The Portal of Geriatrics Online Education

POGOe Editor's Choice Archives

How much longer can I expect to live? Can a physician truly answer this question? Prognosticating is one of the most challenging tasks clinicians face. It is often difficult to gauge a patient’s life expectancy, especially for patients without adominant terminal illness like advanced dementia, cancer or congestive heart failure. In fact, clinicians typically make overly optimistic estimates of patient survival. Nowadays, clinicians are much less versed in discussing prognosis than treatment options. A 1998 national survey of 697 physicians showed that 57% felt inadequately trained in prognostication. (Christakis and Iwashyna, Arch Intern Med, 1998)


ePrognosis - Estimating Prognosis for Elders, this month’s POGOe Editor’s Choice, is an interactive repository of 16 published geriatric prognostic indices where clinicians can enter individual patients’ information and have prognostic information calculated for them. The site’s algorithm is based on the developers’ systematic review of validated geriatric prognostic indices (JAMA, 2011) that can assist clinicians in discussions with patients.

The home page of the site brings you to a sorting algorithm that utilizes an interactive visual chart with the 16 indices, represented as balloons. The balloons are sorted based on the quality of the prognostic indices and their predictive time-frame measured in years. The balloon’s size correlates to its usefulness or clinical efficacy. Hovering over a balloon provides a brief description of the index and most importantly, the geriatric population for which it is most valid. Double clicking will link to the actual calculator for the risk model and provide the predicted outcome, its discriminatory characteristics as well as its calibration. The calculators are easy to complete, with drop-down menus for each patient variable. The site also asks the user to provide their best guess for the outcome risk. The user gets a calculated percentage likelihood of death within a particular time frame as determined by the index used.

The tabs on the top of the home page allow users to navigate through the list of indices, the rationale for each tool, and directions on using the site. External links to geriatric assessment tools, references and other website sources are available throughout the site. ePrognosis’s sister site, GeriPal, the Geriatrics and Palliative Care blog site, is featured prominently. An interesting area on the site is the feedback page where site users can leave non-moderated comments. This is not for the faint of heart, since the comments range from the insightful to just plain inane. This wide range of comments is not surprising for a site which in its first five weeks, according to the AARP, attracted more than half a million visits from clinicians and the general public alike.

The site developers offer a caveat to their tool: Clinicians should keep in mind that every patient is an individual, and that many factors beyond those used in the indices may influence a patient’s prognosis. It should not replace the patient-provider relationship. So try it out here in POGOe.

Dr. Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and associate professor at Harvard School of Public Health, told the New York Times in 2009 that: “There’s been a drastic decline in the number of geriatricians — and just 300 new ones are being trained each year — yet the number of people over 65 will double in the next 20 years.” Unfortunately, 3 years later, the numbers have not budged. Physicians who specialize in treating older adults - a challenging field where doctors treat patients who have multiple, complex issues - are becoming scarce.

Educators must therefore strive to develop effective and efficient strategies to improve medical trainees’ Geriatrics education. Aging Q3, an innovative educational and practice-based program from the Medical University of South Carolina (MUSC), incorporates the Assessing Care of Vulnerable Elders (ACOVE) paradigm and, quite uniquely, the principles of educational outreach or academic detailing. The three Qs signify: Quality of Education, Quality of Care, Quality of Life. It is designed to improve internal medicine residents’ clinical competencies in Geriatrics and improve the quality of care and quality of life for older adults. The program uses content development to improve the quality of geriatrics education, demonstration of appropriate clinical skills required for caring for older adults, and the application of that knowledge and skill during patient care activities.

Aging Q3 is developing curricula on 16 different topics for teaching residents to provide quality care to elderly patients. The program uses a sequence of interventions where residents learn and experience the practice of clinical Geriatrics with limited interruption to the process of patient care. As such, the Aging Q3 program emphasizes learning during clinical rotations rather than through lectures. Each ACOVE indicator, or area, is featured for 3 months. ACOVE areas in the schedule since 2009 include: Vision, Falls and Mobility, Dementia, Medication Use and Safety, Screening/Prevention, Hospital Care/Prevention, End of Life Care, Osteoporosis, Pain Management, Pressure Ulcers/Malnutrition, Osteoarthritis, Depression, Urinary Incontinence, Hearing Loss and Continuity of Care. The POGOe Product Information page provides the URL to access the full Aging Q3 website: http://mcintranet.musc.edu/agingq3/hospitalcareaco.... When you reach the site, the navigation panel on the left gives access to the content areas. The home page shows the Aging Q3 ACOVE area currently being featured in the curriculum, useful clinical tools, an introductory video to the Aging Q3 Program, and a direct link to POGOe.

The product being highlighted in this Editor’s Choice is the Hospital Care & Transitions Aging Q3 ACOVE Area. This product is by Dr. Neal Axon and Dr. William Moran. This product provides a simple, innovative and useful way to get learners used to providing properly detailed discharge summaries. Some of the materials provided for the faculty and residents include a detailing handout for educators, a one-pager that emphasizes important points for the faculty to raise during resident teaching. There are different outpatient and inpatient detailing sheets that highlight differences in approach when seeing the discharged patient in these clinical settings. An editable poster can be displayed strategically in resident areas of the hospital and clinic; a pocket card designed to be printed back-to-back describes the salient features of the ACOVE area for quick access of this information, Blue Sheets that "cue" residents to address the featured issue with older adult patients contain a few brief questions on the ACOVE area that a nurse may have discussed with the patient during intake, and a References list links to an Article Linker on the MUSC website – although it would have been better if it linked to PubMed so non-MUSC users can get journal access through their own institutional log-in*. Some ACOVE areas may also have Patient Education Materials, Local Provider Contact List, and an ACOVE Video Summary.

Given the differences in residents’ schedules and learning styles, the Hospital Care & Transitions working group developed a multipronged educational approach because one intervention cannot reach all residents. This appears to be a consistent theme throughout all of the Aging Q3 ACOVE areas.

Overall, this is an exciting product that covers knowledge and skills that medical trainees need to care for vulnerable adults. The program’s overall goals, concept and implementation strategies are outlined in the recent journal of Academic Medicine (Vol. 87, No. 5 / May 2012). If you are interested in this product access POGOe now or go to the MUSC website!

*Update: MUSC has changed the references list so that the links go directly to PubMed. 
We currently live in a Web 2.0 world where many learners find Facebook, Twitter and text messaging to be the preferred channels for delivering information and communicating ideas. In his book, The World Is Open, Curtis Bonk (2011) captures the essence of this new age of technology by stating that “anyone can now learn anything from anyone at anytime.” In the midst of this explosion of digitized information, there has been an increasing availability of electronic information access for health care providers at the point-of-care. The development of electronic health records, computers, mobile devices and other technology tools within the care environment is proving to be vital in improving the quality of care delivery and the provider’s productivity. This month’s POGOe Editor’s Choice highlights one of these technologies – The University of Texas Medical School at Houston’s Gems & Pearls Mobile App Lite v1. This “app” which is actually a website optimized for use on mobile devices running iOS, Apple’s mobile operating system, is designed to enhance clinician knowledge and skills in the care of older adults. This is a fully functional beta version that contains a limited selection of the gems and pearls in geriatrics and palliative care. It has been released primarily to test functionality and ease of use.

After accessing the website on the browser of your mobile device, the user is able to navigate through various areas and links by multi-touch gestures that touch-screen users are quite familiar with. The content is divided into general topic areas: Current Issues in Aging, Approach to the Patient, Care Systems, Syndromes, Psychiatry and Disease. Each topic area has 2 to 6 sub-topics that start with a gem (for geriatrics) or pearl (for palliative care) followed by a short summary and a list of references. The summaries are very short and focus on fundamental biomedical aspects of aging, geriatric assessment, and care coordination. These concise summaries are akin to a pocket card. Pages can be swiped sideways to navigate and pages scroll vertically with up/down swiping. Supplementary page navigation is available by using the ‘continue’ or ‘next/previous’ buttons. The layout appears to be elastic as one can change the text size display, although one cannot use the pinch/spread gestures. Several helpful hyperlinks direct the user to other pertinent content/topic areas.

However as this is a beta version it comes with some technical issues. The app takes a long time to load when first accessed, but once inside the app, content seems to load pretty quickly. It can be confusing to determine which items on the display can be swiped for navigation. The layout on the screen can be challenging when viewing on a smart phone, especially in landscape. The large image that accompanies each pearl or gem reduces the space for the actual summary to appear. The app appears to be best suited for viewing on a tablet.

These are minor quibbles about this innovative and very current method of information delivery of AAMC/ACMGE competencies on geriatric and/or palliative topics. This was voted as the 3rd Best Educational Product by over 200 geriatrics educators from 46 US medical schools in our October 2011 Reynolds Grantees Meeting. POGOe is looking forward to this app’s release version but for now, you can get the app right here for FREE!

References:
Bonk, C. J. (2011, June). The World Is Open: How Web Technology Is Revolutionizing Education. San Francisco, CA: Jossey-Bass.
In clinical practice, differentiating among the “three Ds” - Delirium, Dementia, and Depression - can be difficult because these disorders may co-exist in the same patient. Clinical pearls are needed in an educational session to assist learners with this clinical challenge. “Distinguishing Delirium, Dementia, and Depression” module, part of the GeriaFlix series, from the Carver College of Medicine at the University of Iowa, has been designed to address that and can be used “anytime, anywhere” by a wide spectrum of learners, from clinical students to practicing clinicians. The educational goals are to improve the learner’s ability to screen, diagnose, treat and increase their appreciation for the co-occurrence of the 3 D’s in the elderly patient.

The educational product is a streaming digital video format with synchronized PowerPoint presentation slides lasting approximately one hour. The lecture presentation, delivered by Dr. Gerald Jogerst, Professor of Family Medicine at the Carver College of Medicine at the University of Iowa, is divided up into three sections (one for each “D”). Each section includes a clinical case report as well as an image of a typical patient with the disorder. Dr. Jogerst is a skilled teacher and has a witty and engaging delivery. He does an excellent job of explaining concepts at a level appropriate to a broad spectrum of learners. He also makes it clear what is evidence-based and what is anecdotal in his recommendations. His presentation slides include a variety of figures, tables, and multiple-choice questions. Simple screening tools are also described that could be easily implemented immediately after watching the presentation. These screening tools are available for download on the University of Iowa website. In addition, the initial pharmacologic and non-pharmacologic therapeutic interventions of the delirious patient are reviewed.

Overall, the material is well-organized and easy to follow. Its ease of use and broad scope of information has allowed it to be embedded within curricula of multiple training programs at the University of Iowa Geriatric Education Center. Data provided by the authors at University of Iowa showed that, 96% of learners felt confident that they have achieved the four learning objectives. Many also commented that it provided materials and tools that they would use as teaching tools for their own professional/academic endeavors.

However, it would be helpful if a learner viewing the presentation could go directly to specific parts of the video presentation rather than an ordered approach. Another limitation is that the dementia section draws heavily on Alzheimer’s disease without distinguishing among other diagnostic possibilities such as vascular, frontal lobe or Lewy body. Some materials are also not adequately referenced so learners could not refer to the primary source for additional information. Most importantly, watching a digitized presentation can be a passive learning experience so the product should be an adjunct to a planned blended learning educational session.

This month’s Editor’s Choice, “Distinguishing Delirium, Dementia and Depression,” will help learners recognize and diagnose these conditions as they occur and co-exist in the geriatric patient population. Practical clinical tools for assessment are given and appear easy to employ. And this product is available here – for FREE - on POGOe.

Guest Reviewers: Andrew B. Rosenzweig, MD, Clinical Assistant Professor of Medicine and Margot I. Boigon, MD, Clinical Associate Professor of Medicine, Drexel University College of Medicine and Abington Memorial Hospital.

Peripheral neuropathy is a common complication of systemic diseases such as diabetes mellitus. Although the exact cause remains unknown, peripheral neuropathy can cause significant health concerns and decrease the quality of life for those with this condition. Although a prevalent problem in the clinical setting, instruction in this debilitating process is quite poor or even lacking. Drs. Vivyenne Roche, Mike Singer and Lindsay Oksenberg from The University of Texas Southwestern Medical Center have certainly filled a curricular gap with their POGOe product: Numb and Number: A Practical Approach to Peripheral Neuropathy. Attendees of the Reynolds Grantees’ Meeting with over 40 medical schools represented have acknowledged this and have rightly chosen it as the 2011 Product of the Year.


Numb and Number: A Practical Approach to Peripheral Neuropathy is a self-directed interactive instructional web-based module, which comprehensively reviews the approach to peripheral nerve disorders. As described by its authors, it will tune up your anatomy skills (including the brachial plexus and lumbosacral plexus) and is presented within a clinical framework. It includes key aspects of history-taking, a step-wise clinical exam, etiologies, evaluation, management, a quiz, references and even the Texas Plexus Game to test your new skills.

The flash-based module is divided into sections: 1) an instructional module focusing on data gathering (history and physical exam), a detailed review of the upper and lower limb plexuses, common etiologies and management utilizing both non-pharmacologic and pharmacologic approaches; 2) a 5-item multiple choice type pre- and post-test; 3) a game/quiz (Texas Plexus Game) that tests one’s knowledge of the brachial and lumbosacral plexuses and their associated dysfunctions by rolling over their diagrammatic representations; 4) a summary pocket card; 5) further readings and references.

Highlights include a brief tutorial at the start of the module that introduces the user to specific navigation tools. The flash-animation and illustrations are of high quality. The navigation buttons allow you to control the instructional pace of the module giving the user the ability to advance or review materials. The post-test allows the users to review their submitted answers and see what they got correct. However, it does not give the rationale for the incorrect choices. One other limitation is the audio quality, which can sound muffled and difficult to understand. This improves with increasing the volume or using headphones. However, if one sets the volume while listening, it seems to reset to default volume setting as soon as you hit ‘Continue’ thus forcing the user to readjust the volume control each time. The pocket card would be more useful if it also included the important nerve distributions emphasized thoroughly in the module.

These are definitely minor quibbles on this well-designed and conceived POGOe product. Try this 2011 Product of the Year at POGOe.org! It’s FREE!

Primarily utilized to monitor learning progress during patient encounters, the Mini Clinical Evaluation Exercise (Mini-CEX) is a formative assessment method that simultaneously assesses clinical skills and offers feedback to the learner. It has been extensively evaluated in the context of internal medicine and found to be a reliable assessment tool of workplace performance for medical housestaff. A 2009 systematic review by Kogan et al in JAMA found that medical student programs have extensively utilized this assessment tool for various skills domains. This may partially be in response to the Liaison Committee on Medical Education (LCME) standard which requires that medical education programs include ongoing assessment activities that ensure that medical students have acquired, and can demonstrate on direct observation, the core clinical skills, behaviors, and attitudes that have been specified in the program's educational objectives.

This month’s Editor’s Choice highlights three mini-CEXs in our product library. They are the Health Care Proxy (HCP) Mini-CEX and Mini-Cog Mini-CEX from Albert Einstein College of Medicine and the MMSE CEX from UCSF. Commonalities include the delineation of the specific tasks the learner should perform, summary assessments of competency in both performing the task and the relevant ACGME competency, sections for comments, satisfaction questions for both student and faculty, and faculty guides. Although each is designated as appropriate for learners from medical students to fellows, only the MMSE Mini-CEX gives suggestions for the level at which these tasks should be mastered by each.

The HCP Mini-CEX (click here) developed by Drs. Amy Ehrlich and Hannah Lipman assesses 5 specific steps important in setting the stage and discussing HCPs with patients. Examiners are asked to judge whether the learner has completed each step. The Mini-Cog Mini-CEX (click here) by Drs. Ehrlich and Kim Freeman similarly assesses 12 steps when conducting the Mini-Cog, however it does not require the student to interpret the test results. Both tools ask the examiner to judge overall competency in Interpersonal and Communication skills using a 9 point scale. This scale is similar to that used in ABIM evaluations, however the scale’s anchors differ- with a score of 2 considered passable (compared with 4 on the ABIM).

The MMSE Mini-CEX (click here) by Dr. C. Bree Johnston from UCSF assesses both the performance and the scoring of each of 11 items. Interpretation of the score, humanistic qualities, counseling performance, and a summary score are evaluated using the ABIM 9-point scale with 4 as the lowest satisfactory rating. Examiners are also asked to note things that were done particularly well. The faculty guide is comprehensive, providing examples of what is considered incorrect for certain items.

In this day where we are being asked to document not just that learners were exposed to, but that they actually achieved competency in specific areas, it is important that we have a shared mental model of what that competency looks like. These 3 Mini-CEXs provide examples of this that you may wish to use ‘off-the-shelf’ or modify for your learners. They allow you to provide feedback based on direct observation, improving your skills in observation and increasing the likelihood that all learners will learn the same key points in how to perform these tasks.

So try out these Mini-CEXs today! They are available for free in POGOe.org! (You can find all of them under the following link or by searching for "mini-CEX")

Doc.com, a repository of 41 learning modules that cover various topics in healthcare, has offered a free demo of their geriatric module product called Module 23: Communicating with Geriatric Patients. Authored by Dr. Brent C. Williams from the University of Michigan Geriatrics Center and Institute of Gerontology and Dr. James T. Pacala from the University of Minnesota Department of Family Medicine and Community Health, this module introduces the learner to the basic skills in communicating with older patients and their caregivers in order to optimize patients’ functioning, management of their medical conditions, and long-term health outcomes. This web module allows the learner to observe the physician’s interaction with different patients so that by the end of the module, the learner will have a better idea of how to communicate effectively with an older patient.


Highlights include annotated videos, including a patient presentation, a clinic encounter and a panel discussion with the clinical team. It is also interesting to see videos of the same clinical problem from both the patient’s view and the physician’s view. There is a menu on the side panel of the screen for easy navigation as well as highlighting key points for the learner. Text and video explain the material and the learner clicks through it. There are several cases presented and Dr. Williams explains his communication process as he goes along. Limitations include a very linear module format, and there is no assessment section to ensure that the learner has grasped the material (see below).

In summary, this web module provides the learner with a self paced tutorial on how to communicate with older patients. Doc.com also offers access to two other modules free of charge. They are the complete modules from the doc.com series - with just one limitation: the assessment feature is not available, which is an important part of the full doc.com version. The Communicating with Geriatric Patients module is accessible online here at POGOe right now!

The statement “assessment drives learning” emphasizes the critical place of assessment in a learner’s education. Attributed to the educator George Miller, this statement is of particular importance in medical education nowadays given the focus on clinical competency assessment. Miller proposed in 1990 a schematic hierarchical representation (pyramid) of clinical competence: factual knowledge (knows), concept building and understanding (knows how), competence to perform (shows how) and ability to carry out a task competently in real life situations (does). The context-specific nature of medical education requires educators to rely on multiple assessment methods in multiple levels in this competence pyramid to reliably gauge a medical learner’s skills. As one moves up the levels, performance approaches professional authenticity or expertise.

A fine example of an outcome focused (summative) assessment product in the POGOe Library is the OSCE Geriatric Patient with Fall and Cognitive Impairment: Margaret Donovan from Dr. Lisa Strano-Paul at SUNY Stony Brook School of Medicine.

Designed as a 20-minute station in a multi-station OSCE, it assesses clinical students’ or residents’ performance of functional and cognitive assessments. The standardized patient (SP) case scenario is of an older adult person in whom the spouse notices progressive memory loss. Set in an outpatient clinic, the station requires the learner to evaluate the patient's and the spouse’s chief concerns; assess the patient's functional status through history including ADLs, IADLs and social support; perform the Get Up and Go Test, a Mini Mental status exam, and clock drawing and make recommendations to improve the patient’s functional status.

The product consists of SP instructions and facilitator guide, a presenting case scenario, a multi-domain skills checklist including communication and interpersonal skills and a critical action sheet. Highlights include the straightforward case scenario, minimal SP requirement, and detailed instructions that provide examples of what to look for when observing the learner’s performance. However the presence of multiple items in a single checklist may make it difficult for the observer to provide an accurate assessment of the learner’s performance. It also would be helpful to have specific descriptions of poor or borderline performance to anchor observations and increase inter-rater reliability.

The use of OSCEs to make judgments about the attainment of competence requires that sufficient evidence is collected. Studies have shown that OSCEs with more stations of shorter duration have better reliability and validity of performance assessment than those with fewer and longer stations. This is a 20-minute encounter followed by a 10-minute rest; if the other stations follow a similar pattern, a 2-hour OSCE would just consist of 4-6 stations at most. Shorter stations with fewer more specific skills performance may improve the overall multi-station OSCE performance.

This OSCE provides an easy to use assessment of a student’s ability to evaluate and begin management for geriatric Patients with falls and cognitive impairment. Try this month’s POGOe Editor’s Choice now, and browse through the POGOe Library which currently contains 58 other learner assessments that address multiple levels in Miller’s clinical competence pyramid.

Some of you may recall the “That Was the Year that Was” plenary presentation at AGS where the year’s practice-changing literature was critically reviewed and commented upon by Mount Sinai faculty and fellows.

Although we’re not yet ready to reprise this, POGOe is now able to offer concise critical appraisal summaries of recent articles in ReCAP (Repository of electronic Critically Appraised Papers). Since its launch, over 100 CAPs have been posted. ReCAP is intended to become a national online evidence-based journal club in geriatrics, and a forum for geriatrics fellows and faculty to keep abreast of new studies and comment on their concerns about them, including the significance and application to the care of geriatric patients.


Where do the CAPs come from? Currently they’re written by fellows and faculty from the Mount Sinai School of Medicine and Duke University. Fellows complete a critical appraisal of a recent journal article and post it on ReCAP using a template. Any type of study is eligible, be it Clinical Prediction Rule, Diagnosis, Meta-Analysis, Prognosis, or Therapy. A list of citations to the latest journal articles in geriatrics is provided by an alert from Evidence Updates at McMaster University. These citations (from over 120 premier clinical journals) are pre-rated for quality by Evidence Updates research staff, then rated for clinical relevance and interest by at least 3 members of a worldwide panel of practicing physicians. Each citation includes a link to the article on PubMed. Fellows choose one of these articles for their review and submission. Articles not appearing on the list can be added once approved by member’s faculty advisor.

The POGOe readership can read the CAP and comment on their concerns about the article or the review. This will give us the opportunity to discuss as a community the validity of applying the results of an article to our patients. It will also enhance a fellowship directors’ ability to teach evidence-based medicine and hone fellows’ skills by critically examining evidence presented in recent clinical research articles.

We are currently looking to expand the number of ReCAP contributors to involve more fellowship programs or individual faculty. If you have faculty who would like to participate, or if you would like to have your fellows write CAPs as part of their academic scholarship, let us know by contacting the POGOe Editor here. The basic steps to posting a CAP are minimal, and we will contact you directly to discuss the details of the process. The CAPs can be cited on one’s CV.

Get involved, and who knows, perhaps at the next AGS meeting it will be your fellow presenting “That Was the Year that Was”.

Those in clinical practice routinely see older adults with undiagnosed or undertreated mental health problems. These elders usually present with physical complaints or for monitoring of chronic illnesses such as diabetes or hypertension. It takes a skilled practitioner to move beyond the obvious and discern the presence of mental health issues. This skill is invaluable since nearly one in five older women have some type of psychiatric disorder, with depression being the most common (Colenda et al., 2010).

The Geropsychiatric Nursing Collaborative, with support from the American Academy of Nursing, has recognized the burgeoning need for psychiatric competencies among all levels of nurses by developing Geropsychiatric Nursing Competency Enhancements to help educators prepare nurses to be competent in the care of older adults with mental health concerns and psychiatric/substance misuse disorders. Many of these competencies are applicable to physician as well as nursing practice.

The Geropsychiatric Nursing Competency Enhancements were developed to augment both existing and planned practice competencies proffered by relevant professional nursing organizations. The first competency enhancement addresses the care of the older adult at the baccalaureate nursing level. The remaining documents address geropsychiatric competency enhancements for: nurse practitioners or clinical nurse specialists who are geriatric specialists; adult nurse practitioners or clinical nurse specialists who provide clinical care to older adults but who are not geriatric specialists; and psychiatric mental health nurse practitioners or clinical nurse specialists.

The competency enhancements are easy to use and understand by all types and practice level of Nurse Practitioner or Clinical Nurse Specialist. The authors have highlighted new competencies, or modifications to existing ones, in order to make them easily identifiable within the text. The competency enhancements are also grouped by type of advanced practice nurse and scope of practice, which aids an educator in incorporating geropsychiatric competencies into a curriculum. For example, in a women’s health nurse practitioner program, an educator would incorporate the competencies for nurse practitioners without being a geropsychiatric specialist.

This product is highly recommended for all nursing educators; these competencies are necessary to provide safe and effective care to older adults across care settings. Educators outside of nursing can also examine these competency enhancements when critically evaluating existing curricula or contemplating changes to the education of clinicians responsible for any aspects of older adult care.

The Geropsychiatric Nursing Competency Enhancements can be accessed online right here at POGOe.





 

References

Colenda, C. Legault, C.; Rapp, S.; DeBon, M.; Hogan, P. et al. (2010). Psychiatric Disorders and Cognitive Dysfunction Among Older, Postmenopausal Women: Results From the Women's Health Initiative Memory Study. American Journal of Geriatric Psychiatry, 18(2), 177-186.

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