of CCF |

|Incontinence | |

| |Osteoporosis |

|Frustration and anger | |

1 Past Medical History: Osteoporosis

Hypertension

COAD – bronchiectasis with recurrent infections

#RNOF; #LNOF

Recurrent vaginal thrush

NIDDM – diet controlled

Incontinent of Urine

Medication: Enalapril 10 mg mane

Alendronate 10 mg mane

Frusemide 40 mg mane

NKA

Family History: no important findings

Social History: non-smoker, no alcohol intake

Lives in a hostel. Prior to admission she was fully independent and able to attend to all ADLs. However since being in hospital she feels less able to attend to these. She is able to eat and drink, toilet, but requires assistance showering. Mobility is a problem. She feels less able to walk due to pain in her hips. She was frustrated as she felt ready to go home.

System Inquiry: GIT-regular motions, no blood, no change in habit, no pain, no indigestion

GUS-Has been incontinent for 1 year – stress incontinence. Uses pads. No dysuria, haematuria, frequency, hesitancy, discharge.

Neuro-no seizures, faints, funny turns, headaches, poor balance or changes in high function.

M-S – Her hips are painful, and stiff

O & E:

Pleasant elderly lady, in no obvious respiratory distress. She had difficulty ambulating, and required a Zimmer frame. There were pressure areas on her buttocks requiring dressing. Incontinent of Urine.

A febrile; BP 140/60; RR26; Hr 70 regular, no cyanosis, jaundice or clubbing.

MMSE-25/30.

CVS – Implanted pace maker evident in right upper thorax

No carotid bruits

Pansystolic murmur, grade ¾ loudest in the apex with axillary radiation

Early inspiratory crackles bi-basally

PPP, Pitting oedema present to knees

ABDO – soft and contender. No organomegaly. No Hernias. BS normal

RESP – No peripheral signs of lung disease

No evidence of anaemia. No central cyanosis

Trachea midline, apex undisplaced. Expansion was reduced

Resonant percussion note, decreased breath sounds bilaterally, especially

bases

Bi-basal crackles evident. No other added sounds.

NEURO – grossly normal

Summary – there is some evidence of heart failure, in a lady with long standing COAD, and difficulty in walking. Her initial problems have for the most part resolved, and the main focus must be assessing and preparing her to return to the hostel.

She was discharged on the 29th of June. Prior to discharge, the O.T. was involved. She felt that the hostel environment was adequate for her needs. She further assessed self-care, and concluded that Mrs H would cope well. She had transport organised to return her to the hostel. Medication for discharge was arranged. A discharge letter was sent to her GP.

PART 2 - THE RETURN HOME

I was able to visit Mrs H at her hostel one week post discharge. I was also briefly able to converse with the hostel nurse. Mrs H said she felt fine. She walked to the dining room for breakfast (about 40 metres each way) and did not describe any SOB. The two remaining meals were brought to her room. She required assistance with drying her feet after the shower, but all other ADLs were successfully done. She had been given sufficient medication. Her family had been very supportive, visiting at least once a day. The hostel staff was very happy with her, and other than the needs mentioned above, did not feel she was a greater burden. This seems to have been a very smooth transfer, and the hostel had adapted very well to the needs of Mrs H.

PART 3 – FEEDBACK FROM THE GP

Mrs H’s GP had not had the opportunity to have contact with her. He had received the letter of discharge, but no phone call as to the latest changes in her condition. He expressed the need for more legible discharge summaries, and questioned the practice of receiving the bottom carbon copy. He further explained that the normal procedure is for him to get the information regarding the patient, and if there are any major changes, to contact the nursing home and inform them of these. There did seem to be a lack of communication between the primary care givers at the hostel and the GP, but this may be attributed to the recent discharge.

PART 4 – AN OVERALL ASSESSMENT

This has been a very interesting case to study especially in terms of the multiple levels of communication required for a successful discharge. There is a large amount of responsibility on the discharging officer, and the GP in ensuring this is done smoothly. Some important concepts were evident in this case:

1. The critical threshold of muscle power, and the hazards of bed rest - In this case, too much bed rest seemed to have contributed to Mrs H’s worsening mobility and her SOB.

2. Multidisciplinary approach – There was active involvement of ACAP-with adequate assessment by the O.T. and physiotherapist. It seemed, however, that it took 11 days before there was any active rehabilitation.

3. Frailty – “Frailty results from an interaction between ageing, disease and disability” (1). This was exquisitely evident in this case, and demonstrated the multitude of influences.

4. The patient’s mental state and drug statue (her medication) did not have a large role in this case. If these had been, the complexity is evident.

5. ADLs – Her daily ability was succinctly assessed, and had an important impact on when and how to discharge her.

6. Her hostel was very well adapted to her needs, and the addition of a supportive family helped immensely.

7. The GP had received the necessary information, however no contact had been made with either the patient or the staff (admittedly this was only 8 days post discharge). Perhaps a more active role of the GP would have been beneficial.

BIBLIOGRAPHY

(1) Bruce, D. Increasing frailty in the elderly patient: an approach to management. Modern Medicine, 1998; 5: 41-48

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