Aging Q3 2011 Fall Faculty Retreat

1. Aging Q3 2011 Fall Faculty Retreat Kiawah Island Golf Resort Charleston, SC

2. Welcome to Kiawah Island!

3. Aging Q3 Update • Completed 9 ACOVEs to date • In the middle of Pain Management (ends Jan 20) • 5 remain • (Pressure Ulcers and Malnutrition are combined in 1 ACOVE)

5. # = ≥67% correct answer; # # = ≥80% correct answers

6. Manuscripts and Publishing • Patrick

8. End of Life Care ACOVE # 8

9. End of Life Care Working Group Chair:Paul Rousseau, MDWorking Group Members: Leigh Vaughan MD Rog Kyle MD Elisha Brownfield MD William P. Moran MD Cara Litvin MD Mary Adler RN Lisa Roberge PA-C Leah Clanton MD (Resident) Amanada Overstreet MD (Resident)

10. Objectives • How to estimate life expectancy • How to communicate about Advanced Care Directives • How to lead a family meeting to discuss EOL issues and/or deliver bad news

11. Interesting Results • 57% (568/998) of patients seen were asked if they have an ACD • 23% of patients asked (131/568), DO have an ACD • 51% (67/131) Resident knows their wishes • 20% (26/131) Copy in the chart • 77 % (437/568)of patients asked, don’t have ACD • 49% (214/437) want to discuss ACD today • 25% (111/437) want to discuss ACD at a follow up visit

12. More! • In 18% (99/537) of those patients for whom the resident estimated life expectancy using the Covinsky scale, the resident documented the results did have an influence on the clinical decision making.

13. Role Plays60/96 (62.5%) of Residents participated in at least 1 Role Play

14. OsteoporosisACOVE #9

15. Osteoporosis ACOVE Working Group Working Group Chair:Jay Brzezinski, MD Working Group Members: Pamela Pride MD Leonard Lichtenstein MD Amy Thompson PharmD Brad Keith MD Lara Hourani (Resident) Tamela Sill, RN

16. Learning Objectives • Who to refer for a DXA scan • How/when to use a FRAX • Treatment options for Osteoporosis

17. Have you ever calculated a FRAX score?

18. A FRAX score is useful when:

19. A 70 year old female patient has a symptomatic compression fracture of her thoracic spine. Which of the following is true?

20. The # of treated patients that are needed to cause osteonecrosis of the jaw (NNH) is rouhgly:

21. The # of treated osteoporosis patients that are needed to prevent any fracture (NNT) is roughly:

22. Which of the following is not a risk factor for osteoporosis?

23. On a scale of 1-5 with 1 being no confidence and 5 being very confident, rate your confidence in your ability to decide ho to treat Osteoporosis in elderly females:

24. 220/613=35.9% of patients seen (females 65+) had a DEXA scan documented it was done or referred N=116 (done ‘yes’) + 104 (order ‘yes’)=220 D=613

25. 81/95 = 85.3% of residents demonstrated use of FRAX

26. 158/170=92.9% of those patients who had a frax calculated and documented, the resident reported the results had influence on clinical decision

27. Pain ManagementACOVE #10

28. Pain Management ACOVE Working Group Chair: Rogers Kyle, MD Working Group Members: Deborah Dewaay MD Amy Thompson PharmD Jayne Quinn, RN

29. Objectives • All patients 65+ presenting in the clinic will be assessed for chronic and persistent pain. • All hospitalized adult patients on Gen Med will be assessed for uncontrolled pain, including the use of PCA management for pain. • All hospitalized adult patients on Gen Med on opioid therapy for pain will be assessed for efficacy and side effects.

30. Skills • Manage PCA’s • Conversion • Pain assessment

31. Key Detailing Messages • Opioid Use for Control of Pain • Opioid Side Effects • Non-Opioid Treatment Options • Conversion

32. Pain ACOVE Participation Progress • 6/24 = 25% of residents on IP rotation have demonstrated how to properly read a PCA • 27/94 = 29% of residents in OP have been detailed • 20/94 = 21.3% of residents in OP have demonstrated pain assessment

33. NSAIDS are useful in the treatment of moderate to severe pain. • True • False

34. A 70 year old woman has been taking 20 mgs of oxycodone every 6 hours for two weeks for pain related to a pelvic fracture. A reasonable next step in her pain management would be to initiate a long acting opioid such as: • MSContin 60 mg BID • Fentanyl transdermal 75 mcg • Oxycontin 20 mg BID • Methadone 20 mg BID

35. Which of the following medications might be useful in the management of neuropathic pain in the elderly? • NSAIDS • Anticonvulsants • Topical anesthetics • Antidepressants • B,C, and D • All of the above

36. When prescribing pain medications, it is often useful to combine an opioid with either acetaminophen or an NSAID. • True • False

37. A “Word” from our Residents!

38. Why “Assess Geriatric Competencies? • Drs. Clyburn and Keith

39. IM-FM ResidentsMinimum Geriatric Competencies • Medication Management • Cognitive, Affective, and Behavioral Health • Complex or Chronic Illness(es) in Older Adults • Palliative and End of Life Care • Hospital Patient Safety • Transitions of Care • Ambulatory Care

40. Competencies and Curriculum Development Dr. Wong

41. ACGME Competencies • Patient Care • Medical Knowledge • Interpersonal and Communication Skills • Professionalism • Practice Based Learning • Systems Based Practice

43. Let’s Play a Game! Drs. Caton and Thompson

44. M2M“Madness to Methods”Amy ThompsonCathryn Caton • Medical College of Wisconsin • Can be adapted to any learning task • Engages the learner and their “competitive” spirit • Encourages Creativity • Promotes transfer of behavior to real task

45. Upcoming ACOVEs • Osteoarthritis – Cathryn Caton, MD • Depression – Bill Moran, MD • Urinary Incontinence – Fletcher Penney, MD • Pressure Ulcers/Malnutrition – Keri Holmes-Maybank, MD • Hearing Loss – Brad Keith, MD

46. OsteoarthritisACOVE # 11 Chair: Cathryn Caton, MD Working Group Members: Theresa Cuoco, MD Pam Charity, MD Keri Holmes-Maybank, MD Don Fox, MD Cara Litvin, MD Amy Thompson, PharmD Kathy Wiley, MD Lynn Manfred, MD Cheryl Lynch, MD Ashley Morris (Med Student)

47. Objectives • Perform & Document functional assessment at the time of admission (H&P) • Found under ROS section of the H&P • Improve knowledge of treatment options • Medications • Physical Therapy • Joint Replacement

48. Osteoarthritis • Skill for outpatient? • Joint injection labs • Joint exams – knees, hips • Tools for evaluating patients with osteoarthritis

49. DepressionACOVE # 12 Chair: Bill Moran, MD Working Group Members: Cara Litvin, MD Delores Tetrault, MD Cathryn Caton, MD AmyThompson, PharmD Brad Keith, MD Temeia Martin, MD (Resident) QI Residents

50. PHQ-2 Screen for Depression Over the past two weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things. 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day Feeling down, depressed, or hopeless. 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day Thibault, JM, Prasaad Steiner, RW. (2004) “Efficient Identification of Adults with Depression and Dementia.” American Family Physician (70):6.