Lisa Granville

Practicing Physician Education in Geriatrics: Lessons Learned from a Train‐the‐Trainer Model

Evidence of poor performance in the evaluation and management of common geriatric conditions suggests the need for changing physician behavior in these areas. Traditional lecture‐style continuing medical education (CME) has not been shown to be effective. Expert faculty initially trained 60 nonexpert peer educators to conduct small‐group, learner‐centered CME using tool kits on memory loss, incontinence, and depression. Peer educators presented 109 community‐based sessions to 1,309 medical practitioners. Surveys were administered to community participants immediately and 6 months after a session. Evidence of effectiveness included statistically significant increases in self‐reported knowledge, attitudes, and office‐based practices on the target topics at the time of training and at the 6‐month follow‐up (P<.001) and two‐thirds of respondents reporting continued use of three or more tools at 6 months. Participants reported that the interactive presentation aided their understanding of and ability to use the tool kits more than an off‐the‐shelf review (mean rating±standard deviation 4.1±0.71, with 1=not at all and 5=significantly). After the formal evaluation period, additional information about the project dynamics and tool kits was obtained through a small interview sample and an on‐line survey, respectively. Receiving copies of the tool kits was an important factor in enabling educators to offer sessions. Barriers to offering sessions included finding time, an audience, and space. Findings suggest that modest positive changes in practice in relation to common geriatric problems can be achieved through peer‐led, community‐based sessions using principles of knowledge translation and evidence‐based tool kits with materials for providers and patients.

What Is a Geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs End-of-Training Entrustable Professional Activities for Geriatric Medicine

Entrustable professional activities (EPAs) describe the core work that constitutes a disciplines specific expertise and provide the framework for faculty to perform meaningful assessment of geriatric fellows. This article describes the collaborative process of developing the end‐of‐training American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP) EPAs for Geriatric Medicine (AGS/ADGAP EPAs). The geriatrics EPAs describes a geriatricians fundamental expertise and how geriatricians differ from general internists and family practitioners who care for older adults.

A Collaborative National Model to Assess Competencies for Medical Students, Residents, and Other Healthcare Practitioners in Gait and Falls Risk Evaluation

To ensure that the healthcare workforce is adequately prepared to care for the growing population of older adults, minimum competencies in geriatrics have been published for medical students and primary care residents. Approaches to teaching and assessing these competencies are needed to guide medical schools, residencies, and continuing medical education programs. With sponsorship by the Education Committee and Teachers Section of the American Geriatrics Society (AGS), geriatrics educators from multiple institutions collaborated to develop a model to teach and assess a major domain of student and resident competency: Gait and Falls Risk Evaluation. The model was introduced as a workshop at annual meetings of the AGS and the American College of Physicians in 2011 and 2012. Participants included medical students, residents, geriatrics fellows, practicing physicians, and midlevel practitioners. At both national meetings, participants rated the experience highly and reported statistically significant gains in overall competence in gait and falls risk evaluation. The largest gains were observed for medical students, residents, and practicing physicians (P < .001 for all); geriatrics fellows reported a higher level of baseline competence and therefore had a lower magnitude of improvement, albeit still significant (P = .02). Finally, the majority of participants reported intent to disseminate the model in their institutions. This article describes the design, implementation, and evaluation of this collaborative national model. A number of institutions have used the model, and the goal of this article is to aid in further dissemination of this successful approach to teaching and assessing geriatrics competencies.

Women's Sexual Health and Aging

Older women are often sexually active, but physicians caring for older women rarely address sexual concerns. Although womens desire for sex declines with age, a majority of older women rate sex as having importance in their lives. Women identify emotional intimacy as an important reason for engaging in sexual relationships. Women are less likely than men to have an available spousal or intimate partner and more likely to have a partner with sexual difficulties of their own. Up to half of sexually active older women report a distressing sexual problem, with low desire and problems related to genitourinary syndrome (vulvovaginal atrophy) being most common. Difficulty with orgasm in older women is often associated with a partners erectile dysfunction. Sexually transmitted infections (STIs) are increasingly prevalent in older women. A minority of older women report discussing sexual issues with a physician. Most commonly, the patient initiates discussions. Physicians should ask regularly and proactively about sexual activity and function. Important interventions include offering practical advice to common chronic medical conditions and sexual problems that confront older women; treating vulvovaginal atrophy; and providing STI screening, prevention strategies, and treatment when appropriate.

Older Adults with Cognitive Impairment Have Sex: More Evidence Against the Medical Myth of Sexless Aging

In this edition of the Journal of the American Geriatrics Society, Lindau and colleagues have published important, novel work describing the relationship between sexual function and cognition in approximately 3,200 homedwelling adults aged 62 to 91; 83% of men and 57% of women reported that they were partnered. Although the likelihood of partnership was lower in those with lower cognitive scores, nearly half of men and one-fifth of women with dementia were reported to be sexually active, and 60% of partnered men and 51% of partnered women reported engaging in sexual activity. More than 40% of partnered men and women with dementia aged 80 and older reported being sexually active . There are many reasons that older adults should discuss sexual activity with their physician or other healthcare provider. Most do not. Evidence suggests that a major reason is that healthcare providers do not initiate such conversations, despite evidence that people are open to such discussions . Lack of communication results in missed opportunities to improve quality of life and preventive care. There are effective medical treatments for common causes of sexual dysfunction in men and women, including erectile dysfunction and dyspareunia from vulvovaginal atrophy. Screening for sexually transmitted infection (STIs) is recommended for high-risk older adults. The highest rates of increase in STIs in recent years in the United States have been in people aged 45 and older 3,4 . Lindau and colleagues found that men were more likely than women to discuss sex with a partner or a doctor . This is probably because of multiple factors. One reason may be that men become more likely to see a specialist in men’s sexuality (urologist) as they age and develop prostate and bladder problems. In contrast, women are less likely to attend routine visits with a specialist in women’s sexuality (gynecologist) as they “age out” of cervical cancer screening, which is no longer routinely recommended after the age of 65 or after hysterectomy . Attitudes that sexuality should be natural and spontaneous, not requiring skills or communication, or that sexuality is “something dirty” that should not be discussed may also affect women more . Sex steroid levels decline in aging men and women, but most healthy partnered home-dwelling older adults remain sexually active into their eighth decade . The influence of sex steroids on dementia and cognitive function in older men and women is complex. Low sex steroid levels have been suggested as a risk factor for dementia, as well as a consequence . Despite the association between low sex steroid levels and cognitive dysfunction and dementia, treatment with sex steroids is not associated with improvement in cognitive function in men or women . Lindau and colleagues found that a majority of older men and women across cognitive groups felt that sex was an important part of life and were satisfied with the quality of their sex life. There were interesting sex differences, in that men with dementia were less likely than other men to be satisfied with their sex life and that men with dementia were many times as likely to report having sex primarily out of obligation or duty as other men. These findings were not present in women . Men with dementia have lower testosterone levels, which has been associated with lower sexual desire and higher rates of sexual dysfunction concomitant with cognitive decline . Lindau and colleagues report that erectile dysfunction was less commonly seen in men with worse cognitive function. Low testosterone levels in older men are most strongly linked to decrease in sexual desire , and lack of libido is the symptom most likely to improve in response to testosterone treatment . Erectile dysfunction also responds to testosterone treatment but is etiologically more complex, with multiple contributing factors; dementia and dementia treatment may influence it. Studies have not shown a consistent association between lower testosterone levels and sexual dysfunction in women . Sexual abuse is of concern across the lifespan. Lindau and colleagues’ work found that people with dementia had obligatory sex and sex without feeling aroused more frequently than those who were more cognitively intact. Subjects were not asked directly about sexual assault and rape . More research is needed on effective ways to identify sexual abuse in cognitively impaired adults. There is much work to do to build consensus around what constitutes consent for sexual activity in this population. Experts advocate supporting autonomy and preventing exploitation and abuse a balance which may be difficult to achieve in clinical practice. Only 2 of more than 3000 older adults reported being in a same-sex relationship. The authors attributed this to a focus on marital dyads. It is also likely that subjects in same-sex relationships chose not to participate in the study or did not disclose same-sex relationships when they did. Physicians and other healthcare providers, while respecting people’s decisions and autonomy, should remain open to the possibility that same-sex persons identified as This editorial comments on the article by Lindau et al.