A Conceptual Model for a Geriatric Syllabus for Podiatric Medicine

Abstract

Foot disorders and the complications of chronic disease in the older population have a significant effect on society, the cost of health care, and individuals’ quality of life. Given podiatric medicine’s role in the management of problems of the aging, it is critical that the profession’s educational system produce practitioners who understand the process of aging and the needs of the older patient and who are prepared to serve on the health-care-delivery team as the primary providers of footcare services. The geriatric syllabus presented here is one approach to attaining that goal.

The need for podiatric physicians to be involved in the care of older patients makes it important for all podiatrists to be educated about and trained in the special needs of older people. Geriatric and gerontologic training must therefore be provided during the first-professional-degree curriculum as well as in postgraduate training programs, fellowships, and continuing education. Faculty resources must be expanded so that the profession can remain responsible and responsive to the public it serves. It is essential that podiatric physicians possess the knowledge and skills needed to manage the increasingly complicated problems of geriatric patients. In addition, the podiatric physician must be able to assess and recognize other systemic and psychological needs and appropriately refer patients for proper care in these areas.

Podiatric medicine has always served a large number of geriatric patients. However, today’s geriatric care by podiatric physicians does not consist of just treating the foot problems of older people and making appropriate referrals. It is an integrated team approach to patient care and management that requires special training in multidisciplinary ambulatory, hospital, institutional, and program settings.

Foot problems associated with aging and resulting from disease, disability, and deformity, as well as complications associated with many chronic diseases, are among the most distressing, disabling, and quality-of-life-limiting conditions known. As society considers the basic needs of older people—including the needs of older people with such chronic diseases as diabetes mellitus, arthritis, and peripheral arterial disease or with conditions that produce sensory, peripheral, musculoskeletal, and motor deficits—it must recognize that health is but one of those needs and does not always receive the highest priority. Two important factors determine the patient’s ability to remain self-sufficient and reasonably independent: a keen mind and the ability to remain mobile, particularly the ability to remain ambulatory.

Foot problems in the older patient and in patients with chronic diseases are a significant health concern, in terms of both incidence and prevalence. Immobility that results from a foot problem or from a complication of a systemic disease can significantly limit the patient’s ability to maintain a good quality of life and remain a productive member of society.

Perhaps no program is more in need of podiatric involvement at the public policy and clinical levels than gerontology and geriatrics. Today there are about 27.4 million Americans older than 65 years; that is one out of every nine Americans. Furthermore, one out of every five Americans is older than 55. By the year 2025, it is projected that one out of every three Americans will be older than 55, and one out of every five, older than 65. The 65+ population will continue to grow twice as fast as the nonelderly population from 2005 to 2025, and by the year 2025, the 65+ population is expected to double to 58.8 million. Today, for every American at retirement age (age 65+), there are five of working age (22 to 64). This ratio is expected to decrease in the future.

Aging presents a major public health problem in the United States today. Given the projected growth of the elderly over the next 25 or more years and the concern that this population group remain independent as long as possible, a major public health focus will have to be on this segment of the population. It has also been projected that almost half of the aging population suffer from what might be defined as one or more chronic diseases. This adds to the concern about this public issue and also adds to the potential cost in dollars and in quality of life.

Foot conditions seldom are associated with mortality, but the foot is often the site of, and related to, morbidity, disability, impairment, and limitation of activity. Through prevention programs—including health education, early screening and detection, and periodic assessment and surveillance—many diseases can be diagnosed when they are still asymptomatic. Therapeutic measures can then be instituted to alleviate early complaints and to prevent, delay, minimize, or reverse disability. Measures can also be instituted to get patients to change their lifestyle as an approach to secondary and tertiary prevention.

There is a need to focus on aging as a public health and policy issue in podiatric medicine and to provide opportunities for podiatric physicians to increase their expertise in the area of practice termed “podogeriatrics.” Because of the relationship between foot health and ambulation, a broad program should include the following:

• An expansion of the concept of health maintenance to include community podiatric services in presentations to social, welfare, and religious organizations and facilities.
• A focus by all public health personnel on secondary prevention in relation to foot health as a way of raising the index of suspicion for disease and condition management.
• The addition of podiatric medicine to multiphasic screening and diagnostic programs as a way both to sensitize other health-care personnel to foot-health examination procedures and to maximize findings.
• The addition of podiatric services as a follow-up to educational, screening, surveillance, and diagnostic procedures in addition to ensuring that podiatric medicine is provided as a primary-care service.
• A recognition that arthritic, diabetic, arterially compromised, and aging patients must remain ambulatory for as long as possible. There is a need to limit impairment; restore function; limit atrophy, contracture, and periarticular fibrosis; prevent ulceration and amputation; and maintain functional restoration. When foot health enables a patient to remain ambulatory, then other forms of therapy can be provided in a noninstitutional setting.

Podiatric care is part of the triad of care for the aging: etiologic treatment, symptomatic treatment, and functional management.

Education in Gerontology and Geriatrics at the First-Professional-Degree Level

Following are educational concepts appropriate for students in podiatric medicine in relation to aging:

Goals

• To provide formal clinical training in podogeriatrics for all students and residents as a component of the geriatric curriculum and clinical education
• To provide students and residents with specific learning objectives that will prepare them to provide high-quality care for the older patient
• To increase the number of podiatric medical practitioners who provide care to older adults

Curriculum Content

The majority of medical and psychosocial problems unique to older adults can be learned and taught in clinical settings to foster the following attitudes, knowledge, and skills.

Attitudes

• Respect and compassion for older persons, particularly in terms of their autonomy and dignity
• Appreciation of the importance of maintaining and restoring function and quality of life in older adults, especially in those with chronic and incurable conditions
• Realization of the importance of family and the entire social network, including the nursing-home staff, in patient care
• Appreciation of the value of an interdisciplinaryteam approach to patient evaluation and management

Knowledge

• Adjustments in history taking and physical examination
• Standardized instruments for assessing physical function, cognition, affect, and gait
• Advance directives and competency
• Understanding the assessment of nutritional needs and treatment of malnutrition, including the appropriate use of oral supplements and parenteral feeding
• Understanding the evaluation and management of infections common to the older patient
• Understanding the evaluation and management of the following geriatric conditions and topics: dementia, depression, urinary incontinence, polypharmacy, falls, immobility, and pressure sores
• Understanding the evaluation and management of disruptive behaviors
• Podiatric assessment, evaluation, and management of foot syndromes and chronic manifestations common to older patients
• Understanding regulations (on physical restraints and use of psychotropic medications) as applied to the older patient
• Understanding the principles of rehabilitation and the concept of excess disability
• The function of interdisciplinary teams
• Compatibility of various therapeutic modalities
• Strategies to minimize hospitalization and the importance of the transition to and from the hospital when hospitalization is necessary
• The role of long-term care
• Spectrum of health care for the older patient, including long-term care, and the financing of health care for the older patient

Skills

• Administration and interpretation of standardized instruments
• Diagnosis and management of patients with multiple chronic illnesses and functional disabilities, particularly those involving the lower extremities and mobility
• Medical decision making and goal setting that incorporate the patient’s values and preferences
• Determination of decision-making capacity and understanding the assistance needed in the establishment of advance directives
• Effective participation in interdisciplinary teams
• Telephone management of patient-care problems
• Coordination of care among settings, especially among ambulatory-care, acute-care, and nursinghome settings
• Diagnosis and management of foot and related problems

Instructional Strategies

Structure

• Participation in patient care under faculty supervision
• A block of clinical exposure that includes a) a longitudinal experience with ambulatory and short-stay patients with a focus on rehabilitation, acute problems, and subacute problems, and b) long-term care
• Longitudinal clinical exposures involving multiple patients

Activities

• Geriatric topics integrated into educational-conference series
• Teaching rounds with faculty
• Interdisciplinary rounds and patient-care conferences

Materials

• Orientation packets containing service objectives, a list of responsibilities, and administrative information
• Syllabus and recommended readings covering curriculum content areas

Faculty

• Enthusiastic and consistent. Faculty should include internists and/or family practitioners with additional qualifications in geriatrics who act as preceptors and serve as role models in the provision of primary care to older patients.
• Podiatric faculty who have teaching qualifications equal to those of other personnel and have added experience in the management of older patients and their specific foot-care needs.
• On-site or seeing patients accompanied by students
• Staff should provide educational and program coordination, as well as administrative support.

Evaluation Strategies

• Faculty evaluation of students
• Student attendance and participation
• Chart reviews of patients
• Examinations covering curriculum content areas

General Recommendations

• Include the clinical experience as a component of a comprehensive podogeriatric curriculum that involves multiple settings and emphasizes primary care.
• Use the clinical exposure to maximize the existing syllabus in gerontology and geriatrics.
• Collaborate with other training programs, when these are available, to enhance interdisciplinary care.
• Discuss program goals and objectives with the clinical staff and involve them in the planning and program evaluation.
• Choose high-quality facilities in close proximity to the college, with an attractive physical plant, an appropriate program, a supportive administrative and clinical staff, and medical and podiatric personnel who are faculty members.
• Inform patients and their families about the educational training program.
• Provide orientation to the geriatric experience to address attitude problems and myths.
• Maximize continuity of care among settings so that longitudinal care can be established.

Principles of Geriatrics and Gerontology

The following outline lists the areas involved in a basic understanding of the health and social needs of the older patient; special needs as they relate to the aging process; the geriatric patient and patients with chronic diseases; and the relationship of these needs to foot health, podiatric care, health-care delivery, preventive services, and other related considerations.

• Biomedical sciences
  • Biology of aging
  • Anatomy
  • Biochemistry
  • Immunology
  • Microbiology
  • Pathology
  • Physiology
  • Pharmacology
    • Prescribing for the older patient
  • Social sciences
    • Characteristics of the elderly
    • Social changes in aging
  • Effects of aging on activity
• Clinical sciences
  • Interviewing
    • Communication skills

      1)

      Physical, emotional, and attitudinal influences

  • Assessment and evaluation
  • Physical examination
    • Care planning for the elderly
  • Organ systems
    • Cardiovascular

      1)

      Peripheral vascular disease

      2)

      Cerebrovascular disease

      3)

      Hypertension

    • Endocrine-metabolic

      1)

      Diabetes mellitus

    • Gastrointestinal
    • Genitourinary
    • Hematopoietic-lymphatic
    • Integumentary
    • Musculoskeletal

      1)

      Osteoarthritis

      2)

      Rheumatoid arthritis

      3)

      Gout

    • Neurologic
    • Respiratory
    • Special senses
    • Nephrology
  • Preventive measures
    • Nutrition
    • Safety, accidents, and injuries
    • Exercise
    • Rehabilitation, restorative services, and physical medicine
  • Chronic-disease management
  • Chronic-pain management
  • Communication disorders
  • Health services: medical, podiatric, dental, optometric, pharmacy, nursing, public health, physical therapy, social services, audiology, etc
  • Drug use
  • General surgical considerations
  • Interaction and management of multiple diseases
  • Recordkeeping for chronic illness
• Podiatric considerations
  • Primary care
  • Podiatric public health
  • Podiatric medicine
  • Podiatric radiology
  • Podiatric orthopedics
  • Podiatric surgery
  • Podiatric dermatology
    • Onychopathy
    • Keratotic lesions
  • Institutional care
  • Patient management
  • Foot-health education
  • Preventive services
  • Long-term care
• Mental-health considerations
  • Psychological development
  • Psychological assessment
  • Clinical psychiatry
  • Major health problems
    • Anxiety and other nonpsychotic reactions
    • Depression
    • Dementia
    • Paranoia
    • Schizophrenia
    • Alzheimer’s disease
• Life crises
  • Chronic disease burden
    • Stroke
    • Amputation
    • Fractured hip
  • Death, dying, and bereavement
    • Religious and cultural perspectives
    • Grief and personal perspectives
  • Family changes
  • Life-crisis overview
  • Retirement
  • Role changes
  • Sensory impairments
    • Speech impairments
    • Hearing impairments
    • Visual impairments
    • Mobility and ambulatory dysfunction
  • Sensuality and sexuality
  • Substance abuse
  • Suicide
• Society
  • Sociologic theories of aging
  • Demography and epidemiology
  • Economics
  • Health-care delivery
    • Medicare

      1)

      Reimbursement

      2)

      Payment policies

      3)

      Parameters of care

      4)

      Risk diseases

    • Medicaid
    • Managed care
    • Utilization
    • Quality of care
    • Guidelines for services
  • Housing and alternative living options
  • Institutionalization
    • Nursing care
    • Long-term care
    • Home care
    • Nursing homes
    • Day care
    • Alternative care
    • Transitional care
    • Hospice care
    • Rehabilitation
  • Law and legal considerations
  • Minority aging
  • Myths and stereotypes
  • Religion
  • Transportation
  • Protective services
  • Special services for the elderly
• Preventive services to be considered in older adults
  • Screening
    • History

      1)

      Diet

      2)

      Physical activity

      3)

      Tobacco/alcohol/drug use

      4)

      Functional status at home

      5)

      Prior symptoms of transient ischemic attack

    • Assessment and physical examination

      1)

      Height and weight

      2)

      Blood pressure

      3)

      Visual acuity

      4)

      Hearing and hearing aids

      5)

      Clinical breast examination

      6)

      Foot evaluation and ambulatory status

      7)

      Oral-cavity examination

      8)

      High-risk groups

      a)

      Auscultation for carotid bruits

      b)

      Skin examination

      c)

      Palpation of thyroid nodules

    • Laboratory/diagnostic procedures

      1)

      Nonfasting total blood cholesterol level

      2)

      Urinalysis

      3)

      Blood glucose level

      4)

      Mammogram

      5)

      Thyroid function

      6)

      High-risk groups

      a)

      Tuberculin skin test (purified protein derivative)

      b)

      Electrocardiogram

      c)

      Papanicolaou smear

      d)

      Fecal occult blood and sigmoidoscopy/colonoscopy

  • Counseling
    • Diet and exercise

      1)

      Fat (especially saturated fat), cholesterol,complex carbohydrates, fiber, sodium, calcium, etc

      2)

      Caloric balance

      3)

      Selection of exercise program

    • Substance use

      1)

      Tobacco use cessation

      2)

      Alcohol and other drugs

      a)

      Limiting alcohol consumption

      b)

      Driving/other dangerous activities while under the influence

      c)

      Treatment for abuse

    • Injury prevention

      1)

      Prevention of falls

      2)

      Safety belts

      3)

      Smoke detectors

      4)

      Smoking near bedding or upholstery

      5)

      Hot-water-heater temperature

      6)

      Safety helmets

      7)

      High-risk groups

      a)

      Prevention of childhood injuries

    • Podiatric health

      1)

      Podiatric visits and primary care

      2)

      Patient, family, and caregiver educationand health promotion

      3)

      Risk identification and stratification

      4)

      Comprehensive podogeriatic assessment

    • Dental health

      1)

      Regular dental visits, tooth brushing, flossing

    • Other primary preventive measures

      1)

      Glaucoma testing by eye specialist

      2)

      High-risk groups

      a)

      Discussion of estrogen replacement therapy

      b)

      Discussion of aspirin therapy

      c)

      Skin protection from ultraviolet light

  • Conditions to remain alert for
    • Depression symptoms
    • Suicide risk factors
    • Abnormal bereavement symptoms
    • Changes in cognitive function
    • Medications that increase risk of falls
    • Signs of physical abuse or neglect
    • Malignant skin lesions
    • Peripheral arterial disease
    • Tooth decay, gingivitis, loose teeth
    • Inappropriate footwear and pedal hygiene
  • Immunizations
    • Tetanus-diphtheria (Td) booster
    • Influenza vaccine
    • Pneumococcal vaccine
    • High-risk groups

      1)

      Hepatitis B vaccine

• Ethical concerns in the care of the aging
  • Health as a basic human right
    • Community health
    • Human rights
    • Needs and values
    • Dignity
  • Health and disease
    • Integrity
    • Health and illness perception
    • Biologic versus social health and disease
  • Responsibility for health
    • Preventive medicine
    • Lifestyle
    • Conscience
    • Informed consent
    • Truth
    • Ethical decisions and doubts
    • Spiritual guidance
    • Well-informed consumer
    • Moral decision: morality versus immorality
    • Patient’s rights

      1)

      Freedom of choice

      2)

      Protection of rights

  • The health-care professions
    • Depersonalizing trends
    • Concepts of a profession
    • Doctors and patients with acquired immunodeficiency syndrome
    • Counseling
    • Tradition: clergy or scientist
    • Professional education and its biases
  • Personal health care
    • Doctor-patient relationships
    • Psychotherapy
    • Models of care
    • Health-care fees
    • Professional involvement
    • Communications
    • Confidentiality
    • Peer relations
    • Professional disciplines
    • Quality assurance
  • Social organization of health care
    • Models
    • National priorities
    • New models of care
    • Limits of care
    • Hospital care
    • Health team
    • Patient advocates
    • Long-term care
    • Ethics committees
    • Health care, ethics, and public policy
    • Evaluation
  • Bioethics and the right to die
    • Ethical principles
    • Love and dignity
    • Common good
  • Bioethical decisions
    • The human subject in research
    • Experimentation
    • Abortion
    • Triage and extending care
    • Quality of life
    • Right to die
  • Podiatric medicinea
    • Laws and codes
    • National, state, and local associations: codes and principles
    • Fraud and abuse
    • Quality assurance
    • Doctor profiles
    • Fees
    • Care without compensation
    • Professional liability
  • Sexuality and reproduction
    • Contraception
    • Abortion
    • Family planning
    • Sterilization
    • Artificial insemination, in vitro fertilization
    • Rape-victim management
  • Human reconstruction
    • Plastic surgery
    • Organ transplantation
    • Sexual reassignment
    • Genetic intervention
    • Genetic screening
  • Psychotherapy and behavior modification
    • Mental illness
    • Mental retardation
    • Psychotherapy
    • Acquired immunodeficiency syndrome
    • Addiction and chemical dependency
    • Value systems
    • Sex therapy
  • Suffering and death
    • Fear of death
    • Defining death

      1)

      Brain death

    • Telling the truth about dying
    • Care of the corpse

      1)

      Autopsy

    • Euthanasia
    • Suicide
    • Allowing to die

      1)

      Decisions

      2)

      Pain

      3)

      Norms and values

• Governmental concerns and policies
• The future
• Special health concerns
  • Intensive care
  • Pressure sores
  • Osteoporosis
  • Delirium and agitation
  • Rehabilitation
  • Cardiac arrythmias, congestive heart failure,and cardiomyopathy
  • Anxiety and depression
  • Parkinson’s disease and other movement disorders
  • Psychotropic medications
  • Transient ischemic attack and stroke
  • Impotence
  • Pain
  • Low vision
  • Hearing loss
  • Speech therapy
  • Incontinence
  • Nursing-home-care needs—quality of life
  • Constipation and diarrhea
  • Ethical dilemmas
  • Kidney function and disease
  • Elder abuse
  • Cancer
  • Benign prostatic hyperplasia and cancer of theprostate
  • Breast cancer
  • The price of longevity
    • Poverty
    • Loneliness
  • Social networks

Strategies for Meeting Future Needs in Podogeriatrics

The initial strategy for meeting future needs in podogeriatrics is to ensure that courses with didactic and clinical elements concerned with podogeriatrics are provided at all colleges of podiatric medicine. A second strategy is to ensure that all residency programs expand the knowledge of podogeriatrics obtained during the first-professional-degree program. A third strategy is to provide practitioners with continuing education that focuses on the special needs of the older population.

To meet these needs, additional faculty members are needed who understand the aging process and know the theory and utilization of pedagogic tools necessary for teaching geriatrics. These faculty members will strengthen the first-professional-degree, postgraduate, and continuing-education curricula. The most valuable tool for developing the needed faculty expertise is the use of short-term training resources provided by geriatric education centers.

The long-term approach consists of fellowship training in geriatrics for new faculty members who can coordinate future training for the entire educational system. Such training and commitment are critical to the successful implementation of lasting changes in faculty and student attitudes and in curricula. In the future, such faculty members can also provide opportunities to conduct needed podiatric medical research related to the aging process and older patients.

Future continuing-education activities need to be expanded to upgrade practitioners’ understanding of elderly patients and the diagnosis and treatment of their foot problems, particularly among frail elderly persons living either at home or in nursing homes and other institutional settings. The profession must recognize the important role it plays in the management of the older patient.

Following is a sample course outline for continuing education in podogeriatrics:

Podogeriatrics and Geriatric Medicine Course: Program Description for Continuing Podiatric Medical Education

The program in podogeriatrics and geriatric medicine emphasizes a functional approach to comprehensive care of the older adult. The program is directed toward health professionals who care for older persons and toward faculty in teaching programs and residencies, with a focus on geriatrics and gerontology.

Learning Objectives. At the conclusion of the program, participants will be better able to do the following:

• Identify the basic principles of geriatric medicine
• Apply the principles of geriatric assessment, geriatric pharmacology, rehabilitation, and long-term care to patient settings
• Apply the principles of podogeriatric assessment
• Understand the key elements of problems associated with the foot and related structures and resulting from complications associated with chronic disease and aging
• Understand the key aspects of neurology, rheumatology, endocrinology, dermatology, and medicine as they apply to older patients
• Identify psychosocial and ethical issues in decision making and understand the key role that participation in interdisciplinary care plays in formulating approaches to management
• Comprehend the major geriatric syndromes and their relationship to podiatric medicine, such as incontinence, pain, osteoporosis, and swallowing disorders
• Be more effective caregivers or teachers, as appropriate

Program Outline

• General principles of aging
  • Physiologic changes of aging
  • Biology of aging
  • Cultural aspects of aging
  • Geriatric pharmacology
    • Drug interactions
    • Pharmacokinetic considerations
    • Alcohol and prescription drugs
  • Ethical issues in geriatrics
    • Elder abuse
    • Advance directives
    • Decision-making capacity
    • Suicide
    • Health-care rationing
    • End-of-life issues
  • Approach to the older patient
  • Ambulatory geriatric assessment
  • Comprehensive podogeriatric assessment
  • Preoperative assessment
  • Rehabilitation
    • Gait and balance
    • Falls
    • Immobility
  • Pain management
  • Preventive services
  • Legal issues in geriatric care
    • Competency
  • Program direction
  • Managed care
  • Mental-status assessment
  • Sexual disorders in older persons
  • Home health care
  • Hospice care
  • Swallowing and feeding disorders
  • Common diseases in older persons
    • Infectious diseases
    • Rheumatologic diseases

      1)

      Joint pain

      2)

      Rheumatoid arthritis

      3)

      Osteoarthritis

      4)

      Polymyalgia rheumatica

    • Endocrine disorders

      1)

      Diabetes

      2)

      Hypothyroidism

      3)

      Paget’s disease

    • General orthopedic disorders

      1)

      Fractures

    • Congestive heart failure
    • Coronary artery disease
    • Hypertension and stroke
    • Peripheral arterial disease
    • Renal diseases

      1)

      Prostatic disease

    • Anemia
    • Respiratory diseases
    • Neurology and psychiatry

      1)

      Dementia

      2)

      Stroke

      3)

      Parkinson’s disease

      4)

      Vertigo and gait disturbances

      5)

      Stress

      6)

      Cognitive impairment

      7)

      Depression

      8)

      Behavioral disorders

      9)

      Alzheimer’s disease

      10)

      Transient ischemic attack

    • Infections

      1)

      Pneumonia

      2)

      Tuberculosis

      3)

      Urinary tract infections

    • Geriatric syndromes

      1)

      Osteoporosis

      2)

      Urinary incontinence

      3)

      Pressure sores

    • Sensory problems

      1)

      Vision

      2)

      Hearing

• Special issues of aging
  • Dermatology
  • Sleep disorders
  • Cancer
  • Anticoagulation
  • Nutrition
  • Nontraditional remedies
  • Team care
  • Nursing-home laws and regulations
• Podogeriatrics
  • Dermatology
  • Foot orthopedics
  • Radiology
  • Surgery
  • Primary care
  • Podiatric medicine
    • Peripheral vascular disease
    • Diabetes mellitus
  • Preventiona
    • Primary
    • Secondary
    • Tertiary
  • Public health issues
    • Health-care financing
    • Medicare
    • Medicaid
    • Managed care

      1)

      Capitation

    • Long-term care