Geriatrics

The geriatrics rotation is a required two week rotation for the internal medicine residents. The rotation will provide a comprehensive experience in geriatric medicine through varied clinical and didactic experiences. The program will be directed by Dr. Michael Bogaisky. The rotation has capacity for up to 2 residents every two weeks.


I. Goals and Objectives

The Goal of this rotation is to provide geriatric training and experiences for residents to optimize the quality of clinical care they provide to elderly patients.

The specific Learning Objectives for trainees are:

  • To review knowledge of aging physiology and diseases common to the elderly; particularly complex medical and neuropsychiatric syndromes such as dementia, falls and delirium.
  • To perform geriatric assessments, specifically the medically-oriented physical examination of an older adult, cognitive assessment, functional status and gait assessment
  • To identify the staging and description of skin ulcers
  • To integrate clinical, cognitive, functional and social assessment data into a treatment and management plan to optimize care of the elderly.
  • To list and utilize clinical services, health insurances, and other components of the health care and support system serving the elderly (e.g. home care, hospice, long term care)
  • To improve trainees’ understanding of bioethics and its implications for medical decision-making for the elderly, particularly for those who lack capacity.

Level for PGYIII Rotators

Patient Care: Perform an in-depth geriatric assessment which includes history of current and past medical illness, medications, social history, physical examination, functional examination, cognitive and mental statues examination, and an impression and plan for care including interventions planned by the multidisciplinary team.

Medical Knowledge: Develop an understanding of aging physiology and how it interacts with disease, the pathophysiology of diseases common to the elderly, atypical presentations of disease in the elderly, geriatric syndromes, geriatric pharmacology and appropriate prescribing, geriatric health screening and preventive services, information about social gerontology as it pertains to patient care, and health care systems.

Professionalism: Maintain patient confidentiality when caring for older patients and interacting with families and staff; perform duties with reliability, demonstrating respect and patience with elderly patients and their families; work co-operatively with the geriatric interdisciplinary team; and request advice and assistance when needed. Complete patient care responsibilities in a timely fashion, complete charting, return calls and attend rounds and conferences.

Interpersonal and Communication Skills: Create and sustain a therapeutic relationship with patients demonstrating the ability to listen, respond and integrate both verbal and nonverbal communication

Practice-based learning and Improvement: Search and use suggested literature sources to increase clinical and basic science fund of knowledge as it applies to geriatric medicine. Explain standards of care and how to provide this through literature and chart review. Solicit feedback; accept feedback with a goal toward performance improvement.

Systems-based practice: Identify the functions of different sites of geriatric care and the appropriate referrals to them (home care, long term care, etc.) as well as the functions of various members of the interdisciplinary geriatric care teams during rounds and interdisciplinary team meetings.


II. Curriculum Content

  1. Physiology of Aging and Epidemiology of Aging
  2. Medical geriatric assessment incl Hx & PE & labs
  3. Social Support, Environmental Assessment
  4. Affective & Cognitive Assessment
  5. Cognitive Impairment
  6. Functional Status & ADLs, IADLs
  7. Interdisciplinary Team Coordination of Care
  8. Falls
  9. Incontinence
  10. Osteoporosis and fractures
  11. Pressure Ulcers
  12. Presentation and management of common medical illness in geriatric patients e.g. CHF, pneumonia, urinary tract infection, diabetes, thyroid disease
  13. Geriatric pharmacology
  14. Interpersonal & family relationships, social support systems
  15. Health care systems and insurances (Home care, Long term care, etc.)

Residents will receive a reading packet at the orientation to the rotation. The faculty will assess interests and, with the resident, identify a learning project for the rotation. For residents going into subspecialties this should be a topic in geriatrics related to their subspecialty. Residents will do a 10 minute presentation on their project at the end of the rotation.

Handouts include a self-learning packet of geriatric assessment tools with logs/checklists to document use of the tools:

1. Dementia screening (Memory Impairment Screen, Category Fluency Test, Oral Trails B)

2. Gait Assessment (Get Up and Go Test, Progressive Balance Testing)

3. Medication Review Exercise (Using the Beers Criteria and the Good Palliative-Geriatric Practice Algorithm), residents will review the med list of 5 of their outpatients over the age of 75 4. Delirium Screening (Confusion Assessment Method).

These will be reviewed at rotation end. There will also be a pre-test at the beginning and a post-test at the end of the rotation.


III. Sites of Training and Clinical Exposure

Outpatient (1 week, split into the following activities):

· Home Visit: Residents visit homebound patients with our nurse practitioner, social worker or attending

· Wound Care (inpatient): Residents will receive a handout with wound-care staging (pocket card).

· Subacute Rehab and Long Term Care

1. Internists’ role in Subacute Rehab - Residents admit a patient and present to the SAR geriatrics attending. Goals are to learn about transitions of care from the perspective of the nursing home provider and modalities of care provided in SAR.

2. Long Term Care- residents interview a verbal patient about their life in the nursing home. They’re given a list of suggested questions to ask which help them to explore why patients live in nursing homes, their quality of life, social networks, recreation and features of life in a “total institution.”

        • ½ Day Rehabilitation: Residents accompany Physical and Occupational Therapists doing assessments on newly admitted patients and attend PT and OT sessions. Residents will learn how PT and OT assessments are conducted and about therapeutic interventions.

· Geriatrics Outpatient Ambulatory Practice- 2.5 days - Under the supervision of geriatrics faculty, residents will see community dwelling older adults patients and present them to the attending and write notes documenting their assessments and plans.

        • This is a forum for performing mentored Gait Assessments and Dementia Screening.

Inpatient (1 week)

        • Residents will be assigned patients whom they will admit, write daily notes, round daily, discuss with attendings, talk with families, all from a geriatric approach. This will also serve as a forum to practice Delirium Screening, Dementia Screening and Gait Assessment.


IV. Clinical Conferences and Didactic Experiences

1. Resident Report (1 hour) - a “most difficult case conference” where residents present an older outpatient from their own patient panel who they are challenged by and receive an informal consult. Geriatrics attendings, a geriatric social worker, nurse practitioner and a geriatric psychiatrist hear the presentation and comment on the cases, offering insight, services and input for best clinical care.

2. Hazards of Hospitalization Rounds (1 hour)- residents interview an inpatient and learn how to assess for risk of loss of function, delirium and malnutrition during hospitalization and create individualized prevention plans.

3. Health Care Financing Lecture (45 min) - Medicare and Medicaid benefits

4. Journal Club (1 hour) - 1 session per rotation

5. Geriatrics Grand Rounds (1 hour) - 2 sessions per rotation

6. Core Curriculum (1 hour) - 2 sessions per rotation. A lecture on a core geriatrics topic

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Kings Harbor Care Center http://kingsharbor.com/

2000 East Gun Hill Rd

Bronx, NY 10469

http://kingsharbor.com/

Parking is available in the lot by the front entrance which usually has room in the morning and there is easy street parking nearby.

Bus Option: Bx 38 or Bx 28 (which can be taken at Bainbridge Ave & East 210th St.) Take to Bartow Avenue and East Gun Hill Road. Cross East Gun Hill Road, make a left and walk 0.6 miles on East Gun Hill Road to Kings Harbor.


V. Methods of Teaching Competencies and Competency Assessment

Geri

Evaluation: Residents will be evaluated through the use of the New Innovations.com evaluation system used by the Internal Medicine Residency Program for resident evaluation. The residents will similarly evaluate the rotation and the faculty.

Geriatrics Division Faculty for Residency Rotation

Joseph Verghese, MBBS, MS, Division Chief, Geriatrics, Professor of Medicine

Amy Ehrlich, MD, Associate Chief, Division of Geriatrics, Associate Professor of Clinical Medicine

Michael Bogaisky, MD, MPH, Director Geriatrics Residents Rotation, Assistant Professor of Clinical Medicine

Paul Cavaluzzi, DO, Instructor in Medicine

Claudene George, MD, RPh, Medical Student Clerkship Director, Assistant Professor of Clinical Medicine

Alice Guo, MD, Instructor in Medicine

Debra Greenberg, MSW, PhD, Instructor in Medicine

Shikta Gupta, MBBS, Assistant Professor of Clinical Medicine

Wanda Horn, MD, Director, Geriatrics Inpatient Service, Assistant Professor of Clinical Medicine

Hannah Lipman, MD, Chief, Bioethics Consultation Service, Associate Professor of Clinical Medicine

Rubina Malik, MD Assistant Professor of Clinical Medicine

Paulette Wald-Cagan, ANP Geriatric Home Visiting Program, Co-director

Harold Ramos, MD, Assistant Professor of Clinical Medicine

Wound Care Faculty for Residency Rotation

Cary Andrews, PA

Manuel Bulauitan, MD

Giacomo Vinces, DO

Wei Wang, PA