Laurie Mallery, M.D., FRCPC, Janet Gordon, M.D., FRCPC, Susan Freter, M.D., FRCPC

     Caring for elderly patients is a common experience for most physicians. Although seniors represented only 12% of the Canadian population in 1997/1998, they accounted for 35% of all hospital discharges in Canada and for 52% of patient days in the hospital.¹ Similarly, the 1997 National Hospital Ambulatory Medical Care Survey in the United States^2,3 documents that persons over age 75 had the highest rate of emergency department and ambulatory care visits.

     Despite frequent interactions with elderly patients, it is not uncommon for physicians to become frustrated when caring for frail elderly adults and for the true medical needs of this group to remain unrecognized.⁴ For example, a prospective study of 297 patients, aged 70 years or older,⁵ showed that cognitive impairment was common among older adults presenting to the emergency department, occurring in 26% of all older adults. However, only 30% of the patients with mental status impairment had documentation of mental status evaluation while in the emergency department. In addition, of the patients who met the criteria for delirium, 37% were discharged home. Likewise, acute confusional states are frequently missed amongst elderly orthopedic inpatients⁶ and medical patients.^7,8

     Older patients frequently have multiple interacting diseases, in addition to cognitive and functional disabilities. Atypical disease presentation can cause misdiagnosis, and inappropriate prescribing is common.⁹ Cognitive impairment amongst elderly inpatients is associated with greater cost and longer length of stay.¹⁰ Effective treatment of this age group, therefore, depends on understanding complex medical illnesses and how they affect cognition and function. Indeed, evidence shows that tailoring treatment plans to the needs of the frail elderly significantly improves outcome.^11-15

     To enable physicians to provide appropriate care to older adults, specific training in Geriatric Medicine is needed. Unfortunately, many medical schools offer little education in Geriatric Medicine.^16,17 Until 2001, the Dalhousie Medical School in Halifax, Nova Scotia had only 15 hours of Geriatric Medicine teaching in the entire 4-year curriculum. In September 2001, the Dalhousie Medical School introduced a mandatory 3-week rotation in Care of the Elderly for 4th year medical students. The curriculum for this rotation was developed by the Division of Geriatric Medicine. This paper reviews the principles and format of this program so that it can be reproduced at other medical centers.

Structure

     The course entitled “Care of the Elderly” runs over 12 weeks (i.e. 4 three week blocks), during which time the entire 4th year medical school class, comprising approximately 90 students, completes the rotation. Every three weeks 22-23 students present to the Division of Geriatric Medicine for learning. The course focuses on both didactic teaching and clinical experience. Our main objective is to comprehensively teach the following topics

Teaching

     In this course, we emphasize the importance of developing the necessary skills to evaluate and diagnose problems of cognition, as this subject is often deficient in the medical school curriculum. To accomplish this goal, we spend four hours during the introductory session reviewing basic principles of cognitive assessment. The “Memory Disability Clinic Checklist” (MDCC), a tool developed by the Division of Geriatric Medicine at Dalhousie University, is used to organize and document the history, cognitive evaluation, and physical examination (Table 2).

Specific skills the students are expected to learn to assess cognition include:

To summarize, students are taught to evaluate problems of cognition by:

     The second focus of the Care of the Elderly Course is to teach medical students how to identify the medical needs of the elderly. To facilitate assessment, students use the Comprehensive Geriatric Assessment (CGA) form (Table 4), designed to collect and record information about common medical, functional, and psychosocial problems of the elderly. The domains of the CGA form include cognition, mood, mobility, balance, bowel and bladder function, functional ability and social situation. Evaluating and describing these areas highlights their important contribution to the health of the individual. Subsequently, problems identified are targeted for treatment.

     The third topic we comprehensively teach is the assessment and treatment of mobility problems. Students have a 1½ hour session about falls and fall prevention and an interactive small group session with a physiotherapist to learn basic information concerning how to safely transfer and ambulate patients. Additionally, they learn how to perform gait assessment. This section also reviews the benefits of exercise and the effects of specific exercise protocols, such as the ability of high intensity resistance training to strengthen muscle. Students are taught about the deterioration of function and mobility that commonly occurs when older adults are hospitalized, emphasizing the importance of observing and describing a hospitalized patient’s mobility on a regular basis to detect and treat any change in ambulating ability. Finally, students are taught about common geriatric syndromes, as outlined in the syllabus (appendix 2).

Clinical Experience

     The students work with preceptors throughout Atlantic Canada, including geriatricians and family physicians caring for older adults. While working with these physicians, students meet and assess frail elderly patients. Interview and clinical experiences are structured using the CGA and MDCC forms.

Assignments

      During the three-week rotation, the students complete and submit the following to the geriatrician acting as the course preceptor:

Evaluation

     An evaluation form documents the goals and accomplishments of the student (Table 5), including satisfactory completion of the assignments, oral presentation, written examination, and preceptor assessment.

      To date, three medical schools classes have completed the geriatric program. Assessment at the end of the rotations demonstrated that the medical students acquired detailed knowledge of geriatric medicine. Review of the assignments documented acquisition of specific skills, such as how to complete comprehensive geriatric assessment, assess cognition, and manage common geriatric syndromes. The examination, held at the end of each three-week period, included 10-15 clinically based open-ended questions that covered the subject matter outlined in the syllabus and required detailed knowledge to answer correctly. For example, the students were shown an interview of a patient who had dementia and asked about diagnosis, stage, other expected associated symptoms and treatment options (see appendix 2 for examples of other questions). The answers to these questions clearly demonstrated the comprehensive knowledge the students attained during the 3-week course, as all but one participating student were able to provide detailed answers to most questions about core geriatric topics. Since the course began in 2001, one student has failed this examination.

     Prior to participating in the geriatric program, a pre-test evaluation of one group of medical students (n=23) showed they had little knowledge of how to assess cognition or integrate comprehensive geriatric assessment into the medical history and physical examination. After participating in the 3-week geriatric course, this same group provided detailed answers about these topics in a posttest, demonstrating that they achieved an understanding of how to assess dementia and perform CGA.

     One hundred percent of the students in all three years completed course evaluations. The majority of participating students rated the course positively. Eighty-three percent of the comments made by the students were positive, and students complimented the lectures, organization of the course and the amount of learning that occurred over three weeks. During each year, several students made superlative comments, such as: “Overall the best learning experience in the past four years” and “this was the best rotation in the clerkship”. Seventeen percent of the comments were critical. Of these, 6% of students stated that the oral presentation was unnecessary and 5% of students said there were too many assignments. Other recommendations made by the students included shortening the lecture time (1%), eliminating the examination (1%), putting the course in the third year rather than the fourth year (1%), and providing different reading material about dementia because the recommended text was too expensive (1%). Two percent of students reported an inadequate clinical experience and 1% of students said they were not yet “comfortable assessing patients with dementia”. On the basis of this feedback, the number of mandatory assignments was decreased to three CGA/treatment plans and one assessment of medication use, mobility and cognition. The duration of lectures was changed to 2 days.

Discussion

     Other programs for undergraduate geriatric education have been described in the literature. Several are similar to the Dalhousie Curriculum in that they include lectures,^22-30 mandatory reading assignments,^22,24,26,29 clinical experience,^22-30 cases^22,24,26-28 and examinations.^20,22-27 The Mt. Sinai³² program differs from the others in that it uses standardized patients, actors that pose as patients using a scripted geriatric problem. Many published curriculum document the topics covered in didactic lectures ^22-25,27-29, however, few articles extensively describe the way in which they teach these topics. Of these, the University of Kansas²⁴ most comprehensively outlines its course. The course syllabus, objectives, seminar topics, cases, and coursework are available on their website.³¹

     Our curriculum is unique in that it specifies how didactic subject matter is incorporated into clinical experience. Particularly, the four-hour teaching session on dementia, in addition to reading “Understanding Dementia; A primer of Diagnosis and Management”¹⁶ provide a focused approach for the assessment of cognition. The student then uses these learned skills and the MDCC to assess at least one patient with cognitive problems. Each of these assessments is critiqued by a geriatrician for feedback. Similarly, the CGA form provides a template for the student to assess core geriatric problems, including functional assessment, for patients they evaluate during their clinical time.

As with our course, most,^22-24,26-30 but not all programs²⁵ were highly rated.

Conclusion

     By instructing students to attend to common medical, functional and cognitive problems of the older adult, this educational program appears to meet the goal of teaching students how to assess and care for geriatric patients. In light of the increasing need to care for this population, we believe that these important skills should be taught to all medical students in a comprehensive and meaningful way so that the needs of this patient group can be properly identified and treated.