a geriatrics curriculum for emergency medicine training programs

ORIGINAL CONTRIBUTION curriculum, geriatrics; education, geriatrics, curriculum; emergency medicine, residency training, geriatrics; residency t~aining, emergency medicine, geriatrics

A Geriatrics Curriculum for Emergency Medicine Training Programs

The growing number of elderly in the United States will continue to in- crease the demand for emergency services. Although the emergency medicine core curriculum, as defined by the American College of Emergency Physicians, requires mandatory training in pediatrics, there is no mention of geriatric care. A special body of knowledge regarding normal aging as well as the special presentation of disease in the elderly is required to provide optimum care for the aged patient. We present an integrated geriatric curriculum designed to operate within a three-year emergency medicine residency program. This curriculum identifies specific educational objectives for training in geriatric emergencies that can be summarized as follows: identify those impairments and functional disorders that often complicate diagnosis and therapy; acquire an understanding of how physiologic changes in aging affect normal laboratory and radiologic values; develop knowledge of drug side effects and interactions in this population; understand and treat the group of disease peculiar to the elderly; recognize diseases and injuries that present a different clinical picture in old age; and differentiate and treat common psychosocial emergencies in the elderly. These educational objectives are further defined using a specific interlinked framework of didactic presentations, journal clubs, case conferences, therapeutic audits, formal rotations, and consultants. This format will provide valuable educational ex- periences for the emergency medicine resident and may strengthen positive attitudes toward geriatric medicine. [Jones J, Dougherty J, Cannon L, Schel- ble D: A geriatrics curriculum for emergency medicine training programs. Ann Emerg Med November 1986;15:1275-1281.]

INTRODUCTION In 1909, when IL Nascher introduced the term "geriatrics," a newborn

child could expect to live approximately 48 years. 1 Today, 25 million Ameri- cans, or 11% of the population, are over 65. 2 By the year 2030, that figure is predicted to reach 9.0%. 3 This demographic change gains significance when one realizes that even today our relatively small geriatric population oc- cupies more than 33% of acute hospital beds and buys one-quarter of all drugs consumed. 4

This growing geriatric population will result in increased demands for health care services, particularly emergency medical care. As changes come about in the public funding of health care (ie, diagnostic-related groups [DRGs]) the elderly will turn to the emergency department for primary as well as crisis care.2, s In addition, the emergency physician may increasingly play a gatekeeper role in the distribution of acute and long-term health services to elderly patients. Better trained professional and support personnel will be needed to provide these services effectively and economically. The American Geriatrics Society, the Institute of Medicine, and the Association of American Medical Colleges have recommended that appropriate actions be taken for better preparation of future practitioners to render health care to the growing elderly populationJ

A review of the emergency medicine core content developed by the Gradu- ate/Undergraduate Education Committee of the American College of Emer- gency Physicians 6 reveals no specific requirements for geriatric care skills. Furthermore, only three articles on the subject of geriatric emergency care have appeared in Annals of Emergency Medicine in the past five years.7 ;9

Jeffrey Jones, MD James Dougherty, MD, FACEP Louis Cannon, MD Daniel Schelble, MD, FACEP Akron, Ohio

From the Department of Emergency Medicine, Akron General Medical Center, Northeastern Ohio Universities College of Medicine, Akron, Ohio.

Received for publication May 13, 1986. Accepted for publication July 8, 1986.

Address for correspondence: Jeffrey Jones, MD, Department of Emergency Medicine, Akron General Medical Center, 400 Wabash Avenue, Akron, Ohio 44307.

15:11 November 1986 Annals of Emergency Medicine 1275/31

GERIATRICS CURRICULUM Jones et al

The American Medical Student As- sociation's Task Force on Aging has stated that, "The failure to expose the student to the special health care needs of the elderly in the same sys- tematic fashion that pediatrics in- structs in the fundamentals of child- hood results in an approach to health care that draws a line between growing up and growing old. "1o

The health needs of the elderly are sufficiently different from those of younger patients to require special knowledge and skills on the part of physicians.8, u The resident physician must become familiar with the current body of'knowledge regarding normal aging as well as the atypical presentation of disease in the elderly. We present a proposed integrated geriatrics curriculum designed to operate within a three-year emergency medicine residency program. Specific educational objectives are identified for training in geriatric emergencies.

OBJECTIVES The first step in preparing the com-

prehensive geriatrics curriculum was a review of more than 30 articles from existing family practice and internal medicine programs. However, few programs have attempted to reflect the skills and knowledge of acute geriatric care. Joint planning sessions were organized between a group of experi- enced teachers of emergency medicine and emergency medicine residents to identify those educational objectives necessary for training in geriatric emergencies (Table 1). The first three objectives concern the clinical aspects of aging: physiological changes, diag- nost ic testing, and altered pharmacokinetics. The remaining objectives deal with disease states in the elderly. These six objectives then were further defined using a framework of specific topics or subject areas (Table 2). Topics were chosen because they reflected a survey of needs perceived by the residents and faculty members and dealt with subject areas not adequately covered by other aspects of the training program.

The first objective focused on the physical impairments and functional disorders common with aging. The clinician should have the knowledge and skills to dist inguish between aging and the diseases associated with aging. 12 Physiological changes associated with growing old become ap- parent after age 30 and have a direct

TABLE 1. Educational objectives

1. Identify and assess physical and functional impairments common with aging (three hours)*

2. Understand how physiological changes in aging affect diagnostic testing (two hours)

3. Knowledge of the altered pharmacokinetics in elderly patients and its role in toxicology (three hours)

4. Understand and treat the group of diseases peculiar to the elderly (six hours)

5. Recognize certain diseases and injuries that present a different clinical picture in old age (ten hours)

6. Differentiate and treat common psychosocial emergencies in the elderly (four hours)

*Approximate conference time necessary to adequately cover the educational objective.

bearing on the patient's lifestyle, the diagnosis of disease, and the patient's response to the stress of illness. 12 Preservation of function is of particular concern to older persons. Thus history taking and physical examination should include not only the detection of disease, but also functional assessment. 12

Appropriate use of diagnostic testing, such as ECGs, radiographs, and laboratory tests, requires an understanding of how physiological changes in aging affect normal standards (Ob- jective 2).

Another area requiring special emphasis is the altered pharmacokinetics in aged patients (Objective 3). Poor patient compliance, multiple drug reg- imens, communication problems, and changes in enzyme and organ function combine to make drug therapy more difficultA 3 The sum of these difficul- ties is that elderly patients have twice the risk for an adverse drag reaction as younger persons.~3

Unique medical problems include not only those essentially limited to the elderly (Objective 4), but also those that present atypically in the elderly patient (Objective 5). It is well known that the classic signs and symptoms of diseases in older patients may be delayed, altered, or absent. 3 Other diseases and problems should be given repeated emphasis in a geriatrics curriculum because they require a diagnostic and therapeutic approach different from that used for the younger patient. 14 Examples of these include syncope, acute dementia, pulmonary embolism, and the acute abdomen.

Objective 6 deals with common

psychiatric and behavioral disorders. In the elderly population, physical disease may manifest as a psychiatric disorder, or conversely, emot ional problems may present as a physical problem. 4 Most of the psychiatric syndromes manifested by elderly patients are amenable to early treatment. 15 Prompt recognition and intervention are therefore imperative. The emergency physician also should expect to see more social and adaptational problems in elderly patients and learn effi- cient utilization of available social services. 5

INSTRUCTIONAL METHODS Emergency medicine residencies are

under constant pressure for more block curriculum time in the various specialty areas. This curriculum is not intended to create a geriatric block rotation; it is designed to be integrated into an existing curriculum of an es- tablished program and still achieve the primary goal of exposing the residents to more intensive training in geriatric emergencies.

These objectives and subject topics are not order-dependent and can be completed during the 36 months of residency training. Because residents respond differently to various methods of instruction, a variety of instructional methods, including individual readings, didactic lectures, clinical case conferences, clinical audits, and supervised patient care, are used and can be individualized by each program.

To encourage independent reading, the faculty members gave residents a bibliography of current articles relat- ing to geriatric emergencies with ref-

32/1276 Annals of Emergency Medicine 15:11 November 1986

TABLE 2. The emergency geriatrics curriculum emphasizes those emergency medicine problems and disease that require a diagnostic and therapeutic approach different from that used in the younger patient, and that are not customarily covered in other sections of the emergency medicine curriculum

Objective 1. Identify and assess physical and functional impairments common with aging Specific Topics (Reading List) Instructional Methods

Physiology of aging 20,21

History and physical examination in elderly 22

Common signs and symptoms 23

Evaluation of functional ability 24 Health maintenance in the elderly25, 26

Didactic ,Case Journal Learning Lectures Conferences Clubs Activity

X Lecture by retired physician

X History-taking forms X X

Functional assessment test Chart audit review

Objective 2. Understand how physiologic changes in aging affect diagnostic testing Specific Topics (Reading List) Instructional Methods

Didactic Case Journal Learning Lectures Conferences Clubs Activity

X Lecture by pathologist X ECG review, CCU rotation

X Radiology teaching files, radiology rotation

Effects of age on common lab tests 27 ECG changes in the elderly28, 29

Radiologic changes with aging 30

Objective 3. Gain a knowledge of altered pharmacokinetics in elderly patients Specific Topics (Reading List) Instructional Methods

Didactic Case Journal Lectures Conferences Clubs

X X

Age-related pharmacokinetics31, 32 Prescribing in the elderly13, 33

Common drug reactions 34,35

Poisoning in the elderly 36

Cardiovascular drug therapy37, 38

Over-the-counter medications 39 Psychotropic drug use 40

X

X

X

Learning Activity

X Methods to simplify pill counting

X X

X X Poison control presentation, toxicology cases

Lecture by cardiologist

Lecture by psychiatrist

erence to particular subject areas (cur- r i cu lum syllabus). Art ic les were selected from a recent bibliography published by the American Geriatrics Society 16 and from a review of the geriatric literature by staff physicians. Preference was given to recent pub- lications; almost all of the references are from the past five years. Few high- quality books are concerned with diseases and disorders common to the elderly, and this lack is especially no- ticeable in emergency medicine.

Resident conferences and grand rounds should include four to eight hours per year on geriatrics topics (Table 1). This is significantly less than

the 38 hours of pediatric conference time suggested by the Task Force on Length of Training in Emergency Med- icine, tZ The presentations may be made by guest speakers, geriatrics faculty, or emergency medicine faculty and residents. One staff physician should maintain liaison with faculty members of other departments with similar interests and expertise in the problems of aging. In addition, there may be local communi ty agencies that show interest and abilities in ad- dressing the special needs of the elderly that can be utilized for guest lec- turers.

Much of the teaching can be done

on a case-by-case basis. Clinical case conferences should include special history taking and examination tech- niques needed to properly evaluate an aged patient. The discussion should include references to the general aspects of aging and its effect on diagnostic testing, as well as such ne- glected topics as clinical pharmacol- ogy and ethical and legal issues. In addition, journal clubs may be used to focus on specific geriatrics topics, such as oncologic emergencies, infections, and rheumatic diseases.

Frequent chart audits may be used to evaluate pa t ien t m a n a g e m e n t skills, lo The auditor reviews patient




Objective 4. Understand and treat those diseases peculiar to the elderly Specific Topics (Reading List)

Geriatric dermatoses 41

Failure to thrive in elderly 42

Gynecology in the aged female 43

Thyroid disease in the elderly44, 45

Geriatric ophthalmology - - cataracts, glaucoma, macular degeneration 46,47

Parkinsonism 48

Paget's disease, osteoporosis49, 5o

Rheumatic diseases and their complications51,52

Temporal arteritis, polymyalgia53, 54

Common foot disorders 55

Anemia and hematologic emergencies in the elderly56,57

Urinary retention58

Didactic Lectures

X

X

X

X

Instructional Methods Case Journal Learning

Conferences Clubs Activity Lecture by dermatologist,

slides X Medicine rotation

X X Lecture by gynecologist, gynecology rotation

X

X

X

X X

Lecture by ophthalmologist, discuss examination of the aging eye

Videotape of patient, differential diagnosis of tremor

Radiology teaching file

X

X

Lecture by rheumatologist

Orthopedic clinic, radiographs, lecture by podiatrist

X Medicine rotation Demonstrate suprapubic

catheter

charts and provides feedback to the res ident to help iden t i fy areas of strength and weakness. Other stan- dard educational tools and forums also may be used to supplement and ex- pand the knowledge and skills of trainees and staff. They include library resources, slide presentat ions, au- diovisual teaching aids, special sym- posia on aging, and research forums. It is not necessary to adhere rigidly to suggested methods of instruct ion. Flexibility and creativity in the deliv- ery of information is a necessary part of any successful curriculumA s

To give residents adequate oppor- tunity to practice clinical skills, these objectives may be emphasized during the training program, such as the off- service rotations in orthopedics, internal medicine, cardiology, and general surgerg. In the emergency department, there should be considerable emphasis on the geriatric aspects of the patient's illness, including social problems,

men ta l s tatus examinat ion, appropriate diagnostic testing, and health maintenance.

A number of formal and informal methods provide feedback to residents. All residents should review their evaluations from each clinical rotation and from the yearly in-training examination. In addition, a modi- fied "Palmore Facts on Aging Quiz "19 is given to all residents and students each year. The test consists of 25 true/ false s ta tements covering the basic physical , menta l , and social facts about aging. The purpose of this test is to s t imula te group discussions, measure and compare different groups' levels of information, identify common misconceptions about aging, and study attitudes toward the aged.

C O N C L U S I O N The growing number of elderly in

the United States will continue to in- crease the demand for emergency ser-

vices. To meet this demand, a geriatrics curriculum was designed jointly by emergency medicine educators and residents. We have described a comprehensive set of educational objectives and topics for training in geriatric emergencies.

Portions of the cur r icu lum have been implemented this year with fa- vorable response from house staff and students. The variety of specific topics offered has assisted residents in realiz- ing their deficits in the area of acute geriatrics and has inspired further individual study. When used in com- bination with enthusiastic faculty, the program may strengthen positive attitudes toward geriatric medicine and improve medical care.

The authors thank Lynn Chapman for her assistance in this project and Suzanne Worcester for preparation of the man- uscript.

34/1278 Annals of Emergency Medicine 15:11 November 1986


Objective 5. Recognize certain disorders presenting a different clinical picture in old age Specific Topics (Reading List) Instructional Methods

Thermoregulation - - hypothermia and heat-related problems59, 60

Infection and antibiotic therapy 6~-63 Injuries/common fractures in late life 64,65

Didactic Case Journal Learning Lectures Conferences Clubs Activity

X X X X X

Cardiovascular disease in aging (congestive heart failure, myocardial infarction, arrhythmias)66, 67

Endocarditis in geriatrics 68 Hypertension in the elderly69 Silent pulmonary embolism4,70

Respiratory problems in the aged TM X

Evaluation of acute abdomen in the elderly 62,72,73 X

Constipation in the aged TM

Pain syndromes (chest, back, abdominal) 75 Hypercalcemia, hyperparathyroidism76

Complications of diabetes in elderly 77 X Oncologic emergencies 78 X

Evaluation of syncope in elderly 79 X The weak and dizzy patient 80,8~ X

Bedside diagnosis of cerebrovascular accidents 82 X

X X X

X X

X

X

X

X X

Review of chart audit Lecture by orthopedic

surgeon, trauma conference, radiographs

CCU rotation, ECG review, Mega Code Scenario

Discuss modes of therapy Ventilation-perfusion scan

revi ew ICU rotation Surgery rotation, abdominal

radiographs

Lecture by oncologist

Videotape of patient

Objective 6. Differentiate and treat common psychosocial disorders in the elderly Specific Topics (Reading List) Instructional Methods

Organic brain syndrome83,84

Acute dementia/confusion 9,85,86 Depression, suicide in the elderly 87,88

Alcoholism, drug abuse in elderly89

Social problems and community service programs90,91

Economic resources (Medicaid, Medicare)92,93

Abuse and neglect in the aged 94 Doctor-patient relationship95, 96

Didactic Case Lectures Conferences

X

X X X X X

X X

Journal Clubs

X

X

X

Learning Activity

Mental status examination, videotape

Review of chart audit Lecture by psychiatrist

Lecture by social worker, visiting nurse service

Discuss cost containment, DRG coordinator

Videotape of patient Lecture by retired physician,

discuss ethical considerations



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a geriatrics curriculum for emergency medicine training programs

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