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INSTITUTIONAL ISSUES: ARTICLES

Core Competencies for the Care of Older Patients

Recommendations of the American Geriatrics Society

 The Education Committee Writing Group of the American Geriatrics Society

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Abstract

Demographic projections that indicate a dramatic rise in the number of older Americans in the first half of the 21st century have led the Institute of Medicine, the Association of American Medical Colleges, and other organizations to call for an increase in the amount of clinical geriatrics training in medical schools.1,2,3,4,5 To help medical schools develop geriatrics curricula, the Education Committee of the American Geriatrics Society (AGS) undertook the development of a recommended set of core competencies for medical and osteopathic schools.

A subcommittee of the AGS Education Committee was assigned the task of defining basic competencies for the knowledge, attitudes, and skills students must develop to care for older people. The committee felt that the competencies they identified could be attained through a variety of curricular strategies. In drafting their initial recommendations, the subcommittee reviewed the published medical literature as well as information from a number of medical schools and organizations, including the Institute of Medicine and the Association of American Medical Colleges. Members of the subcommittee then formulated a document for review by the full AGS Education Committee. Over a period of several years the document was edited and revised with input from leaders in the field of geriatric education. The final document was approved by the Executive Committee of the AGS in November 1998.

This document provides the framework medical schools can use in developing comprehensive curricula on aging that best fit their own programs. The AGS's recommendations, which are presented below, are not meant to be comprehensive or all-inclusive, but medical educators may find them useful both in developing new curricula on aging and in evaluating existing curricula.

BASIC ATTITUDES, KNOWLEDGE, AND SKILLS NECESSARY FOR THE CARE OF OLDER PATIENTS

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 practitioners need to care for older people.

Attitudes

Students should

  • be aware of the various myths and stereotypes related to older people.
  • recognize that ageism, like racism, affects all levels and aspects of society, including health professions, and can adversely affect optimal care of elderly patients.
  • recognize that “the elderly” are a diverse group with different personalities, different values, different functional levels, and different medical illnesses, and understand that each person needs to be viewed and cared for as an individual regardless of chronological age.
  • be open and willing to work with colleagues in other disciplines in caring for older patients.
  • be aware of their attitudes about their own aging, disability, and deaths.
  • be compassionate toward those who provide day-to-day care for frail elderly and the difficulties they face.
  • appreciate the need for improving and optimizing older people's functioning rather than just focusing on diseases.

Knowledge

Basic science. Students must acquire knowledge of

  • the demography and epidemiology of aging, including the growth in numbers of older people and heterogeneity of the older population.
  • theories of aging, including biochemical/molecular, cellular, genetic, and biopsychosocial.
  • “normal” aging versus diseases at the molecular, cellular, tissue, and organism levels.
    • Normal aging is heterogeneous, affecting different tissues and organs in different individuals at different rates.
    • Preventable, reversible, and treatable aging processes need to be identified by practicing physicians and managed accordingly.
    • Loss of homeostatic control mechanisms may account for much of the aging process.
  • anatomic and histologic changes associated with aging.
  • pathology associated with normal aging and age-associated disease processes.
  • the physiology of aging in various organ systems.
  • pharmacologic issues in aging and relevance to therapeutic decisions.

Clinical. Students should be familiar with

  • common geriatric syndromes and conditions, and have a basic understanding of risk factors, causes, signs, symptoms, differential diagnoses, initial diagnostic evaluations, and preventive strategies. These geriatric syndromes, conditions, and related problems include
    • dementia;
    • inappropriate prescribing of medications;
    • incontinence;
    • depression;
    • delirium;
    • iatrogenic problems, including consequences of hospitalization and bed rest;
    • falls;
    • osteoporosis;
    • sensory alterations, including hearing and visual impairment;
    • failure to thrive;
    • immobility and gait disturbances;
    • pressure ulcers;
    • sleep disorders; and
    • nonspecific presentations of disease.
  • diseases and disorders that are more common to or that have particular features in older people. Although students' 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 diagnoses, and initial diagnostic evaluations for common diseases for older people, including
    • rheumatologic diseases (e.g., osteoarthritis, rheumatoid arthritis, temporal arteritis/polymyalgia rheumatica);
    • genito-urological diseases (e.g., benign prostatic hyperplasia, sexual dysfunction);
    • neurologic diseases (e.g., Parkinson's disease, stroke and transient ischemic attack, dizziness/syncope);
    • cardiovascular diseases (e.g., congestive heart failure, atrial fibrillation, valvular heart disease), and hypertension (diastolic and systolic);
    • endocrinologic diseases (e.g., type II diabetes mellitus, hyperosmolar nonketotic coma, hyper- and hypothyroidism, Paget's disease of the bone);
    • cancers of various organs, including breast, lung, colon, prostate, and hematologic malignancies;
    • infections, including pneumonia, tuberculosis, and urinary tract infections;
    • renal diseases (e.g., fluid and electrolyte disturbances);
    • gastroenterologic disorders (e.g., constipation, malnutrition, diverticulitis, diverticulosis);
    • psychiatric diseases (e.g., depression); and
    • others, such as fractures and amyloidosis.
  • the presenting signs and symptoms of and appropriate referral for psychosocial problems and issues common to elders, including
    • normal late-life changes, including retirement;
    • psychological problems, including affective disorders, psychotic disorders, anxiety disorders, responses to medical illness, depression, and substance abuse;
    • under-reporting of symptoms and illnesses;
    • sexuality and aging;
    • elder abuse and neglect;
    • suicide;
    • home safety;
    • community resources, including those used to prevent institutionalization; and
    • adaptation to care in alternative living situations, including long-term care facilities.
  • disease prevention, including
    • primary prevention (for example, exercise and nutritional and psychosocial interventions designed to maximize function and allow independent living);
    • secondary prevention with age-appropriate screening for diseases and identification of geriatric syndromes; and
    • tertiary prevention strategies (for example, rehabilitation and chemoprophylaxis in the post-myocardial infarction patient).
  • ethical issues in geriatric care, including
    • advance directives;
    • decision-making capacity;
    • euthanasia, assisted suicide;
    • health care rationing; and
    • pain management and end-of-life care.
  • health care financing, including
    • mechanisms and implications; and
    • Medicare, Medicaid, managed care, and capitation.
  • 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
    • demographic information for ethnic elders in the United States;
    • the heterogeneity of federally designated minority groups;
    • risk factors and disease prevalence in these elders; and
    • the components of culturally competent medical care.

Skills

Students must be competent in

  • performing the basic elements of geriatric assessment, including the standardized methods for assessing physical, cognitive, emotional, and social functioning as appropriate. For example, students should be able to conduct screening examinations for mental status, geriatric depression, and functional status (including activities of daily living and instrumental activities of daily living).
  • physical diagnosis skills, including the ability to perform mobility and gait and balance assessments, recognizing normal versus abnormal signs of aging, and performing preoperative assessment.

INSTRUCTIONAL STRATEGIES

Instructional strategies vary considerably among medical schools, depending on available resources (locations, faculty, etc.). In general, it is important in student training to include discussions of healthy as well as non-healthy elders, since referring only to ill elderly people perpetuates many of the myths and stereotypes associated with aging and may promote ageism. The AGS also encourages schools to provide

  • longitudinal experiences in geriatrics throughout all four years of the medical curriculum, particularly clinical work with community-dwelling elderly.
  • settings for conducting clinical experiences that include inpatient and outpatient areas and also such sites as retirement communities, assisted living facilities, and community care homes; home care visits; and the teaching nursing home.

CONCLUSION

Today, there are approximately 34 million people over the age of 65 in the United States; by the time the 2000–01 entering class graduates in 2004, that number will have increased by over a million.6,7 Whatever area of specialization these graduates choose to pursue, it is likely that they will care for significant numbers of elderly patients. It is crucial, then, that medical schools provide students with the attitudes, knowledge, and skills they will need to competently care for older people. This document provides a framework that medical and osteopathic schools can use in developing curricula that meet this goal, as well as basic competency requirements to develop evaluation strategies.

REFERENCES

1. Academic geriatrics for the year 2000. An Institute of Medicine report. N Engl J Med. 1987;316:1425–8.
2. Undergraduate medical education preparation for improved geriatric care. Report of the Steering Committee. In: Proceedings of the Regional Institutes on Geriatrics and Medical Education. Washington, DC: Association of American Medical Colleges, 1983:113–32.
3. American Association of Retired Persons. A Profile of Older Americans. Washington, DC: AARP, 1998.
4. Strengthening Training in Geriatrics for Physicians. Washington, DC: Institute of Medicine, National Academy of Sciences, 1993.
5. Barry PP. Geriatric clinical training in medical schools. Am J Med. 1994;97(suppl 4A):4A8S–4A9S.
6. U.S. Bureau of the Census. Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995–2000. 〈http://www.census.gov/population/projections/nation/nas/npas9600.txt〉. Accessed 12/6/99.
7. U.S. Bureau of the Census. Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 2001–2005. 〈http://www.census.gov/population/projections/nation/nas/npas0105.txt〉. Accessed 12/6/99.
© 2000 Association of American Medical Colleges