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Fourth Year Medical Students’ Required Patient Care Reflections in Patients with Advanced Illness and Complete Functional Assessment. Are They Including Nutritional Status? John Agens, M.D. Associate Professor in Geriatrics Florida State University College of Medicine John Agens, M.D. Associate Professor in Geriatrics Florida State University College of Medicine I have no conflicts of interest to disclose! Objectives • Discuss very briefly results of a survey of awareness of vitamin D deficiency states and treatment among faculty at a medical school. • Know how often our community faculty prescribe vitamin D using the window of our 4th year geriatrics medical students’ written medication review assignments on frail older patients. • Know how often students address nutrition using the window of our 4th year geriatrics medical students’ written functional assessment and advanced illness assignments on frail older patients. • Compare your performance on seven final exam questions with our students’ performance on those questions. Mission and Vision of our Medical School • The Florida State University College of Medicine will educate and develop exemplary physicians who practice patient-centered health care, discover and advance knowledge, and are responsive to community needs, especially through service to elder, rural, minority, and underserved populations. • The FSU College of Medicine will lead the nation in preparing compassionate physicians to deliver the highest quality 21st Century patient-centered medicine to communities of greatest need. • Florida has the highest proportion of older persons in the US and the lowest per capita number of geriatricians. Geriatric education is mandated by law in the founding of our school. • Among a handful of medical schools with a department of geriatrics. Fall prevention with supplemental vitamin and active forms of vitamin D: a meta-analysis of randomized controlled trials Bischoff-Ferrai, et al; BMJ 2009;339:b3692 • A dose of 700 IU -1000 IU supplemental vitamin D a day reduced falls by 19%, and by up to 26% with vitamin D3, within 2-5 months of treatment initiation. • Vitamin D may not reduce falls at doses of less than 700 IU per day. • In the introduction and literature review for this study it was pointed out that vitamin D has a direct beneficial effect on muscle, and improved strength and balance in several trials in older persons Bishoff-Ferrari, et al. J Bone Miner Res 2003:18343-51 Pfeifer M, et. al. Osteporosis Int 2009; 20:315-22 Pfeifer M, et. al. J Bone Miner Res 2000; 15: 1113-8 American Geriatrics Society Consensus Statement on Vitamin D for Prevention of Falls and Their Consequences JAGS 2013 • Clinicians are strongly advised to recommend vitamin D supplementation of at least 1000 IU/d with calcium to older adults residing in institutional settings to reduce the risk of fracture and falls. • There are insufficient data at this time to support a recommendation for increased vitamin D without calcium for older persons residing in the community or institutional settings. • Clinicians should review older adults vitamin D intake form all sources and discuss strategies to achieve a total vitamin D input associated with fall and fracture prevention. • Routine laboratory testing for 25(OH)D serum concentrations is not necessary. Awareness of vitamin D deficiency states and recommended supplementation doses: survey of faculty and staff at a medical school Agens JE, Galasko GT, Purandare AV, Lin J ESPEN December 2012 Volume 7, Issue 6 • Anonymous survey of faculty at Florida State College of Medicine • 209 respondents approximately half were physicians • 1800 faculty across six campuses across Florida, low response rate • Geographically distributed, community based medical school model • 3rd and 4th year student do their clinical years in physician practices • Purpose of this survey was to determine the level of awareness of vitamin D deficiency states, physician awareness of their own vitamin D status, and recommendation of vitamin D supplementation and treatment for their patients Survey: Vitamin D Deficiency Categorical Variables of Responders • Are you personally taking vitamin D yourself? (yes/no) • Are you personally taking calcium? (yes/no) • Your age? • Sunlight exposure (less than 20 minutes a day?) • Have you ever had your vitamin D level checked? (yes/no) • If your vitamin D level has ever been checked, was it low? (yes/no) • If you are a physician, what dose of vitamin D do you recommended for prevention of vitamin D deficiency? Treatment? 200 IU, 400 IU, 800 IU, 1000 IU, or greater than 1000 IU Vitamin D survey: Key Findings • Osteomalacia and rickets were widely recognized as associated with vitamin D deficiency. Osteoporosis as well, but significantly less so. • Few surveyed listed fractures or falls as associated with vitamin D deficiency. • 70% of the female physicians were taking vitamin D, 43% of males • Only 23% of the physicians had ever had their vitamin D level checked • Older age, less than 20 minutes of sun exposure, and taking calcium was associated with having a vitamin D level checked. • Two thirds who knew their vitamin D level said it was low. Prevention Treatment Response (Percentage) 58 31 25 22 12 2 2 16 10 10 10 2 200 400 800 1000 >1000 Unsure Figure 3. MD Recommended Daily Dose Vitamin D International Units Vitamin D survey: Additional findings • Physicians who had their own vitamin D level checked were 4.5 times more likely to recommend greater than or equal to 800 IU per day for supplementation for their patients. Fourth Year Medical Students’ Required Written Patient Care Assignments on Geriatrics Clerkship • Perform a medication review including a patient-centered analysis of general efficacy, specific risk/benefit analysis, calculation of remaining life expectancy and comparison with time to benefit for each medication, reasoning out a person-centered therapeutic plan. • Demonstrate proficiency in detecting and describing functional impairment detailing the patient's premorbid status, the events leading to the observed functional changes and a brief description of the functional changes, exam, and proposed plans for rehabilitation including nutrition. The goals of the patient must be included. • Submit 'reflections at the end of life' using a patient summary, patient goals, plan of care, efficacy of existing care plan, recommendations for proposed changes including nutrition, critique of the healthcare delivery system and description of any ethical issues. Fourth Year Medical Students’ Competencies Assessed by Observation and Case Discussion • Demonstrate to Clerkship Director or designated faculty the ability to perform fall risk assessment with correct interpretation of results, including gait assessment. • Demonstrate to Clerkship Director or designated faculty the ability to assess for cognitive impairment using the appropriate screening tools (CAM, Minicog, MMSE or MoCA observation) with correct interpretation of results (case discussion). • Demonstrate knowledge and understanding of the key components of a safe and comprehensive discharge/admission plan for an older adult. A case presentation to Clerkship Director that includes plans to assist the patient in maintaining or improving function including nutrition. Fourth Year Medical Students’ Competencies Required Procedures • Calculate Creatinine Clearance • Depression Screening Tool • Incontinence Assessment • Nutritional Assessment • Perform Therapeutic Review • Functional Assessment Complete • Confusion Assessment Method • Cognitive Assessment with MoCA/ MMSE, or Mini-Cog • Get up and Go/ Gait Assessment How frequently is vitamin D supplementation used in a cross section of a frail older population? • Subjects: consenting medical student’s medication review assignments- one patient per student, 82 assignments about one out of four students taking the required clerkship in geriatrics • Three consecutive academic years of data: 2013, 2014, 2015 • Patient age range 55-102 years of age, average age 81 years old • Patients on 6-17 medications including OTC and dietary supplements • 57% of the patients in rehabilitation settings, nursing homes, or ALFs • Almost all patients had functional impairment • Students are required to include all non-prescription and dietary supplements in their medication review written assignments. Answer: Vitamin D was used in < 1 of 3 frail patients • 2012-13: 26% of patients on 800-2000 IU, one patient on < 800 IU and student recommended increase, and in two patients student recommended vitamin D be added. • 2013-14: 27% of patients, most on 400 IU with 1200mg calcium/ day; but two patients without dose specified, one on 50,000IU noted deficient (level 22ng/ml), one patient noted deficient but not on D, and in one case the student recommended D should be added. • 2014-15: 30% of patients, ranging 400 IU to 2000 IU/ daily, in one case student recommended a decrease from 50,000 IU weekly to 1000- 2000 IU daily after reviewing records for deficiency, and one student recommended starting 1000 IU of D daily. Word search finds on students’ assignments representing 73 frail older persons Functional Assessment search ‘diet’ 2014-15 53 % 2013-14 2.5% 2012-13 18% Advanced Illness word search ‘diet’ 2014-15 57% 2013-14 45.8% 2012-13 46.4% nutrition 50% 24% 13% nutrition 56% 39% 52% A 76-yr-old male comes to the office for follow-up and medication refills. His examination is unchanged since his last visit 3 months ago, except that his weight has decreased from 99.8 kg (220 lb.) to 92.5 kg (204 lb.). He expresses surprise about the weight loss, “Since my daughter and grandchildren moved out, all I do is sit and read with the TV on”. Which one of the following is most appropriate? a. Administer the Simplified Nutritional Assessment Questionnaire b. Conduct a motivational interview about intentional weight loss c. Discuss the weight loss and evaluate him for causes d. Encourage him to continue to lose weight e. Set exercise and diet goals, and schedule follow-up in 2 months f. Suggest a nutritional supplement to help him regain the lost weight Answer c. Discuss the weight loss and evaluate him for causes • p-Bis statistic 0.32 (desired value 0.20 – 0.80) • 80% {82% high performers 74% low performers} • 20% choose answer a. Administer the Simplified Nutritional Assessment Questionnaire A 68-year-old male has severe vascular dementia and lives in a nursing home. A gastrostomy was placed 1 year ago because of severe dysphagia following a stroke. Recently, the patient has become increasingly agitated and pulled out the feeding tube several times. Efforts to conceal and anchor the tube have been unsuccessful. Changes in environment and judicious use of medications also have been ineffective. Which of the following is most appropriate action? a. Increase medication dosage to sedate the patient. b. Place mitts on the patient’s hands. c. Place restraints on the patient’s wrists. d. Reevaluate the need for the gastrostomy. e. Replace the gastrostomy with jejunostomy Answer d. Reevaluate the need for the gastrostomy. • p-Bis statistic 0.23 (desired value 0.20 – 0.80) • 86% {100% high performers 92% low performers} • 4% choose answer a. Increase medication dosage to sedate the patient. An 84-year-old female moved to a nursing home 6 months ago, following her husband's death. She has severe dementia and requires considerable assistance with eating. Since admission, she has lost 5 kg (11 lb), which is 20% below her ideal weight. No aspiration is noted on swallowing evaluation. The patient eats very slowly. The staff confirm that a long period of time is required to feed the patient. Her dentures fit well, and a psychiatric evaluation reveals no evidence of depression. The patient never made any statements about artificial feeding and does not have the capacity to understand that option now. Which of the following is the most appropriate action? a. Arrange for a temporary nasogastric feeding tube b. Begin donepezil therapy c. Develop interdisciplinary strategies to improve feeding d. Order nutritional supplements to be placed at her bedside e. Place a percutaneous endoscopic gastrostomy Answer c. Develop interdisciplinary strategies to improve feeding • p-Bis statistic 0.01 • 88% {92% high performers 85% low performers} • 8% choose answer d, Order nutritional supplements to be placed at her bedside • 4% e, Place a percutaneous endoscopic gastrostomy A 74-year-old female who had a stroke 1 week ago is reported by her caregiver to be coughing at mealtimes, drooling intermittently, requiring a prolonged period of time to eat, and failing to finish more than half of her food. The patient's recent stroke was her second stroke in 1 year, and there is clinical evidence that both hemispheres are now involved. Concerning her mealtime behavior, what is the most appropriate test for establishing a diagnosis? a. Esophageal manometry b. Esophagography c. Esophagoscopy d. Ultrasound evaluation of swallowing e. Video fluroscopy evaluation of swallowing Answer e. Video evaluation of swallowing • p-Bis statistic 0.52 (desired value 0.20 – 0.80) • 79% {93% high performers 65% low performers} • 4% choose answer c, Esophagoscopy • 3% a, Esophageal manometry Which of the following statements regarding the use of tube feeding in patients with severe dementia is correct? a. It does not improve survival. b. It improves functional status. c. It improves patient comfort. d. It protects against aspiration pneumonia. e. It promotes the healing of pressure ulcers. Answer a. It does not improve survival. • p-Bis statistic 0.41 • 80% {86% high performers 71% low performers} • 13% choose answer d, It protects against aspiration pneumonia. • 2% b, It improves functional status. A 78-year-old female who lives alone comes for an office visit as a new patient. She has osteoarthritis, macular degeneration, hypertension, and mild hearing loss. She has no symptoms except knee pain when she walks. On examination, she is thin (body mass index [kg/m2] of 19.2). On examination, crepitus is present in both knees. The rest of the examination is within normal limits. Hemoglobin and hematocrit are normal, as was a colonoscopy approximately 10 years ago. What is the most appropriate next step in evaluating her nutritional status? a. Check lymphocyte count b. Check serum albumin c. Check serum cholesterol d. Inquire about recent weight loss Answer d, Inquire about recent weight loss • p-Bis statistic 0.52 • 96% {100% high performers 87% low performers} • 4% choose b, Check serum albumin. An 84-year-old female of Middle-Eastern descent has been in your nursing home for 3 years following a hemi-plegic stroke. She is tube fed due to dysphagia. She rarely leaves the facility and shares a room with another resident who has the bed by the only window. Nursing staff reports a general decline in her strength and balance in recent months, and report that she moans in non-specific discomfort when moved. Exam confirms the above observations. There is tenderness when putting pressure tibial bones bilaterally. • Which of the following tests are likely to show the problem? a. 25 hydroxy vitamin D b. CPK c. ESR d. LDH e. SGOT Answer a. 25 hydroxy vitamin D Thank You!