Geriatrics and Gerontology

Clinical Elective Program for Foreign Medical Students

Introduction:

Population aging is the most critical issue in both individual and societal aspects nowadays. The percentage of people aged over 60 years will increase from 11.5% at present to 22% in 2050. However, increased life expectancy and decreased fertility rate are accompanied with overwhelming health, economic and social problems.

Aging is associated with changes of body composition, organ insufficiency, and progressive physical and cognitive functional decline. Multiple chronic diseases and increased pills burden are common problem in the elderly that increased the risk of inappropriate medications and adverse effects. Furthermore, functional deterioration, emotional stress and environmental limitation that will influence the independency and quality of life among the elderly. Accelerated aging process, that indicated by geriatric symptoms, represents the status of decreased physical reserves, increased vulnerability to external stressors, thus poor health outcome and increased mortality risk. Frailty is compatible with accelerated aging that is featured by functional limitation and sarcopenia. Multiple factors have been reported to contribute to the development of frailty and sarcopenia, including altered hormone homeostasis, chronic inflammation, excessive oxidative stress and undernutrition. Therefore, early identification of frailty and sarcopenia may play an important role to prevent the related adverse health outcome for the elderly.

More than controlling chronic diseases, functional interventional program and continuous caring models in different stages of aging plays important roles that assists those elderly to live individual life at home or in the community. Seamless transition between homes, institutes, acute-care unites and post-acute care facilities are an ideal way that decreases the burden of seeking assistance and also improves their quality of life. To efficiently running these caring models, interdisciplinary team work for each individual setting is necessary. At the final end of life, how to help the elderly understating the meaning of advanced life directives, palliative care, and do-not-resuscitate decision elderly on their own decision is also an important issue in life.

Therefore, that’s important to learn how to identify geriatric syndromes including frailty and sarcopenia, how to cope with multimorbidities and polypharmacy, and how to manage the seamless continuous caring models by interdisciplinary team work through this course. The main point is to improve the quality of life of the elderly, but not to increase the suffering in prolonged life expectancy.

Leaning Objective

1. Understand the basic principle of managing chronic diseases and multi-mobidities
2. Learn how to identify geriatric syndromes, frailty and sarcopenia through comprehensive geriatric assessment, and set the appropriate treatment goal of each individual
3. Learn how to cope with problems of polypharmacy and adverse drug effects
4. Understand the interdisciplinary team work models when taking care of complicated patient
5. Familiar with seamless caring models on transition between community, institutes, acute hospital, and post-acute care facilities
6. Learn the role of past-acute care program and the timing for referral
7. Learn the significance of dementia, treatment options, and non-pharmacological therapies
8. Take a galance of gerotechnology and assistant prosthesis in patient with functioanl or cognitive limitation
9. Familiar with advanced life directives, palliative care, and end-of-life decisions in the elderly

Available Supervisors  

Liang-Kung Chen,         Ming-Hsien Lin,           Li-Ning Peng,           Liang-Yu Chen

Li-Kuo Liu,                     An-Chun Hwang,         Yi-Hui Wu,                Chung-Yu Huang

Tentative Schedule       

WEEK ONE:

1. Introduction of geriatric syndromes and comprehensive geriatric assessment tools
2. Set up reasonable and acheivable goals of chronic diseases, and learn the unique treatment goals among the elderly
3. Functional interventional program after recovery from acute illness
4. Interdisciplinary team work in acute care unites for each individuals
5. Understand the cognitive impairment, mood disorders and management of behavioral and psychological symptoms of dementia
6. Learn the model of mutual communication through discussion in family conferences

WEEK TWO:

1. Introduction of Post-acute care (PAC) program for functional decline
2. Community-caring program at home and in long-term care facilities
3. Social resources and family support through care-manager
4. Parameters for monitoring at home for patients with chronic diseases
5. Emergent symptoms/signs for seeking medical assistance at home and in the facilities
6. Visit PAC hospital at Yuan-Shan veteran hospital or Taoyuan veteran hospital

WEEK THREE:

1. Learn the importance of “International Classificantion of Functioning, Disability, and Health.”
2. Learn the assessment of physical functional and undernutrition
3. Training program for functional dependence: muscle power, endurance, and balance
4. Intervention for gait disturbance and fall prevention
5. Walking assistance and other assistance devices in patients with functional impairment

WEEK FOUR:

1. Dementia caring projects in the elderly and different caring settings for patients with dementia
2. Visit dementia caring, education, and research center at Jia-Li Veteran Home, Tainan, Taiwan
3. Skillings when taking care of people with dementia
4. Non-pharmacological therapies and activites for people with dementia
5. Management of behavioral and psychological symptoms of dementia in facilities

Assessment    

1. Describe the significance of geriatric syndrome, frailty and sarcopenia
2. Describe the different interventional and caring models for functional decline
3. Describe how to identify problems of polypharmacy and potentially inappropriate medications
4. Describe the significance of dementia, delirium, medication choices and non-pharmacological therapies
5. Describe the basic principles of rehabilitation program designing

References               

1. Hazzard’s Geriatric Medicine& Gerontology, 6^th edition
2. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-31.
3. Boyd et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716-24
4. Hochberg MC1, Altman RD, April KT, et al. American Collage of Rheumatology 2012 Recommendation for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). 2012;64:465-74.
5. Kane RL1, Shamliyan T, Talley K, Pacala J. The Association Between Geriatric Syndromes and Survival. J Am Geriatr Soc 2012;60:896-904.
6. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in Older Adults: A Consensus Report. Diabetes Care 2012;35:2650-2664
7. Craen KV, Braes T, Wellens N, et al. Effectiveness of Inpatient Geriatric Evaluation and Management Units: A Systemic Review and Meta-Analysis. J Am Geriatr Soc 2010;58:83-92.
8. Young J. The development of intermediate care services in England. Arch Gerontol Geriatr. 2009;49 Suppl 2:S21-5