GERIATRIC MEDICINE - BEHAVIOUR CARE ELECTIVE
Overview:
During this elective, residents will work with Behavioural Supports Ontario (BSO) clinicians and the Geriatric Inpatient Consultation team at St. Joseph’s Hospital in managing a variety of older patients with responsive behaviours. This rotation focuses on the assessment and management of behavioural and psychological symptoms of dementia (BPSD), including identifying possible contributing/precipitating factors across the spectrum of BPSD and establishing pharmacological and non-pharmacological management options. Experiences will develop the ability of the resident to integrate input from the interprofessional team and caregivers, and engage caregivers and the interprofessional team in the implementation of non-pharmacological interventions.
Learning Objectives:
Medical Expert
To develop specialized knowledge about:
-Diagnosis and management of delirium, encephalopathy, and other causes of reversible cognitive impairment
-Diagnosis of dementia, as well as non-pharmacological and pharmacological management of responsive behaviours
-Diagnosis and management of common psychiatric disorders in the elderly population
-Understanding pharmacokinetic and pharmacodynamic properties of psychotropics, particularly when applied to the elderly population
-Understanding adverse drug-drug and drug-disease interactions related to psychotropics
To develop enhanced clinical skills within these domains:
- Mental status exam
- Neurological exam
- Safe approach to a targeted physical examination of a patient with BPSD
- Observation-based assessment of physical symptoms that trigger behaviour.
- Application of screening cognitive testing instruments
- Application of specialized frameworks and scales for assessment of BPSD (e.g PIECES, Dementia Observation Scale, ABC charting, NPI, CMAI)
- Effective gathering of collateral history that will aid in developing individualized management plan for each patient with responsive behaviour
- Effective collaboration with allied team members to discern meanings behind responsive behaviours and tailor treatments accordingly
Communicator
To develop specific communication strategies which allow the resident to:
-Communicate effectively with patient and family members possessing varying degrees of health literacy
-Communicate respectfully and effectively with all allied health team members
-Complete clear and concise medical records and treatment recommendations
Collaborator
To develop knowledge and experience as a core member of a dedicated interdisciplinary team, including:
-The roles and expertise of allied health team members
-How to work cooperatively with interdisciplinary team members to optimize patient care and recovery
-How to effectively participate in and contribute to interdisciplinary team meetings
Leader
To develop knowledge and competencies required for physician leadership and management roles including:
-Awareness of resources available as well as limitations of different types of inpatient care units
-To implement care plans that support and empower all interdisciplinary team members
-Become informed of community-based behaviour support resources
-Become informed of resources available in various supported-living settings
Advocate
To gain experience in advocacy and develop advocacy skills in:
-Promote understanding of dementia and responsive behaviours
-Assist patient and family in finding the safest and most suitable discharge destination
-Appreciate personal as well as public resources limitations and adapt recommendations accordingly
Scholar
To practice lifelong learning habits by:
-Learning from other specialty services
-Regularly consult guidelines and most up-to-date literature when managing clinical problems
-Critically appraising medical literature and integrating it to daily clinical care
-Reading around patient cases to continually expand and reinforce learning
Professional
To develop professional knowledge, behaviours and attitudes including:
-Responsiveness to the concerns of other team members
-Reliability with respect to patient care duties, and commitment to providing excellent care
-Balance of professional and personal priorities for personal health and sustainable practice.
-Awareness of one’s own limitations, seeking advice when necessary
Expectations:
Specifically, the resident on this rotation will be expected to:
· Provide longitudinal care to all inpatients with BPSD who are being followed by the geriatric consults service. These patients should be monitored at least weekly and more frequently if needed/requested. This work will be provided collaboratively with the geriatrics case manager, BSO clinician, and other members of the health care team.
· Be available to provide in-patient consultation for new referrals for BPSD. This may involve acting in a junior attending role, with a junior learner having an opportunity to initiate the assessment.
· Be available to assess patients in ambulatory clinics with BPSD, either new presentations or follow up care. All geriatricians with clinics at St. Joseph’s Hospital will be asked to screen upcoming clinics and contact the resident pro-actively if suitable patients are booked during the rotation.
· Spend 2-3 half days per week providing direct clinical care to assigned geriatrics patients under supervision and guidance of the attending geriatrician.
· Watch/participate in new patient assessments and follow up visits with the BSO clinician 2-3 half days per week.
· Observe work by the community-based BSO transitional lead program 1-2 half day per week.
· Complete one personal learning project on a topic of self-identified knowledge gap or contribute to a relevant quality improvement initiative.
· Present one teaching session to junior learners on a topic related to BPSD.
· Participate in behaviour care team meetings which occur on the 3rd Wednesday of each month, 3-4P.
· Observe therapies offered by the recreation therapist involved in the care of assigned patients. (optional)
· Take initiative to organize a learning schedule that meets criteria listed above and facilitates broad exposure to the core experiences. This requires attention to avoidance of scheduling conflicts and timely communication with participating supervisors and facilitators.