Training In Geriatric Medicine Research Articles

Ten ways to improve the care of elderly patients in the hospital

Hospitalists care for elderly patients daily, but few have specialized training in geriatric medicine. Elderly patients, and in particular the very old and the frail elderly, are at high risk of functional decline and iatrogenic complications during hospitalization. Other challenges in caring for this patient population include dosing medications safely, preventing delirium and accidental falls, and providing adequate pain control. Ways to improve the care of the hospitalized elderly patient include the following: screening for geriatric syndromes such as delirium, assessing functional status and maintaining mobility, and implementation of interventions that have been shown to prevent delirium, accidental falls, and acute functional decline in the hospital. This article addresses these issues with 10 evidence-based pearls developed to help hospitalists provide optimal care for this expanding population.

Teaching and learning geriatric medicine

SummaryPopulations throughout the world are ageing, with the oldest old the most rapidly growing segment of society. Caring for this ageing population, some of whom have multiple chronic and disabling diseases, will be challenging to healthcare systems. Current training programmes are generating relatively low numbers of geriatricians, largely because students and residents lack interest in a career in geriatric medicine. Therefore, specialists in geriatric medicine cannot directly provide care for all older people. There is a responsibility to ensure that successful practices and essential skills are shared.Here we explore negative attitudes towards geriatric medicine and contrast these with factors motivating change. Educational theories are discussed to investigate how processes of learning and the personal development of students can be optimized. An understanding of geriatric medicine is important for undergraduates, postgraduate trainees in geriatric medicine, general practitioners and allied health professionals. The different challenges presented by each group are reviewed, accompanied by recommendations to enhance learning and examples of effective teaching practices.

In-hospital cardiopulmonary resuscitation: Trainees' worst and most memorable experiences

To examine the personal experiences of higher specialist trainees in Geriatric Medicine (GM) with regard to cardiopulmonary resuscitation (CPR) and do not attempt resuscitation (DNAR) decision making. UK. Two hundred and thirty-five higher trainee members of the British Geriatrics Society (BGS) at the Specialist Registrar (SpR) level. Postal questionnaire survey. We distributed a questionnaire examining the various issues around DNAR decision making among the trainee members of the BGS in November 2003. In one of the questions, we asked the participants, 'Briefly describe your worst or most memorable experience of DNAR'. Responses to this question were analysed by thematic schema and are presented. Overall the response rate was 62% (251/408) after second mailing and 235 of these were at SpR grade. One hundred and ninety-eight participants provided an answer to the above question, providing diverse and often detailed accounts, most of which were negative experiences and which appeared to have had a powerful influence on their ongoing clinical practice. The emerging themes demonstrated areas of conflict between trainees and other doctors as well as patients and relatives. SpR grade geriatricians are exposed to extreme and varied experiences of DNAR decision making in the UK. Efforts to improve support and training in this area should embrace the complexity of the subject.

Policy for an Aging Society

MEDICAL STUDENTS AND RESIDENTS ARE TAUGHT to perform a complete review of systems in a thorough patient workup. Through this process, patients may report less prominent concerns that may be meaningful to the physician’s evaluation. As a complement to the new series, Care of the Aging Patient: From Evidence to Action, in this issue of JAMA, a Commentary will provide a forum for discussion of a policy review of systems for the care of older adults. In the first article, Reuben brings into sharp relief the need for greater expertise and new approaches to caring for older patients as they face physical decline and advanced illness. Using the case of Mr Z, Reuben examines the patientcare encounter and the analytical and interpersonal processes that the physician must undertake. For most US physicians, both specialists and generalists, this story is likely unfamiliar, and physicians may hardly be able to imagine themselves or colleagues conducting the kind of extensive evaluation described. Patients would flock to this comprehensive yet individualized care. Although this approach is at the core of training in geriatric medicine, such specialists are rare, and fewer students are seeking careers in geriatrics or primary care. In each year from 2007 to 2009 fewer than 100 US medical graduates pursued postdoctoral training in geriatrics. The crisis represented by this shortage is made clear by imagining an alternate scenario: usual care rather than best case. In the usual care scenario, Mr Z would have been considered a healthy older man. His falls would not have been explored and his concerns would have been referred to specialists. He ultimately could have sustained a major fracture, requiring surgical intervention. During that hospitalization, he most likely would have become weak and had iatrogenic complications, such that even a very prolonged rehabilitation would not return him to his prior function. During this time, someone most likely would have discovered that his wife at home had Alzheimer disease and was unable to care for herself. Hopefully, a capable social worker would have helped husband and wife to be admitted to the same long-term care facility, but they might have been separated since he would be in rehabilitation and she in custodial care. Their complex health care could lead not only to poor patient care but to costly overuse of technologies and most importantly loss of the function, dignity, and personal values they would have chosen. Reuben’s careful analysis suggests that anticipating and addressing patients’ evolving short-term, midterm, and longterm issues provides better care in all metrics: quality, fewer errors, and reduced overuse of health care services. Everyone is better off. Why don’t patients have more access to this kind of care and what will it take to provide it? The 6 characteristics of optimal quality of care for a patient facing frailty are: (1) extensive knowledge of the aging process, of prognostic indicators, and the multiple geriatrics syndromes; (2) proactive and anticipatory care that is longitudinal; (3) a well-functioning practice structure with a multidisciplinary team or network, in which care is coordinated efficiently and effectively and linked to community resources; (4) personal interaction with the relationship grounded in good communication skills and a clear sense of the patient’s values, goals, and preferences; (5) practices that manage care across diverse settings to ensure safe transitions and continuity; and (6) health care institutions, especially hospitals, that incorporate acute care of the elderly units, early mobilization, careful attention to drug interactions, and other best practices to reduce the grave risk they currently pose to frail, older individuals. Several current US policy initiatives may have the potential to improve the situation. First, workforce support for primary care should always include explicit attention to geriatric medicine. Most geriatric specialists begin postgraduate training in family medicine or general internal medicine, the 2 largest and mostthreatened primary care specialties. Geriatric medicine is at even greater risk—less widely sought than primary care. As initiatives to reallocate residency positions under the graduate medical education (GME) limits are considered, geriatric medicine should be foremost on that list—a core discipline for Medicare and Medicare GME payment priorities. Incentives such as loan forgiveness or repayment may help bridge the gap until effective payment reform occurs.

Training in elder abuse: The experience of higher specialist trainees in Geriatric Medicine in the UK

Little is known about elder abuse training in post-graduate medical education in the United Kingdom. A questionnaire survey was conducted among Specialist Registrars (SpRs) in Geriatric Medicine attending a single training day within five UK Post-graduate Deaneries to assess self-report experience of elder abuse training during their post-graduate medical education. The questionnaire included quantity, quality and self-report confidence in dealing with elder abuse issues. A total of 112 questionnaires were returned (response rate 100%, representing 78.9% of eligible trainees within these five deaneries). The majority of the participants rated low scores for both quantity and quality of training they received. This finding was consistent across all 5 years of training with no significant difference in rating scores in more experienced (years 3–5) SpRs. The majority (62.5%) of final year SpRs reported feeling inadequately prepared to deal with cases of elder abuse. The results of our survey suggest that the provision and quality of training regarding elder abuse is poor for trainees in Geriatric Medicine. The majority of SpRs approaching the completion of their training felt ill-prepared in managing such cases. Our study highlights the requirement of structured approach in elder abuse training for trainees in Geriatric Medicine.

Book reviews

Acta Neurologica ScandinavicaVolume 82, Issue 2 p. 154-158 Book reviews First published: August 1990 https://doi.org/10.1111/j.1600-0404.1990.tb01609.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Abstract Book reviews in this articles: Gunderson CH. Essentials of clinical neurology. Igbal K, Wisniewski HM, Winblad B, eds. Alzheimer's disease and related disorders. Levin HS, Eisenberg HM, Benton AL, eds. Mild head injury. Wieser HG, Elger CE. Presurgical evaluation of epilepsies. Godaux E. Electromyographie. Amiologie et physiopathologie. Miner GD, Richter RW, Blass JP, Valentine JL, Winters-Miner LA, eds. Familial Alzheimer's disease: molecular genetics and clinical perspectives. Cytowic RE, Synesthesia: a union of the senses (Springer series in neuropsychology). Cummings J, Miller BL, eds. Alzheimer's disease. Treatment and long-term management. Pepeu G, Tomlinson B, Wischik C, eds. New trends in aging research. Fox J. Atlas of neurosurgical anatomy. The pterional perspective. Foldstein SE. Huntington's disease. A disorder of families. Critchley M. The ventricle of memory: personal recollections of some neurologists. Lange S, Grumme T, Kluge W, Ringel K, Meese W, eds. Cerebral and spinal computerized tomography. Davies DC, ed. Alzheimer's disease: towards an understanding of the aetiology and pathogenesis. Pearlman AL, Collins RC, eds. Neurobiology of disease. Szobor A. Myasthenia gravis. Wurtman R, Corkin S, Growdon J, Ritter-Walker E, eds. Alzheimer's disease. Meier-Ruge W, ed. Teaching and training in geriatric medicine. Jensen K, Knudsen L, Stenager E, Grant I, eds. Mental disorders and cognitive deficits in multiple sclerosis. Boller F, Katzman R, Rascol A, Signoret J, Christen Y, eds. Biological markers of Alzheimer's disease. Stern G, ed. Parkinson's disease. Franks AJ, Ironside JW, Mindham RHS, Smith RJ. Spokes EGS, Winlow W, eds. Function and dysfunction in the basal ganglia. Koller WC, Paulson G, eds. Therapy of Parkinson's disease. Volume82, Issue2August 1990Pages 154-158 RelatedInformation

Effect of Extracurricular Geriatric Medicine Training: A Model Based on Student Reflections on Healthcare Delivery to Elderly People

Although many professional and accrediting bodies have identified competencies for medical students pertaining to caring for older patients, including understanding the basics of the healthcare delivery system, the highly structured curriculum in medical school provides few opportunities for these competencies to be achieved. One possible solution is to let students participate in geriatrics-related extracurricular educational and clinical activities and ask them to reflect on their experiences. This article presents the results of a qualitative analysis of student reflections from participating in such a program implemented at the University of Cincinnati College of Medicine. One hundred thirty of 321 student journal entries (collected over 3 academic years) containing any mention of the healthcare system were qualitatively analyzed. The themes and resulting model that emerged from the data includes three distinct levels of healthcare delivery: individual, organizational, and systems. Each level is presented and explained using illustrative student quotes. As a whole, the model indicates that students in this innovative extracurricular experience gained important knowledge about how medical care is provided to elderly people. The model developed may provide additional structure for future medical students as they reflect on their early encounters with the complex health and social forces affecting the quality of care received by older adults.

After‐Hours Calls from Long‐Term Care Facilities in a Geriatric Medicine Training Program

To describe after-hours telephone calls from nurses in long-term care (LTC) facilities to doctors in a geriatric medicine training program. Evaluation of 1,928 after-hours calls from LTC facilities over a 10-month period in 2005/06. Geriatrics fellowship program and three affiliated LTC facilities. Eight geriatrics fellows and 40 medicine interns. Data were collected on call characteristics (such as reason for call and call outcome) and physician attitudes about the call, scored using a 5-point Likert scale. Clinical problems were the focus of 70.4% of the calls. The range of clinical problems was broad; most common reasons for calls were falls (n=377), pain (n=138), and agitation (n=100). The majority of calls resulted in medical intervention, including new medications or treatments (43.4%), diagnostic tests (10.2%), or more-extensive medical evaluation in the emergency department (9.1%) or by an on-site physician (2.4%). Overall, physician trainees had favorable attitudes about most after-hours calls, although medicine interns taking calls had a less-favorable impression and felt less prepared to manage them. After-hours telephone calls from LTC facilities are common, reflect the heterogeneity of geriatric health concerns, and typically result in intervention. As the LTC population grows, more study is needed on telephone care and optimal strategies for training physicians in this important aspect of LTC.

Undergraduate training in geriatric medicine: getting it right

It is perhaps inevitable that every specialty within medicine believes that its fundamental principles should be included in the core undergraduate curriculum and should be accompanied by a compulsory placement. The General Medical Council’s (GMC) policy document ‘Tomorrow’s Doctors’ [1] stresses the importance of students learning about the special problems associated with older people’s health. For example, it states that young doctors must respect age and the vulnerability of particular patient groups including older people. They also emphasise that graduates must understand human development, which includes growing old. Importantly, the document states that students must have opportunities to interact with a range of people including visiting an older person, a learning experience that is now included in many curricula. However, they are silent on the issue of whether there should be a compulsory attachment to a geriatric medicine unit, as indeed they are, about other hospital specialties. The present policy suggests that a quarter to a third of the curriculum should be based on studentselected components. The interpretation and implementation of such advice will be different in each medical school but the risk is, that at this time of demographic change, with growing numbers of older people, and with other demands on the curriculum, exposure to geriatric medicine might be overlooked and reduced. The concern that the teaching of geriatric medicine now has a reduced place in UK medical schools has been supported by the findings of a recently published survey [2]. Questionnaire responses from UK medical schools found that although geriatric medicine is taught to all students in almost all responding medical schools (21/23), it was taught as a distinct discipline in only two. This contrasts with the findings of studies undertaken twenty years ago [3, 4] when geriatric medicine was more likely to be taught as a separate subject. The 1981 survey found that geriatric medicine was formally taught separately in all but two of the thirty medical schools. The comparable figures in the 1986 follow-up survey were 25 out of the 27 medical schools. The mode of teaching then, was mainly clinical instruction (74% in 1981 and 70% in 1986) with tutorials taking up about 25%. Although placement in geriatric medicine is now less likely, some positive changes are noted. For example, geriatric medicine subjects are now more likely to be included in examinations than during the 1980s and geriatric medicine cases are being included in problem-based learning. Alongside the apparent decline in geriatric medicine content in the curriculum is a decline in the number of medical schools with separate departments or divisions of Geriatric Medicine. At the time of writing, at least seven medical schools in England which previously had academic departments no longer have professorial appointments in the subject. The effects of the reduction in academic support on the research agenda has been commented upon by the House of Lords Select Committee on Science and Technology [5, 6] and the effects of this loss on training is equally worrying. The presence of a professor within the discipline is likely to result in that subject having a greater share of the curriculum as was highlighted by the previous survey [3]. These issues pertaining to the teaching of geriatric medicine are not confined to the UK. In the USA there is no national medical curriculum and the inclusion of geriatric medicine placements is optional, although geriatric medicine is to some extent included in most curricula [7]. One recent publication has identified geriatric medicine education there as having the ‘largest education gap in any field’ in terms of the number of educators available [8]. The American Geriatrics Society has promulgated suggested core competencies in geriatric medicine that should be included in the training of all doctors at the undergraduate level [9]. A WHO survey of geriatric medicine teaching [10] found that of countries that had national regulations governing the overall curricula, only 41% mentioned geriatrics in the regulations in some way. It was reported that of these, only half had mandatory geriatric medicine training and that 27% of the 161 schools participating in the survey had no training in geriatric medicine at all.

Training in geriatric medicine in UK undergraduate medical schools

Training in geriatric medicine in UK undergraduate medical schools

Undergraduate Training in Geriatric Medicine in the United Kingdom

Undergraduate Training in Geriatric Medicine in the United Kingdom

The role of research training during higher medical education in the promotion of academic medicine in the UK

Objectives: To examine the research activities and perceived barriers to research among higher specialist trainees in geriatric medicine and to show how trainees active in research might have a role...

Australian Society for Geriatric Medicine

Australasian Journal on AgeingVolume 25, Issue 4 p. 218-222 Australian Society for Geriatric Medicine Position Statement No. 4Education and Training in Geriatric Medicine for Medical Students – Revised 2006 First published: 31 October 2006 https://doi.org/10.1111/j.1741-6612.2006.00196.xCitations: 5 This Position Statement represents the views of the Australian Society for Geriatric Medicine. This Statement was approved by the Federal Council of the ASGM on 29 March 2006. The original paper was prepared by Professor Paul Finucane (1996). The revision of this paper was coordinated by Dr Vasi Naganathan. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume25, Issue4December 2006Pages 218-222 RelatedInformation

Improving Recruitment into Geriatric Medicine in Canada: Findings and Recommendations from the Geriatric Recruitment Issues Study

As the number of Canadians aged 65 and older continues to increase, declining recruitment into geriatric medicine (GM) raises concerns about the future viability of this medical subspecialty. To develop effective strategies to attract more GM trainees into the field, it is necessary to understand how medical students, residents, GM trainees, and specialists make career choices. The Geriatric Recruitment Issues Study (GRIST) was designed to assess specific methods that could be used to improve recruitment into geriatrics in Canada. Between November 2002 and January 2003, 530 participants were invited to complete the GRIST survey (117 Canadian geriatricians, 12 GM trainees, 96 internal medicine residents, and 305 senior medical students). Two hundred fifty-three surveys (47.7%) were completed and returned (from 54 participating geriatricians, 9 GM trainees, 50 internal medicine residents, and 140 senior medical students). The survey asked respondents to rate factors influencing their choice of medical career, the attractiveness of GM, and the anticipated effectiveness of potential recruitment strategies. Although feedback varied across the four groups on these issues, consistencies were observed between medical students and residents and between GM trainees and geriatricians. All groups agreed that role modeling was effective and that summer student research programs were an ineffective recruitment strategy. Based on the GRIST findings, this article proposes six recommendations for improving recruitment into Canadian geriatric medicine training programs.

Survey of training in geriatric medicine in UK undergraduate medical schools

Survey of training in geriatric medicine in UK undergraduate medical schools

… But Does It Stick? Evaluating the Durability of Improved Knowledge Following an Undergraduate Experiential Geriatrics Learning Session

Canada's aging population, fewer medical students training in geriatric medicine, and inadequate geriatric curricula require that medical schools immediately address how future physicians will be able to care for older people effectively. The medical literature suggests that experiential learning strategies improve undergraduate medical students' knowledge of and interest in less-popular subjects, but the durability of improvements resulting from these resource-intensive learning approaches remains unclear. In October 2001, a convenience sample of all University of Western Ontario medical students attending the geriatric component of their first year was randomized to attend one 3-hour didactic lecture or 3-hour experiential learning session. Approximately 1 year later, students completed a follow-up knowledge and attitudes survey that was matched to their first-year surveys using date-of-birth data. Of 100 completed follow-up surveys, 42 were used in formal analysis. Although initially the experiential group demonstrated a better knowledge score, at 1-year follow-up, there was no significant difference in knowledge, attitudes toward older people, or interest in geriatric medicine between the didactic (n=17) and experiential (n=25) groups. Nevertheless, these students (n=42) demonstrated better attitude scores than those (n=22) who had not attended either educational intervention. This study challenges the belief that an experiential approach is a superior training method to a didactic approach. One year after an educational intervention, there was no difference in geriatric knowledge, attitude scores, or interest in geriatric medicine between students who underwent a didactic lecture or a participatory, experiential learning session.

Perspectives on the Future of Geriatric Medicine

The following comments were presented to the 20th anniversary celebration of the geriatric medicine fellowship training program at the Baylor College of Medicine in the Texas Medical Center, Houston, Texas, on June 24, 2005. The author, who was the first graduate of the geriatric medicine training program at Baylor, proposes that geriatrics is at a critical juncture and that the voice and identity of geriatric medicine should be that of advocacy for our patients, and that in such a role geriatric medicine is well suited to become the "soul of medicine." She encourages all geriatricians to read the report of the Task Force on the Future of Geriatric Medicine and to look for opportunities to personally be involved in implementing the recommendations. She suggests that since our visions of the future are often only caricatures of our past, we must be creative and dream big dreams of what the future may hold. She challenges each of us to get involved in actively creating the future of geriatric medicine.

Docencia y asistencia geriátricas en el Reino Unido: perspectivas actuales

Ever since geriatric medicine was established by Marjory Warren in the late 1930s specialist geriatric services have developed as an integral part of the National Health Service in the United Kingdom (UK). This article offers first hand experience of the present state of geriatric medicine in the UK supported by a comprehensive literature review. It confers an overview of the range of clinical, preventive, remedial, and social services available to older people. It describes a relentless move towards an integrated model of care where all adult emergency admissions, irrespective of age, are cared for in joint acute wards staffed by general physicians and geriatricians. We also analyse the similarities and differences between the Spanish and British models of geriatric care. Special attention is given to the development of specialist geriatric services (falls, stroke), the expansion of the specialty of psychogeriatrics and possibilities for training in geriatric medicine in the UK.

Care of hospitalized older patients: Opportunities for hospital‐based physicians

Half of patients admitted to hospital for reasons unrelated to childbirth are age 65 years or older. Nonetheless, few hospital-based physicians have received training in geriatric medicine, and few geriatricians practice in the hospital. This paper describes the state of the science of hospital care for older patients, and identifies opportunities and barriers to improving their care. General medical journals from 1980 to the present were selectively reviewed to identify original articles on the treatment of specific diseases and syndromes on hospitalized persons age 65 years or older. Information was synthesized to describe the course of these patients during and after hospitalization, and to identify effective management strategies and gaps in knowledge. Older persons in hospitals pose substantial clinical challenges: they have high rates of cognitive impairment, delirium, disability, and difficulty walking, and they often require increased attention, longer lengths of stay, and higher hospital costs than younger patients with the same diagnoses. Disease-specific interventions have not been studied extensively in those older than 75 years. Multicomponent interventions can reduce short-term rates of disability and delirium without increasing costs, but they have not been widely disseminated. Interventions to treat or prevent other common conditions in hospitalized older patients have not been proven effective. Fundamental discoveries in the science of hospital medicine are needed to prevent or treat geriatric syndromes, to treat common diseases in the very old, and to put into practice what is known. Hospital-based physicians can address these gaps in knowledge and practice with geriatricians, building from their shared perspectives on the care of the aged in complex health systems.

Körperliches Training im Alter

For the prevention of diseases and especially functional deficits in old age, physical activity is a simple, practicable and successful method. With increasing age and frailty or in rehabilitation training, these activities have to be more and more individualized and medically supervised. The paper defines from today's viewpoint suitable activities and the amount of training necessary. Finally, the need for research about physical training in geriatric medicine is pointed out.