Education

GUIDELINES FOR COMPETENCY BASED POSTGRADUATE TRAINING PROGRAMME FOR MD IN GERIATRIC MEDICINE AT AIIMS

PREAMBLE:

Older Indians carry a large burden of disease and disability and pose a tremendous challenge for the health sector as well as also social and economic infrastructure. Several initiatives of Government of India namely: National Policy on Older Persons, National Health Policy, National Population Policy,  Maintenance and Welfare of Parents and Senior Citizens Act, 2007 and the National Program for Health Care of the Elderly launched in the financial year 2010-11, have emphasized the need for provision of quality and specialist health care of  the older population. Specialized training in the field of gerontology and Geriatric medicine has become the need of the hour to realize the state initiatives in old age care.

GOALS

The goals of this curriculum are to create a cadre of health professionals in the care of the older people; who would:

i)        provide comprehensive health care and rehabilitation of the elderly

ii)       provide undergraduate and postgraduate training

iii)     carry out research in geriatrics and gerontology

 

SUBJECT SPECIFIC LEARNING OBJECTIVES

After completion of post graduation in Geriatric Medicine, the physician should be able to fulfill the following objectives:

i)        to provide necessary care to older people in both hospital and home settings

ii)       to organize and implement different health care programs for the older person

iii)     to conduct research to improve health status of the older person and thereby improve quality of life, to reduce disability and arrest or delay age related problems.

 

CURRICULUM

Course Contents

A)     Basic Sciences: biology of human ageing, epidemiology of human ageing, immunology of human ageing, pharmacokinetics and pharmacodynamics in ageing, effect of ageing on different organs, death.

B)      Clinical Geriatric Medicine: Cardiology, pulmonary medicine, gastroenterology, endocrinology, nephrology, neurology, infectious disease, rheumatology, critical care medicine, hematology and oncology.

C)      Allied specialties: Anesthesiology, Urology, Gynecology, Ophthalmology/ENT/ Dentistry, Orthopedics, dermatology, Psychiatry, Surgery, Pre – operative and post operative management, .

D)     Preventive Geriatrics: Rehabilitation, end of life care, legal, ethical, social and economic aspects

 

SUBJECT SPECIFIC THEORETICAL COMPETENCIES

Paper I: Applied Basic Sciences

Anatomy, Physiology, Biochemistry, Pharmacology, Microbiology, Pathology, Forensic and toxicology

Paper II: General Medicine and Psycho-Geriatrics

Introduction to Clinical Medicine: Headache, chest pain, abdomen pain, joint pain, chills and fever, lassitude and asthenia, dyspnea, cough, hemoptysis, cyanosis, edema, palpitations, nausea and vomiting, dysphagia, gastrointestinal bleeding, jaundice, ascites, weakness, sexual dysfunction, tremor, chorea, athetosis, syncope, dizziness and vertigo, disorders of sensation and motor weakness,delirium, memory loss, sleep disorders, convulsions, anemia, carcinoma of unknown primary.

Immunological Factors in Disease: Components of immune system, mechanism of the immune response, immune deficiency and lympho-proliferative disorders, types of immune reaction and their relation to disease, suppression of immune reactions and its effects, Sjogren’s syndrome, systemic lupus erythematosus, vasculitis and sarcoidosis.

Infection and Diseases: Nature of microorganisms, epidemiology and spread of infections, defense of human host, diagnosis of infections, pyrexia of unknown origin, streptococcal infections, staphylococcal infections, typhoid, tetanus, brucellosis, sexually transmitted infections, hospital acquired infections, gram negative bacterial infections, anaerobic infections, fungal infections, parasitic infections, tuberculosis and HIV.

Chemotherapy of Infections: Antibiotics and other antibacterial agents, anti-virals, anti-fungals, anti-retroviral, anti-parasitic therapy and antimicrobial stewardship.

Disturbances in Electrolyte and Water Metabolism: Hyper- and hyponatremia, hyper- and hypokalemia, calcium and magnesium metabolism, disturbances in h⁺ ion concentration

Diseases of the Cardiovascular System: Cardiac arrhythmias, heart failure, valvular heart disease. ischemic heart disease, pericardial diseases, cardiomyopathies, myocarditis, atherosclerosis, hypertension, diseases of the aorta, peripheral vascular disease, deep venous thrombosis.

Diseases of the Respiratory System: Disease of the upper respiratory tract, bronchial asthma, chronic obstructive pulmonary disorder (COPD), cor-pulmonale, bronchiectasis, interstitial lung disease (ILD), occupational and environmental lung disease, sleep apnea, acute and chronic respiratory failure, neoplasm of lung, diseases of pleura, mediastinum and diaphragm

Diseases of the Gastrointestinal System: Diseases of the esophagus, gastro-esophageal reflux disorder (GERD), peptic ulcer, gastritis and other diseases of the stomach, inflammatory diseases of small and large intestine, diverticulosis, malignancy of stomach, colon; mal-absorption syndrome, diseases of the peritoneum

Diseases of the Liver and Biliary Tract: diagnostic procedures in liver disorders, derangement of hepatic/ biliary metabolism, acute hepatitis, chronic active hepatitis, cirrhosis of liver, tumors of liver, suppurative diseases of liver, infiltrative and metabolic diseases of liver, disorders of gall bladder and bile duct

Diseases of the Pancreas: Diagnosis of pancreatic diseases, acute and chronic pancreatitis, Tumors of pancreas

Diseases of the Kidney and Urinary System: Acute renal failure, chronic kidney disease, dialysis, glomerulonephritis, nephrotic syndrome, vascular diseases of the kidney, infections of the urinary tract, obstructive uropathy, urinary incontinence, nephrolithiasis

Diseases of the Endocrine System: Hypothalamus and pituitary gland, hyper- and hypothyroidism; hyper- and hypoparathyroidism; diabetes mellitus, hyperinsulinism / glucagon and its effects; diseases of the adrenal cortex and medulla; diseases of the testes and ovaries, disorders of bone and mineral metabolism, osteoporosis and metabolic syndrome.

Diseases of Blood and Blood Forming Organs: Blood formation and destruction, 2, bone marrow failure, blood groups and blood transfusion; abnormal hemoglobins, myeloproliferative disorders, leukemia, lymphomas, amyloidosis, plasma cell disorders, diseases of spleen and reticulo-endothelial system, febrile neutropenia, disorders of platelets, hemorrhagic disorders, coagulation disorders, antiplatelet, anticoagulant and fibrinolytics, chemotherapy and it side-effects.

Diseases of Connective Tissue, Joints and Bones: Osteoarthritis, Rheumatoid arthritis, including late onset rheumatoid arthritis (LORA), spondyloarthritides,polymyalgia rheumatica, fibromyalgia, gout and pseudo-gout, tumor of bone.

Diseases of the Nervous System: Diagnostic methods in neurology, coma, headache, epilepsy, sleep disorders, dementia, diseases of cranial nerves, cerebro-vascular diseases, diseases of the spinal cord, diseases of the peripheral nervous system and muscles, diseases of the autonomic nervous system, Parkinson’s disease and other movement disorders, pyogenic infections of the CNS, viral infections, multiple sclerosis and other demyelinating diseases; metabolic and nutritional diseases of brain; degenerative diseases

Diseases of the Skin: Skin lesions of general medical significance, generalized pruritus, pigmentation of the skin, disorders of melanin metabolism, photosensitivity and other reactions to light; hirsutism and alopecia; cutaneous manifestations of internal malignancy, Psoriasis, Scabies, Fungal infections of skin

Psycho-Geriatrics: Epidemiology of mental disorders in the elderly, definition and classification of psychiatric disorders, delirium /acute confusional state,depression in old age, bipolar disorder, functional psychiatric disorders in old age, personality and behavioral disorders, psycho-geriatric service - principles of treatment

Critical care Medicine: Sepsis and septic shock, shock and cardiac arrest, cardiopulmonary resuscitation, neurological critical care, oncological emergencies, mechanical ventilation, nutrition in critically ill, respiratory critical care, analgesia and sedation in ICU, fever in ICU, fluid and inotrope management.

Management of Psychiatric Illness: Alcoholism and other substance abuse, care-giver problems, depression and other mood disorders, acute psychosis and other psychotic disorders, anxiety disorders, somatoform and somatization disorders.

 PAPER III: Geriatric Medicine

General: Demography, world trends, Trends in India and developing countries, the aged and society – past and present, evolution of geriatric medicine

Gerontology: Normal and abnormal ageing, theories of ageing, metabolic and structural aspects of ageing, biochemical changes in the normal ageing brain, ageing in tissues and cells, atherosclerosis and ageing, ecology of human senses, the milieu interior and ageing

Geriatric Medicine: How are older patients different; common patterns of disease in old age, frailty, alteration in pain and temperature responses, missing symptoms, complications of illness, non-specific presentations, masking by known disease, history taking in the elderly, physical examination of the old patient, comprehensive geriatric assessment.

Investigations in the elderly: Policy and interpretation; Radiological, hematological and biochemical investigations; ECG, Urinalysis, Radio isotope tests; Bone Scan; Imaging – ultrasound, CT Scan, MRI and PET Scan; How much to investigate; Concept of normal range

Immunology: Genetic aspects of immunity and immunological diseases; mutation, alternative theories of ageing, cancer, immunological surveillance

Nutrition: Nutritional requirement; changes in total body mass and body composition; nutritional assessment, nutritional deficiency in old age, vitamin D, iron, trace elements, vitamins, recommended intake of nutrients, prevention of nutritional deficiency

Cardiovascular System: Physiology and pathology of cardiovascular system in old age; investigation of heart diseases in old age, cardiac arrhythmias, coronary artery disease and acute myocardial infarction; hypertension and hypertensive heart disease; postural hypotension, valvular heart disease, chronic congestive heart failure, aortic aneurysm, infective endocarditis, peripheral vascular disease, deep venous thrombosis and pulmonary embolism

Endocrine and Metabolic Disorders: Changes with ageing, diabetes mellitus, diseases of the pituitary, parathyroid, and thyroid; obesity, sexual dysfunction, disorders of sodium, potassium, calcium, magnesium and zinc; disturbances of fluid metabolism, hyperpyrexia / heat stroke

Central Nervous System: The ageing brain, vascular lesions of the central nervous system, dementia, degenerative disorders including Parkinsonism, head trauma, infections of the nervous system, epilepsy, peripheral neuropathy, disorders of spinal cord and nerve roots; neoplasia

Genitourinary System: Structural changes with ageing, acute and chronic renal failure; infections of the genitourinary tract, diseases of the bladder and prostate; urinary incontinence, ageing changes in the genital tract, post-menopausal bleeding, gynecological disorders in the elderly

Disorders of the Special Senses: Disorders of the eye, Hearing disturbances, Disturbance of taste and smell; Dental problems

Infections in the Elderly: Host defenses – natural barriers; white cell response, immune mechanism; diagnosis of fevers, urinary tract infection -diagnosis and treatment; pneumonias -cause, diagnosis and treatment; septicemia, bacterial endocarditis, antibiotic treatment, rational use of antibiotics, vaccination of elderly.

Gastro-intestinal System: Changes with age, investigations of the gastro-intestinal tract, disorders of the mouth, GERD, hiatus hernia, acid peptic disease, disease of the pancreas, diseases of the small intestine, diseases of the large intestine, fecal incontinence, gi malignancy, disease of the liver and biliary system; constipation – prevention and management

Respiratory System: Changes with age, infections of the respiratory system, chronic obstructive airway disease, bronchial asthma, cor pulmonale, bronchogenic carcinoma, respiratory abnormalities in extra-pulmonary conditions, respiratory failure

Musculoskeletal System: The ageing joints, gait and balance impairment, degenerative joint disease, gout and pseudo-gout; rheumatoid arthritis, infective arthritis, myopathy, myositis, polymyalgia rheumatic, temporal arteritis, osteoporosis, osteomalacia

Hematopoietic System: Changes with ageing, anemia in the elderly, the leukemia and lymphomas; paraproteinaemia, myelodysplastic syndromes, disorders of hemostasis

Dermatology: The ageing skin, pruritus, cancers/benign lesions, pemphigus and pemphigoid; senile purpura, herpes zoster, intertrigo, leg ulcer

Malignancy in old age: Incidence, clinical significance, Presentation, investigation and management; counseling

Pharmacological Aspects of Ageing: Pharmacokinetics in the elderly, pharmacodynamics, drug selection and dosage; drug interactions, adverse drug reactions, drug compliance, drug misuse

Surgery in the Elderly: Pre-operative assessment, priorities for surgery, surgical emergencies, fractures, gangrene –amputation, elective surgery, post-operative problems and management; anesthesia in old age

Special Problems: Pressure sore, care of the chronically ill, care of patients with terminal illness; religion and illness; falls; nursing home placement, ortho-geriatric care

PAPER IV: Social and Preventive Geriatrics including rehabilitation, and advances in Geriatrics Social Geriatrics:

• Types of Family - Joint family system- promotion of Joint Family System – Role of Elders and the younger generation
• Isolation, loneliness and dependency - Dependency ratio - Generational equality
• Social changes due to urbanization and industrialization with respect to Elders
• Financial aspects - sources of income, old age pension
• Role of Government and NGOs in up-liftment of socio-economic status of older people
• International and national policies on ageing and old age care
• Geriatric Service for the Elderly in Western Countries and in India - Structure of geriatric Service - Family as basic Unit - Models of Geriatric Service
• Day Hospital, Day Care Centre, Long Stay Care Institution, Home for the Aged
  Functions of the Day Hospital - Staff and patients of day Hospital
• Nursing Home in Western Countries - Goals of Geriatric Care - Need for similar services in India
• Psycho-geriatric services - structure and facility -domiciliary assessment and community care
• Terminal Care Services - social and spiritual problems in terminally ill
• Ethical Issues in Geriatric Medicine -self determination an decision making in treatment options -informed consent -quality of life -age limits on health care
• Euthanasia -acts of omission and commission

Preventive Geriatrics:

• Preventing Diseases and promoting health in old age - Types of preventive activities - Risk factor management in elderly - screening
• Health belief model - General Health practices in elderly
• Exercise in the elderly - Physical and Mental domain - Benefits of Exercise
• Development of Anticipatory Care and its Rationale - methods of Anticipatory Care
• Health promotion and Health Education in the Elderly
• Anti-Ageing interventions

Rehabilitation:

• The concepts and history of rehabilitation
• The goals of rehabilitation
• Principles of rehabilitation -assessment, goals, priorities and monitoring progress
• Rehabilitation in old age -special features in relating to ageing, multiple pathology, policies, expectation, carers, acute illness, social and financial support
• Clinical evaluation of rehabilitation -impairment, disability and handicap
• Prevalence of disability, types of disability
• Rehabilitation as Team work - Team leadership, therapist, physiotherapy, occupational therapy, social worker, physician and nursing personnel.
• Self care evaluation and management of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) -self care assessment tools
• Aids and application - tools for living
• Role of physiotherapy in the elderly
• Contractures and other deleterious effects of immobility
• Pressure Ulcer -factors, prevention and management
• Rehabilitation of stroke in the elderly
• Rehabilitation of specific diseases -parkinsonism, paraplegia, facture neck of femur, acute and chronic arthritis, lower limb amputation, low back pain
• Organization and effectiveness of rehabilitation services -community Services
• Geriatric Unit, day hospital, day care centre, long stay institution - role of rehabilitation in the above services

Advances in Geriatric Medicine: Alzheimer’s disease, Parkinsonism, osteoporosis, urinary incontinence, falls / prevention of fractures, parenteral nutrition, stroke clinic and memory clinic; anti-ageing research

 

SUBJECT SPECIFIC PRACTICAL COMPETENCIES

• History taking and Physical Examination of the old patient
• Functional Assessment, Commonly used scales of assessment
• Investigations: Policy and interpretation of investigations- Hematological and Biochemical investigations, ECG, Urinalysis, Radioisotope tests, Radiological- X-Ray, Ultrasound, CT, MRI, PET
• How much to investigate?
• Concept of normal range
• Comprehensive Geriatric Assessment
• Nutritional assessment
• Investigation and management of: frailty, cognitive impairment and dementia, postural hypotension, fall, incontinence, polypharmacy, multi-morbidity, pressure ulcers and other geriatric syndromes
• Investigation and management of: Cardiac arrhythmias, Coronary artery disease and acute myocardial infarction; Hypertension and hypertensive heart disease; Postural hypotension, Chronic congestive heart failure, Aortic aneurysm, Infective endocarditis, Peripheral vascular disease, Deep venous thrombosis and pulmonary embolism
• Investigations and management of: Disorders of the mouth/loss of teeth, GERD / hiatus hernia/ acid peptic disease, Disease of the pancreas, Diseases of the small intestine, Diseases of the large intestine, Fecal incontinence, GI malignancy, Disease of the liver and biliary system, Constipation
• Investigations and management of: Urinary tract infection, Benign hypertrophy of the prostate and cancer of the prostate; Urinary incontinence
• Diagnosis and management of  - Depression, anxiety state/ acute confused state/delirium
• Investigations and management of: Diabetes, Thyroid diseases
• Investigation and management of: Stroke, Parkinson’s disease
• Investigation and management of: Osteoarthritis, Osteoporosis
• Investigation and management of: Chronic Obstructive Pulmonary Disorder /bronchial asthma; Acute and chronic respiratory failure; Tuberculosis, Pulmonary thromboembolism, Pneumonias
• Investigation, counseling and management of cancers of various organs
• Vaccination of elderly
• Pain management and palliative care of the elderly including advance directives and end of life care
• Manage surgery in old age: Priorities for surgery, Anesthesia in old age Surgical emergencies, Fractures, Gangrene and amputation; Pre-operative assessment, Management of Post-operative problems

TEACHING AND LEARNING METHODS

Organization of contents

Duration:  3 years

1^st year: First 6 months Geriatric Medicine and Rotation in periphery

2^nd year: Rotation in peripheryand Geriatric Medicine

3^rd year:Rotation in periphery and Geriatric Medicine

Rotations include: Geriatric Medicine: 18 months; Emergency Medicine (2months), Pulmonary Medicine (1 months), Intensive Care Unit (3months), Cardiology (2 month), Neurology (2 months), Hematology (15 days ), Physiotherapy (15 days), Rheumatology (15 days), Psychiatry (15 days), Gastroenterology (1 month), Endocrinology (1 month), Nephrology (1 month), Medical Oncology (1 month), Palliative Medicine (15days) and Day Care and Special Clinics (45days)

Procedures’ skills performed: IV line insertion, arterial line insertion, central line insertion, endo-tracheal intubation, bone marrow biopsy, thoracocentesis, peritoneocentesis, lumbar puncture, ICD insertion, peritoneal catheter insertion, foley’s catheter insertion, point of care ultrasound,synovial fluid aspiration, intraarticular injection,skin biopsy,nerve biopsy, muscle biopsy etc.

Procedures’ skills observed: Angiography, 2 D-echocardiography, Endoscopy, Colonoscopy, Fibroscan, Bronchoscopy, Dialysis, Renal biopsy, Plasmapheresis, NCV/ EMG etc.

Educational strategies: It should be problem oriented as well as integrated with other disciplines. Apart from that the curriculum should be both hospital and community oriented.

Teaching method: Teaching methods should include the following:

1. Lecture and demonstration
2. Case presentation
3. Small group discussion
4. Seminars, journal club
5. Audit and mortality meets

ASSESSMENT

Formative Assessment: during the training programme

Internal Assessment is mandatory in postgraduate curriculum in AIIMS. It should be valid, objective and reliable; it should cover cognitive, psychomotor and affective domains. The Internal Assessment should be conducted in theory and clinical examination. The thesis is assessed separately.

Feedback from the internal assessment should be given to the students, and contribute towards final evaluation.

Assessment

• Academic  activities                                                         Assessment after each Journal club/ Seminar
• Theory assessment                                                         End of every semester (80)
• Practical assessment                                                      End of every semester (80)

Continuous formative assessment: Log books

End Assessment: At the end of the training programme

Scheme of Examination:

1. Thesis

Thesis will be submitted by each candidate at least six months before the theoretical and practical examination. The thesis shall be examined by a minimum of three examiners; one internal and two external examiners, who shall not be the examiners for theory and practical; on the acceptance of the thesis by two examiners, the candidate shall appear for the final examination.

2. Theory: Theory consists of four papers:

Paper I:                                Applied Basic Sciences

Paper II:               General Medicine and Psycho-Geriatrics

Paper III:              Geriatric Medicine

Paper IV:             Social and Preventive Geriatrics including rehabilitation, and advances in geriatrics

Theory Examination:

Paper       Title                                                                                                  Duration                          Max. Marks

                   Internal Assessment                                                                                                             80

1.               Applied Basic Sciences                                                              3 hours                             80

2.               General Medicine & Psycho-geriatrics                               3 hours                             80
3.               Geriatric Medicine                                                                      3 hours                             80
4.               Social & Preventive Geriatrics including,                           3 hours                             80
                   Rehabilitation & Advances in Geriatrics

             

3. Clinical:          

Clinical examination will comprise of 4 cases with different problems and will carry 80 marks each and the candidate will be provided 45 minutes to complete the evaluation. The candidate will be assessed for his/her ability to complete total assessment and management of medical and social problem with stress on multiple pathologies. The communication skills and case sheet writing skill shall also be evaluated. Score out of 80 marks from internal assessment will be added to the final tally.                            

4. Practical:         X-ray, ultrasound, CT, MRI, ECG, biochemical report, psychiatric assessment, retinal assessment via Ophthalmoscope

5. Oral and Practical

1. Diagnostic charts / problem charts
2. Biochemical / blood gas analysis / pulmonary function test
3. X-Ray / CT Scan / MRI/ PET scan
4. E.C.G
5. Ventilator wave forms

Recommended Reading:

Books

1. Brocklehurst’s Text Book of Geriatric Medicine and Gerontology
2. Oxford Text Book of Geriatric Medicine
3. Hazzard’s Text Book of Geriatric Medicine
4. Pathy’s Text Book of Geriatric Medicine
5. Harrison’s Principles of Internal Medicine

Journals

1. Journal of Indian Academy of Geriatrics
2. Age and Ageing
3. Journal of American Geriatrics Society
4. Gerontology
5. JNHA
6. JAMDA
7. NEJM
8. Lancet
9. BMJ
10. Journal of Cachexia, Sarcopenia and Muscle.
11. BMC Geriatrics