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Areas of Basic Competency for the Care of Older Patients for Medical and Osteopathic Schools *Last Updated January 1, 1998* Introduction

The majority of medical students will enter a specialty caring for older patients. This document provides a framework for medical schools to develop a curriculum on aging and to lay the foundation for students who will subsequently be caring for older patients. This document is not meant to be comprehensive or all-inclusive. Rather, it is meant to provide a reference for those involved in curriculum development, implementation, and evaluation. It also attempts to provide minimum competency standards in geriatrics for graduating medical students who will enter a variety of specialties.

Goal

The overall goal of the undergraduate medical curriculum in geriatrics for medical students is to provide the foundation for competent, compassionate care of older patients. This foundation includes attitudes, knowledge, and skills that are needed to care for older people.

Recommended Proficiencies

I. Attitudes

A. Awareness of the various myths and stereotypes related to older people.

B Recognition that ageism, like racism, affects all levels and aspects of society including health professions and can adversely affect optimal care of elderly patients.

C. Recognition of the heterogeneity of older persons--a diverse group with different personalities, different values, different functional levels, and different medical illnesses. Thus, each person needs to be viewed as an individual regardless of chronological age and to be cared for in a unique fashion.

D. Openness and willingness to work with other disciplines in caring for older patients.

E. Self-awareness of the students’ personal attitudes towards their own aging, disability, and death.

F. Compassion and understanding attitude on the part of the physician for care givers of the frail elderly and the difficulties they face.

G. An appreciation of the need for improving and optimizing function for older people, rather than just focusing on diseases.

II. Knowledge

A. Related to Basic Sciences

a. "Normal" aging is heterogeneous affecting different tissues and organs in different individuals at different rates.

b. Preventable, reversible, and treatable aging processes need to be identified by practicing physicians and managed accordingly.

c. Loss of homeostatic control mechanisms may account for much of the aging process.

4. Anatomic and histologic changes associated with aging.

5. Pathology associated with normal aging and age associated disease processes.

6. Physiology of aging in various organ systems.

7. Pharmacologic changes in aging and relevance to therapeutic decisions

B. Related to Clinical Practice

a. Dementia

b. Inappropriate prescribing of medications

c. Incontinence

d. Depression

e. Delirium

f. Iatrogenesis, include consequences of hospitalization & bed rest

g. Falls

h. Osteoporosis

i. Alterations in the special senses including hearing and vision impairment

j. Failure to thrive

k. Immobility and gait disturbances

l. Pressure Ulcers

m. Sleep Disorders

n. Non-specific presentation of disease

2. Knowledge of diseases and disorders that are more common or have particular features in older people. Although student’s individual clinical experiences may provide greater or lesser exposure to these disorders, students should have at least "broad" knowledge of pathophysiology, presenting signs and symptoms, differential diagnosis, and initial diagnostic evaluation for common diseases older people, including:

a. Rheumatological diseases (e.g. osteoarthritis, rheumatoid arthritis, temporal arteritis/polymyalgia rheumatica)

b. Genito-urological diseases (e.g. benign prostatic hyperplasia, sexual dysfunction)

c. Neurological diseases (e.g. Parkinson’s disease, stroke and transient ischemic attack, dizziness/syncope)

d. Cardiovascular diseases (e.g. congestive heart failure, atrial fibrillation, valvular heart disease) Hypertension (Diastolic and Systolic)

e. Endocrinological diseases (e.g. type II diabetes mellitus, hyperosmolar non-ketotic coma, hyper- and hypothyroidism, Paget’s disease of the bone)

f. Cancer of various organs, including: breast; lung; colon; prostate; and hematologic malignancies

g. Infections, including: pneumonia; tuberculosis; and urinary tract

h. Renal diseases (e.g. fluid and electrolyte disturbances)

i. Gastroenterological disorders (e.g. constipation, malnutrition, diverticulitis, diverticulosis)

j. Psychiatric diseases (e.g. depression)

k. Others, such as fractures, amyloidosis

3. Knowledge of psychosocial issues. Students should be familiar with identification, presenting signs and symptoms, and appropriate referral of common psychosocial problems and issues, including:

a. Normal behavioral late life changes, including retirement

b. Psychopathology, including: affective disorders, psychotic disorders, anxiety disorders, responses to medical illness, depression, and substance abuse

c. Under-reporting of symptoms and illnesses

d. Sexuality and aging

e. Elder abuse and neglect

f. Suicide

g. Home safety

h. Community resources, including those used to prevent institutionalization

i. Adaptation to care in alternative living situations, including long-term care facilities

4. Knowledge of Prevention, including:

a. Primary prevention (for example, exercise, nutrition, and psychosocial interventions designed to maximize function to allow independent living);

b. Secondary Prevention with age appropriate screening for diseases and identification of geriatric syndromes;

c. Tertiary prevention strategies; for example, rehabilitation and chemoprophylaxis in the post-myocardial infraction patient.

5. Knowledge of Ethical Issues in Geriatric Care

a. Advance Directives

b. Decision-Making Capacity

c. Euthanasia, Assisted Suicide

d. Health Care Rationing

e. Pain Management

f. End-of-Life Care

6 Health Care Financing

a. Mechanisms and Implications

(Medicare, Medicaid, Managed Care, Capitation)

7. Cultural aspects of aging. Students should be familiar with the influence of culture and ethnicity on the aging process, health and disease perception, and access to medical care, with emphasis on:

a. Demography of ethnic elders in the United States

b. The heterogeneity of the federally designated minority elder groups

c. Risk Factors and disease prevalence in these elders

d. The components of providing culturally competent medical care

III. Skills

A. Students should be competent in performing the basic elements of geriatric assessment with standardized methods for assessing physical, cognitive, emotional and social functioning as appropriate. Specific examples include: screening examinations for mental status, geriatric depression, and functional status including activities of daily living and instrumental activities of daily living.

B. Students should be competent in physical diagnosis skills, including: mobility assessment, gait and balance assessment, and recognizing normal versus abnormal signs of aging, and pre-operative assessment.

Instructional Strategies

Instructional strategies vary considerably from medical school to medical school, depending on available resources (locations, faculty, etc.). In general, it is important to include healthy as well as the non-healthy for training students since using only ill elderly people perpetuates many of the myths and stereotypes associated with aging and may promote ageism.

I. Longitudinal experiences with aging throughout all four years of the undergraduate medical curriculum are to be encouraged, particularly with community dwelling elderly.

II. Settings for conducting clinical experiences should include the inpatient and outpatient areas, but also sites such as retirement communities, assisted living facilities, community care homes, home care visits, as well as the teaching nursing home.

Developed by the AGS Education Committee and approved November 1998 by the AGS Board of Directors. The American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118, 212-308-1414, Fax: 212-832-8646, info.amger@americangeriatrics.org.