Geriatric Assessment: An Office-Based Approach.

Family physicians should be proficient in geriatric assessment because, as society ages, older adults will constitute an increasing proportion of patients. Geriatric assessment evaluates medical, social, and environmental factors that influence overall well-being, and addresses functional status, fall risk, medication review, nutrition, vision, hearing, cognition, mood, and toileting. The Medicare Annual Wellness Visit includes the key elements of geriatric assessment performed by family physicians. Comprehensive geriatric assessment can lead to early recognition of problems that impair quality of life by identifying areas for focused intervention, but a rolling geriatric assessment over several visits can also effectively identify subtle or hidden problems. Assessment should be tailored to patient goals of care and life expectancy. By asking patients and families to self-assess risks using precompleted forms, and by using trained office staff to complete validated assessment tools, family physicians can maximize efficiency by focusing on identified problems. Fall risk can be assessed with a single screening question: "Have you fallen in the past year?" The Beers, STOPP (screening tool of older persons' prescriptions), and START (screening tool to alert doctors to right treatment) criteria are helpful resources for reviewing the appropriateness of medications in older adults. Screening for depression is recommended when depression care supports are available; this can be performed with a brief two-item screen, the Patient Health Questionnaire-2. Older adults should be screened for unintentional weight loss and malnutrition. Although rates of hearing loss and vision loss increase with age, there is insufficient evidence to recommend screening in asymptomatic individuals. The U.S. Preventive Services Task Force advises clinicians to assess cognition when there is suspicion of impairment. Urinary incontinence can impair patients' quality of life, and it can be assessed with a two-question screening tool. Immunizations and advance care planning are also important components of the geriatric assessment.

End-of-Life Care: Palliative Management of Symptoms at the End of Life.

As the health status of patients living with multiple chronic conditions declines, these patients experience a variety of symptoms (eg, respiratory, gastrointestinal, psychological symptoms; overall symptoms of decline; and pain). Respiratory symptoms can include dyspnea, cough, and excessive upper respiratory tract secretions. Gastrointestinal symptoms can include nausea and vomiting, constipation, and malignant bowel obstruction. Overall symptoms include anorexia, cachexia, and fatigue. Psychological symptoms may manifest as depression, anxiety, or delirium. For patients with chronic pain and progressive disease, it is important to identify the etiology and type of pain (ie, visceral, somatic, neuropathic) because management differs. An evaluation of total pain should consider the various domains of suffering, including physical, psychological, and spiritual suffering. It is imperative to attempt to identify the underlying causes of the symptoms and address it if possible. It also is important to relieve symptoms using nonpharmacologic and pharmacologic approaches. In patients unable to self-report symptoms, family members and/or caregivers can provide insight into the condition of the patient.

Childhood abuse and neglect histories in low-income women: prevalence in a menopausal population.

OBJECTIVES: To examine the prevalence of self-reported childhood abuse and neglect in a primary care population of menopausal women. DESIGN: A cross-sectional questionnaire-based study. RESULTS: Three of four women (119/160, 74%) reported histories of childhood abuse and neglect. The prevalence of emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect were 43%, 35%, 33%, 49%, and 44%, respectively. Eleven percent of the sample reported maltreatment in all five categories of trauma. Fifteen percent of women studied met criteria for severe-extreme levels of maltreatment, usually in more than one category. CONCLUSIONS: A high prevalence of self-reported childhood trauma was detected in our low-income population of menopausal women attending primary care clinics. Because of the potential impact of childhood trauma on physical and mental health, clinicians need to inquire about childhood maltreatment in women of menopausal age and appropriately refer women to mental health intervention and treatment.

Hospice and palliative medicine: curriculum evaluation and learner assessment in medical education.

Major efforts have been pursued to improve palliative care education for physicians at all levels of their training. Such changes include the incorporation of palliative care curriculum and guidelines, an established process for competency-based evaluation and certification, faculty development, innovative educational experiences, the improvement of textbooks, and the establishment of accredited palliative medicine fellowships. Hospice and palliative medicine (HPM) has been clearly defined as a subspecialty and a crucial area of medical education. As innovative curricular approaches have become available to educate medical and other interprofessional trainees, this article aims to describe different models and methods applied in curriculum evaluation, tailoring such approaches to the field of palliative medicine. A stepwise process of curriculum development and evaluation is described, focusing on available curriculum evaluation competency-based tools for each level of learners. As HPM evolves and its educational programs grow, curriculum evaluation will provides invaluable feedback to institutions and programs in many ways.