System

Question 1

12 Choosing Wisely guidelines?

Answer 1

1. asymptomatic bacteruria
2. benzodiazepines for insomnia, agitation or delirium.
3. percutaneous feeding tubes
4. antipsychotics for BPSD
5. hypoglycemia
6. physical restraints for BPSD
7. ChEi or memantine deprescribing
8. med rec and deprescribing
9. virtual visits
10. discarding unused and expired medications
11. ordering investigations
12. discarding adaptive equipment

Question 2

Per Healthy Aging in Canada (2021), what are five topics of health promotion?

Answer 2

Social connectedness
Physical activity
Healthy eating
Falls prevention
Tobacco control

Others include elder abuse, income disparaties, literacy and lifelong learning, etc.

Question 3

List 5 ways to resolve conflict among team members

Answer 3

Be an active listener

Use disarming statements

Find common ground

Keep it thoughtful

Know your limits

Question 4

As opposed to a clinic visit, why may a home visit by a geriatrician be helpful? List 5 reasons

Answer 4

● Identify problems not readily apparent in office setting
● Reduce burden for patients who experience difficulty with transportation
● Assess patient daily environment for safety, patient unique needs
● Environmental modifications based on home safety and function assessment
● Opportunity to address caregivers needs in home environment
● Physician-patient rapport
● Checking medication adherence, storage, use

Question 5

Evidence behind Geriatric Day Hospital?

Answer 5

Less likely to: die, be institutionalized, become more dependent
—-21 patients need to attend day hospital to prevent one admission to LTC

Small reduction in hospital bed use compared with all other treatments

economic value is unclear
—-7 studies GDH more expensive than comparison treatment, 3 costs same, 2 less expensive

Overall, low quality of evidence for GDH, and outcomes are disappointing

Question 6

Define a CGA?

Answer 6

Multidimensional, interdisciplinary diagnostic process to determine medical, psychological and functional capabilities of frail elderly person to develop integrated treatment plan

Question 7

What are the benefits of a CGA in…
- community dwelling frail older adults
- adults admitted to the hospital
- hip fracture

Answer 7

CGA for community dwelling frail older adults (Cochrane 2022)
— Decr risk of unplanned hospital admissions

CGA for adults admitted to the hospital (Cochrane 2017, Age and Aging)
— Incr patients will be alive in their homes at 3-12 months follow-up
— Decr admission to NH at discharge

CGA for hip fracture
— Decr mortality, institutionalization, cost, risk of delirium

Question 8

5 examples of primary and secondary prevention programs in health care of the elderly.

Answer 8

Primary Prevention Programs
- Falls prevention
- Vaccinations: zosta vax, pneumovax, annual flu, covid
- Hearing Care Counselling Program
- Nutrition
- Smokers’ Helpline
- Alcohol moderation
- Pharmacist led medication reviews

Secondary prevention - this includes early disease detection and screening for subclinical forms of the disease.
- HTN – BP check at all appropriate primary care visit
- Cancer screening programs
- Osteoporosis screening
- AAA screening
- Depression and cognitive screening

Question 9

5 ACE unit principles

Answer 9

1. Prepared environment
2. Patient centred care
3. Frequent medical Review
4. Early rehab
5. Enhanced Discharge planning

PrePaRED

Question 10

List 5 outcomes to measure the effectiveness of an ACE unit

Answer 10

Discharge to institutional care
Readmission
Cognition
Depression
LOS
Cost
Falls
Function
Pressure injuries

Counsell et al., 2000 → ACE improved combined outcomes of functional decline or LTC admission

Question 11

5 harms of physical restraints

Answer 11

Death
Functional decline
Increased agitation
Limit access to food and water
Immobilization
Decubitus ulcers
Aspiration pneumonia
Injuries

Question 12

4 justifications for using catheter?

Answer 12

• palliative care
• healing of stage III or above sacral ulcer
• hourly assessment of urine output if critically ill
• acute urinary retention or obstruction
• CBI for hematuria
• required immobilization for trauma or surgery

Question 13

8 elements of a FLS?

Answer 13

dedicated coordinator
proactive case finding
investigation of fracture risk
initiate treatment
falls prevention
monitoring
integration with primary care
monitor FLS performance

Question 14

3 reasons why women are more likely to suffer from poverty in old age than men

Answer 14

1) Women live longer - outlive their spouse and savings
2) Lower pensions
3) Lower savings

2) and 3) due to lower paying jobs and interruptions in their work for childcare

Question 15

4 reasons LTC residents at higher risk of c diff?

Answer 15

Abx exposure
Close living quarters (shared bathrooms)
Frequent healthcare transitions (adm to hospital)
Colonization rates

Question 16

3 infection control measures to reduce spread

Answer 16

contact precautions
soap and water to kill spores
sporicidal disinfecants

Question 17

8 components in CGA not in internal medicine consult

Answer 17

Cognitive assessment
Functional assessment
Gait/Falls assessment
Nutritional assessment
Medication reconciliation
Mood screening
Frailty assessment
Goals of care / matters most

Question 18

4 factors predicting patient will be discharged to community home from inpatient rehab

Answer 18

Pre-admission functional status
Cognition
Social supports (family)
Younger age
Male
Lack of depression

Question 19

2 screening tools used in the ER for predicting outcomes in the elderly

Answer 19

ISAR: (Identification of Seniors at Risk)

4Ms: mentation, mobility, meds, matters most

Question 20

8 evidence-based models of care for caring for older adults in acute care

Answer 20

ACE
MACE
HELP
Orthogeri
Geri consultation
Geri trauma
Periop geri
EASE (Elder-Friendly Approaches to the Surgical Environment)

GEM
Geri cardio
Geri ICU
Age friendly health systems

Question 21

4 patient populations where ACE principles have been applied

Answer 21

Surgery
Ortho
Stroke
ED / GEM

Question 22

3 barriers to “minimum data set” use in LTC?

Answer 22

1. High staff burden and time
2. Limited training
3. High staff turnover
4. Incomplete/inaccurate data entry
5. Lack of mandates, incentives, system-level endorsement/integration

Question 23

What are 3 characteristics of a patient suitable for GDH?

Answer 23

– clear goals
– potential to return to baseline function
– lives in community
– medical condition needs to be addressed by multiple team members
– cognitively able to carry over

Question 24

4 psychosocial (non-medical) reasons for transferring a patient from nursing home to acute care hospital

Answer 24

SI / HI
Harm to staff
Neglect or harm to patient
Lack of goals of care/advanced directives

Question 25

What does SMART stand for in goal-setting?

Answer 25

Specific Measurable Achievable Relevant Timely / time-limited

Question 26

What are the 9 steps of a QI project?

Answer 26

1. identify opportunities / audit 2. establish team 3. set aim 4. understand the problem 5. establish measures 6. develop ideas for change 7. test changes 8. implement changes 9. spread improvements

Question 27

Name 3 QI tools for identifying root causes

Answer 27

Ishikawa / fishbone diagram Five whys Process mapping Pareto chart

Question 28

4 components of a functional project team

Answer 28

● Executive sponsor (someone very high up that can advocate and financially support, often hospital CEO or administrator) ● Local system leaders (power to get things done, department head, etc) ● Clinical/technical experts (know the current standards of care, often MDs) ● Day-to-day leaders (will get everyone on board with change, nursing managers, pharmacy leads)

Question 29

5 change concepts (broad categories of ideas that can guide teams in developing specific changes to improve processes or outcomes)

Answer 29

● eliminate waste and error ● improve workflow ● optimize resources ● change the work environment ● customer/client/patient interface

Question 30

Regarding the Canada National Dementia Strategy 2019 – name the 3 national objectives

Answer 30

1. Prevent dementia 2. Advance therapies and find a cure, and 3. Improve the quality of life of people living with dementia and caregivers

Question 31

6 barriers that underrepresented people in Canada have to accessing culturally sensitive geriatric services

Answer 31

1. language barrier 2. limited cultural competency training in providers 3. geographical location / transportation 4. mistrust 5. misconceptions about "normal aging" 6. other medical conditions may take precedence