Geriatrics

Hospital Geriatrics Consultation

  • Our hospital-based Geriatrics team is commonly asked to provide consultation for older inpatients.  We are able to provide this consultation, as long as the patients involved are followed in the outpatient or nursing home setting by Geriatrics Division providers.
  • A comprehensive, hospital-based geriatrics consultation provides more than competent internal-medicine management of the older inpatient’s problems.  A well-executed geriatric consultation will add value in the following domains:
    • Superb assessment and management of clinical conditions that are especially prevalent in the older population:  hip fracture and its medical management, peripheral vascular disease and its complications, various degenerative neurologic conditions, orthostatic hypotension, etc.
    • Peerless management of classical geriatric syndromes (falls, delirium, syncope, frailty and failure to thrive, etc.)
    • Improved overall diagnostic approach, given geriatricians’ knowledge of atypical and nonspecific presentations of acute illness
    • Outstanding use of interprofessional resources
    • Optimal incorporation of psychosocial context into medical decision making (both by virtue of geriatrics training and by close contact with the primary providers who know the patient well)
    • Practiced transitional care, employing a deep knowledge base regarding non-hospital care venues
    • Outstanding skill in eliciting and negotiating health care goals, facilitating family meetings, etc.
    • Judicious and effective palliative care of older patients with disturbing symptoms
    • Meticulous use of an evidence-based, systematic approach to reduce risk of iatrogenic injury and functional decline in the hospital (this is spelled out below)

 

  • SYSTEMATIC APPROACH TO HOSPITAL CARE  The following data elements should be routinely determined and documented (in addition to the more conventional elements that typically are collected for patients of younger age):
    • HPI
      • Informant (family, caregivers, nursing) reports of illness
      • Functional changes (not just usual signs and symptoms)
    • PMH/PROBLEM LIST (in addition to the usually listed medical problems….)
      • Functional diagnoses (gait impairment, dysphagia, etc.) are included, not just medical ones
      • Synthesize, using geriatric sophistication:  For example, “Gait impairment and falls due to Parkinson’s disease and knee osteoarthritis”
    • MEDICATIONS
      • Method employed for administration at home
      • Assessment of adherence, and true as-taken regimen
    • SOCIAL HISTORY
      • Who lives with the patient?  Time alone?  Other social network?
      • Surrogate decision maker?
      • Functional status:  ADL, IADL, mobility
      • Possibility of neglect, mistreatment, or other lack of safety
      • Global health care goals, resuscitation wishes
    • ROS (in addition to the usual, be sure to include…)
      • Appetite and weight loss?  Chewing/swallowing problems?
      • Falls
      • Bowels and bladder
      • Vision and hearing impairment
      • Depression
      • Cognition
    • PHYSICAL EXAMINATION (in addition to the usual comprehensive exam, include…)
      • General appearance:  Vitality?  Hygiene?  Repetition or word-finding?  Affect?
      • Nutritional status (temporal fossae, deltoids, BMI)
      • Mental status:  objective cognitive assessment (e.g., Mini-Cog, CAM)
      • Oral cavity
      • Mobility
      • Vision and hearing
      • Skin:  for patients at risk of decubitus ulcers
    • IMPRESSION/RECOMMENDATIONS:  synthesize as far as data permit, and employ functional, psychosocial, and quality-of-life language.

Geriatric Hospital Consultation: Model Example

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