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Table of Competency Fellowship Curriculum Milestones

Caring for the Elderly Patient

Chapters in the 7th Edition

Caring for the Elderly Patient–Communication

7, 9, 27, 28, 30, 55, 58, 60

1. Practice culturally sensitive shared decision-making with patients and families/caregivers in the context of their health literacy, desired level of participation, preferences and goals of care.

14, 15, 21, 26

2. Work effectively as a member or leader of an interprofessional health care team.

38, 39, 66, 74

3. Use strategies to enhance clinician-patient oral and written communication in patients with hearing, vision, or cognitive impairment.

9, 30, 33, 55, 58, 59, 61

4. Skillfully discuss and document goals of care and advance care planning with elderly individuals and/or their families/caregivers across the spectrum of health and illness.

12, 30, 31, 61

5. Assess patients for capacity to make a specific medical decision and, if lack of capacity is determined, identify strategies and resources for decision-making, including guardianship.

7, 9

6. Provide compassionate care while establishing personal and professional boundaries with patients and families/caregivers.

9, 55, 58

7. Effectively lead a family/caregiver meeting.

Caring for the Elderly Patient–Gerontology

1, 2, 3, 4, 5

8. Demonstrate current scientific knowledge of aging and longevity, including theories of aging and epidemiology of aging populations.

8, 38, 39, 40, 41, 43, 44, 45, 62, 63, 75, 83, 86, 89, 90, 91, 103, 104, 108, 110, 111, 113, 115

9. Describe the primary physiologic changes of aging of each organ system and their clinical implications, including how they may impact lab findings.

Caring for the Elderly Patient–Medication Management

17, 24, 24, 56, 64

10. Demonstrate expertise in medication management by justifying medication regimen and duration based upon:

  1. age-related changes in pharmacokinetics and pharmacodynamics.

  2. maximizing medication adherence.

  3. the common lists of medications that should be avoided or used with caution in older adults.

  4. a consideration of the reported benefits and known and unknown risks when prescribing a newly-released medication, realizing that older adults with multimorbidities are often underrepresented in clinical trials.

10, 24, 25

11. When a patient presents with a new symptom or geriatric syndrome, investigate whether a medication(s) is contributing.

25, 55, 56, 122, 124

12. Individualize pain control utilizing the most effective pharmacologic and nonpharmacologic strategies based on the etiology and chronicity of the patient's pain.

25, 55, 56

13. Prescribe pain medications with instructions and methods to prevent common complications including constipation, nausea, fatigue and opioid toxicity (myoclonus and hyperalgesia), using equianalgesic dosing conversion and opioid rotation when needed.

Caring for the Elderly Patient–Functional Impairment and Rehabilitation

10, 16, 21, 29, 33, 36, 38, 39, 114, 115, 116, 117

14. Know the indications and contraindications for referring patients to physical, occupational, speech or other rehabilitativetherapies, and refer if appropriate.

29, 116

15. Know indications for durable medical equipment, prescribe and evaluate for appropriate use.

11, 18, 24, 26, 29, 33, 36, 48, 65, 114, 116, 119

16. Recognize and manage the care of patients at high risk for poor outcomes from common conditions such as deconditioning, stroke, hip fracture, and dysphagia.

Caring for the Elderly Patient–Diseases in Older Adults

Part V

17. Identify and manage medical disorders that occur in older adults.

33, 77, 82, 86, 109, 118, 125, 126, 127, 128, 129, 130

18. Know the different presentation, management and underlying pathophysiology of common diseases in older adults (including but not limited to: hypertension, coronary artery disease, osteoporosis, hypothyroidism, infections, and the acute abdomen; adjusting drug dosage for renal function).

3, 13, 24, 96, 97, 98

19. Know the national guidelines for preventive care, adjust as appropriate for clinical circumstances or patient preferences, and document reasons if these guidelines are not followed.

20. Recognize the limitations of the evidence base and critically review the medical literature for studies that are valid and applicable to the care of older adults.

Caring for the Elderly Patient–Complex Illness (es) and Frailty in Older Adults

10, 16, 33, 46, 58, 96, 99, 101, 119, 125

21. Identify patients who are frail or otherwise at risk for death, dependency and/or institutionalization over the next few years.

9, 10, 31, 55, 99, 105, 110

22. Demonstrate the ability to manage the care of patients with multimorbidities by integrating the evidence, patient's goals, life expectancy and functional trajectory. Document clinical reasoning when management differs from standard treatment recommendations.

7, 27, 41, 55

23. Demonstrate the ability to manage psychosocial aspects of the care of older adults including interpersonal and family relationships, living situations, adjustment disorders, bereavement, and anxiety.

7, 16, 21, 22, 54, 55, 74

24. Assess and incorporate family/caregiver needs and limitations, including caregiver stress, into patients' management plans.

10, 22, 24, 25, 26, 34, 36, 37, 46, 116

25. Provide geriatric consultation in all settings with attention to multimorbidity, age-related changes in physiology, function, treatment efficacy and response, medication management and psychosocial issues.

10, 55, 66, 79, 84, 85, 88, 110, 128

26. Regularly re-assess goals of care to recognize patients likely to benefit from palliative and/or hospice care, including those with non-cancer diagnoses (e.g, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Dementia).

Caring for the Elderly Patient–Palliative and End of Life Care

16, 18, 55, 56, 57, 58, 59, 60, 61, 99

27. Counsel patients and families/caregivers about the range of options for palliative and end of life care.

27, 55, 57, 79, 84, 85, 99

28. Assess, manage, and provide anticipatory guidance for patients and families/caregivers for common non pain symptoms during severe chronic illness or at the end of life.

Systems-Based Care for Elder Patients

Systems-Based Care for Elderly–General

16, 17, 18, 19, 20, 31, 35, 47, 48, 51, 52, 53, 87, 114, 115, 119, 125, 127

29. Reduce iatrogenic events among elders in all settings through implementation of patient-specific and system-wide strategies to prevent falls*, immobility, delirium*, pressure ulcers*, incontinence*, malnutrition*, indwelling catheter use, nosocomial infections, deep vein thrombi, restraints, depression*, functional decline*. (NB: asterisk indicates additional competencies in syndromes or functional impairment section.)

14, 15, 16, 17, 19, 20, 21, 29, 59

30. Demonstrate expertise in transitions of care byidentifying, with the interprofessional team, the most appropriate care setting(s) for a patient, including independent living, assisted living, long-term care, acute rehabilitation , subacute rehabilitation, home care, primary care at home, adult day care, Program of All-Inclusive Care for the Elderly (PACE)-like program, and hospice based on the needs and preferences of the patient and families/caregivers, and the admission and payment requirements for each setting.

15, 16, 17, 18, 19, 20, 21

31. Demonstrate expertise in transitions of care by communicating the following to the receiving provider through discussion or timely discharge summary: medication reconciliation, an assessment of patient’s cognition and function, pending medical results and follow-up needs .

23, 127

32. Demonstrate knowledge of commonly accepted geriatric quality indicators.

23

33. Participate in quality improvement efforts to enhance the quality of care of older adults.

14

34. Describe the services provided by Medicare Parts A, B and D, the Hospice Benefit, and by Medicare and Medicaid for patients who are "dual eligible," including the basics of the patient’s fiscal responsibility for each.

21, 22, 27

35. Identify patient and family/caregiver needs and refer to appropriate local community resources.

27, 54

36. Recognize and document signs of elder abuse and/or neglect and refer to community resources and adult protective services when appropriate.

9, 10, 13

37. Recognize the complexity of geriatric care and demonstrate the ability to prioritize care, in a time-efficient manner, during encounters with geriatric patients

22, 23, 27

38. Serve as an advocate for older adults and caregivers within various healthcare systems and settings.

23, 125

39. Recognize health-care system issues that negatively impact the care of the geriatric patients, and identify improvement strategies.

28

40. Demonstrate the ability to teach patients, caregivers and others about aging-related healthcare issues.

14, 15, 16, 21, 26, 47, 48

41. Describe models of care that have been shown to improve outcomes for older adults, e.g., ACE Units, PACE, multifactorial interventions to prevent falls, delirium prevention.

System-Based Care–Hospital Care

16, 17, 18, 19, 20, 31, 35, 47, 48, 51, 52, 53, 87, 114, 115, 119, 125, 127

42. Reduce iatrogenic events (see System-Based CareBC General #29)

18, 33, 47

43. Recognize common and subtle presentations of delirium and manage appropriately.

31, 32, 33

44. Perform pre-operative assessments for older patients and document specific peri-operative management recommendations to improve patient care and safety based on type of surgery and patient characteristics.

System-Based Care–Ambulatory Care

9, 10, 22, 27, 31, 38, 39, 116

45. Perform and interpret an outpatient geriatric assessment, and develop a management plan that includes appropriate consultation with and referrals to other disciplines and community based resources.

38, 61, 66

46. Recognize patients who are at risk for hazardous driving, identify strategies to reduce risk, and integrate state and local laws into the management plan.

System-Based Care–Home Care

21, 22

47. Perform home visits, demonstrate modification of the physical exam for the home setting, and assess physical safety of the environment.

15, 21, 37

48. Refer patients to appropriate home health and support services to maximize ability to remain in their homes.

System-Based Care–Long-Term Care and Nursing Home Care

19, 20, 24, 35, 36, 37, 66

49. Individualize l ong-term care patient management considering prognosis, comorbidity, patient and caregiver goals, and available resources especially in the following situations: (a) consideration for transfer to the acute care hospital; (b) weight loss, dehydration, swallowing disorders; (c) agitation and problem behaviors.

14, 19, 20

50. Describe the role of a long-term care medical directorand demonstrate an understanding of nursing home and long-term care regulations and requirements, including the minimum data set.

20

51. Manage acute problems in long-term care via telephone call.

Geriatric Syndromes

Geriatric Syndromes–Falls and Dizziness

10, 11, 48, 114, 116

52. Perform and interpret common gait and balance assessments, recognizing abnormal gaits associated with specific conditions.

17, 29, 48, 114, 115, 116, 118, 119

53. Conduct an appropriate evaluation of patients who fallor are at risk for falling, implement strategies to reduce future falls, fear of falling, injuries, and fractures, and follow up on referrals.

17, 50, 51

54. Evaluate, manage, and refer (when appropriate) patients with symptoms of dizziness or lightheadedness, differentiating among those with single or serious causes and those that are multifactorial.

Geriatric Syndromes–Cognitive, Affective, and Behavioral Health

11, 12, 33, 47, 63, 66, 69

55. Distinguish the clinical presentation and prognosis of changes in cognition and/or affect among people with normal aging, mild cognitive impairment, dementia, delirium, and depression.

10, 12, 66, 73

56. Perform, interpret, and articulate the strengths and limitations of the commonly used cognitive and mood assessment tools.

47, 73, 74

57. Identify clinical situations where a psychiatric referral, psychological counseling, or neuropsychological assessment is indicated and integrate the findings into the patient's plan of care.

11, 12, 47, 63, 66

58. Diagnose and manage the potentially reversible/treatable causes of cognitive and affective changes in older adults.

66, 71, 73, 74

59. Identify and manage depression.

66, 67, 68, 69, 74, 128

60. Diagnose and manage the causes of dementia, including Alzheimer's disease, vascular dementia, Lewy body dementia, dementia of Parkinson's Disease, alcoholic dementia, frontotemporal dementia, Creutzfeldt–Jakob Disease and Normal Pressure Hydrocephalus as well as other rare causes. Recognize and appropriately refer ambiguous cases for further evaluation.

20, 24, 66

61. Care appropriately for patients at each stage of dementia (mild, moderate or severe) and provide anticipatory guidance based on prognosis and their goals of care.

66, 74

62. Assess and manage cognitive, functional, and disruptive behavioral manifestations of dementia, both behaviorally and pharmacologically.

Geriatric Syndromes–Pressure Ulcers

52

63. Recognize patient risk factors for pressure ulcers, and in high risk patients work with an interprofessional team to develop a prevention plan.

52

64. Stage pressure ulcers and demonstrate proficiency in describing their clinical characteristics (e.g., size, color, exudate).

52

65. Develop a treatment plan for pressure ulcers with an interprofessional team, incorporating the indications for surgical and non-surgical treatments for ulcers (e.g., debridement, classes of wound care products and treatments, pressure relieving devices, etc.).

Geriatric Syndromes–Sleep Disorders

25, 49, 108

66. Provide initial evaluation and management of insomnia and other sleep disorders and, when indicated, refer to a sleep specialist.

Geriatric Syndromes–Hearing and Vision Disorders

39

67. Screen for hearing loss and recognize when referral is appropriate.

38

68. Recognize common ophthalmologic conditions associated with aging, including changes of normal aging, cataract, glaucoma, age-related macular degeneration, and refer when appropriate to ophthalmology, optometry and/or low vision services

Geriatric Syndromes–Urinary Incontinence

10, 53

69. Evaluate and treat the most common forms of both reversible and chronic urinary incontinence using nonpharmacological interventions where possible.

41, 42, 44, 53

70. Refer when appropriate for urologic or gynecologic evaluationincluding urodynamic testing, pessary evaluations, pelvic floor muscle training.

16, 19, 20, 44, 53, 127

71. Evaluate and manage urinary retention and incomplete bladder emptying including the appropriate use of intermittent catheterization or indwelling bladder catheters.

Geriatric Syndromes–Weight Loss and Nutritional Issues

10, 34, 35, 46

72. Identify and appropriately evaluate and manage involuntary weight loss.

25, 35, 36

73. Discuss with patients and families/caregivers the risks and benefits of appetite stimulants, nutritional supplementation, enteral tube feeding, and parenteral nutrition, particularly in patients with advanced dementia or near end-of-life.

36, 90

74. Identify swallowing disorders in patients with involuntary weight loss or recurrent pneumonias, and work with an interprofessional team to evaluate, manage, and educate patient and caregiver(s) based on goals of care.

Geriatric Syndromes–Constipation and Fecal Incontinence

95

75. Evaluate and manage constipation and fecal impaction using nonpharmacological and pharmacological modalities.

53

76. Provide initial evaluation and management of fecal incontinence.

From Parks SM, Harper GM, Fernandez H, Sauvigne K, Leipzig RM. American Geriatrics Society/Association of Directors of Geriatric Academic Programs curricular milestones for graduating geriatric fellows. J Am Geriatr Soc. 2014 May;62(5):930-5. doi: 10.1111/jgs.12821. Epub 2014 Apr 18.

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