Care of the College Student.

Approximately 19 million students attend college in the United States. Although they are generally healthy, about 20% of youth have special health care needs, including asthma, diabetes mellitus, and learning, mental health, and substance use disorders. Physicians can facilitate the transition of a youth to an adult model of health care by using structured processes to orient the youth to self-care before entry into college. Stimulant medications are effective for treatment of students with attention-deficit/hyperactivity disorder, but physicians should monitor for signs of drug diversion. Learning disorders may manifest with emotional or physical symptoms and are managed in a multidisciplinary fashion. Depression, anxiety, sleep problems, and posttraumatic stress and eating disorders are common in this population and can affect school performance. Screening and/or interventions for obesity, depression, anxiety, violence, nicotine use, and substance use are effective. Immunizations for influenza, human papillomavirus, meningococcus, and pertussis are crucial in this high-risk population. Lesbian, bisexual, gay, transgender, and queer students have unique health care needs.

Diagnosis and Management of Osteoporosis.

Osteoporosis-related fractures affect approximately one in two white women and one in five white men in their lifetime. The impact of fractures includes loss of function, significant costs, and increased mortality. The U.S. Preventive Services Task Force recommends using dual energy x-ray absorptiometry to screen all women 65 years and older, and younger women who have an increased fracture risk as determined by the World Health Organization's FRAX Fracture Risk Assessment Tool. Although guidelines are lacking for rescreening women who have normal bone mineral density on initial screening, intervals of at least four years appear safe. The U.S. Preventive Services Task Force found insufficient evidence to recommend screening for osteoporosis in men; other organizations recommend screening all men 70 years and older. In patients with newly diagnosed osteoporosis, suggested laboratory tests to identify secondary causes include serum 25-hydroxyvitamin D, calcium, creatinine, and thyroid-stimulating hormone. First-line treatment to prevent fractures consists of fall prevention, smoking cessation, moderation of alcohol intake, and bisphosphonate therapy. Clinicians should consider discontinuing bisphosphonate therapy after five years in women without a personal history of vertebral fractures. Raloxifene, teriparatide, and denosumab are alternative effective treatments for certain subsets of patients and for those who are unable to take or whose condition does not respond to bisphosphonates. The need for follow-up bone mineral density testing in patients receiving treatment for osteoporosis is uncertain.

Delirium in older persons: evaluation and management.

Delirium is defined as an acute, fluctuating syndrome of altered attention, awareness, and cognition. It is common in older persons in the hospital and long-term care facilities and may indicate a life-threatening condition. Assessment for and prevention of delirium should occur at admission and continue throughout a hospital stay. Caregivers should be educated on preventive measures, as well as signs and symptoms of delirium and conditions that would indicate the need for immediate evaluation. Certain medications, sensory impairments, cognitive impairment, and various medical conditions are a few of the risk factors associated with delirium. Preventive interventions such as frequent reorientation, early and recurrent mobilization, pain management, adequate nutrition and hydration, reducing sensory impairments, and ensuring proper sleep patterns have all been shown to reduce the incidence of delirium, regardless of the care environment. Treatment of delirium should focus on identifying and managing the causative medical conditions, providing supportive care, preventing complications, and reinforcing preventive interventions. Pharmacologic interventions should be reserved for patients who are a threat to their own safety or the safety of others and those patients nearing death. In older persons, delirium increases the risk of functional decline, institutionalization, and death.

Care of the college student.

There are approximately 20 million students in U.S. colleges and universities. Although this population is characterized as having good health, 600,000 students report some form of disability or some type of medical problem, including attention-deficit/hyperactivity disorder, learning disabilities, psychiatric disorders, and chronic illnesses, among others. Physicians can enhance youth transition to an adult model of health care; the use of self-care skills checklists is one recommended method to assist with the transition. Stimulant medications are effective for treating adults with attention-deficit/hyperactivity disorder, but physicians should use caution when prescribing stimulants to college students because of the high rates of medication diversion in this population. Depression, anxiety, posttraumatic stress disorder, sleep problems, and eating disorders are common in college students and can significantly impact performance. Emphasis on immunization of students for influenza, meningococcus, and pertussis is necessary because of the low rates of compliance. Screening and interventions for obesity, tobacco use, and substance abuse are important because of the high prevalence of these problems in college students. Screening for alcohol abuse facilitates identification of students with problem drinking behaviors. Students who are war veterans should be monitored for suicidal ideation and posttraumatic stress disorder. Lesbian, gay, bisexual, transgender, and questioning students are at risk of harassment and discrimination. Caution should be exercised when prescribing medications to college athletes to avoid violation of National Collegiate Athletic Association eligibility rules.

House calls.

House calls provide a unique perspective on patients' environment and health problems. The demand for house calls is expected to increase considerably in future decades as the U.S. population ages. Although study results have been inconsistent, house calls involving multidisciplinary teams may reduce hospital readmissions and long-term care facility stays. Common indications for house calls are management of acute or chronic illnesses, and palliative care. Medicare beneficiaries must meet specific criteria to be eligible for home health services. The INHOMESSS mnemonic provides a checklist for components of a comprehensive house call. In addition to performing a clinical assessment, house calls may involve observing the patient performing daily activities, reconciling medication discrepancies, and evaluating home safety. House calls can be integrated into practice with careful planning, including clustering house calls by geographic location and coordinating visits with other health care professionals and agencies.

Nursing home care: part I. Principles and pitfalls of practice.

Approximately 1.5 million Americans reside in nursing homes. A family physician often leads the interdisciplinary team that provides for the medical, functional, emotional, nutritional, social, and environmental needs of these patients. The treatment of nursing home residents is a dynamic process of ongoing assessment, transitions, and shifting care plans. The clinical assessment of nursing home residents focuses on cognition, mood, disability, skin integrity, and medication management. Advance care planning includes the development of realistic goals of care with the patient and family that go beyond living wills and do-not-resuscitate orders. The nursing home medical record and Minimum Data Set document the interdisciplinary findings and care plan. Transitions between different health care environments are facilitated by communication among health care professionals and detailed transfer documentation. Palliative care encompasses continuing reassessment of the goals of care; general supportive care (e.g., family, cultural, spiritual); and legal planning. Identifying and reporting resident abuse and neglect, and infection control practices are also essential in nursing home care.

Nursing home care: part II. Clinical aspects.

Understanding the distinctions between the management of clinical problems in nursing homes compared with the community setting helps improve the overall care of nursing home residents. Liberalizing diets helps avoid unintentional weight loss in nursing home residents, although the use of feeding tubes usually does not improve nutrition or decrease aspiration risk. Medical assessment, treatment of comorbidities, and appropriate use of rehabilitation therapies minimize the frequency of falls. Toileting programs may be used to treat incontinence and retention in cooperative patients. Adverse effects and drug interactions should be considered when initiating pharmacologic treatment of overactive bladder. Urinary tract infection and pneumonia are the most common bacterial infections in nursing home residents. Signs and symptoms of infection include fever or hypothermia, and functional decline. Virus identification is recommended for influenza-like illnesses. Nonpharmacologic behavioral management strategies are the preferred treatment for dementia-related problem behaviors. The Beers criteria, which outline potentially inappropriate medication use in older persons, provide guidance for medication use in the nursing home.

Practice tools to meet the complex needs of older vulnerable military beneficiaries.

The elderly military beneficiary is a valued, high-risk, high-cost, and complex individual with unique medical needs. Attention to common geriatric syndromes (such as incontinence) and quality end-of-life care is critical in this population. Care of older adults is part of every adult medical and surgical specialty and represents a significant portion of the care rendered by the Military Health System (MHS)--a system that is currently oriented to warrior care and the care of young adults and families. Unique additional knowledge and expertise to care for the age-related geriatric syndromes is required by all providers. Maintaining quality of care for this older vulnerable population also requires unique measurement metrics and is facilitated by use of validated practice tools. This article will review validated practice tools that can assist military physicians and facilities in prospective and retrospective quality improvement (QI) initiatives to improve the therapeutic and palliative care of our older beneficiaries.

Therapeutic home adaptations for older adults with disabilities.

Family physicians commonly care for older patients with disabilities. Many of these patients need help maintaining a therapeutic home environment to preserve their comfort and independence. Patients often have little time to decide how to address the limitations of newly-acquired disabilities. Physicians can provide patients with general recommendations in home modification after careful history and assessment. Universal design features, such as one-story living, no-step entries, and wide hallways and doors, are key adaptations for patients with physical disabilities. Home adaptations for patients with dementia include general safety measures such as grab bars and door alarms, and securing potentially hazardous items, such as cleaning supplies and medications. Improved lighting and color contrast, enlarged print materials, and vision aids can assist patients with limited vision. Patients with hearing impairments may benefit from interventions that provide supplemental visual and vibratory cues and alarms. Although funding sources are available, home modification is often a nonreimbursed expense. However, sufficient home modifications may allow the patient and caregivers to safely remain in the home without transitioning to a long-term care facility.

Palliative Care Education in the Family Medicine Clerkship: A CERA Study.

INTRODUCTION: Inadequate training of medical students in palliative care has been identified as a barrier to its universal provision. Family medicine physicians frequently provide these services, yet the extent of palliative care training in the family medicine clerkship has been unknown. This study describes the status of palliative care training in the family medicine clerkship, as well as clerkship director perceptions of this training. METHODS: Data were attained through a cross-sectional survey of 141 US and Canadian family medicine clerkship directors administered in fall 2016. Survey items included clerkship director perceived value, interest, and background in palliative care education; presence of educational objectives; hours of training provided; and perceived barriers to palliative care instruction. RESULTS: Of the clerkship directors who responded (120/141, 81.5%), 31 (25.8%) reported providing no palliative care education and 75 (62.5%) reported palliative care competencies were not specifically assessed. Background in palliative care and explicit educational objectives were associated with more hours of training in palliative care. Clerkship director training in palliative care correlated with value of teaching it in the clerkship. CONCLUSION: Palliative care education in the family medicine clerkship is prevalent but a large portion of clerkships do not offer it, and the majority of clerkship directors do not evaluate this learning. Our study found a positive correlation between clerkship director training in palliative care and value placed on palliative training in the family medicine clerkship. Assessing this training in the family medicine clerkship and pursuing additional clerkship director training in the subject could improve the overall quality of education provided.