geriatric case presentation

Geriatric Clinico-Social Case in Community Medicine

The case information can be collected under the following broad headings as already discussed in the blog and lecture on ‘Format for CSC in Community Medicine’: 1. Identification and family data 2. Clinical history, general, and systemic examination of the index case 3. Family health and Housing Environment 4. Clinico-social diagnosis 5. Effect of the illness on the family 6. Management suggested (curative, preventive, and promotive) Points no. 1 and 3 i.e. ‘Identification and family data’ and ‘Family health and Housing Environment’ have already been Explained in the following blogs and lectures: • ‘Format for CSC’ and ‘Format for CSC’ Blog: http://www.ihatepsm.com/blog/format-clinico-social-case-taking-community... ‘Format for CSC’ Lecture: http://www.ihatepsm.com/resource/format-clinico-social-case-presentation... ‘Format for CSC’ Lecture in HINDI: http://www.ihatepsm.com/resource/format-clinico-social-case-presentation... • ‘Family Health Study – definitions and explanations’ Hence, here we will discuss the remaining 4 headings i.e. History & examination, Clinico- social diagnosis, effect on the family and management of the individual geriatric case .

Health Problems of the elderly: 1. Problems due to ageing process: a. Senile cataract b. Glaucoma c. Nerve deafness, presbycusis d. Osteoporosis affecting mobility e. Emphysema f. Failure of special senses g. Changes in mental outlook etc. 2. Chronic diseases whose prevalence is high among the elderly: a. Atherosclerosis leading to hypertension and MI b. Cancer – incidence rapidly rises after the age of 40 yr. carcinoma prostate is common after the age of 65 c. Accidents leading to fractures of fragile bones, fracture neck of femur is very common among the geriatric population d. Diabetes Mellitus 3. Loco-motor system disorders: a. Osteoarthritis b. Rheumatoid arthritis c. Fibrositis d. Myositis e. Neuritis f. Spondylitis of spine etc. 4. Respiratory illnesses: a. Chronic bronchitis b. Asthma c. Emphysema 5. Genitourinary system: a. BPH: dysuria, nocturia, frequency and urgency of micturition etc. 6. Psychological Problems: a. Mental changes: Impaired memory, rigid outlook and dislike of change, reduced income leading to fall in standard of living, b. Sexual adjustment: leading to irritability, jealousy and despondency c. Emotional disorders: due to social maladjustment resulting in inner withdrawal, depression and even suicide.

Remember: • They may have multiple disorders. • Early detection of problems and early intervention can avert further deterioration and improves quality of life, often needing relatively minor, inexpensive interventions e.g. Lifestyle changes. • The management has to take into account the social handicap (eg, isolation) and lack of resources • The history and physical examination should screen elderly patients for disorders that occur commonly in the elderly. • There is a need to identify the caregivers and the support system.

Geriatric Clinic Social Case Taking: as per WHO Age-friendly Primary Health Care (AF PHC) toolkit, should include : • Assess health/illness by conducting a complete history including mental status and social support • Perform a comprehensive functional assessment • Perform a comprehensive physical exam considering the changes associated with ageing. • Assess the relationship between acute illness and known chronic illness in older persons. • Assess the strengths and weaknesses of the care giving system of the elderly

History: Unless the mental status seems compromised, the elderly should be interviewed alone to facilitate the discussion of personal matters. You may need to speak with a relative/caregiver, for their viewpoint on the functional and mental status. 1. Identification and family data: as explained in the blog/lecture on “Format for CSC” 2. Presenting complaints, if any and history of present illness • Sometimes there may not be ANY presenting complaints as the elderly consider them as a part of normal aging e.g. dyspnoea, hearing or vision deficits, incontinence, constipation, dizziness, falls etc. • No symptom should be attributed to normal aging unless a thorough evaluation is done and other possible causes have been eliminated. • Sometimes disorders may manifest merely as functional deterioration. For example, when asked about joint symptoms, patients with even severe arthritis may not report pain, swelling, or stiffness, but if asked about changes in activities, they may, for example, report that they no longer go out for walking • Questions should be asked specifically to check for the disorders frequently affecting the elderly, which he/she may have forgotten to mention. The list mentioned at the outset may be of help in ruling out common disorders of the elderly. E.g. o Dysuria, nocturia, frequency and urgency of micturition etc. o Hearing loss o Breathlessness, orthopnoea o Vision change, r/o cataract and glaucoma o Polyuria, polydipsia, weight loss in spite of good hunger to r/o DM o Symptoms to r/o cancers like haemoptysis, blood in urine, vaginal bleeding after menopause, seizures, blood in stool, etc. o Peripheral neuropathies: abnormal sensation or loss of sensation in any limb o Especially assess for the 4 ‘Geriatric Giant’ problems of the elderly (WHO)  Memory loss  Depression  Urinary Incontinence  Falls/immobility A PG student can use the WHO AF PHC Tool 1: a 10-minute comprehensive screening 3. History of past illness: stroke, MI, cancers, fall & injury, depression, TB etc. 4. Known case of any illness: HT, DM, hypo/hyper thyroid, peripheral neuropathy etc. a. Duration of the illness: b. Treatment taken and from where: c. Treatment compliance: 5. Personal History: a. Bladder: history of stress incontinence, history suggestive of any degree of uterine prolapse, burning micturition etc. b. Bowel: regular/ irregular, any change in bowel habits, blood in stool etc. c. Smoking d. Alcohol e. Exercise 6. Dietary History: Calculate the percent deficit/high intake of calories as compared to the RDA. Don’t forget to consider the reduction in the calorie requirement according to the age. Any other problem in eating e.g. inability to chew leading to decreased intake etc. 7. Menstrual history (female): a. Age at menarche b. Regularity of the cycles c. Age at menopause d. Menopausal symptoms 8. Obstetric history (female): a. Number of children b. Mode and place of delivery of each child c. Was regular ANC taken in all pregnancies? 9. Contraception use (especially the cause of uncommon observation e.g. unusually large age gap between births)

11. Functional Status: a. History to assess mental status and the ability to function independently b. A PG student is expected to fill out a standardized ADL and IADL scales, calculate the score and classify the functional status as: Independent/Needs assistance/Dependent c. Any circumstance (e.g., recent loss of a loved one, a change in residence or living situation, loss of independence) which may contribute to depression. 12. Social History: a. Interpersonal relationship with other members of the family b. Economically dependent/independent c. Do family members take care of him/her during illness d. Is he/she socially active e. Are they aware of any social service schemes for elderly? f. Are they availing any social service schemes for elderly? The student is expected to know about the services and schemes for the elderly in the area.

General PHYSICAL EXAMINATION 1. General appearance: 2. Vitals: a. Respiratory rate: A normal respiratory rate in elderly patients ranges from 16 to 25 breaths/min. A rate of > 25 breaths/min may be the first sign of a lower respiratory tract infection, heart failure etc. b. Pulse: pulse rate, rhythm and character, posterior tibial and dorsalis pedis pulses should also be felt. c. BP All elderly patients should also be assessed for orthostatic hypotension because it is common. • BP is first measured with patients in the supine position, • Then after they have been standing for 3 to 5 min. • If systolic BP falls by ≥ 20 mm Hg after patients stand, or any symptoms of hypotension are detected, orthostatic hypotension is diagnosed. Caution is required when testing hypovolemic patients. d. Temperature 3. Anthropometry: a. Height (in cms) b. Weight (in Kgs) c. BMI d. Waist circumference 4. Skin: Ecchymoses may be seen as they readily appear, because the dermis thins with aging; most often seen on the forearm Normal age related findings are: • Longitudinal ridges on the nails and • Absence of the crescent-shaped lunula Look for any sign of a neoplasm 5. Pallor, icterus, cyanosis, clubbing, LNE and edema • Pedal edema, if present it may be more likely due to venous insufficiency. STILL congestive heart failure (CHF) is common and should be ruled out. 6. EYES: a. Conjunctiva b. Cataract c. Pseudoptosis (decreased size of the palpebral aperture) d. Entropion (inversion of lower eyelid margins)/ Ectropion (eversion of lower eyelid margins) e. Arcus senilis (a white ring at the limbus) f. Pupils symmetrical and reactive g. Testing visual acuity: both near and distant vision in field conditions e.g. finger counting at 6 and 3 meters and reading or any near work h. Glaucoma i. Extra-ocular movements (may be affected due to a previous/current stroke) j. Ideally Ophthalmoscopy should be done to check for cataracts, optic nerve or macular degeneration, and evidence of glaucoma, hypertension, or diabetes 2. Ears: a. Any abnormality of the pinna b. External auditory canal is examined for cerumen and tympanic membrane abnormality to determine possible reversible causes of hearing loss and disequilibrium (e.g. cerumen impaction, serous otitis media, ruptured tympanic membrane). c. Evaluate auditory acuity (hearing): • Keeping the face out of the patient’s view, whisper 3 to 6 random words into each of the patient’s ears. • If a patient correctly repeats at least half of these words for each ear, hearing is considered functional for one-on-one conversations. • Patients with presbycusis are more likely to report difficulty in understanding speech than in hearing sounds. 3. Mouth: a. Missing teeth, artificial denture b. The mouth is examined for signs of cancer (e.g. leukoplakia, erythroplakia, ulceration, mass) Systemic Examination All systems should be examined as per the standard protocol. However, some additional points are to be especially observed for, in an elderly: 1. Cardio Vascular System: • Unexplained and asymptomatic sinus bradycardia in apparently healthy elderly people may not be clinically important. An irregularly irregular rhythm suggests atrial fibrillation • Systolic murmurs are frequently present and most are due to benign aortic sclerosis • All diastolic murmurs need evaluation

2. Respiratory System : In men and women, the breasts should be examined for irregularities and nodules. Look if the nipples are retracted. Observe the skin over the breast for any abnormal appearance like ‘peau d’orange’ • Some rales may be age related findings and may not indicate pneumonia or pulmonary edema. Hence look for other symptoms or signs to rule out these disorders • Localized ronchi may point towards an obstruction in the bronchi (e.g. carcinoma).

3. Central nervous system: Cranial Nerves examination: Following observations may be associated with normal aging: • Upward and downward eye movement can be slightly limited. • When tracking the finger of the examiner, the eye movements may seem jerky. • Bell phenomenon (reflex upward movement of the eyes during closure) may be absent. • Sense of smell may diminish with age YET an asymmetric loss is always abnormal Muscle tone: • Increased muscle tone, assessed by flexing and extending the elbow and knee, is a normal finding in elderly people; o However, jerky movements during examination and cogwheel rigidity are abnormal • Presence of ‘Intention tremor’ and some resting tremors are benign conditions. o Unilateral tremors may indicate stroke. o A resting tremor with a "pill-rolling" character is worrisome o Extrapyramidal signs (muscle rigidity, tremor) may indicate Parkinson's disease or may be the adverse effects of drugs like neuroleptic medication

Muscle strength: • Muscles may appear weak in the elderly especially among those who don’t do regular resistance training o If weakness is symmetric, does not worry the elderly, and has not affected his/her functional level, it may not indicate any neurologic disease • Deep tendon reflexes and vibratory sense may be decreased normally due to aging • Coordination difficulty may indicate cerebrovascular disease

Reflexes: • Diminished or absent tendon reflexes, if bilateral, may be due to aging process. o Asymmetric tendon reflexes usually indicate a disorder Sensations: • Check for loss of sensations due to peripheral neuropathies (e.g. diabetic). Especially important if the case has history suggestive of diabetes. • Vibratory sense may be decreased normally due to aging Gait: Normal age-related findings may include the following: • Short and slow steps, possibly because of weak limb muscles, poor balance or fear of falling • Slight changes in walking posture (e.g., greater pelvic rotation, may be due to a combination of increased abdominal fat, weak abdominal muscles, and tight hip flexors etc.) 4. Gastro intestinal system: • Look for any type of hernia as the muscles are weak. Ventral, inguinal and femoral hernias, if present, should be checked for reducibility • Age related emphysematous changes in lungs may cause the liver edge to be palpable below the costal margin without actual hepatomegaly. This must be assessed by percussion. 5. Genitourinary system: Male: If facility present, examine for BHP.. Female: If facilities exist, do a bimanual pelvic examination. Postmenopausal estrogen reduction leads to atrophy of the vaginal and urethral mucosa; the vaginal mucosa appears dry and smooth (lacks rugae). The ovaries should not be palpable 10 yr after menopause; palpable ovaries suggest cancer. Examine for any degree of prolapse of the urethra, vagina, cervix, and uterus. They are asked to cough to check for urine leakage and intermittent prolapse. If not possible in the field, comment to the examiner that it was not possible for you to conduct this examination 6. Musculoskeletal system examination Inspect for abnormal posture, as well as assess the joints for any swelling and normal movement. This screening may be conducted systematically using the acronym ‘GALS’ , which stands for Gait, Arms, Legs and Spine Gait Ask the patient to walk a few steps, turn and walk back. Observe the patient’s gait for symmetry, smoothness and the ability to turn quickly. Normal age-related findings have been already discussed before. Arms • Ask the patient to put their hands behind their head. • Assess shoulder abduction and external rotation, and elbow flexion • Examine the hands: • Bony overgrowths at the distal interphalangeal joints; i.e. Heberden nodes or bony overgrowths at the proximal interphalangeal joints i.e. Bouchard nodes: both suggest Osteoarthritis (OA) • Subluxation of the metacarpophalangeal joints with ulnar deviation of the fingers suggests Chronic Rheumatoid Arthritis (RA) • Swan-neck deformity also suggests RA (Swan-neck deformity results due to hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint)) • Boutonnière deformity also points towards RA ((hyperextension of the distal interphalangeal joint with flexion of the proximal interphalangeal joint) • Ask the patient to squeeze your fingers. Assess grip strength. • Gently squeeze across the metacarpophalangeal (MCP) joints to check for tenderness due to an inflammatory joint disease. Also look at the face too for any wincing due to pain. Legs • Ask the patient to lie on the couch, assess full flexion and extension of both knees, feeling for crepitus. • With the hip and knee flexed to 90º, hold the knee and ankle and assess internal rotation of each hip in flexion (this is often the first movement affected by hip problems). • Perform a patellar tap to check for a knee effusion. • Inspect the feet for swelling, deformity, and callosities on the soles. o Common age-related findings include hallux valgus, medial prominence of the 1st metatarsal head with lateral deviation and rotation of the big toe, and lateral deviation of the 5th metatarsal head. Hammer toe (hyperflexion of the proximal interphalangeal joint) and claw toe (hyperflexion of the proximal and distal interphalangeal toe joints) may interfere with functioning and daily activities. o Toe deformities may be a result of years of using poorly fitting shoes or from RA, diabetes etc. o Look for injuries and ulcers suggestive of neuropathy or DM • Squeeze across the matatarsophalangeal (MTP) joints to check for tenderness suggesting inflammatory joint disease. Observe the face for expression of discomfort. Spine • With the patient standing, inspect the spine from behind for evidence of scoliosis, and from the side for abnormal lordosis or kyphosis. • Ask the patient to tilt their head to each side, so as to bring the ear towards the shoulder. Assess the lateral flexion of the neck (this is sensitive in the detection of early neck problems) • Ask the patient to touch their toes and simultaneously palpate the vertebrae for normal movement. The lumbar spine flexion can be assessed by positioning two or three fingers on the lumbar vertebrae. Your fingers should move apart during flexion and back together during extension Family health and Housing Environment As explained in detail in the blog and lecture on ‘Format for CSC taking in Community Medicine’ Clinico social diagnosis Clinical Diagnosis: Provisional diagnosis along with other age related problems which may be present e.g. problems with vision, hearing, continence, gait, and balance

Functional Assessment: Independent/ needs assistance/ dependent. A postgraduate student presenting the case in an examination may apply the ADL and IADL scale, calculate the scores and present the interpretation of the scores to the examiner. Social Diagnosis: • The problems detected in the physical, biological and psychosocial environment are listed here. These have been discussed in detail in the blog and lectures on ‘CSC format’ • In addition, the elderly person’s social network, support system, resources, safety and accessibility of the patient’s environment are to be mentioned. Safety threats at home should also find a mention. These factors influence the treatment approach. • Social security: a. Which schemes and facilities for the elderly are available in the area, is the elderly benefitting from them? Why not? b. Which schemes are not functional in the area? Advice and Suggested Management: Comprehensive management comprises of • Physical and mental health, • Functional status, • Social adaptability, and • Environmental conditions. Hence, the treatment plan includes measures for protecting the health and functional status and to maximize their quality of life of the elderly Look for treatable conditions that could improve functional status and Refer to the appropriate facility for management of medical problems E.g. • Treatment of arthritis to improve activities of daily life • Muscle weakness can be improved with resistance training; especially for the legs. Also, it can improve mobility and reduce fall risk. • Referral to an ophthalmologist should be considered when visual acuity is low or visual impairment is interfering with daily activities or evidence of glaucoma/cataract etc. Note: undergraduate students are not authorized to render the above advice directly to the patient. They should only discuss the management with the examiner and their senior doctors, who will in turn deliver the advice and referrals. Inform about social security schemes which may benefit the elderly Suggest steps to improve function and safety at home and outdoors, which are feasible in the given circumstances. The format can be completed within the 45 minutes given for the case in any exam. While presenting the case, only the relevant information may be given under the broad headings e.g. ‘Systemic examination findings were normal except reduced muscle power in all the limbs’, The student must have knowledge of all the schemes and social security measures available for the benefit of the elderly in that area at that time. Another lecture/blog deals with those available in India at present (2018) Attention Students!! You must see the lecture and blog on ‘Format for Clinico Social Case Taking in Community Medicine’ as the details of ‘Family Health Study’ have been omitted in this lecture for avoiding repetition. Otherwise you may MISS taking these EXTREMELY IMPORTANT assessment in a CSC.

Modified Kuppuswamy Classification of Socio - Economic Class: http://www.ihatepsm.com/blog/modified-kuppuswamy-scale Prasad's Scale: http://www.ihatepsm.com/blog/prasad%E2%80%99s-scale Dependency Ratio: http://www.ihatepsm.com/blog/dependency-ratio Assessment of Overcrowding in a Household: http://www.ihatepsm.com/blog/assessment-overcrowding-household Family and the Types of Family : http://www.ihatepsm.com/blog/family-and-types-family Checking for Mosquito Breeding Areas in a Household: http://www.ihatepsm.com/blog/checking-mosquito-breeding-areas-household Housefly Breeding Sites : http://www.ihatepsm.com/blog/checking-fly-breeding-sites-household Life Cycle of Housefly: http://www.ihatepsm.com/blog/life-cycle-housefly Types of Piped Water supply: http://www.ihatepsm.com/blog/types-piped-water-supply Reference Indian Adult Man and Woman: http://www.ihatepsm.com/blog/reference-indian-adult-man-and-woman Concept of the “Consumption Unit”: http://www.ihatepsm.com/blog/concept-%E2%80%9Cconsumption-unit%E2%80%9D Methods of Dietary Survey: http://www.ihatepsm.com/blog/methods-dietary-survey 24-Hour Recall (Questionnaire) Method : http://www.ihatepsm.com/blog/24-hour-recall-questionnaire-method Determination of Socio-economic Status of a Family in a Rural Area (the Uday Pareekh Scale): http://www.ihatepsm.com/blog/determination-ses-family-rural-area-uday-pa... 7 Terms used in Maternal and Child Health: Definition and Explanation : http://www.ihatepsm.com/blog/7-terms-used-maternal-and-child-health-defi... Terms used in Family Health Study: Definitions and Explanations: http://www.ihatepsm.com/blog/terms-used-family-health-study-definitions-...

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British Geriatrics Society

Community geriatrics: video case presentations.

A selection of case presentations on community geriatric services and initiatives which were first presented at the BGS Autumn Meeting 2021 (24-26 November). The authors and presenters have kindly given permission for us to share these more widely with BGS members and other interested groups.

An integrated care home service in Islington

Case presentation from Dr Celia Bielawski, consultant geriatrician, Whittington Hospital and Radha Shah, Islington Care Home Pharmcist.

Leeds Virtual Ward (Frailty): Supporting people to age well, through improving community health crisis response

Case presentation from Dr Graham Sutton, Leeds Teaching Hospitals NHS Trust, and Angela Gregson, Leeds Community Healthcare NHS Trust.

Taking a population health management approach to delivering community led anticipatory care in falls prevention

Case presentation from Dr S M Yule, Clinical Director, The Vale (BVP) and Janine Ord PHM lead, Dorset ICS.

Management of delirium in a Hospital at Home service: Challenges and opportunities

Case presentation from Dr Catherine Butchart, Consultant Geriatrician, NHS Grampian and Mrs Pamela Allan, Occupational Therapist, NHS Grampian.

Enhanced health for care homes: Evidence for liaison matron and MDT working Hammersmith and Fulham

Case presentation from Pandora Wright, Consultant Geriatrician, Imperial College Healthcare NHS Trust

Community anticipatory and reactive approach to supporting people living with frailty

Case presentation from Dr Daniel Harman, Consultant Community Geriatrician, CHCP, Dr Anna Folwell, Consultant Community Geriatrician, CHCP, and Wayne Morrow, Advanced Nurse Practitioner, CHCP.

Enhanced care in care homes: Advance care planning in care homes in Ealing

Case presentation from:

Dr Anna Down, GP/Clinical Lead, The Argyle Care Home Service
Dr Graham Stretch, Chief Pharmacist, Argyle Health Group
Grace Birch, Pharmacist, Argyle Health Group
Dr Sukhdeep Chahal, GP ST1, Argyle Surgery
Dr Kate Senger, Consultant Geriatrician, Ealing Hospital
Dr Annabelle Lee, Acute and Geriatric Medicine ST5, Ealing Hospital

Urgent community response in Dorset: A case study

Case presentation from Mrs Amy Hassan, Project Lead for Urgent Community Response, Mr Rob Taylor-Ball, Senior Advanced Clinical Practitioner and Cliff Kilgore, Consultant Practitioner for Older People (all from Dorset Healthcare NHS Trust).

EDITH (Emergency Department in the Home)

Case presentation from Dr Conor Prendergast, SpR in Emergency Medicine, Dr Rosa McNamara, Consultant in Emergency Medicine and Aidan Delany, Occupational Therapist.

Acute care at home for acute cholecystitis: A challenging case.

Case presentation from Dr Patricia Mc Caffrey Consultant Geraitrician Southern Trust, Northern Ireland and Dr Kerry Maxwell, Specialist Registrar, Northern Trust, Northern Ireland.

The frailty support team: Delivering a one team approach to urgent community response

Case presentation from Mrs Lucy Lewis, Consultant Practitioner in Frailty and Eleanor Corbett, Trainee Consultant Practitioner in Frailty Frailty Support Team, Southern Health NHS Foundation Trust.

South Somerset Neighbourhood Team delivering anticipatory care in the community

Case presentation from Dr Deb Gompertz, Lead Complex Care GP, Sue Crisfield, Social prescribing project lead, and Emma Blake, Neighbourhood Development Manager, South Somerset.

How to reduce the number of 999 calls to your home, keeping patients safe and avoiding A&E

Case presentation from Dr Rod Kersh, Consultant Physician, Rotherham NHS FT and Manor Field Surgery.

A Patient Journey: Assessing the impact of a dedicated frailty multidisciplinary team to deliver a proactive virtual Comprehensive Geriatric Assessment to the local community

Case presentation from Dr Elise Spiers, Frailty Fellow, Surrey Downs Health & Care.

Rapid Response: Sutton Health and Care @Home Rapid Response Team. Urgent Care in a Suburban and Urban Diverse Community

Case presentation from Dr Eva Kalmus, Interface Medicine GP Sutton Health and Care; Binu Cherian, Head of Adult Interface Services, Sutton Health and Care; Tracey Appleyard, Nurse Practitioner, At Home Services Sutton Health and Care; Nicole Smith, Band 7 Specialist Physiotherapist, Sutton Health and Care At Home Services; and Sarah Mendonca, Specialist Occupational Therapist, Sutton Health and Care At Home Services.

MidMed: A General Practitioner-led intervention for people living with moderate to severe frailty in Midlothian, Scotland

Case presentation from Dr Helen Jones, Specialty Registrar in Geriatric Medicine, Western General Hospital, Edinburgh and Dr Simon Hurding, General Practitioner, Newbattle Medical Practice, Midlothian

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The 12 Ds of geriatric medical-psychiatry: A new format for geriatric case presentation

Richard Shulman Roles: Conceptualization, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Reenu Arora Roles: Conceptualization, Investigation, Methodology, Project Administration, Validation, Visualization, Writing – Original Draft Preparation Amna Ali Roles: Data Curation, Project Administration, Writing – Review & Editing Judith Versloot Roles: Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

geriatric psychiatry, collaborative care, care management, integrated care, mental health

Introduction

With increasing age, multi-morbidities that include both mental and physical health problems become more prevalent. Traditionally the health care system is organized according to disease categories which can result in fragmented care across multiple health care providers ( Geist et al. , 2020 ; Stange et al. , 2010 ). New and innovative integrated care models, such as collaborative care, are promising solutions to provide optimal care to people suffering from multi-morbidities that include both mental and physical health problem. Collaborative care models are designed to support primary care providers in integrating care for patients with both mental and physical health problems. The model emphasises the care intersections among different health conditions, the need for care coordination and the different roles of the health care professionals from various disciplines ( Woltmann et al. , 2012 ). Adopting collaborative care models often requires healthcare professionals to change the way they work which can form a barrier to adoption ( Janse et al. , 2016 ; Lipschitz et al. , 2017 ).

Collaborative Care Project

The Medical Psychiatry Alliance (MPA) - Trillium Health Partners (THP) Seniors Outpatient Community Collaborative Care Project was developed to create a model of integrated geriatric medicine and geriatric psychiatry collaborative care for seniors aged 65 and over with at least one chronic physical condition impacting function and co-occurring symptoms of depression or anxiety ( Geist et al. , 2020 ). The project was implemented as an outpatient service at THP, a large community teaching hospital (University of Toronto) in Mississauga, Ontario. The project underwent an evaluative study that was approved by the THP Research Ethics Board as reported in our publication describing the collaborative care model. ( Shulman et al. , 2021 )

In our collaborative care model, care managers (CMs) who may either be a nurse, social worker, or occupational therapist, provided holistic care with initial and follow-up assessments based on treat to target rating scales. A central part of the care model is structured case reviews (SCR) where the CMs present cases to a geriatrician and geriatric psychiatrist. Recommendations from the SCR are communicated by the CMs to the primary care provider (PCP). The patient in this care model does not meet directly with the specialist physicians therefore a concise but holistic presentation of the patient during the case reviews becomes instrumental to the success of the program.

Structured Case Reviews (SCR)

Good communication is key to the success of collaborative care. SCRs are essential part of the collaboration in an integrated care team to foster effective communication. We realized that healthcare workers from different disciplines would benefit from a common means to discuss cases. One commonly used framework to ensure effective communication during patent care is the SBAR (situation, background, assessment, recommendations) where the presenter conveys the overall “story” of the patients using the structure from the SBAR ( Shahid & Thomas, 2018 ). Although, the SBAR framework promotes collaboration through effective communication, it is not specifically designed to capture both mental and physical health problems as they present itself in older adults. Additionally, since the CM within a collaborative care model plays the central role in the care coordination and management it is often this role that performs the case presentation. However, CMs often lack formal training or education in traditional medical-model case presentation for which the order of issues presented can differ between mental health and physical health models. To overcome these challenges, we developed a new format for case presentation based on modifying the SBAR framework of communication using a novel clinical approach we named the 12 Ds of Geriatric Medical-Psychiatry.

The 12 Ds of Geriatric Medical-Psychiatry

The 12 Ds of Geriatric Medical-Psychiatry was developed by extrapolating on the concept of the SBAR, the 3 Ds ( Arnold, 2004 ; Dharia et al. , 2011 ; Edwards, 2003 ; Milisen et al. , 2006 ) and 4 Ds ( Insel & Badger, 2002 ) of geriatric psychiatry. Alternate approaches to conceptualizing the geriatric patient considered included the Geriatric 4 Ms ( Molnar, 2016 ) and 5 Ms ( Molnar et al. , 2017 ).

The case presentation model including the 12 Ds as part of a case review is presented as follows:

Situation : includes referral source, reason for referral, and patient’s expectations.

Background : includes age, gender, language spoken, marital status, and living arrangements.

Assessment : described using the 12 Ds of Geriatric Medical-Psychiatry. The 12 Ds for case presentation are described in Table 1 and a schematic representation of the 12 Ds can be found in Figure 1 .

Recommendations : for investigations, pharmacological and non-pharmacological treatment suggestions to patient and PCP.

Table 1. 12 D s of Geriatric Medical-Psychiatry.

Figure 1. schematic of the 12 ds of geriatric medical-psychiatry presented like a team of players on a baseball field to facilitate easier recall of the clinical concepts..

We successfully used the 12 Ds model to present more than 180 patients and found the model easy to use and well received by learners and colleagues. All verbal and written reports to our referring PCPs utilized the 12 Ds case format presentation rather than the traditional format of case reporting and we did not receive one complaint or criticism.

The 12 Ds of Geriatric Medical-Psychiatry appears to be an efficient means for case presentation and is particularly suitable for integrated collaborative care for seniors by inter-disciplinary teams. In our experience, the 12 Ds of Geriatric Medical-Psychiatry can be applied to discussion of any geriatric patient, not only those with depression/anxiety and physical health symptoms. Furthermore, the 12 Ds was also well received by medical students as a helpful clinical approach to developing a holistic understanding of the current healthcare issues facing any geriatric patient. We suggest the 12 Ds of Geriatric Medical-Psychiatry could be used as an efficient and effective means for presenting cases and teaching an integrated, holistic approach to understanding complex geriatric cases.

Practice points

• The 12 Ds of Geriatric Medical-Psychiatry within a modified SBAR framework provides a comprehensive, well organized, and holistic format to discuss the pertinent issues facing geriatric patients.

• The 12 Ds of Geriatric Medical-Psychiatry appears to be an efficient means for case presentation and is particularly suitable for integrated collaborative care for seniors by inter-disciplinary teams.

• In our experience, the 12 Ds was well received by learners as a helpful clinical approach to developing a holistic understanding of the current healthcare issues facing any geriatric patient.

Author contributions

We confirm that all authors made a significant contribution to the work and the manuscript according to common authorship guidelines.

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Open peer review.

In the following two sentences: "Collaborative care models are designed to support primary care providers in integrating care for patients with both mental and physical health
In the following two sentences: "Collaborative care models are designed to support primary care providers in integrating care for patients with both mental and physical health problems. The model emphasises..." - for consistency, are you referring to a specific model or models more generally?
I would list out 3 and 4 D's, along with Geriatric Ms. Also, I would spell out what SBAR is, even if it is widely known.
I would avoid using the word "dope" which has negative connotations.
In your discussion, do you have any data, surveys, etc. to back up your claims?

Is the rationale for the Open Letter provided in sufficient detail?

Does the article adequately reference differing views and opinions?

Are all factual statements correct, and are statements and arguments made adequately supported by citations?

Is the Open Letter written in accessible language?

Where applicable, are recommendations and next steps explained clearly for others to follow?

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Geriatric psychiatry, interprofessional education, Alzheimer's disease

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Reviewer Expertise: Geriatric Psychiatry, CL Psychiatry

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Reviewer Reports

Ana Hategan , McMaster University, Hamilton, Canada James A. Bourgeois , University of California, Davis, Sacramento, USA
Steven F. Huege , University of California, San Diego, La Jolla, USA

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Introduction

Incorporating evidence into clinical teaching: enhanced geriatrics specialty case-based residency presentations.

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James S. Powers , Molly Cahall , Marcia Epelbaum , Ralf Habermann , Donna Rosenstiel , Nunzia Giuse; Incorporating Evidence into Clinical Teaching: Enhanced Geriatrics Specialty Case-Based Residency Presentations. J Grad Med Educ 1 March 2012; 4 (1): 83–86. doi: https://doi.org/10.4300/JGME-D-11-00056.1

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Case-based presentations are widely used in medical education and are a preferred education modality to teach about the care of geriatric patients across a range of medical specialties.

We incorporated evidence-based materials from topical literature syntheses into case-based presentations on the care of geriatric patients for use by specialty residents. These enhanced case-based presentations were used to augment learning and to facilitate detection of additional educational needs for future resident training sessions.

Forty case-based presentations were presented to 11 specialty programs during a 4-year period. The program was popular, and program directors and residents requested additional presentations. Geriatric evidence-based summaries were viewed online 375 times during the course of the project. Geriatric clinical consults increased from an average of 10 consults a year to 141 from 64 different providers during the first year.

Case-based presentation, enhanced with evidence-based summaries of research literature generated by information specialists, is a feasible and effective approach to teaching clinical content. These presentations can be used to target geriatrics educational competencies for resident trainees in nongeriatric specialties.

Editor's note: The online version of this article contains a sample literature summary and an example case presentation .

Case-based presentations have been used traditionally to apply developing medical knowledge. There are few descriptions of the use of evidence-based medicine to enhance case presentations.

Incorporation of evidence-based materials from topical literature syntheses into case-based presentations on geriatric care topics resulted in additional review of geriatric evidence-based summaries and increased geriatrics consults for 64 physicians from 10 to 141 consults per year.

Small sample, single specialty and single site, use of surrogate markers and subjective feedback among the outcome measures.

Case-based presentations, enhanced with evidence-based literature, are a practical and feasible modality for teaching geriatric competencies to residents in nongeriatric specialties.

Case-based presentations have a long tradition in medical training, linking trainees' developing knowledge to clinical practice in an interactive environment. 1 – 4 The literature is sparse in describing use of evidence-based techniques to enhance case presentations.

The Vanderbilt University Knowledge Management/Eskind Biomedical Library developed a Clinical Informatics Consult Service in 1996 to provide literature searches for clinicians. 5 All information specialists undergo Masters level training in literature searching and critical appraisal and demonstrate proficiency in their understanding of medical terminology, research design, and biostatistics. In 2004, the program was expanded to include ambulatory settings through an Outpatient Clinical Informatics Consult Service. 6 The service included an electronic communication tool that allowed physicians to request a literature search for complex questions arising during patient encounters, including capturing the answers to clinical questions at the point of care. 7 , 8

We describe an innovative approach to case-based learning that uses a messaging tool within the electronic medical record system, coupled with the expertise of information specialists, to enhance case-based presentations delivered by geriatricians to nongeriatric specialty residents.

To effectively disseminate geriatric educational content to nongeriatric specialty residencies, we invited all adult specialty training program directors at our institution to meet individually with presenting geriatricians to assess geriatric learning needs as defined by the American Geriatric Society's Assessing Care of Vulnerable Elders 9 quality indicators.

Participants

Eleven specialty program directors from emergency medicine, general surgery, neurology, neurosurgery, obstetrics/gynecology, ophthalmology, oral surgery, orthopedics, psychiatry, thoracic surgery, and urology consented to participate in the needs assessment and training initiative in 2006. Program directors were interviewed individually about curricular needs and training models related to competencies for caring for geriatric patients; they overwhelmingly identified case-based presentations as an effective and preferred mechanism for training residents in nongeriatric specialties. The 1949-8357-4-1-83-box01 box lists the top educational competency needs expressed during individual interviews with the specialty program directors. In addition to the definitions in the Assessing Care of Vulnerable Elders , the case-based presentations we designed incorporated the Accreditation Council for Graduate Medical Education competencies 10 and the Association of American Medical Colleges medical student 11 and resident 12 geriatric competencies that mapped to the identified curricular needs.

Geriatric syndrome management

Comorbidity

Postoperative delirium

Systems-based practice

Practice-based learning and improvement

Preparation of Geriatric Information Summaries

Through collaboration with the information specialists in the Outpatient Clinical Informatics Consult Service, we obtained tailored, evidence-based literature searches that informed our clinical decision making for the care of geriatric patients. They consisted of (1) a concise statement of the current state of the research literature, including all available viewpoints, conflicting study results, and limitations; (2) written or tabular summaries of the individual studies selected and reviewed for their quality, strength, or representation of the research evidence, with links to the full text articles when available; (3) information on the search strategies used to retrieve the relevant literature; and (4) additional readings that included practice guidelines or related research pertinent to the clinical question. 13 – 14 The Knowledge Management team also created a Geriatrics Library to provide access to a collection of online information resources for geriatric education, research, and patient care, including the geriatric-related literature summaries, and granted open access to the summaries for non-Vanderbilt users through a web portal sponsored in part by the Donald W Reynolds Foundation, called the Portal of Geriatrics Online Education or POGOe ( http://www.pogoe.org ).

The appendix , provided as online supplemental material, shows a sample summary of a literature review and synthesis of all results developed in response to a clinical question submitted by the geriatrics consult service regarding the survival of dementia patients who receive primary nutrition via percutaneous endoscopic gastrostomy tube feeding. The final report sent to the clinicians is organized into 2 sections: (1) a summary of the current evidence on patient survival given percutaneous endoscopic gastrostomy tube feeding, and (2) a detailed table of study data filtered from each research study selected for the summary (provided online).

Case Selection

In preparing for the nongeriatric residency specialty training sessions, presenting geriatricians developed geriatric cases derived from actual patients (inpatient, outpatient, and emergency department) treated at the Vanderbilt Senior Care Service or the Tennessee Valley Healthcare System Geriatric Evaluation and Management Unit. The content targeted the educational competency needs identified by nongeriatric residency specialty program directors and included concise case descriptions with clearly defined objectives, goals, and critical actions; a list of geriatrics education resources; and supplemental teaching handouts containing a summary of the corresponding synthesized literature.

Case Presentation Development

The time required to develop each case-based presentation involved approximately 2 hours for geriatricians and 6 to 8 hours for the information specialist, depending on the complexity of the clinical question, the number of related questions posed, the information specialist's familiarity with the research base for the topic, and the quantity and quality of the relevant primary literature available.

Case Presentation Delivery

Case presentations were delivered during mandatory division teaching conferences. Geriatricians introduced the cases and conducted interactive small-group discussions about the cases with the specialty resident audiences. A typical case discussion lasted 30 minutes and consisted of 15 minutes for the case presentation and 15 minutes for small-group discussion. The presentation to the residents included clearly stated educational objectives, a critical actions list, and appended resources in addition to the evidence-based information packet concerning tube feeding in dementia patients.

Resident and program directors provided verbal feedback following the presentations to determine additional learning objectives and corresponding competencies for development of future cases and new evidence-based information packets. Baseline and subsequent geriatric consult requests and electronic access to geriatric information summaries were also tracked to measure the effect on specialty service awareness of the availability of geriatric expertise hospital wide.

Forty enhanced case-based presentations were distributed to specialty resident training programs at our institution during a 4-year period. There was a surge in geriatric clinical consults among hospitalized patients, including 141 consults from 64 different providers in the first year, compared with a previous average of 10 sporadic geriatric consults yearly. Consult requests mirrored competencies and identified educational needs ( 1949-8357-4-1-83-box01 box ). Currently, 39 geriatrics summaries have been added to the Geriatrics Library repository since October 2006. Twelve summaries were used for the case-based presentations and were subsequently viewed through the electronic medical record portal a total of 193 times (4.29 views per month) and via the Geriatrics Library 182 times (4.04 views per month) between October 30, 2006, and June 30, 2010. Because of the individualized approach in developing the curriculum, a summative evaluation of the program, including comprehensive qualitative data analysis, was not performed.

Acceptability

The increase in geriatric clinical consults, online viewing of topically related geriatric information summaries, positive subjective feedback received from residents, and program directors' requests for additional presentations validated our approach to enhance geriatric education by incorporating skilled information specialists into a case-based learning approach. Additional complex clinical questions were generated from discussions that arose during case presentations, and these literature summaries will be incorporated into the development of future case-based presentations.

Strengths and Limitations

A major strength of our approach for training residents in geriatric competencies is the provision of evidence-based literature summaries for geriatric topics mapped to competencies to enhance case-based presentations with just-in-time learning tailored to specialty needs. Additionally, the curricular needs assessment conducted after each presentation further informed the educator for the next presentation, targeting new competencies and revisiting complex aspects of those previously taught. A limitation of our approach is the use of surrogate markers as outcomes, including the change in the number of accesses to the Vanderbilt University Knowledge Management/Eskind Biomedical Library literature summaries, change in the number of subsequent geriatric consults, and subjective feedback, to measure the success of the curriculum.

Feasibility and Replication

The use of an electronic medical record messaging tool through which physicians can communicate their complex clinical questions to information specialists may be unique to the Vanderbilt setting. At the same time, the training and collaborative ventures between librarians as expert information specialists and medical educators to answer physicians' complex clinical questions during hospital rounds or via the Internet has been used in other settings. 15 – 18 Although a committed geriatric teaching faculty and receptive specialty training programs are prerequisites, replication of our collaborative approach to delivering enhanced case-based presentations is feasible for geriatric faculty at other academic medical institutions with access to appropriately trained information specialists.

Case-based presentations enhanced with evidence-based summaries of research literature generated by information specialists is a feasible and effective approach to teaching clinical content targeting geriatric educational competencies to resident trainees in nongeriatric specialties. Presentations to nongeriatric residents are associated with an increase in clinical geriatric consults.

Author notes

All authors are at Vanderbilt University. James S. Powers, MD, is Associate Professor of Medicine, Associate Clinical Director in Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, and Medical Director at Meharry-Vanderbilt-Tennessee State University Consortium Geriatric Education Center; Molly Cahall, MA, MSLS, is Coordinator at Outpatient Clinical Informatics Consult Service, Eskind Biomedical Library; Marcia Epelbaum, MA, is Assistant Director at Eskind Biomedical Library; Ralf Habermann, MD, is Assistant Professor of the Department of Medicine; Donna Rosenstiel, LCSW, is Administrative Director at the Office of Health Sciences Education in the School of Medicine; Nunzia Giuse, MD, MLS, is Assistant Vice Chancellor for Knowledge Management, Director at Eskind Biomedical Library, and Professor of Medicine and Biomedical Informatics.

The authors would like to thank Kellie Flood, MD, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, and Kelly Floyd, OTR, Vanderbilt University Medical Center, Nashville, for their kind review of the manuscript.

Presented in part at the Annual Meetings of the American Geriatrics Society 2009, and the American Association of Geriatric Psychiatry 2010.

Funding: This study was supported in part by a grant from the DW Reynolds Foundation for Geriatric Education and the Meharry-Vanderbilt-Tennessee State University Consortium Geriatric Education Center, HRSA Award 1D31HP08823-01-00.

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J Grad Med Educ
v.4(1); 2012 Mar

Incorporating Evidence into Clinical Teaching: Enhanced Geriatrics Specialty Case-Based Residency Presentations

Introduction.

Case-based presentations are widely used in medical education and are a preferred education modality to teach about the care of geriatric patients across a range of medical specialties.

Editor's note: The online version of this article contains a sample literature summary and an example case presentation .

What was known

Case-based presentations have been used traditionally to apply developing medical knowledge. There are few descriptions of the use of evidence-based medicine to enhance case presentations.

What is new

Limitations

Small sample, single specialty and single site, use of surrogate markers and subjective feedback among the outcome measures.

Bottom line

Case-based presentations, enhanced with evidence-based literature, are a practical and feasible modality for teaching geriatric competencies to residents in nongeriatric specialties.

Case-based presentations have a long tradition in medical training, linking trainees' developing knowledge to clinical practice in an interactive environment. 1 – , 4 The literature is sparse in describing use of evidence-based techniques to enhance case presentations.

Participants

Eleven specialty program directors from emergency medicine, general surgery, neurology, neurosurgery, obstetrics/gynecology, ophthalmology, oral surgery, orthopedics, psychiatry, thoracic surgery, and urology consented to participate in the needs assessment and training initiative in 2006. Program directors were interviewed individually about curricular needs and training models related to competencies for caring for geriatric patients; they overwhelmingly identified case-based presentations as an effective and preferred mechanism for training residents in nongeriatric specialties. The box lists the top educational competency needs expressed during individual interviews with the specialty program directors. In addition to the definitions in the Assessing Care of Vulnerable Elders , the case-based presentations we designed incorporated the Accreditation Council for Graduate Medical Education competencies 10 and the Association of American Medical Colleges medical student 11 and resident 12 geriatric competencies that mapped to the identified curricular needs.

Box Specialty Residency Geriatrics Educational Needs

Geriatric syndrome management

Comorbidity

Postoperative delirium

Systems-based practice

Practice-based learning and improvement

Preparation of Geriatric Information Summaries

Case Selection

Case Presentation Development

Case Presentation Delivery

Forty enhanced case-based presentations were distributed to specialty resident training programs at our institution during a 4-year period. There was a surge in geriatric clinical consults among hospitalized patients, including 141 consults from 64 different providers in the first year, compared with a previous average of 10 sporadic geriatric consults yearly. Consult requests mirrored competencies and identified educational needs ( box ). Currently, 39 geriatrics summaries have been added to the Geriatrics Library repository since October 2006. Twelve summaries were used for the case-based presentations and were subsequently viewed through the electronic medical record portal a total of 193 times (4.29 views per month) and via the Geriatrics Library 182 times (4.04 views per month) between October 30, 2006, and June 30, 2010. Because of the individualized approach in developing the curriculum, a summative evaluation of the program, including comprehensive qualitative data analysis, was not performed.

Acceptability

Strengths and Limitations

Feasibility and Replication

The use of an electronic medical record messaging tool through which physicians can communicate their complex clinical questions to information specialists may be unique to the Vanderbilt setting. At the same time, the training and collaborative ventures between librarians as expert information specialists and medical educators to answer physicians' complex clinical questions during hospital rounds or via the Internet has been used in other settings. 15 – , 18 Although a committed geriatric teaching faculty and receptive specialty training programs are prerequisites, replication of our collaborative approach to delivering enhanced case-based presentations is feasible for geriatric faculty at other academic medical institutions with access to appropriately trained information specialists.

Presented in part at the Annual Meetings of the American Geriatrics Society 2009, and the American Association of Geriatric Psychiatry 2010.

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Submissions Open: December 1, 2023
Submissions Due: January 7, 2024 11:59 PM EDT

Please note that the above deadlines are subject to change. The Program Committee will not accept or consider late submissions.

Presentation Slides

All presentation slides are due by January 24, 2024 for review by the AAGP CME Committee. Instructions to submit slides will follow acceptance of presentations. These materials are required for attendees to receive Continuing Medical Education (CME) credit. As such, all materials must be in compliance with Accreditation Council for Continuing Medical Education (ACCME) rules ( https://www.accme.org/accreditation-rules ) and are reviewed by the AAGP CME Committee. Specifically, all presentations must include a  disclosure slide  (see next section) and a  declaration whether or not any off-label use of medication is discussed . Materials are also made available online for all meeting attendees, including those unable to attend your live presentation.

Please note that failure to submit your presentation by January 15, 2024, could result in a loss of CME credit for the entire meeting and every attendee as well as automatic withdrawal of your general session or case presentation from the 2023 AAGP Annual Meeting.

Disclosure of Conflicts of Interest

AAGP requires disclosure by presenters at CME activities of any financial interest or other affiliation with commercial organization(s) that may have a direct or indirect impact on the subject matter of the scientific program. AAGP’s policy on disclosure applies to financial interests of a presenter’s spouse/partner as well. A “financial interest” may include, but is not limited to, being a shareholder in the organization; being on retainer with the organization; or having research or honoraria paid by the organization. An “affiliation” may include holding a position on an advisory committee or some other role or benefit to a supporting organization. The existence of such relationships does not necessarily constitute a conflict of interest, but the prospective audience must be informed of the presenter’s affiliation with every commercial supporter by an acknowledgment in the slides as well as orally at the start of every session. In addition, each faculty who identifies a potential conflict will be asked to identify steps to resolve that conflict. This policy is intended to openly identify any potential conflict(s) so that members of the audience in an educational activity are able to form their own judgments about the presentation. AAGP also requires oral disclosure of discussion of unapproved uses of a commercial product or investigational use of a product not yet approved for this purpose.

Registration and Travel Policy

All presenters must be paid registrants of the AAGP Annual Meeting. Expenses associated with the preparation, submission, and presentation of an abstract are the responsibility of the author(s)/presenter(s) . All speakers and presenters are expected to make their own travel arrangements and pay their own expenses (with the exception of industry-supported programs and other sponsored workshop programs). All presenters will need to be available to present live in Atlanta during their presentation.

Limit on Multiple Presentations

A speaker’s name may be submitted for multiple symposia. However, if all of the proposed symposia are accepted, any speaker at the AAGP Annual Meeting is limited to only participating in  four   (4)  educational programs (industry supported and non-industry supported). If a speaker is listed as faculty on more than four programs, the speaker will be asked to find an appropriate substitute for one of the programs. This policy does not apply to scientific poster presentations. If a speaker is on more than one industry-supported symposium, they may only receive a travel stipend and an honorarium for one sponsored session.   

Eligibility

You do  not  need to be a member of AAGP to submit an abstract! Clinicians and investigators in geriatric psychiatry, psychology, neurology, medicine, nursing, social work, and other related disciplines are encouraged to submit abstracts of original work for presentation at the AAGP Annual Meeting. AAGP also welcomes the involvement of   trainees  and  early career professionals  as presenters.

All session abstracts are reviewed by the AAGP Annual Meeting Program Committee and ranked on the basis of scientific merit and educational needs of AAGP attendees. All accepted session and poster abstracts (except Late-Breaking Research Posters**) will be published and available to all meeting attendees in a PDF supplement to the  American Journal of Geriatric Psychiatry . The Annual Meeting Program Committee’s decisions are final. Reviews are based on the following criteria:

Relevance to identified attendee needs
Inclusion of new data
Timeliness of topic
Diversity among presenters
Presentation balance between research and practice applications
Applicability to practice of geriatric psychiatry
Relationship to the Annual Meeting theme
Attention to diversity, culture, and ethnicity

Please note that potentially outstanding presentations are, at times, given a lower priority score because the information and data supplied with the submission were incomplete or inappropriate for a particular format.

Publication

By submitting a proposal, you give AAGP the authority to electronically post your presentation, abstract, and learning objectives online, and to publish them in printed materials. You are responsible for editing your abstract and providing copy in final, print-ready form. However, AAGP reserves the right to edit any part of the abstract submission for consistency, grammar, and target audience as we deem necessary.

Don’t Wait till the Last Minute!

Submission is a multi-step process, and it requires advance information from all participants. Begin the submission process early so that you have time to edit or add additional information. You can save your submission in draft form and re-visit it prior to the submission deadline to make changes as needed.

General Sessions

Each general session will be 90 minutes, including at least 20 minutes committed to audience participation. General sessions include a Session Chair and up to five additional Session Speakers/Discussants for a total of no more than six total presenters. Please note that given the brief time, fewer speakers will lead to a more in-depth presentation.

The Session Chair will serve as the contact person for the Program Committee and facilitate any changes as directed by the Program Committee, work with the faculty to refine individual presentations to ensure that the program is well rounded and free from commercial bias, and ensure final slides are submitted in a timely manner. In addition, the Session Chair is responsible for entering the entire submission in the Abstract Submission Portal.

The Session Chair should submit:
A title, session description , overall abstract (detailed description of the session), needs assessment (description of why this session is important and relevant to the meeting theme), four learning objectives, track, and three CME questions with reference and a brief agenda (for reviewers only). Maximum of 5,000 characters combined.
Background/Introduction (10 minutes), Speaker name
Speaker 1 and topic (20 minutes)
Speaker 2 and topic: (20 minutes)
Speaker 3 and topic (20 minutes)
Discussion/Questions (20 minutes)
For each individual Speaker or Discussant, including the Chair, the Session Chair should also submit participant abstracts. Participant abstracts describe what each presenter will discuss during the session.
A title for the portion of the session led by each session faculty member, including the Chair and each Speaker or Discussant
An individual abstract for each Speaker or Discussant, including the Chair, limited to 5,000 characters.
The name, degrees, affiliation, phone, email, CV and brief bio (100 words) for each Speaker or Discussant, including the Chair.

Helpful Tips for Your Submission

Learning Objectives

Educational activities offering CME/CE should be designed with the intent of changing competency/skills/performance/patient outcomes. Objectives must be behavioral rather than instructional:

Competence (knowing how to do something; having the knowledge/ability to apply knowledge, skills and judgment in practice; new strategies one might consider putting into practice)
Performance (what one actually puts into practice)
Patient outcomes (patient health status)

Tips for Writing Good Objectives:

Objectives should address these questions¹:

What should the result of the educational activity be for participants?
What should the participant be able to do after attending the activity?
Make sure that objectives are measurable and relate directly to reducing the identified practice gap
State what the learner might do differently (behavioral change) because of what has been learned
Use verbs which allow measurable outcome and thus can then be used in the evaluation process

¹Adopted from the APA Guidelines for Developing CE Learner-Centered Objectives

CME Questions

Each submission will require three (3) CME questions related to the content of the presentation to test the learner’s knowledge on the information presented. Each question also requires a reference to be submitted.

CME questions should:

Ensure that each objective is assessed by at least 1 question.
Questions are simple, clearly stated, and measure only the educational objective for which they were designed.
Questions should be written either in multiple-choice or true/false format. In general, no more than 20% of the questions should be true/false.
Multiple choice questions should have four options, and options should be specific and distinct. Avoid using “all of the above” and language like “b and c are both correct.”
Assess the important, take-home concepts of the educational activity.

Guidelines for developing questions:

Ensure that each question is similar in terms of grammatical construction, length, and complexity.
Answer choices should be uniform in length and style and grammatically consistent with the question.
Avoid using the same or similar words in both the question and the correct answer as this may clue the participant to the correct answer.
Write options that are grammatically consistent and logically compatible with the question stem; list them in logical or alphabetical order.
Write distractors (the incorrect answers) that are plausible and the same relative length as the correct answer.
Avoid using vague terms such as usually and frequently .
Pose the question in the affirmative; avoid the use of negative statements such as "not" and "except" because they are often confusing.

Avoid the following:

Grammatical cues: one or more incorrect answers don’t follow grammatically from the question stem.
Long correct answer: correct answer is longer, more specific, or more complete than other options.
Word repeats: a word or phrase is included in the question stem and in the correct answer.
The easy way out: “None of the above” or “all of the above” used as an option. ²

²Adopted from ASHP Preparing Test Questions and Answers for CE Activities

CME Question References

Each CME question requires a reference submitted. Provide the reference in Vancouver style (examples below) and provide the page and paragraph number. Note, that you do not need to type out a defense of your answer as a rationale. The page number and location will suffice.

Reference style examples:

Journal article: Smith JJ. The world of science. Am J Sci. 1999; 36:234-5.
Article by DOI: Slifka MK, Whitton JL. Clinical implications of dysregulated cytokine production. J Mol Med. 2000; doi:10.1007/s001090000086
Book: Blenkinsopp A, Paxton P. Symptoms in the pharmacy: a guide to the management of common illness. 3rd ed. Oxford: Blackwell Science; 1998.
Book chapter: Wyllie AH, Kerr JFR, Currie AR. Cell death: the significance of apoptosis. In: Bourne GH, Danielli JF, Jeon KW, editors. International review of cytology. London: Academic; 1980. pp. 251-306.
Online document: Doe J. Title of subordinate document. In: The dictionary of substances and their effects. Royal Society of Chemistry. 1999. http://www.rsc.org/dose/title of subordinate document. Accessed 15 Jan 1999.

Clinical Case Presentations

Clinical Case Presentations are 90 minute sessions with three individual clinical presentations chosen by the Program Committee. Total presentation time (including questions) will be 30 minutes per clinical case. If you would like to submit an individual case presentation, please include:

Overall abstract (description of the case), needs assessment (description of why this case is important and relevant to the meeting theme), Two (2) learning objectives, and at least three (3) keywords. Maximum of 5,000 characters.

New Research Posters

New Research posters are self-explanatory visual presentations of unpublished research work. Abstracts should not be submitted for consideration as a New Research Poster if the same research work is already accepted for publication in a scientific journal at the time of submission for the AAGP Annual Meeting. Poster Abstracts should include:

A Title, Introduction, Methods, Results, Conclusion, funding sources, upload tables and/or images, topic area and at least 1 keyword (maximum of 5,000 characters). Abstracts for accepted posters will be published in the American Journal of Geriatric Psychiatry, and available to attendees online. AAGP will not edit poster abstracts, so please ensure the written submission is in final form. Abstracts cannot be withdrawn from publication after December 31, 2023. The presenter is required to be present during specified poster session hours for informal discussions about their research with meeting attendees. Posters will be attached to a bulletin board that measures 45" (vertical) by 90" (horizontal).

Early Investigator Posters

This special section is a sub-set of the New Research Posters, designed to highlight the research of students, residents, trainees, research fellows and clinical fellows, as well as junior faculty and K-awardees who are no more than two (2) years post fellowship training. If you wish to be considered in this special category, please submit under the Early Investigator submission role when submitting your abstract online. The abstract submission requirements for early investigator posters are the same as those described above for new research posters.

Late-Breaking Research Posters

The AAGP Annual Meeting Program Committee has reserved a few select slots for a limited number of late-breaking research posters with a deadline of January 7, 2024. Please note that due to the lateness of the submission, late-breaking posters might not be included in the AJGP Abstract Supplement. Late-breaking research posters should include abstracts that describe important current research advances and have not been submitted previously. Late-breaking abstracts are not a second chance for those who missed the official abstract deadline. State-of-the-art studies with up-to-date results will be considered as late-breaking abstracts. Late-breaking abstracts reporting secondary data analyses must include an explanation for why they were not submitted as of the regular deadline. The selection of abstracts will be based on scientific quality and novelty of research either in basic or clinical science.

Each poster submitter will have the opportunity to indicate if they would like to considered for an oral presentation. There will be three sessions that feature oral abstract presentations as selected by the Research Committee. Each oral presentation will be 12 minutes with 3 minutes for Q&A. Submitters will be notified in late January 2024 if selected for an oral presentation.

All submissions are made through the 2024 Annual Meeting Abstract Submission Portal . We welcome you to submit a proposal for a symposium or case presentation that will enhance our ability to provide care to our patients, conduct research on late-life mental illness and its effective treatments, and train the workforce needed to provide high quality care now and in the future.

Click Here To Submit

We cannot wait to see you all in Atlanta!

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Advance your career, engage in the community, and maximize your knowledge and potential within our growing field.

Monthly Case Conference Presentations:

These monthly conferences consist of a 15-20 minute discussion of a geriatric medicine topic followed by one or two patient cases presented by staff from primary care clinics. Geriatric specialists provide the brief didactic and the panel for the case discussion. Each panel includes a geriatrician, geriatric psychiatrist, pharmacist, social worker and primary care liaison (community services representative). Only the didactic components are posted to protect patient confidentiality. Submit a case for review.

Upcoming Presentations Thursday, April 4, 2024 – Alëna Balasanova, MD – “Approach to substance use disorder in older people” Thursday, May 2, 2024 – Brandi Flagg, MD and Nubia Quiros – “Sharing What Matters as patients complete Advance Care Planning” Thursday, June 6, 2024 – Jane Potter, MD – “Collaborating in Care of Older Patients under the Geriatrics Workforce Enhancement Program: What did we do, and did it make a difference?”

Archived Presentations and Resources:

Additional Presentations

Case report

Case reports submitted to BMC Geriatrics should make a contribution to medical knowledge and must have educational value or highlight the need for a change in clinical practice or diagnostic/prognostic approaches. We will not consider reports on topics that have already been well characterised or where other, similar, cases have already been published.

BMC Geriatrics will not consider case reports describing preventive or therapeutic interventions, as these generally require stronger evidence.

BMC Geriatrics welcomes well-described and novel reports of cases that include the following:

• Unreported or unusual side effects or adverse interactions involving medications.

• Unexpected or unusual presentations of a disease.

• New associations or variations in disease processes.

• Presentations, diagnoses and/or management of new and emerging diseases.

• An unexpected association between diseases or symptoms.

• An unexpected event in the course of observing or treating a patient.

• Findings that shed new light on the possible pathogenesis of a disease or an adverse effect.

Authors must describe how the case report is rare or unusual as well as its educational and/or scientific merits in the covering letter that will accompany the submission of the manuscript. Case report submissions will be assessed by the Editors and will be sent for peer review if considered appropriate for the journal.

Case reports should include relevant positive and negative findings from history, examination and investigation, and can include clinical photographs, provided these are accompanied by a statement that written consent to publish was obtained from the patient(s). Case reports should include an up-to-date review of all previous cases in the field. Authors should follow the CARE guidelines and the CARE checklist should be provided as an additional file.

Authors should seek written and signed consent to publish the information from the patient(s) or their guardian(s) prior to submission. The submitted manuscript must include a statement that this consent was obtained in the consent to publish section as detailed in our editorial policies .

Professionally produced Visual Abstracts

BMC Geriatrics will consider visual abstracts. As an author submitting to the journal, you may wish to make use of services provided at Springer Nature for high quality and affordable visual abstracts where you are entitled to a 20% discount. Click here to find out more about the service, and your discount will be automatically be applied when using this link.

Preparing your manuscript

The information below details the section headings that you should include in your manuscript and what information should be within each section.

Please note that your manuscript must include a 'Declarations' section including all of the subheadings (please see below for more information).

Title page

The title page should:

"A versus B in the treatment of C: a randomized controlled trial", "X is a risk factor for Y: a case control study", "What is the impact of factor X on subject Y: A systematic review, A case report etc."
or, for non-clinical or non-research studies: a description of what the article reports
if a collaboration group should be listed as an author, please list the Group name as an author. If you would like the names of the individual members of the Group to be searchable through their individual PubMed records, please include this information in the “Acknowledgements” section in accordance with the instructions below
Large Language Models (LLMs), such as ChatGPT , do not currently satisfy our authorship criteria . Notably an attribution of authorship carries with it accountability for the work, which cannot be effectively applied to LLMs. Use of an LLM should be properly documented in the Methods section (and if a Methods section is not available, in a suitable alternative part) of the manuscript
indicate the corresponding author

The Abstract should not exceed 350 words. Please minimize the use of abbreviations and do not cite references in the abstract. The abstract must include the following separate sections:

Background: why the case should be reported and its novelty
Case presentation: a brief description of the patient’s clinical and demographic details, the diagnosis, any interventions and the outcomes
Conclusions: a brief summary of the clinical impact or potential implications of the case report

Keywords

Three to ten keywords representing the main content of the article.

The Background section should explain the background to the case report or study, its aims, a summary of the existing literature.

Case presentation

This section should include a description of the patient’s relevant demographic details, medical history, symptoms and signs, treatment or intervention, outcomes and any other significant details.

Discussion and Conclusions

This should discuss the relevant existing literature and should state clearly the main conclusions, including an explanation of their relevance or importance to the field.

List of abbreviations

If abbreviations are used in the text they should be defined in the text at first use, and a list of abbreviations should be provided.

Declarations

All manuscripts must contain the following sections under the heading 'Declarations':

Ethics approval and consent to participate

Consent for publication, availability of data and materials, competing interests, authors' contributions, acknowledgements.

Authors' information (optional)

Please see below for details on the information to be included in these sections.

If any of the sections are not relevant to your manuscript, please include the heading and write 'Not applicable' for that section.

Manuscripts reporting studies involving human participants, human data or human tissue must:

include a statement on ethics approval and consent (even where the need for approval was waived)
include the name of the ethics committee that approved the study and the committee’s reference number if appropriate

Studies involving animals must include a statement on ethics approval and for experimental studies involving client-owned animals, authors must also include a statement on informed consent from the client or owner.

See our editorial policies for more information.

If your manuscript does not report on or involve the use of any animal or human data or tissue, please state “Not applicable” in this section.

If your manuscript contains any individual person’s data in any form (including any individual details, images or videos), consent for publication must be obtained from that person, or in the case of children, their parent or legal guardian. All presentations of case reports must have consent for publication.

You can use your institutional consent form or our consent form if you prefer. You should not send the form to us on submission, but we may request to see a copy at any stage (including after publication).

See our editorial policies for more information on consent for publication.

If your manuscript does not contain data from any individual person, please state “Not applicable” in this section.

All manuscripts must include an ‘Availability of data and materials’ statement. Data availability statements should include information on where data supporting the results reported in the article can be found including, where applicable, hyperlinks to publicly archived datasets analysed or generated during the study. By data we mean the minimal dataset that would be necessary to interpret, replicate and build upon the findings reported in the article. We recognise it is not always possible to share research data publicly, for instance when individual privacy could be compromised, and in such instances data availability should still be stated in the manuscript along with any conditions for access.

Authors are also encouraged to preserve search strings on searchRxiv https://searchrxiv.org/ , an archive to support researchers to report, store and share their searches consistently and to enable them to review and re-use existing searches. searchRxiv enables researchers to obtain a digital object identifier (DOI) for their search, allowing it to be cited.

Data availability statements can take one of the following forms (or a combination of more than one if required for multiple datasets):

The datasets generated and/or analysed during the current study are available in the [NAME] repository, [PERSISTENT WEB LINK TO DATASETS]
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
All data generated or analysed during this study are included in this published article [and its supplementary information files].
The datasets generated and/or analysed during the current study are not publicly available due [REASON WHY DATA ARE NOT PUBLIC] but are available from the corresponding author on reasonable request.
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
The data that support the findings of this study are available from [third party name] but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of [third party name].
Not applicable. If your manuscript does not contain any data, please state 'Not applicable' in this section.

More examples of template data availability statements, which include examples of openly available and restricted access datasets, are available here .

BioMed Central strongly encourages the citation of any publicly available data on which the conclusions of the paper rely in the manuscript. Data citations should include a persistent identifier (such as a DOI) and should ideally be included in the reference list. Citations of datasets, when they appear in the reference list, should include the minimum information recommended by DataCite and follow journal style. Dataset identifiers including DOIs should be expressed as full URLs. For example:

Hao Z, AghaKouchak A, Nakhjiri N, Farahmand A. Global integrated drought monitoring and prediction system (GIDMaPS) data sets. figshare. 2014. http://dx.doi.org/10.6084/m9.figshare.853801

With the corresponding text in the Availability of data and materials statement:

The datasets generated during and/or analysed during the current study are available in the [NAME] repository, [PERSISTENT WEB LINK TO DATASETS]. [Reference number]

If you wish to co-submit a data note describing your data to be published in BMC Research Notes , you can do so by visiting our submission portal . Data notes support open data and help authors to comply with funder policies on data sharing. Co-published data notes will be linked to the research article the data support ( example ).

All financial and non-financial competing interests must be declared in this section.

See our editorial policies for a full explanation of competing interests. If you are unsure whether you or any of your co-authors have a competing interest please contact the editorial office.

Please use the authors initials to refer to each authors' competing interests in this section.

If you do not have any competing interests, please state "The authors declare that they have no competing interests" in this section.

All sources of funding for the research reported should be declared. If the funder has a specific role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript, this should be declared.

The individual contributions of authors to the manuscript should be specified in this section. Guidance and criteria for authorship can be found in our editorial policies .

Please use initials to refer to each author's contribution in this section, for example: "FC analyzed and interpreted the patient data regarding the hematological disease and the transplant. RH performed the histological examination of the kidney, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript."

Please acknowledge anyone who contributed towards the article who does not meet the criteria for authorship including anyone who provided professional writing services or materials.

Authors should obtain permission to acknowledge from all those mentioned in the Acknowledgements section.

See our editorial policies for a full explanation of acknowledgements and authorship criteria.

If you do not have anyone to acknowledge, please write "Not applicable" in this section.

Group authorship (for manuscripts involving a collaboration group): if you would like the names of the individual members of a collaboration Group to be searchable through their individual PubMed records, please ensure that the title of the collaboration Group is included on the title page and in the submission system and also include collaborating author names as the last paragraph of the “Acknowledgements” section. Please add authors in the format First Name, Middle initial(s) (optional), Last Name. You can add institution or country information for each author if you wish, but this should be consistent across all authors.

Please note that individual names may not be present in the PubMed record at the time a published article is initially included in PubMed as it takes PubMed additional time to code this information.

Authors' information

This section is optional.

You may choose to use this section to include any relevant information about the author(s) that may aid the reader's interpretation of the article, and understand the standpoint of the author(s). This may include details about the authors' qualifications, current positions they hold at institutions or societies, or any other relevant background information. Please refer to authors using their initials. Note this section should not be used to describe any competing interests.

Footnotes can be used to give additional information, which may include the citation of a reference included in the reference list. They should not consist solely of a reference citation, and they should never include the bibliographic details of a reference. They should also not contain any figures or tables.

Footnotes to the text are numbered consecutively; those to tables should be indicated by superscript lower-case letters (or asterisks for significance values and other statistical data). Footnotes to the title or the authors of the article are not given reference symbols.

Always use footnotes instead of endnotes.

Examples of the Vancouver reference style are shown below.

See our editorial policies for author guidance on good citation practice

Web links and URLs: All web links and URLs, including links to the authors' own websites, should be given a reference number and included in the reference list rather than within the text of the manuscript. They should be provided in full, including both the title of the site and the URL, as well as the date the site was accessed, in the following format: The Mouse Tumor Biology Database. http://tumor.informatics.jax.org/mtbwi/index.do . Accessed 20 May 2013. If an author or group of authors can clearly be associated with a web link, such as for weblogs, then they should be included in the reference.

Example reference style:

Article within a journal

Smith JJ. The world of science. Am J Sci. 1999;36:234-5.

Article within a journal (no page numbers)

Rohrmann S, Overvad K, Bueno-de-Mesquita HB, Jakobsen MU, Egeberg R, Tjønneland A, et al. Meat consumption and mortality - results from the European Prospective Investigation into Cancer and Nutrition. BMC Medicine. 2013;11:63.

Article within a journal by DOI

Slifka MK, Whitton JL. Clinical implications of dysregulated cytokine production. Dig J Mol Med. 2000; doi:10.1007/s801090000086.

Article within a journal supplement

Frumin AM, Nussbaum J, Esposito M. Functional asplenia: demonstration of splenic activity by bone marrow scan. Blood 1979;59 Suppl 1:26-32.

Book chapter, or an article within a book

Wyllie AH, Kerr JFR, Currie AR. Cell death: the significance of apoptosis. In: Bourne GH, Danielli JF, Jeon KW, editors. International review of cytology. London: Academic; 1980. p. 251-306.

OnlineFirst chapter in a series (without a volume designation but with a DOI)

Saito Y, Hyuga H. Rate equation approaches to amplification of enantiomeric excess and chiral symmetry breaking. Top Curr Chem. 2007. doi:10.1007/128_2006_108.

Complete book, authored

Blenkinsopp A, Paxton P. Symptoms in the pharmacy: a guide to the management of common illness. 3rd ed. Oxford: Blackwell Science; 1998.

Online document

Doe J. Title of subordinate document. In: The dictionary of substances and their effects. Royal Society of Chemistry. 1999. http://www.rsc.org/dose/title of subordinate document. Accessed 15 Jan 1999.

Online database

Healthwise Knowledgebase. US Pharmacopeia, Rockville. 1998. http://www.healthwise.org. Accessed 21 Sept 1998.

Supplementary material/private homepage

Doe J. Title of supplementary material. 2000. http://www.privatehomepage.com. Accessed 22 Feb 2000.

University site

Doe, J: Title of preprint. http://www.uni-heidelberg.de/mydata.html (1999). Accessed 25 Dec 1999.

Doe, J: Trivial HTTP, RFC2169. ftp://ftp.isi.edu/in-notes/rfc2169.txt (1999). Accessed 12 Nov 1999.

Organization site

ISSN International Centre: The ISSN register. http://www.issn.org (2006). Accessed 20 Feb 2007.

Dataset with persistent identifier

Zheng L-Y, Guo X-S, He B, Sun L-J, Peng Y, Dong S-S, et al. Genome data from sweet and grain sorghum (Sorghum bicolor). GigaScience Database. 2011. http://dx.doi.org/10.5524/100012 .

Figures, tables and additional files

See General formatting guidelines for information on how to format figures, tables and additional files.

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BMC Geriatrics

ISSN: 1471-2318

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Geriatric Case Study

Jan 04, 2020

230 likes | 421 Views

Geriatric Case Study. Patient Centered Care. Meet the patient. H.A 76 y/o white female Allergies: NKDA, NKFA Admitted to MSU on 6/27/15 for LEFT HIP FRACTURE Hospital day: 3 Post-op day: 1

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transfusion
blood loss secondary
significant blood loss anemia

Presentation Transcript

Geriatric Case Study Patient Centered Care

Meet the patient H.A 76 y/o white female Allergies: NKDA, NKFA Admitted to MSU on 6/27/15 for LEFT HIP FRACTURE Hospital day: 3 Post-op day: 1 PMHx: HTN, BLE DVT, splenic vein thrombosis, glaucoma, urinary retention, UTIs, acute kidney injury in the past, Morbitz type I AV block, significant blood loss anemia ? r/t nonbleeding rectal mucosa ulceration in Nov 2014, PE in Nov 2014 , history of mechanical fall with acute compression of L1 Psych Hx: Bipolar affective disorder, dementia Social Hx: non smoker, no alcohol consumption, one son, separated but lives with husband (primary care give)

Shift report, June 30 • Hospital day: 3, Post-op day: 1 • Comes from Summit Elder Care 2days/week • Oriented to person only and confused at baseline • Returned from surgery @ 1700 (June 29), sleepy and lethargic but easily arousable. • @ 0030 agitated, pulled out IV line, POX senor from finger, attempted to “jump out” of bed several times, and tried to pull the catheter out. 0.5 mg Haldol x1 dose was given. • H/H: 6.5/19.4. MD notified. Order: 3 units of PRBC • Heparin drip D/C @0530. Now SCDs only. • LS diminished. O2sat 94% on RA • NSR • D5NS @ 80ml/hr

The Injury • Pt ambulating barefooted to the bathroom • Entangled with the floor rug and had a fall • Found on the floor by the husband • Brought to ED for complains of left hip pain • No report of loss of consciousness or head trauma

Assesment • Neuro: A+O x1, oriented to person only, confused. • CV: No c/o chest pain. Skin pale, warm & dry, cap refill < 3sec. HR 68 irregular. BP 111/68. No edema, +PP bilat. Tele: NSR. • Resp: RR 18, regular, non-labored, no SOB noted. O2sat 95% on RA. LS diminished but clear bilaterally throughout. • GI: Abd soft, non-tender, non-distended. +BS x4Q. 2 small BMs • GU: Foley catheter, clear, yellow urine. Output: 240 ml/shift • MSK: slight muscle atrophy noted, LLE weakness noted. • INTEG: Skin intact, warm and dry. Incision sites intact. Left hip middle dsg w/ serosanguineous drainage. Dsg changed. Dsgs clean, intact, and dry.

Home Medications • Tylenol 5mg PO q6h PRN • Calcium 600+ D3 1 tablet PO daily • Aspirin 81 mg PO daily • MiraLAx PO daily PRN • Potassium chloride ER 20 mg PO daily • Depakote ER 500 mg PO BID • Aricept 5 mg PO daily • Effexor XR 75 mg PO daily • Lovenox 100 mg injection 1.5 mg/kg subcutaneously daily (slightly higher dose) • Olanzapine 10 mg PO daily @ night • Chlorthalidone 25 mg PO daily • Lorazepam 0.5 mg three times/day • meTOPROLOL 12.5 mg PO BID

Medications: A contributing factor? • Valproates (Depakote) ER 500 mg PO BID (Mood Stabilizer) • Dizziness, sedation, confusion, visual disturbances, tremor, ataxia • Donepezil (Aricept) 5 mg PO daily (dementia/AD) • Dizziness, drowsiness, fatigue, syncope, frequent urination • Venlafaxine (Effexor) XR 75 mg PO daily (depression/anxiety) • Dizziness, weakness, urinary frequency, urinary retention • Olanzapine(Zyprexa)10 mg PO daily @ night (Mood stabilizer) • Dizziness, agitation, delirium, restlessness, sedation, speech imparment, tardive dyskinesia , urinary incontinence • Chlorthalidone 25 mg PO daily (HTN) • Dizziness, drowsiness, lethargy, weakness, hypotension, hypokalemia • Lorazepam (Ativan) 0.5 mg three times/day (Anxiety) • Dizziness, drowsiness, lethargy, weakness • meTOPROLOL 12.5 mg PO BID (HTN) • Dizziness, drowsiness, lethargy, weakness, hypotension, urinary frequency

Diagnostics Labs (on admission, 6/27): WBC: 8.5 RBC: 3.94 HGB: 12.7 HCT: 37.7 PLT: 157 Na: 140 K: 3.9 Cl: 106 Ca: 9.1 Mg: 1.8 BUN: 28 Creat: 0.99 Labs 6/30 (post-op day 1) WBC: 5.7 RBC: 2.03 HGB: 6.5 HCT: 19.4 PLT:136 Na: 142 K: 3.1 Cl: 109 Ca: 7.8 Mg: 1.6 BUN 16 Creat: 0.89

Orders • 3 units of PRBC • Potassium chloride 40mEq PO q4h x2 doses • Potassium chloride 40 mEq IV once (infuse 10 mEq over 1 hr) • Magnesium sulfate 1 g in D5W IV once • D5NS @ 80 ml/hr • Flurosemide (Lasix) 20 mg IV push one time after the second unit of PRBC.

Elder care considerations • Acute Delirium • Risk for Falls • Polypharmacy • Self care deficit • Care giver needs

Nursing Diagnosis • Fluid and Electrolyte imbalance r/t blood loss secondary to surgical procedure. • Risk for injury r/t delirium, confusion, wandering, and incontinence. • Self-care deficit (i.e. feeding, ADL performance) r/t cognitive and physical impairment. • Caregiver role strain r/t progression of chronic debilitating disease process

NCLEX QUESTIONS

1. A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take when there is a transfusion reaction? (Select all that apply) • Stop the transfusion • Send the blood bag and IV tubing to the blood bank • Maintain an IV infusion with 0.9% sodium chloride • Elevate the client’s feet • Obtain blood culture

Answer 1 • The first action is to stop transfusion • The blood bag and IV tubing are send to the lab for analysis • 0.9% sodium chloride should be administered through new IV tubing

2. A nurse is providing teaching to the partner of an older adult client who had dementia and has a new prescription for donepezil (Aricept). Which of the following statement by the partner indicates the teaching is effective? • “This medication should increase my wife’s appetite.” • “This medication should help my wife sleep better.” • “This medication should help my wife’s daily function.” • “This medication should increase my wife’s energy level.”

Answer 2 C. Donepezil helps slow the progression of dementia/AD and may help improve behavior and daily functions.

3. A nurse is making a home visit to a client who has dementia. The client’s husband states that the client is often disoriented to time and place, is unsteady on her feet, and has a history of wandering. Which of the following safety measures should the nurse review with him? (Select all that apply) • Remove floor rugs. • Have door locks that are easily opened. • Provide increased lighting in stairwells. • Install handrails in the bathroom. • Place the mattress on the floor.

Answer 3 A, C, D, E

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Presentation Transcript. Geriatric Case Study Patient Centered Care. Meet the patient H.A 76 y/o white female Allergies: NKDA, NKFA Admitted to MSU on 6/27/15 for LEFT HIP FRACTURE Hospital day: 3 Post-op day: 1 PMHx: HTN, BLE DVT, splenic vein thrombosis, glaucoma, urinary retention, UTIs, acute kidney injury in the past, Morbitz type I AV ...
Geriatric Case Presentation
GERIATRIC CASE PRESENTATION - Free download as Word Doc (.doc / .docx), PDF File (.pdf), Text File (.txt) or read online for free.

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Geriatric Clinico-Social Case in Community Medicine

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Urgent community response in Dorset: A case study

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MidMed: A General Practitioner-led intervention for people living with moderate to severe frailty in Midlothian, Scotland

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The 12 Ds of geriatric medical-psychiatry: A new format for geriatric case presentation

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The 12 Ds of Geriatric Medical-Psychiatry

Table 1. 12 D s of Geriatric Medical-Psychiatry.

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