Adult and Geriatric Medicine- AGM 1 Past Paper PDF

Adult and Geriatric Medicine- AGM 1 Introduction to the Course Laura Wylie, MPAS, PA-C [email protected] AGM Course Overview Over the next year, we hope to apply our evidence-based...

Adult and Geriatric Medicine- AGM 1 Introduction to the Course Laura Wylie, MPAS, PA-C [email protected] AGM Course Overview Over the next year, we hope to apply our evidence-based medical knowledge to further our skills in caring for adults and elderly patients.  LEARN THE DO WEEKLY READINGS TAKE WEEKLY What is OBJECTIVES IN THE SYLLABUS AND ASSIGNMENTS BEFORE CLASS FORMATIVE QUIZZES IN LEARN required of you? PARTICIPATE IN TAKE WEEKLY NOTES DISCUSSION IN CLASS FOR STUDYING The Course Grading Evaluations: Weekly formative quiz on LEARN-for practice (no points) Two summatives- 100% of grade Questions?  Readings- Module 1 Tatum III, P., Talebresa, S, Ross, J., Geriatric Assessment: An Office-Based Approach. AAFP. (97) 12. Hansmann KJ. Medicare 101: Navigating the Rules for Coverage and Benefits in Clinical Practice. Fam Pract Manag. 2022 Jan-Feb;29(1):21-25. PMID: 35014774. https://www.cdc.gov/mmwr/volumes/65/wr/mm6537a2.htm CDC STEDI- Stay Independent, Falls algorithm, Timed Get Up and Go Katz Index of Independence in Activities of Daily Living (ADL) Lawton Instrumental Activities of Daily Living (IADL) AGS 2023 BEERS Pocket Guide Adult Preventive Health Care Schedule  Course Rationale Aging- “If it’s not your problem now, it will be.” You get old and then you die live…. Objectives Understand the outline of the AGM course Module 1 – Comprehensive Geriatric Assessment 1. Identify the core components of the comprehensive geriatric assessment. Module 1 2. Explain the importance of knowing and describing a patient's functional, cognitive, and medical baseline. Module 1 3. Identify ways to determine functional, cognitive, and medical baselines for older adults. Module 1 4. Explain how to administer, score, and interpret the results of a Get Up and Go test. Module 1 5. Evaluate what contributes to fall risk. Module 1 6. Define what constitutes fall risk and develop appropriate patient evaluation of high-risk patients. Module 1 7. Determine strategies to improve patient safety by reducing fall risk. Module 1 8. Compare and contrast competency vs capacity as it applies to consent for medical care. Module 1 9. Identify potential members of an interprofessional health care team, and explain each member’s role in patient care and resources available in New Mexico. Module 1 10. Distinguish common presenting symptoms of common cancer types in primary care. Module 1 11. Apply the USPSTF guidelines for cancer screening to patient case scenarios for breast, prostate, lung, cervical, and colon cancer among older adults. Module 1  What is your definition of “elderly”? WHO definition of geriatric populations: elderly: 65 to 75 years of age old: 76 to 90 years of age very old: 90+ years of age Rural New Mexico Demographics Population characteristics – 2.1 million people in 121,365 sq mi (16/sq mi) 33 counties total/ 32 medically underserved – 67% New Mexico residents live in rural areas – 15.8% are over 65 (~33,000) – #3 state in nation in poverty statistics Median Household income $47,169 20.6% live in poverty (13.1% is the national average) – Expect 21% increase in NM elderly by 2025 (~40K) Nationally only 9.1% increase by 2025 Catron and Sierra counties have 30-40% elderly  National Demographics 31% of all office visits for patient >65 years of age Elderly @ 22% USA population by 2030 Life expectancy at age 65 Women 84; independent to 79 Men 80; independent to 78 The Geriatric Imperative: Our medical system is unprepared for the impending aging population (Silver Tsunami)- an urgent issue! – Substandard housing – Low income & isolated – Inadequate nutrition – Unable to afford Rx – Uneducated consumer of healthcare Poverty in NM Elderly Philosophy: Mission UNM PA Program Mission: “Educate PAs ….primary care practice…medically underserved…&…rural areas…New Mexico.” Course Content Adult Medicine “The general rule” Geriatrics Generally, “the exception” Compare & contrast to geriatric Challenge: need to know the rule before learning the exceptions to the rule  Unique Aspects of Elder Care Ambulatory v. Home. v. Institutional Care Curative v. Palliative Care Multiple Co-morbid disorders Patient safety Polypharmacy/ Pharmacokinetics Where are the elderly ? a) Assisted Living Facility b) Nursing Home c) Independently Living d) Living with Family Where are the elderly ? (2010) Age Community Dwelling Institutions 65 - 75 95-99% 1% >85 85% 15% Case Scenario- 45-year-old male comes to his PCP for a wound on his leg from falling 1 week ago. What is your problem list for this patient? 1. 1 week ago- possible infection 2. Tetanus Status What further questions do you want to ask? 1. How did you fall? 2. Are you on any medications? 3. Does it hurt? - Remainder of 7 dimensions Case Scenario- 75 year old male comes to his PCP for a wound on his leg from falling 1 week ago. What is your problem list for this patient? 1. 1 week ago- possible infection 2. Tetanus Status 3. 75 year old What further questions do you want to ask? 1. How did you fall? 2. Are you on any medications? 3. Does it hurt?- Remainder of 7 dimensions 4. Where you able to get up on your own? 5. Do you use an assistive device 6. Have you fallen in the last year? Comprehensive Geriatric Assessment (CGA) is used to address the special needs of the Geriatric population. 6 Core Components: Data gathering Team discussion Development of the treatment plan Implementation of the treatment plan Monitoring Comprehensive Geriatric Assessments requires an interdisciplinary team to complete effectively. 1. Data gathering- Typically MA and nurse help collect data to be evaluated by the provider. Provider will continue data collection and determines if additional evaluation is warranted. 2. Team discussion- Once additional assessments are completed team discusses/evaluates needs from the team. 3. Development of the treatment plan- Typically completed by provider and is prioritized based on the needs from the team discussion. 4. Implementation of the treatment plan- Referrals made, medications prescribed, patient education, resources engaged 5. Monitoring- Follow-up with provider to track progress for each recommendation The more data collected the easier the assessment and treatment. Past Medical History- How far back do you go? Medications/ Medication Review (BEERS Criteria, multiple providers) Social History- Occupation, finances Depression Screening- PHQ2, PHQ9, GDS (will cover in Neuro) ADLS IADLS Falls/ Gait Incontinence- Bowel or Bladder Nutritional Status Vitals- Focus on weight, height, BP Cognitive (will cover in Neuro) Get Up and Go Test Review USPTF recommendations specific to patient Advanced Care planning Medications Medications– match Problem List? “brown bag” approach multiple providers BEERS Criteria- See handout medication allergies/list side effects In Geriatrics, function is a primary focus of the visit. Instrumental Activities of Daily Living Activities of Daily Living (ADL’S) (IADL’S) Personal Care Shopping Continence Finances Mobility Telephone Feeding Driving Cooking Housekeeping There are multiple screening tools designed specifically for the elderly to help you screen for the Geriatric Syndromes. Nutrition Frailty Pressure ulcers Incontinence Syncope Falls Dizziness / Vertigo Delirium Sleep Disorders Abuse There are multiple screening tools designed specifically for the elderly to help you screen for the Geriatric Syndromes. What do you think the number one cause of death in the elderly? Falls are leading cause of injury and death in the Elderly ▪ Every second of every day in the US an elder falls (less than half will admit it) ▪ In 2014 it caused 7 million injuries costing Medicare $31 billion in annual costs. ▪ 50% of deaths from falls are from Traumatic Brian Injury ▪ In 2013, ER departments treated 2.5 million nonfatal fall injuries among older adults; more than 700,000 of these patients had to be hospitalized, 250,000 hip fractures. In New Mexico (2012): Falls are third-leading cause of unintentional injury-related death for all ages Per stats: NM has 3rd highest rate in US, 1.8 times higher than national average 68% occurred at home Increasing age = Increased risk for death (>85 yo 3X more likely) Falls Assessment- essential for the development of an effective treatment plan. Risk factors- History of falls LE weakness Age Female Cognitive impairment Balance (dizziness) Psychotropic drugs Arthritis Orthostatic HTN Anemia Hearing loss Visual impairment Increased # of chronic disease Falls Assessment- essential for the development of an effective treatment plan. Timed Get Up and Go Physical Exam- Orthostatic HTN Visual Acuity- corrected or not? Hearing Extremities- deformities Neuro Diagnostics- CBC, Vit D, Cardiac if indicated (ECG, ECHO)  Fall prevention utilizing a multidisciplinary team is the best treatment. Prescription drugs- Educate your patient, Impaired gait/balance- Tai Chi, PT/OT Management and Reconciliation Muscle Weakness- Regular Exercise Mental Confusion- Diagnose Reduced Vision and depth perception- and Treat cause Regular eye exams Patient’s rarely discuss incontinence unless they are asked. How do you ask? In the past year, have you ever lost your urine or gotten wet? Have you ever not been able to make it to the bathroom in time? Mal-nutrition is often a hidden cause of falls and decline. Vitals Weight- specifically weight change over time BP- Orthostatic BP HR- irregularity, palpitations Saturations- lunch disease undiagnosed Cognitive impairment can be difficult to recognize. MMSE MOCA Min-Cog We will cover the specifics in Neuro….. Capacity vs Competency Capacity is defined as an Competence is a legal state: individual's ability to make an degree of mental soundness to informed decision (medical). Any make decisions about a specific licensed provider may make a issue. Incompetence is defined determination of capacity. An by one's functional deficits that individual who lacks capacity to the person cannot meet the make an informed decision or demands of specific decision- give consent may need to be making, weighed in light of its referred for a competency potential consequences. Only a eval/hearing. court can make a determination of incompetence. Case 1 Mrs. Alcorn is 89 and has dementia. She lives in Manzano del Sol nursing home and requires 24 hour supervision. You received a call from the nurse stating that they are administering flu vaccines for all residents but Mrs. Alcorn won’t allow them to administer hers. She has told the nurse that she does not want the flu vaccine. Can she refuse the vaccine? Is this competency or capacity? Case 2 Mr. Walden is 78 and his MMSE score is 16/30. His daughter wants a letter stating that her father has dementia so that she can access his bank accounts to pay his mortgage and bills. In talking with Mr. Walden, he does not remember that he has a bank account and cannot tell you what bank he uses. He states it is OK for his daughter to ‘do whatever she wants.’ Can you write this letter to give his daughter access to his money? Is this competency or capacity? USPTF screening guidelines are used to prevent major illness before symptoms are present. Understanding the USPSTF recommendations requires that you understand the grading system.  Cancer Biggest Risk Factor Epidemiology- 60% of new cancer and 70% of cancer death is in people >65 years old Theories of cancer risk: Why do we get cancer? Initial presentation is often and excuse for the aging process. Advanced Care Planning should be one of the first discussions you have with the patient. DNR/DNI Advanced Directives- Who, when, exceptions POA- more than one or an alternate, anyone you do not want to make decisions Priorities: What matters to you? What brings joy? What do you look forward to? Covered in greater detail in Module 4. Review the components of the CGA Past Medical History- How far back do you go? Medications/ Medication Review (BEERS Criteria, multiple providers) Social History- Occupation, finances Depression Screening- PHQ2, PHQ9, GDS (will cover in Neuro) ADLS IADLS Falls/ Gait Incontinence- Bowel or Bladder Nutritional Status Vitals- Focus on weight, height, BP Cognitive (will cover in Neuro) Get Up and Go Test Review USPTF recommendations specific to patient Advanced Care planning Other diagnostic tests that might be useful in the development of a plan. Labs/Imaging: Baseline- ECG, Chest x-ray Drug levels RPR Albumin Pre-Albumin Homocysteine Vitamin B12 Vitamin D You are seeing a 68 yo female with a 20 pack year history of smoking. She is otherwise healthy. You would like to screen her for cardiovascular risk. Which lab would best help you determine her cardiovascular risk? a) RPR b) Homocysteine c) Albumin d) Vitamin D e) Vitamin B12 Assessment and Plan is multidisciplinary with ultimate focus on quality of life based on patient’s goals. Areas of Concern Diagnosis : categorize by severity & impact Medications: align with diagnosis, consider polypharm, compliance, $$ What concerns you? What concerns patient/ family? Prognosis Assessment and Plan is multidisciplinary with ultimate focus on quality of life based on patient’s goals. Recommendations, by disease or functional state Discuss Patient’s/Family’s desires for care Goals: function, independence, comfort “Negotiated” plan of care document the agreed upon plan “Shared Decision-Making” Questions?