# data[].attributes.attachment_link.title
The impact of deprescribing: a case of prolonged diarrhea

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Deprescribing is an essential consideration for clinical care, particularly in older adults. This case describes a 78-year-old man with a history of esophageal and colon cancer who experienced wors…

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How to make your program more Age Friendly

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How to make your program more Age Friendly

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https://pubmed.ncbi.nlm.nih.gov/40353013/

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Telemedicine training among geriatric fellowship graduates: a needs assessment for future curriculum development

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Geriatricians are expected to use telemedicine to deliver high-quality care to older adults. Yet, little is known about the training geriatric fellows received prior to the COVID-19 pandemic and th…

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Resident (IM/FM) Geriatric Competencies 

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Resident (IM/FM) Geriatric Competencies 

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https://adgap.americangeriatrics.org/education-training/competencies-and-milestones/minimum-competencies-geriatrics-imfm-residents

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Minimum Competencies in Geriatrics for IM/FM Residents | ADGAP - Association of Directors of Geriatrics Academic Programs

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Minimum Competencies in Geriatrics for Internal Medicine and Family Medicine (IM/FM) Residents

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Manning M, Beyer LN, Tolchin DW. Structuring Palliative Care Education for Medical Students: Impact of a Novel Framework and Pocket Card. Am J Hosp Palliat Care. 2025 Jan 18:10499091251315152. doi: 10.1177/10499091251315152. Epub ahead of print. PMID: 39825763.

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Structuring Palliative Care Education for Medical Students: Impact of a Novel Framework and Pocket Card - PubMed

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First-year medical students were able to use the 6 Ps framework and pocket card after a brief introduction, endorsing new learning and demonstrating significant gains in knowledge and self-assessed confidence. Medical educators across schools may consider adopting this novel tool and approach to int …

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AGS Medical Student Geriatrics Competencies

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AGS Medical Student Geriatrics Competencies

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Academic Medicine 2025

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Updated Geriatrics Competencies for Graduating Medical... : Academic Medicine

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ncies in geriatrics for graduating medical students, framed by the Geriatrics 5Ms (Mind, Mobility, Medications, Multicomplexity, and What Matters Most). Method From 2019-2022, a working group of the American Geriatrics Society (AGS) drafted the updated medical student geriatrics education competencies, using a modified Delphi approach. The working group reviewed the literature, conducted an initial survey of working group members, and drafted and refined proposed updates to the competencies. The 27 resulting competencies were disseminated as a national survey to geriatrics experts and medical school education deans. Following the national survey, the competencies were updated and presented at the 2021 AGS Annual Scientific Meeting and open to public comment before they were finalized. Results The 27 updated geriatrics competencies for medical students included several new competencies, such as a focus on health equity, frailty, deprescribing, and patient priorities. A total of 211 respondents completed the national survey, including geriatrics experts (187/398, response rate: 47.0%) and education deans (24/191, response rate: 12.6%). All 27 proposed competencies met the predetermined threshold of 70% cumulative agreement, with a range of 93.0% (174/187) to 100% (187/187) among geriatrics experts and 87.5% (21/24) to 100% (24/24) among education deans. Conclusions The updated Geriatrics Competencies for Graduating Medical Students met with broad agreement among the geriatrics experts and medical school education deans who responded to the national survey. By focusing on the Geriatrics 5Ms, the competencies highlight key knowledge and skills graduating medical students need for the first day of internship to be prepared to deliver age-friendly care to older adults under their care. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.…

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My Life My Story: Narrative history implementation guide

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My Life My Story: Narrative history implementation guide

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My Life, My Story (MLMS) is a VA program where Veterans are interviewed about their life story. The interview is written up into a first person narrative, reviewed with the Veteran and, with the Veteran’s permission, entered into the healthcare record as a resource for the care team to know more about the Veteran as a person, in their own words.

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Lo que más importa: La historia de Alberto

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Lo que más importa: La historia de Alberto

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Lo que más importa: La historia de Alberto

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Uncertainty in Medicine Residents caring for older adults

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Uncertainty in Medicine Residents caring for older adults

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https://link.springer.com/article/10.1007/s11606-024-08720-y

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Top Tips for Palliative Care for people with Disabilities

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Top Tips for Palliative Care for people with Disabilities

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Tolchin et al, JPM 2024

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Publishing with Mary Ann Liebert, Inc. delivers end-to-end benefits from the time of submission through to publication and beyond.

We welcome the opportunity to work with you and your institution. Find everything you need to get the most out of Liebert journals in your library and to keep your collection up-to-date.

Liebert Open Access incorporates our open access journals, as well as open access articles published in our subscription journals. All content published by Liebert Open Access is freely available online for everyone to discover, read, and share.

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# data[].attributes.attachment_link.description
Publishing with Mary Ann Liebert, Inc. delivers end-to-end benefits from the time of submission through to publication and beyond. We welcome the opportunity to work with you and your institution. Find everything you need to get the most out of Liebert journals in your library and to keep your collection up-to-date.

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Manning Beyer Tolchin 2023

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Hospice and palliative clinical immersion

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Hospice and palliative clinical immersion

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Engel KG, Millham LRI, Yeh IM, Malecha PW, Brizzi K, Schwartz AW, Tolchin DW. Assessing the Impact of a Hospice and Palliative Medicine Mentored Clinical Shadowing Experience for First-Year Medical and Dental Students: A Pilot Study. Am J Hosp Palliat Care. 2023 Nov 11:10499091231214787. doi: 10.1177/10499091231214787. Epub ahead of print. PMID: 37950642. https://pubmed.ncbi.nlm.nih.gov/37950642/

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Rowe KA, Ouchi K, Kennedy M, Breu A, Tolchin DW, Schwartz AW. Preparing Preclinical Medical Students for Routine Code Status Discussions: A Mixed-Methods Study. J Pain Symptom Manage. 2023 Oct 18:S0885-3924(23)00760-1. https://pubmed.ncbi.nlm.nih.gov/37863372/

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Moye et al

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What Matters Most User's Guide and Tools November 2023 

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Optimizing Medications: An Age Friendly Approach

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Optimizing Medications: An Age Friendly Approach

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FormalPara Key Points

The Geriatrics 5Ms of Mobility, Mind, Medications, Multicomplexity, and What Matters Most can help clinicians address polypharmacy among older adults, by addressing how each M domain impacts and is impacted by Medications.

The Age-Friendly Health Systems approach to medication management can help align medication use with what matters to the patient.

Further research is needed to study the impact of an Age-Friendly approach to polypharmacy in older adults and others across the lifespan.

Clinicians are eager for efficient approaches to the challenge of polypharmacy, typified by an older adult with multiple chronic conditions taking five or more medications, whether appropriate or potentially inappropriate. Polypharmacy may be thought of as an issue borne from multiple 'solutions' to separate problems, a consequence of a healthcare system that facilitates isolated disease management and siloed care. Together with the fact that the population as a whole is aging and comorbidities are on the rise, complex medication regimens will continue to proliferate, including in younger populations [ 1]. Polypharmacy increases the risks of frailty, falls, healthcare utilization, and mortality, yet clinicians may lack training in practical approaches to optimizing medications and minimizing risk [ 2]. Many tools exist to assist clinicians in optimizing medications in older adults, including the American Geriatric Society Beers Criteria, STOPP/START, and deprescribing guidelines [ 2, 3, 4, 5, 6, 7]; however, these approaches typically focus primarily on the medications themselves, including risks, adverse effects, and interactions.

The Geriatrics 5Ms framework [ 8] can help clinicians approach medication optimization in a holistic manner, by considering, in additions to Medications, the domains of Mobility, Mind, Multicomplexity, and What Matters Most. By exploring how each of these M domain impacts and is impacted by medications, including how these domains may affect adherence to medications, clinicians can align medication use with what matters to a patient and their loved ones. Consideration of individual patient preferences and context remains critical. What matters to our patients, whether that be independence, spending time with family, continuing to engage with certain activities, or something directly related to their healthcare, must be accounted for with a person-centered vision of medication management.

The Geriatrics 5Ms framework was initially developed by geriatricians to broadly but concisely capture areas of focus in older adult care [ 8, 9]. The 5Ms align with the Age-Friendly Health Systems initiative [ 10], a model for evidence-based care of older adults that emerged around the same time, and focuses on implementing the 4Ms of Mobility, Medications, Mentation, and What Matters in healthcare settings (of note, the 4Ms do not include Multicomplexity, and list Mentation instead of Mind) [ 11, 12]. Initially conceived of through a collaboration between the John A. Hartford Foundation and the Institute for Healthcare Improvement in response to an evolving healthcare system and an aging population, the Age-Friendly Health Systems approach was designed and piloted with experts in implementation science, patient safety, and quality improvement with the goal of creating a system that could better prevent avoidable harms, provide higher quality care to those with serious illness or at the end of life, and build stronger support for caregivers and families all while reducing costs [ 13, 14]. While the Age-Friendly 4Ms does not include Multicomplexity, we include it here in the Geriatrics 5Ms as it can inform a holistic approach to medication management in older adults. Here, we outline the ways in which the Geriatrics 5Ms can be used as an integrated set for thoughtfully approaching medication optimization in older adults, and describe its use in clinical innovation and health profession education. Finally, we outline challenges in implementing an Age-Friendly approach to medication management, along with suggestions for future research in this important area.

The Geriatrics 5Ms provides a memorable framework to guide medication optimization in older adults with multiple chronic conditions and polypharmacy. In Table 1, we describe how each M domain impacts and is impacted by Medications, along with examples of considerations for clinicians and patients. Appropriate prescribing starts with matching each medication with an indication, avoiding drug-drug interactions, and weighing risks and benefits [ 15]. To deliver Age-Friendly medication management, the Geriatrics 5Ms help the clinician meet the patient's needs beyond their specific medical problems. A deeper understanding of the patient's experiences with medications and healthcare and how they align with their health and life goals is gained by engaging and centering the patient and, potentially, their families or caregivers through an exploration of each of the 5Ms and their interconnections.

Consider Mobility: if the patient has difficulty swallowing their pills, poor dexterity, or issues opening pill bottles because of arthritis, these findings may affect the medications and formulations they are prescribed. Conversely, if their medications are causing orthostatic hypotension or dizziness, thereby increasing fall risk, Mobility will be deeply affected by Medications [ 16]. This same principle is consistent for the other M domains. In the Mind domain (also referred to as Mentation in the Age-Friendly 4Ms), cognitive impairment may lead to difficulties organizing and adhering to a complex medication regimen, while some medications may contribute to confusion, delirium, or mood symptoms and may warrant consideration of deprescribing [ 17]. With Multicomplexity, insufficient finances to purchase medications, caregiver burden, or residing in a care facility may affect how medications are accessed, and what we prescribe potentially affects prognosis and frailty. Most importantly, when we ask the patient What Matters to them, we learn which treatments they are willing to tolerate and which they find burdensome; a communication tool such as Patient Priorities Care may help clarify their preferences and goals [ 18, 19]. Additionally, prescribing mis-aligned with What Matters, such as inadequate pain control, can impede patients from doing what they enjoy and reaching their goals. Addressing medications in older patients by considering each of the Geriatrics 5Ms can help clinicians deliver Age-Friendly person-centered care.

Additionally, the 5Ms are broad enough to be potentially applicable beyond the geriatric population and across the lifespan, such as when caring for people with cognitive impairment, physical disabilities that may make administering medications difficult, comorbidities due to chronic disease sequelae, congenital disorders, the activities of caregivers, and end-of-life care for all ages. An Age-Friendly approach to medications could yield benefits beyond older adults, whether proactively applied or as part of a deprescribing or medication-optimization plan.

Research is emerging on how application of the Age-Friendly approach can influence patient care and show a promising benefit [ 20]. While evidence is emerging about the implementation of the 4Ms framework as a set, evidence for interventions within each M domain has been shown to lead to improvements in health status, safer mobility, and reductions in overprescribing-indicating that focusing on these domains leads to the predicted clinical benefit [ 12]. One quality improvement initiative found that implementing the 4Ms to focus on risk stratification of patients and medication safety led to providers having a better understanding of care plans and interventions in high-risk patients, simplification of medication regimens with improvement in medication adherence, and importantly, a reduction in hospitalizations and re-admissions [ 21]. In a rural care setting a focus on the 4Ms was used to develop a screening program for geriatric health issues such as cognitive impairment, malnutrition, and frailty, with subsequent as-needed intervention including exercise programs and cognitive therapy. After identifying these conditions in their study population and stratifying, follow-up evaluations demonstrated improvements after a year in measures of physical and mental status such as the Timed Up and Go Test and the Cornell Scale for Depression in Dementia, respectively [ 22]. Beyond primary care, specialists have considered how the Geriatrics 5Ms can be applied to the care of their complex patients in a variety of specialties [ 23, 24, 25] and settings, including the intensive care unit [ 26]. These frameworks have been applied to guidelines for prescribing statins in older adults [ 25, 27] and many areas of research remain to study the impact of these approaches.

Educational curricula using the 4Ms or 5Ms help provide a common language and structure for health professions trainees early in their training, and provide a framework for deeper dives on polypharmacy and deprescribing [ 15, 28, 29]. Recognizing the challenges and opportunities with providing care to an aging population, health profession education programs are developing creative modules guided by these frameworks [ 30, 31, 32]. At our own institution, we developed the Geriatrics 5Ms pocket card for medical and dental students as a teaching tool that could be carried on the wards as a resource to guide holistic care for older patients [ 33], as well as home visits with older adult patients grounded in the concepts of the 5Ms [ 34]. One small longitudinal pilot of an interactive case-based workshop for primary care residents found high satisfaction amongst participants and improved confidence in applying the elements of the 5Ms in older adult care, with 83% of participants indicating an interest in utilizing medication and pharmacy resources at the conclusion of the workshop compared with 19% prior [ 35]. Interprofessional training, with trainee representation including pharmacy, social work, nursing, and psychology learners among others, has also been implemented to teach Age-Friendly care [ 32, 36]. Continuing education for practicing clinicians [ 37] offers further opportunities to use the shared language of the 5Ms to create a memorable approach to addressing medications in older adults.

While the Geriatrics 5Ms offer a helpful guide for approaching medication management in older adults by considering Mobility, Mind, Multicomplexity, and What Matters Most, challenges remain in its implementation. For example, in the context of a patient encounter where use of the Geriatrics 5Ms may suggest changes or reductions in medications to minimize their impact on mobility or mentation, there may be challenges to implementing a deprescribing plan [ 38]. First, polypharmacy often implies a clinically complex patient. Multiple conditions with interacting and compounding pathophysiology and sequelae may be difficult to approach in a typical encounter limited by time, expertise, or emergent concerns. When it comes to deprescribing, these may be particularly sensitive discussions and recommendations as patients and/or their caregivers may not fully understand the reasons for deprescribing, may have concerns about discontinuing or changing a medication they had been taking for potentially years, or there may not have been enough time to establish a trustworthy patient-physician rapport for shared decision making [ 39, 40, 41]. Confronting some of the uncertainties that come with deprescribing are more easily embraced if pursued holistically, as a thoughtful application of the 5Ms reveals the complexities and power of the Medications domain and their tendency to influence and be influenced by the other M domains. There may be hesitancy to adjust or discontinue medications from other specialists or missing/inaccessible information from non-communicating online medical records [ 42]. Managing multiple conditions can mean encountering conflicting disease-specific guidelines, uncertainties about the indirect effects of deprescribing, and evolving goals of care. Patients may also be reluctant to stop or to make changes to a regimen that has been satisfactory for many years. In the era of COVID-19 and an increase in virtual visits, this may lead to additional hesitancy to deprescribe particularly with visits conducted over the phone and a lack of an in-person physical examination, though telehealth may provide opportunities to gain a new lens on a patient's medication use [ 43, 44]. Finally, inequities related to socioeconomic status, proximity to healthcare centers, and systemic disparities in healthcare create additional barriers for the most vulnerable patients, with the potential consequences being further preventable harms [ 38, 45].

The Geriatrics 5Ms and the Age-Friendly Health System offer a path to approach polypharmacy in a person-centered way. Importantly, the 5Ms are not a checklist, rather, a philosophy and a language that encourage flexibility and individualization during the visit. For this reason, the 5Ms may be helpful beyond the older adult population including patients with chronic diseases and polypharmacy who could benefit from medication optimization and deprescribing. Providers may utilize or inquire about any number of the 5Ms in a single visit, though attention should be paid to all dimensions over the long term. Coordinated or interprofessional care models also work well with the 5Ms by lowering communication barriers between clinicians to better streamline a patient's healthcare. Education on the 5Ms to the next generation of healthcare professionals is ongoing and robust. However, large research trials on how the 5Ms may benefit patient care are lacking. How recommendations originating from a 5Ms approach translate to deprescribing, reduced hospitalizations, or improved quality of life remain important research questions, to which the ongoing implementation of the Age-Friendly Health Systems initiative may be poised to offer answers [ 46].

In conclusion, the Geriatrics 5Ms allow for holistic and adaptable decision making guided by patient preference and evidence-based medicine to optimize medications for patients with (or without) polypharmacy. Age-Friendly medication optimization, including thoughtful deprescribing when appropriate, may improve patient quality of life along with the experience of care for the patient and provider [ 47, 48]. This Age-Friendly approach will benefit medication management for patients across the lifespan [ 49]. With the 5Ms and appropriate support, prescribers in partnership with their patients and care team can be better equipped to optimize polypharmacy to support what matters most to our patients.

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Optimizing Medications with the Geriatrics 5Ms: An Age-Friendly Approach - Drugs & Aging

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Polypharmacy is a common problem among older adults, as they are more likely to have multiple chronic conditions and may experience fragmentation of care among specialists. The Geriatrics 5Ms framework offers a person-centered approach to address polypharmacy and optimize medications, including deprescribing when appropriate.

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One Step at a Time: Implementing Gait Speed Measurement in a Geriatrics clinic

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One Step at a Time: Implementing Gait Speed Measurement in a Geriatrics clinic

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Medical Education in Geriatrics: Strategies for Teaching the Care of Older Adults

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Medical Education in Geriatrics: Strategies for Teaching the Care of Older Adults: 9783031324987: Medicine & Health Science Books @ Amazon.com

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Geriafloat Webinar May 2023

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Guide for clinician educators in Geriatrics

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Guide for clinician educators in Geriatrics

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Student as Teacher curricula: An Innovative Model

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Dr. Andrea Schwartz talks about her passion and methods for training clinicians to provide age-friendly care to Veterans. Dr. Andrea Schwartz is a geriatrician at VA Boston Healthcare System, Associate Director for Clinical Innovation in the VA New England Geriatrics Research Education and Clinical Center, Associate Program Director for the Harvard Multicampus Geriatrics Fellowship, and Assistant Professor at Harvard Medical School.

Listeners are encouraged to visit the VA Boston Education homepage for faculty development programming and other tools to develop as educators.

https://www.va.gov/boston-health-care/work-with-us/internships-and-fellowships/faculty-development/

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Dr. Andrea Schwartz talks about her passion and methods for training clinicians to provide age-friendly care to Veterans. Dr. Andrea Schwartz is a geriatrician at VA Boston Healthcare System, Associate Director for Clinical Innovation in the VA New England Geriatrics Research Education and Clinical Center, Associate Program Director for the Harvard Multicampus Geriatrics Fellowship, and Assistant Professor at Harvard Medical School.

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Telehealth Virtual OSCEs for Development and Assessment of Students’ Clinical Skills Sarah Onorato BA, Rachel A. Blair MD, Susan Farrell MD EdM*, Andrea Wershof Schwartz MD MPH*(*Co-senior authors) picture credit: https://cptlpulses.com/2020/06/18/virtual-osces/

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Widespread of adoption of telehealth had been relatively slow before the COVID-19 pandemic. Now, according to one survey of physicians in the US, close to half are treating patients using virtual visits. This is up from only 18 percent two years ago.

Some health care providers have found this rapid change overwhelming. Fortunately, some early adopters have years of experience with telehealth and are willing to share what they've learned with others.

Andrea Schwartz, MD, MPH, is a geriatrician at the VA Boston and the New England Geriatrics Research Education and Clinical Center, and an Assistant Professor at Harvard Medical School. She has been practicing telemedicine for five years in an interprofessional geriatrics consult clinic, and offers wide-ranging advice for how to improve the telehealth experience for both patients and health care providers.
Before the Visit
A lot of the work that goes into a smooth televisit takes place before the encounter begins:

Check your technology - Make sure your camera and microphone are in good working order. Verify that your internet and wireless quality are adequate and that you have a backup should they go down. Schwartz uses a second monitor in addition to her main computer, so that she can view the patient on one screen and have access to notes and orders on the other.

Make sure you're ready for your close-up - "I like to think of the setup of a visit using a 'lights, camera, action' approach," said Schwartz. "Are your lights bright enough that the patient can see your face? Are you wearing clothing that won't distract or use up too much bandwidth by having, say, a very busy pattern that might cause a lag between the video and the audio?"

Consider the patient's individual needs - Are they learning the telehealth platform for the first time? Will the patient need a medical interpreter? Do they have a vision, hearing, or cognitive impairment that requires special assistance to navigate the technology? If the patient has a hearing impairment, perhaps they can use headphones to hear your voice amplified. Some platforms offer closed captioning. For some patients with cognitive impairments, a family caregiver may be able to help orient them to communicating with their clinician via video.

Plan to have other team members join the call, if needed - Are there other members of your interprofessional team who should also visit with the patient? Decide in advance how and when to make those transitions.

Adequate preparation allows you to put your attention where it should be during the televisit. "Focus on the patient and not the platform," said Schwartz. "We hope that once we get into the visit, we'll forget that the patient is being seen over a screen."
During the Visit
It's important to put thought into how to develop a connection with a patient during a virtual visit:

Remember to look at the camera - To make eye contact with the patient, look at your camera and not just the video display of the patient. Some providers put "googly eyes" or a sticky note near the camera to remind them where to look.

Establish a "webside manner" - Take your bedside manner and translate it to interacting with a patient over a screen. The same things you do in person to establish rapport, develop trust, and make a patient feel relaxed can be used in a virtual visit.

Pay attention to how you speak - It can be helpful to slightly lower the pitch of your voice, speak slowly and clearly, and make sure the patient can see your lips for maximum visual input.

Schwartz recommends using the Age-Friendly Health Systems 4Ms (What Matters, Medication, Mentation, Mobility) Framework to structure optimal telehealth visits for older adults.

Wrapping Up
Ensure your interaction comes to a strong conclusion:

Verify that you've addressed your patient's priorities - As you come to the end of the visit, make sure that you've spent time on what matters most to the patient.

Plan for follow-up - Are there patient instructions you need to share? Send them via secure message or email if they don't contain HIPAA information. Do other members of your team need to connect with the patient? Does a family caregiver need additional support? That may require a separate telehealth phone call or a video visit for the caregiver, possibly with your team's social worker.

Let the patient end the visit first - As in an in-person visit, it's important to allow the patient and family caregiver to ask any questions they may have. You can say, "I'll go ahead and let you end the call when you're ready." This allows them the chance to voice any concerns you didn't already address before the end of the visit.

The future of telehealth is hard to predict. Given its benefits and potential uses, however, it's reasonable to expect that at least some kinds of televisits will continue beyond the COVID-19 pandemic. Taking advice from early adopters can be helpful to those who feel as though they're struggling with a steep learning curve.
You may also be interested in: Learn about becoming an Recommendations for Designing High-Quality Telehealth What to Say During Telehealth Visits with Older Adults Age-Friendly Health System

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Widespread of adoption of telehealth had been relatively slow before the COVID-19 pandemic. Now, according to one survey of physicians in the US, close to half are treating patients using virtual visits. This is up from only 18 percent two years ago. Some health care providers have found this rapid change overwhelming.

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Medical Teacher 2021

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Time Stamps

Show Notes
Pearl 1: Approach to the initial office visit

First understand what matters most to the patient.

What do they value?

What does a good day look like?

Functional status is the ability to perform daily activities to meet basic life needs (ADLs).

There are basic and instrumental ADLs.
Assess baseline function, which can be used to later track disease onset and progression.

Think of toenail length as the hemoglobin A1c of functional independence.
If toenails are too long (>2mm increase in length per month) consider broad differential:

Loss of executive function

Decreased flexibility/muscle strength

Caregiver burnout, social isolation

Poor vision

Pearl 2: "Moves" for mobility

Falls are the leading cause of injury-related death in adults over 65 years old

Think of gait speed as a vital sign and important predictor for fall risk.

Stratify fall risk by assessing mobility.

Slowed gait speed increases risk

Timed get up and go test (TUG): Time how long it takes for a patient to stand up from chair without pushing off with arms, walk to a line on the floor (10 feet away), turn, walk back to the chair and sit down.
If the patient takes longer than 12 seconds to complete TUG they're at risk for falling.

Chair stand: Have the patient cross arms over chest and stand up from chair. If they can't stand up without using hands for support, they're at higher fall risk.

Interventions to decrease fall risk are most effective when combined together and include physical and occupational therapy, home modifications (safe furniture, remove environmental hazards), use of appropriate assistive devices for ambulation and medication review.

Pearl 3: Cognitive evaluation

Cognitive decline is a common concern in the primary care setting

Cognitive Screening Tests

The Mini-Cog is a quick screening test which assesses the ability to recall three words and draw a clock. If unable to complete successfully, need a more elaborate test

Montreal Cognitive Assessment (MOCA): Scored out of 30 points and evaluates naming, memory, attention, language, delayed recall, among other domains.

Delirium is an acute change in mental status from baseline.

Start with quick orientation and attention questions. Ask the patient to name days of the week or months of the year backwards

If cognitive tests show impairment, rule out reversible causes like hearing loss, medications, hypoglycemia, nutritional deficits, thyroid disorders, or electrolyte abnormalities.

Pearl 4: How to manage medications

Ask patients to bring all their meds to the initial visit, including over the counter medications. Figure out what they're actually taking. May need collateral from pharmacy, family members or home health aid.

Match the medications to the problem list. Consider de-prescribing.

Are there extra medications that don't match anything on the problem list?

Are there medications with side effects that are contributing to the problem list?

Is there a less frequent alternative? Example: switching metoprolol tartrate to metoprolol succinate

Are the medications consistent with the person's goals of care and life expectancy?

Underprescribing is a problem too

Osteoporosis often goes undertreated. Use bisphosphonates.

Pain control with tylenol can significantly improve quality of life

Oral anticoagulants require weighing stroke risk versus fall risk

Throwback Pearl: PPIs

Divide adverse effects of PPIs into two big buckets: Malabsorption (Vitamin B12 deficiency, Hypomagnesemia and Osteoporosis) AND Infection (C difficile colitis).

Strategies to take patients off PPIs include short, finite prescriptions to begin with, managing expectations and using rescue meds.

Transcript

S: This is Dr. Shreya Trivedi, and this is Dr. Minali Nigam, a neurology resident . This is the CORE IM 5 pearls podcast bringing you high-yield evidence-based pearls.

M: Today we're going to dive into pearls on the geriatric assessment.
So when I'm meeting an older adult patient, whether it's in the clinic or in the hospital, I always look at the feet. Toenails are like the A1C of functional independence. when you look at, at the feet and you see this long toenail sign, you really get a sense how someone's been managing over the last few months and whether they're able to do this self care task or get help for themselves, if they can no longer do it.
M: That's Dr. Andrea Schwartz, a geriatrician at the Boston VA . [pause] She gave me that advice to look at the toenails when we were on rounds. We were seeing this 90-year-old whose mobility seemed fine so we were asking if physical therapy really needed to see him.

S: So Minali, what did his toenails look like?

M: Sure enough his toenails were several centimeters in length and clearly hadn't been clipped in months so we got PT onboard. Thinking about that toenail gem a bit more, it got me thinking about what are the other high-yield pearls when meeting someone for the first time, especially our geriatric patients.

S: So let's get into those pearls we'll be covering in the episode. Test yourself by pausing after each of the 5 questions. Remember, the more you test yourself the deeper your learning gains.

M: Pearl 1: Approach to the initial office visit

S: What high-yield questions should we be asking when we first meet an older patient?

M: Pearl 2: "Moves" for mobility

S: How do you test someone's mobility and assess their fall risk?

M: Pearl 3: Cognitive Evaluation

S: What are the main differences to know about the different cognitive assessments ?

M: Pearl 4: Managing Medications

S: What is your approach to deprescribing medications? And what are some of the meds that we underprescribe?

M: Pearl 5: Throwback Pearl
Pearl 1: Approach to the initial office visit: what questions should we ask?
S: Okay Minali, I remember so many times being in clinic and chart reviewing for an older patient I was about to meet. It was easy feeling overwhelmed because oftentimes I can tell from the chart that they had a ton of things going on and I wasn't actually sure where to start.

M: So what does that goal setting conversation look like?

S: So what I have learned from my geri colleagues over time is that opening with something like, "Mr. Jones, you have gone through so much, I'm curious after all of this, what matters the most to you?" or "could you tell me what a good day for you look like?" can be a really good starting point

M: You know, I relate to this so much because I can't tell you how many times in resident clinic I've thought the patient is coming in for one thing only to find out they want to talk about something completely different
PERRY: I think about what are the next periods of time that I'm going to meet this person? What do I absolutely have to do now and what can wait?
S: That's Dr. Laura Perry, primary care doctor and geriatrician at the San Francisco VA's Community Living Center.

M: Ok so once we get a sense of the patient's priorities, the geriatricians we spoke with said the next step is to gauge the patient's functional status
It actually takes a lot of flexibility and you can easily think of things that would get in the way of being able to reach whether it's spinal stenosis or, um, vision impairment or dexterity of your hands.
M: The one other thing i'm gonna add the ddx of long toenails is caregiver burnout - I've def seen that!
S: i would def fall into that category, seeing i haven't cut my toenails since my son was born!
M: In addition to the toenails, shreya what else should we think of when assessing someone's functional status?

S: Classically we think about digging into activities of daily living. These are things that I help my 1 year old with -things like bathing, eating, feeding, walking, toileting. Then asking also about their instrumental activities of daily living

S: Amen to those scooter grocery carts! But you know when we're asking our patient's functional status it can sometimes be a little awkward or even make our patients feel a little self-conscious

M: Alright so to recap pearl 1: Some take-aways on best practices for an initial office visit are to to ask explicitly what matters most to the patient, figure out what they can do and something i never considered was looking at the patient's toenails - As Dr. Schwartz says the HgA1c for functional independence
Pearl 2: Moves for Mobility - what tests can we do to decrease fall risk?
S: Ok so we get a good history on how much this patient can do and in what care setting, but then i see a lot of people gloss over seeing how they move objectively on the physical exam

S: Yep the support they need, especially to prevent a fall. Ok so whats the best way to go about assessing functional status objectively?

S: Ouch i feel like that was a little burn. But its true, the best functional test is just one you can actually incorporate into your practice. Noted.

M: I can say even for neurologists, sometimes we end up not really examining how a patient walks because it takes time and effort

S: Wow even coming from a neurologist I really appreciate that realness. Maybe it would be good for us to go over what the different objective assessments are so we can tailor which one might be the best to incorporate for a particular patient.

M: Probably the most well known test that we all learn in med school, is the Timed Get Up & Go. As a refresher, here's how the test works: the patient sits in the back of a chair and is asked to walk to a line about 10 feet away on the floor. You time the patient and say "go," at which point the patient stands up from the chair without using their hands for assistance, walks to the line, turns, walks back to the chair and sits down again.
And then sit back down. Some patients will need to use the arms of the chair to assist them. And that's helpful information as well... SCHWARTZ: I love the chair stand because even one chair stand gives you a lot of information. If a patient can't do even one chair stand they're at high risk for falls. And often those patients are really going to benefit from involvement of physical therapy and potentially occupational therapy.
S: Right, so If that patient takes more than 12 seconds from start to finish, the patient is at an increased risk of falls. And honestly if you don't have 10 feet worth of space or 10 ft measured out, Dr. Schwartz gave us an abbreviated version to assess mobility

M: The caveat here is that we can't just use these mobility tests as of falls - there is so much more that goes into fall risk - the patients comorbidities and even how safe their home is
SCHWARTZ: In his case, he had a painful Bunion. He needed to see podiatry. He was due for a new pair of shoes so that he could be in a steady, comfortable pair of shoes. And he benefited from the involvement of physical therapy that taught him further exercises that he could do at home as well as helped install, uh, helped him figure out where to install, grab bars and a raised toilet seat. like in many, uh, geriatric cases, it was multifactorial. He hadn't been leaving the house as much. Uh, his gym had closed. Uh, the partner he used to go walking with, uh, was at home caring for a loved one. And so, uh, he had had a major decline in his level of activity and he was stiffer. We were able to encourage him to do those chair stands and practice them at home when he was watching TV. And then we were able to do a little more investigation and try to figure out if anything else was wrong.
S: Even just watching the patient walk and eyeball how fast or slow they're going can give us a clue on subtle changes. And thats what happened with Dr. Swartz - she hadn't seen a patient in over a year because of Covid-19 and from gait speed alone she could tell he had a major decline.

M: Who would've thought that slow gait speed would crack the case of the bunion?

S: And probably helped prevent a future fall. And we will link a CDC website called in the show notes, which stands for Stopping Elderly Accidents, Death & Injuries. It lays out interventions and the research behind doing things like balance exercises , using safe furniture and reducing polypharmacy , which we'll dive more into later.
Pearl 3: Cognitive Evaluation - what's the work-up?
M: Great so speaking of being STEADI, let's wrap up this pearl on moves for mobility.

S: Let's recap. Remember that gait speed is the 5th vital sign, especially for older patients. So yes, if you have 10 feet of space use the timed get up and go or just watch the patient walk. And the simple chair stand can also be helpful in gauging balance and coordination.
SCHWARTZ: So many times I've been surprised by how someone could be very facile and completely socially intact and yet do very poorly on the mini-cog.
M: Here's where the neurology nerd in me comes out - thinking about thinking. Going back to Pearl 1 - for many patients and families what's most important to them is being able to think clearly.
SCHWARTZ: I like this tool because it's just a three word recall. The validated words I usually use are banana sunrise chair. And you have the patient repeat them to you two times to make sure that they've been able to register the words and they can hear them. And then you ask the patient to draw the face of a clock, put in all the numbers and set the time is 10 past 11 and you watch them while they draw the clock. And then you end with the three word recall and see if they can recall the banana sunrise chair. SCHWARTZ: So the Mini Cog takes about a minute, which is very quick, but it gives you an objective finding. First of all, if they can't do the recal test, it tells you that you've got to give them written instructions from your patient encounter. If they got ⅓ recall, they're likely to only remember about 1 out of 3 words you said. SCHWARTZ: And, um, in Dr. Soo Borson's work and others who validated the mini-cog, um, it's just a brief screening tool, so you can't diagnose anything off of it, but it tells you that you need to do a longer test.
S: So it's good to have some tools to assess that objectively than just going by our gestalt

M: Just as a quick refresher, how is the mini-cog properly administered and how do you score it
SCHWARTZ: So some of the things to consider when you get an abnormal cognitive screening test, we've already mentioned hearing that's an often overlooked one, but easily modifiable. Uh, another thing to consider is medication effects in particular medications that may impair cognition, such as sleep AIDS, opioids, or medications that indirectly may impair cognition. For example, through hypoglycemia, I've definitely seen patients whose diabetes is too tightly controlled given their age and co-morbidities and are having frequent episodes of hypoglycemia that can manifest as confusion and impaired cognition.
S: The mini cog is scored out of 5 points - 1 point for each correct word & 2 points for normal clock draw. Unfortunately, they get 0 points if the clock is drawn incorrectly or did it wrong. Anything less 5 is a reason for us to get a bit more curious

M: Ok what if they miss a word or can't draw 10 past 11 - What are the next steps?
SCHWARTZ: So A&O times three on a hospitalized patient, doesn't give you enough information to determine if they're delirious. You need to add a test of attention like months of the year backwards or days of the week backwards, which is a little easier. And the UB2, the ultra brief delirium screen is just orientation to day and months of the year backwards. And it's a very sensitive test for delirium. You wanna pick up acute brain failure before the patient is agitated and pulling out their lines and quickly intervene to figure out why they're delirious.
M: Right, so that's when we can think about a longer test like the Montreal Cognitive Assessment, better known as the MoCa. But I think twice on who I administer the MOCA to in practice.

S: A very important caveat indeed. But say you have a college educated, white person and the patient gets a score <26 out of 30 suggesting cognitive impairment, what are the things we should be considering?

S: Practically speaking I've never had any of those be the culprit for me. But, what I have been amazed at how much things like depression was playing into a patient's cognition and side effects of meds.

M: That's a great point. This all good stuff in the outpatient setting but these tests can't really give you an accurate idea when someone's acutely ill. So, if we're in the inpatient setting, we need to think about if the patient is in a state of delirium.

S: The teaching point here is that the hallmark of delirium includes 1) disorientation and 2) inattention, but i see so many just asking if the patient ONLY if they are orientation to name, place and time
Pearl 4: Managing Medications - How should we prescribe and de-prescribe medications?
S: You know since this interview I've actually started to ask my patients to tell me the days of the week backwards and its made me feel a lot more confident about something being off or saying the abx are actually working and their mental status is clearing up

M: I've started asking it too but make it more challenging I start with a day in the middle of the week like Wednesday and then ask them to go backwards.

S: Yep I guess by the time we get the neurologist involved, you really wanna be sure of their cognitive status and challenge them.

M: Happy for the consult! Alright so to wrap up Pearl 3, use the mini cog as a brief screening tool for cognitive impairment. You can do a longer test like the MoCA but in the right patient population, keeping in mind education level and race. If impaired, get a work-up for reversible causes, most importantly the overlooked ones like hearing, depression or a medication side effect.

S: And if you are in the inpatient setting testing for cognition and thinking about delirium, we really want to assess that attention part of it, which is the hallmark for delirium. Like testing for the days of the week backwards or the months backwards, can be helpful.

S: You know one of the big tenets with taking care of an older patient is deprescribing. And yes, in an ideal world this is probably one of the most important things we can do for our patients. But this is so hard to operationalize sometimes. M: Agreed So we asked our geriatricians how they do it
PERRY Like get people on their bisphosphonates, get your chronic pain patients on like a decent schedule dose of Tylenol. It can help like decrease how much opioid and other stuff that they need. Use the medications that don't have a lot of risks, but like make a big difference.
S: I think we've all been there, burnt way too often trusting the med list on paper and there's a big discrepancy with what the patient actually takes and how often. And it makes sense to really dig into this - until we actually learn what a patient actually takes, we can't deprescribe anything

I so wish our EMR systems carried forward the initial indication- or even with the med list, grouped all the HTN ones or the DM ones would make it easier for our overburdened clinical brains to see gosh, this person is on are 4 HTN meds and tamsulosin now or jeez, they're 3 sedative medications and just makes the work up and thinking why this person is unsteady on their feet a little bit easier.

M: I honestly think geriatricians are the true Sherlock Holmes of medicine. They really dig into all the clues to crack what's the best medication regimen for each person.

M: Another low hanging fruit are vitamins and supplements. So unless someone truly has a vitamin deficiency, most of the time you can knock the supplements off.
Pearl 5: Throwback Pearl - PPIs
S: Yep delete, delete, delete. Alright Minali, we've talked a good deal about the approach to deprescribing but there are other blindspots with meds. Actually thinking about things we underprescribe.

S: Ouch! I will think about that burn everytime I go to prescribe a lung CT in a older patient who smokes and not a DEXA

S: No I agree. I think about that a lot when it comes to the risk/benefit conversation. There's that shows that patients in their 80s do benefit from being on a blood thinner to reduce their stroke risk, which as you said can be pretty devastating.

M: Alright glad to know I have some back up here!

S: Maybe the last point to take away is if you do change around the medications, think about who you need to loop in. Especially because the reality is we have such a fragmented healthcare system

M: [much appreciated!] To recap the approach on deprescribing and underprescribing, start with writing down the problem list and matching medications to each problem. That's something I at least try to do mentally for each patient. Peel off the meds that are leftover or have blatant adverse effects. Quick wins are to treat osteoporosis and use tylenol when in pain. And not forgetting to weigh stroke versus bleeding risk for DOACs.

M: I remember that episode. There were two big buckets of harms of PPIs: malabsorption problems and infection.

S: Nice memory. With the malabsorption bucket, people who are on PPIs for a long time we think about Vitamin B12 deficiency, hypomagnesemia and osteoporosis - huge problem for patients who have high fall risk

S: Maybe before we even get to desprecribing... one of the big take aways is thinking about best practices when we actually prescribe. So if someone is having symptoms, I know only give a short duration - 2 to 3 weeks of PPI is enough. Also educating them about lifestyle changes with foods and things like weight loss.

M: And when you do deprescribe and their symptoms come back, we can use rescue meds instead. The simple stuff like aluminum hydroxide aka Maalox can neutralize stomach acid because it's a base.

S: Right and i also love reaching for the H2 blockers, the famotidine , the ranitidine and i get the patients all psyched up because i tell them its a different mechanism and they get all excited about it

M: You all unlocked so many good strategies during the episode! It's all coming back to me!

S: Same here. It's so humbling how much you forget and need to re-remember. And that is wrap for today! If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us!

S: Alright take care!

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5 Pearls on The Geriatric Assessment | Core IM Podcast

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Time Stamps Initial Office Visit Mobility Assessment Cognitive Evaluation Medications Throwback Pearl Show Notes Pearl 1: Approach to the initial...Read full post

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Introduction Intensive glucose lowering in older adults with diabetes leads to increased risks with minimal benefits. Surveys indicate that clinician confidence for individualizing glycemic goals a...

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Introduction Medical students must care for aging patients with growing medication lists and need training to address negative patient outcomes associated with polypharmacy. The literature shows th...

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AGS Medical Student Competencies in Geriatrics

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.@AmerGeriatrics publishes updated Minimum Geriatrics Competencies for Graduating Medical Students, now framed around the #Geriatrics 5Ms http://ow.ly/W5MP50Ff6nQ

New York (June 21, 2021)-The American Geriatrics Society (AGS) has published an updated version of the AGS Minimum Geriatrics Competencies for Graduating Medical Students, which were created to ensure that medical school graduates across the U.S. are prepared to provide high-quality care for us all as we age. A refresh of the original set first published more than a decade ago, the 27 competencies integrate new concepts that have emerged more recently in the field of geriatrics, including frailty and person-centered care, and are framed around five key areas of focus for all geriatrics healthcare professionals.

"The updated competencies reflect an evolution in how we frame the work of geriatrics health professionals, a greater understanding of frailty, and a greater focus nationally on ensuring that care is person-centered and driven by individual goals," explained AGS President Peter Hollmann, MD, AGSF. "With these competencies, the field of geriatrics has defined not just what all physicians should know as they embark on their careers but also how they should put that knowledge into practice."

The updated AGS Minimum Geriatrics Competencies for Graduating Medical Students are organized around the Geriatrics 5Ms, a framework developed in 2017 by Frank Molnar, MD, Allen Huang, MD, AGSF, and Mary Tinetti, MD, AGSF, around five key areas: Mind, Mobility, Medications, Multicomplexity, and what Matters most. Clinical educators in medical schools are rapidly adopting the 5Ms as a framework for teaching medical students the skills, knowledge, and abilities they should have to provide high-quality clinical care for older adults. In the updated competencies set, each of the Ms contains new or modified competencies. Of particular note, multicomplexity, which describes the person who benefits most from geriatrics care, includes guidance on integrating a health equity lens into the practice of medicine.

"When we added a 27th competency, we believed it was critically important to highlight how important it is that physicians not only understand the impact that ageism and other forms of discrimination can have on the health of older adults but also take steps to overcome their own bias in addressing issues of health equity," AGS CEO Nancy E. Lundebjerg, MPA, said.

A workgroup of AGS leaders co-chaired by Rosanne Leipzig, MD, PhD, Andrea W. Schwartz, MD, and Mandi Sehgal, MD, updated the 26 original competencies using a modified Delphi method to reach a group consensus based on expert and stakeholder input and a literature review. Having presented their work at the 2021 AGS Virtual Annual Scientific Meeting, the team is currently working on a paper describing their methodology and key qualitative findings from their research. The updated competencies are now available on the AGS website here.

Moving forward, the AGS will continue to advocate that undergraduate medical education prepares graduating physicians to care for us all as we age. AGS is also developing educational tools to help educators to integrate attention to the new competencies into their programs.

# # #

About the American Geriatrics Society
Founded in 1942, the American Geriatrics Society (AGS) is a nationwide, not-for-profit society of geriatrics healthcare professionals that has-for more than 75 years-worked to improve the health, independence, and quality of life of older people. Our nearly 6,000 members include geriatricians, geriatric nurses, social workers, family practitioners, physician assistants, pharmacists, and internists. The Society provides leadership to healthcare professionals, policymakers, and the public by implementing and advocating for programs in patient care, research, professional and public education, and public policy. For more information, visit AmericanGeriatrics.org.

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AGS Publishes Updated AGS Minimum Geriatrics Competencies for Graduating Medical Students

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@AmerGeriatrics publishes updated Minimum Geriatrics Competencies for Graduating Medical Students, now framed around the #Geriatrics 5Ms http://ow.ly/W5MP50Ff6nQ New York (June 21, 2021)-The American Geriatrics Society (AGS) has published an updated version of the AGS Minimum Geriatrics Competencies for Graduating Medical Students, which were created to ensure that medical school graduates across the U.S.

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From the American Geriatrics Society: The Geriatrics 5Ms Quick Guide

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This quick guide provides a framework for caring for older adults through the aging process and the end of life that aligns with the 4Ms of Age Friendly Health Systems.

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The need for geriatricians and geriatrics training (Science Times, Jan. 7) is becoming increasingly urgent. Yet most medical schools still lack a required geriatrics rotation, despite national guidelines calling for more rigorous training of future physicians.

To address this gap, at Harvard Medical School, we have launched an "Aging and End of Life" curricular theme that integrates these important aspects of caring for older adults throughout the medical school experience.

The updated curriculum includes a home visit to an elder individual living in the community, and mock clinical exams in which the patient-actor ages between visits.

Ongoing federal and philanthropic support of such efforts is critical to ensure that doctors-in-training graduate prepared to deliver the evidence-based, compassionate and individualized care that older patients deserve.

Andrea Wershof Schwartz
Boston
The writer is an assistant professor at Harvard Medical School and a geriatrician at the Veterans Affairs Boston HealthCare System.

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Opinion | Training Geriatricians (Published 2020)

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The need for geriatricians and geriatrics training (Science Times, Jan. 7) is becoming increasingly urgent. Yet most medical schools still lack a required geriatrics rotation, despite national guidelines calling for more rigorous training of future physicians.

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Mededportal 2019

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Better Together: Peer Teaching Geriatrics Residency Specialties

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JAGS 2019

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JAGS 2019 - supplement

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Geriatric 5Ms Pocketcard for Medical Students

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JAGS 2019

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JAGS 2020

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Geriatrics and Geron Educ 2019
https://www.va.gov/boston-health-care/work-with-us/internships-and-fellowships/my-life-my-story/

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NEJM 2021
https://www.nejm.org/doi/full/10.1056/NEJMvcm2009406

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https://podcasts.apple.com/us/podcast/episode-60-geriatrics-overview/id1473382916?i=1000533518529

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Dr. Schwartz, a geriatrician at the VA Boston, gives an overview of Geriatric Medicine in this discussion with host, Walker Redd. They discuss how a systematic approach called the "5Ms of Geriatrics" - which includes mind, mobility, medications, multi-complexity, and matters most - can help us take better care of our older patients.

Run the List podcast on AccessMedicine: https://accessmedicine.mhmedical.com/multimedia.aspx#1460

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‎Run the List: Episode 60: Geriatrics Overview on Apple Podcasts

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Dr. Schwartz, a geriatrician at the VA Boston, gives an overview of Geriatric Medicine in this discussion with host, Walker Redd. They discuss how a systematic approach called the "5Ms of Geriatrics" - which includes mind, mobility, medications, multi-complexity, and matters most - can help us take...

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The Geriatric 5 Ms:  A Framework to Improve Care for Older Adults

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Preparing Future Doctors for Telemedicine: An Asynchronous Curriculum for Medical Students Implemented During the COVID-19 Pandemic.  

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Preparing Future Doctors for Telemedicine: An Asynchronous Curriculum for Medical Students Implemented During the COVID-19 Pandemic.  

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Academic Medicine 2021