WV GEMS (West Virginia Geriatric Educators of the Medical Schools)

 

 

Geriatrics Case for Interdisciplinary Sessions

Created by: Mark A. Newbrough, MD

 

Criteria:

 

Cases for RHEP Interdisciplinary Sessions need to be flexible in order to accommodate groups with different compositions.

Material presented is relevant to all health sciences students.

Material requires students to prepare for session. 

Cases should touch on attitudes and knowledge, at least, and skills when possible (or build on students previous efforts on skills such as assessment of cognition, ADL’s, or mood).

Facilitator should have experience providing care (according to his/her discipline) for the elderly-but only necessary criterion.

Should include material for at least:  Medicine, Nursing, Pharmacy, Dentistry, and Social Work.  Physical therapy may be added when appropriate.

 

Learning Objectives:

 

After participating in this IDS case-based exercise, learners will:

 

  1. Demonstrate awareness of some of the myths and stereotypes related to older people.
  2. Be able to point out examples of ageism in their own experience and explain how that ageism can have an adverse impact on outcomes for elderly patients.
  3. Recognize how the heterogeneity of older persons makes it crucially important to view each older person as an individual regardless of chronological age.
  4. Be able to describe key contributions that health care professionals from different disciplines can make to the care of each older person.
  5. Develop insight into the burdens that caregivers of older persons experience themselves.
  6. Be able to discuss the importance of improving and optimizing function for older people.
  7. Be able to describe the impact of normal aging on organ function.
  8. Be able to describe how aging impacts the management of common medical conditions.
  9. Be able to describe how aging affects pharmacotherapy for older persons.
  10. Be able to describe some of the common geriatric syndromes, including dementia, delirium, incontinence, polypharmacy, iatrogenesis, falls, osteoporosis, and pressure ulcers.
  11. Demonstrate knowledge of aging related psychosocial issues, such as elder abuse and neglect, home safety, and advanced directives.
  12. Describe the use of tools commonly used to assess the health and function of older persons.

 

 

 

Case, Part A

 

Mrs. G. is an 84 year old widow who lives alone and has lost 10 lbs. over the past year.   She has been a patient at your community health center (CHC) for more than 20 years.  Her husband, who also was a patient at the CHC, died 7 years ago.  Her past medical history includes Type II diabetes mellitus and hypertension.  She has one adult daughter who lives in another state.  Mrs. G. is always delightful to talk to, even though she has lately been bringing more physical complaints to her visits at the CHC.  Despite multiple medication adjustments, her blood pressure and serum glucose (or HgA1c) have both been uncontrolled for at least two years.  She wonders to you if she is ever going to “get better”, and after two years without any demonstrable progress, you are beginning to wonder the same thing.  After all, she is 84 years old.

 

Questions, Part A

 

  1. Is it true that older patients can never remember their medications?  Is this a function of normal aging or a dementing illness that occurs in every person if they get old enough?  How can you identify if someone is taking his/her medications properly when they cannot remember them?  What strategies can be employed to improve “medication administration systems” in the home environment?

Facilitator Tips

This question is intended to explore some of the myths and stereotypes related to older patients.  Is memory loss a normal part of aging (and therefore occurs in everyone), and does such memory loss necessarily have a negative impact on care, or is there something that can be done?  In addition, this question introduces the topics of polypharmacy and medication non-adherence/noncompliance. 

 

  1. Is it true that it is impossible to control blood pressure and glycemia in older patients?  What are some of the reasons why it might be harder to achieve optimum control of these two conditions with older patients? 

 Facilitator Tips

This question is intended to explore ways that aging-related changes in organ function/physiology, pharmacokinetics, and pharmacodynamics may have an impact on the care of hypertension and diabetes as people age.  An interesting would be to consider with the group how aging of the involved health care providers may also have an impact on the care delivered.

 

  1. What are reasonable outcome goals for Mrs. G. at this advanced point in her life?  How do decide the goals for your older patients?  Does she have a right to expect that she would “get better”? 

Facilitator Tips

This question is intended to touch on issues related to goal setting, including the principles of informed consent, capacity, and in particular the need to focus on outcomes that are intended to maximize functional status.  If Mrs. G. has problems that are not going to go away, then how can we help her to live with her

condition (s)?  Ask the question:  “What do you mean by “get better”, Mrs. G.?”  Follow with “What do you mean, health care provider, by “get better” for Mrs. G.?”  Shouldn’t there be some overlap in these two definitions?

 

  1. How would you address her weight loss?

Facilitator Tips

This open-ended question is intended to get the learners problem solving on what additional information is needed about Mrs. G. as well as to outline some possible causes of weight loss in such a patient.  Ask if this amount of weight loss is even significant, or just another part of getting older.

 

  1. Give examples of other situations where you experienced a patient, caregiver, or health care professional saying (or if you did it-thinking) something like “After all, she is 84 years old.”  Did such a thought or statement indicate an attitude and belief that might interfere with appropriate diagnostic work-up and/or treatment of the problem at hand?  If you observed a health-care professional making such a statement in front of a patient, a caregiver, or a learner, do you think that making such a statement encouraged the patient, caregiver, or learner to continue trying to get help for that particular problem?

Facilitator Tips

Ageism is so common still that all of the learners will likely be able to recall episodes from their own personal experience.  Hopefully they will begin to understand how destructive the attitudes and misbeliefs that are ageism can be.

 

  1. What general principles of care for diabetes and hypertension should you invoke in the care of Mrs. G.?  How will you know when you are doing enough for her?

Facilitator Tips

This question allows the opportunity to consider established guidelines for care of hypertension and diabetes mellitus in the elderly.  It also encourages the students to revisit the matter of goal-setting.  The facilitator should emphasize that evaluation and goal-setting must be individualized for Mrs. G. because of the difficulty of predicting how any given older patient will likely respond to any given treatment. 

 

 

 

Case, Part B

 

Mrs. G. arrives for a visit to the CHC one day late in the afternoon.  She is obviously confused and running a low grade fever.  Her clothes smell of urine (the first time you have noticed this).  You admit her to the local hospital.  On her first night there, she falls trying to get out bed and fractures her hip.  For the next several days she remains confused to the point that she has to be restrained both physically and chemically.  By the time her delirium clears she has pressure ulcers over her sacrum and both heels.  Her daughter who came in from out of town, reports that Mrs. G.’s home is a total mess, with 8 cats running around, and with multiple old prescription bottles intermingled with more recent bottles.  She comes to the CHC and asks you how long you have known that Mrs. G. was demented.  You are surprised at these revelations, and do not have any good answers for her daughter.  She is distraught to think that her mother has been living in such conditions and asks for your help in getting Mrs. G. into a nursing home.

 

Questions, Part B

 

  1. What could you have done to alert the hospital staff of the need to prevent Mrs. G. from falling?  What additional information would you have wanted if you were taking care of Mrs. G. in the hospital?

Facilitator Tips

Any time an older patient goes from level of care to another, they are at risk.  Proactive communication between all members of the care team is critically important, and should include specifically information about allergies, medications, known medical problems, functional status (including memory and decision making capacity), information about any advanced directives, and caregiver contact information.  Having all of this information may not have prevented Mrs. G.’s fall, but not having it certainly increases her risk.

 

  1. What are Mrs. G. risk factors for hip fracture?  How would you mitigate each of these risks in order to improve her safety, both in the hospital and at home?

Facilitator Tips

Multiple risk factors are identified: including antihypertensive therapy, poorly controlled diabetes mellitus, dementia, delirium, urinary incontinence, strange environment, and acute illness.  This case is a good opportunity for the students to learn and discuss a wide range of very common geriatric syndromes, at least in an introductory fashion, depending on the time allowed.  In fact, there is probably enough here for two learning sessions.

 

  1. What steps should have been taken to make sure that Mrs. G. did not develop pressure ulcers in the hospital?

 Facilitator Tips

Discussion here should center on how to screen patients for increased risk, and what steps to take to prevent pressure ulcers.  This is also a good opportunity to highlight the multiple risks from iatrogenesis that routinely face older patients when they are admitted to the hospital.

 

  1. Is it true that all older patients develop delirium while in the hospital, no matter what you do for them?  If not, then is there any way to predict which patients are at increased for delirium?  How would you have treated the delirium?

Facilitator Tips

Here the issue is again to think about mentation of older patients when they are admitted.  Actually, in this case, Mrs. G. should have already been screened for both cognitive and mood problems at the CHC.  This is a good opportunity to talk about routine screening and periodic screening, even in patients you have known for a long time (or perhaps especially in those patients-in order to keep a fresh perspective).  If the hospital care team had realized that Mrs. G. was confused, they may have taken steps to decrease nighttime confusion.  Have the students list what those steps might include.  Also, they should be able to discuss common treatments for delirium, including the critical need to focus on the underlying cause and address that issue as part of the treatment plan.

 

  1. What do you think is the most likely explanation for the smell of urine on her clothes, and what would you do to evaluate her urinary incontinence?

Facilitator Tips

Differentiate between acute and chronic urinary incontinence and the workup for both.  Part of that workup should probably wait until Mrs. G. has recovered, since the events that occurred in the hospital will likely effects on her continence.

 

  1. What steps would you take to make sure Mrs. G. never falls again?

Facilitator Tips

It is important that we cannot guarantee that any older patient will “never fall again”.  There is no treatment that has been shown to do this, although there are many things that we can evaluate/do for Mrs. G. to decrease the risk of future falls.  In addition, there are also things we can do to address her osteoporosis that may reduce the risk of fracture, even if she does fall.  Review the management of osteoporosis briefly.

 

  1. How would you respond to the daughter’s request to put Mrs. G. into a nursing home?  What if Mrs. G. expresses that she does not want to be put into a nursing home?  Whose direction would you follow?  How would you decide?

Facilitator Tips

This questions touches on many issues.  How would you decide the most appropriate level of care for Mrs. G.’s recovery?  How do Medicare guidelines influence your choices?  Does Mrs. G. have capacity to decide for herself?  How should we choose a surrogate decision maker for Mrs. G. if she has not designated her daughter as her medical power of attorney?  Introduce the topics of incompetence and guardianship.  Remind the learners of how helpful having this type of information before a problem arises is to patients, their families, and the health care team.

 

 

  1. How would you address your concern that the daughter seemed to be so unaware of her mother’s home situation?  How would you respond to her concern that you should have been more aware of her mother’s condition?

Facilitator Tips

This is a fairly common situation, and causes much angst for both families and health care providers.  Routine screening for dementia and mood disorders may have identified the need for more careful home medication management, and perhaps a home safety assessment for Mrs. G.  Discuss with the learners how one goes about obtaining a home safety assessment.  Although not likely in this case, it would also be a good time to introduce the concept of elder abuse and neglect (what if the daughter knew what the home was like and failed to bring it to anyone’s attention?). 

 

 

Finally, this case should have led to discussion about the use of tools to assess/screen cognitive function (e.g. the MMSE), mood problems-especially depression in a patient who is declining in a vague sort of way (e.g. the Geriatric Depression Scale), overall function (ADL’s and IADL’s), and home-safety assessments.  In order to emphasize, it might be a good idea to provider copies of these instruments to the learners.  Emphasize the need to incorporate these types of screenings as just as important as screening for cholesterol or cancer, especially in the elderly.