Instructor Guide

Open Instructor


PGY-1: Older Patient with Co-Morbidities


A PGY-1 resident will be able to evaluate and develop a treatment plan for a young-old patient with several co-morbidities that accounts for changes related to aging.

Patient Care

  • Demonstrate an ability to perform a “diabetes visit,” including assessment of end-organ damage, disease control, and recognition and management of co-morbid conditions, particularly hypertension and hyperlipidemia
  • Demonstrate the diabetic foot exam

Medical Knowledge

  • Describe common physiologic changes with aging
  • Describe common aging-disease interactions that might affect a patient with diabetes
  • Describe principles of prescribing for an older patient with multiple co-morbidities
  • Describe treatment goals for patients with diabetes

Practice Based Learning and Improvement

  • Assess the quality of care they provide for patients with diabetes

Interpersonal and Communication Skills

  • Demonstrate an ability to adapt to history taking and exam skills to accommodate a person with a hearing impairment


  • Demonstrate compassion and empathy in the care of the older patient with a chronic illness

Systems-based Practice

  • Identify local resources for a patient with diabetes


Session Guide


Time Needed: 4 hours, including 30 minutes of breaks. Alternatively, this can be broken into 3 1-hour blocks.

Equipment needed:

  • Computer with DVD-ROM drive and LCD projector
  • Audience response system (optional)
  • Note cards or scraps of paper (4/participant)
  • Large note pad
  • Markers
  • “Up,” Pixar/Disney
  • Monofilaments (10 gm), 1 for each 2 participants

Suggested Reading:

American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2012:60(4);616-31

Mahoney, DO, Gallagher, P, et al.. STOPP and START criteria: A new approach to detecting potentially inappropriate prescribing in old age. Euro Geri Med. 2010;1: 45-51.

Schwartz, RA, Morgan, AJ. Diabetic Skin Ulcer. Essential Evidence Plus. 2012. Wiley-Blackwell.

Instructor Script and Notes

Part 1  – 60 minutes

  1. Introduce the session – 10 minutes
    1. Mini-lecture: PowerPoint presention – “Challenging Patient: The Older Patient with Multiple Co-Morbidities”– a very brief overview of important issues related to Family Medicine and the Aging Population
      1. Goals of session
      2. Demographics of aging
      3. Chronic illness and aging
      4. Role of FM in caring for the elderly
      5. Quality in health care
  1. Aging
    1. Up – Show first 10 minutes of movie (to point after the main character’s wife has died, and he is shown getting up, going down stairs, and resting on his front porch) – 25 minutes
      1. Ask the participants to watch with an eye towards aging changes.
      2. Discuss changes with aging, beginning with those observed in the movie. Ask participants to share their observations of aging changes in the movie.
        1. Physical changes – arthritis, visual impairment, hearing impairment, mobility impairment
        2. Social changes – loss, isolation
    2. PowerPoint presentation – “Aging and the Patient Encounter” – 25 minutes
      1. Audience response system optional
      2. If audience response system not used, then have participants show hands and offer answers for the slides with questions.
      3. Two main topics:
        1. Accommodating common changes with aging in the encounter (e.g. hearing)
        2. Physical findings and aging


Part 2 – 60 minutes

  1. Diabetes as a Prototypical Chronic Illness
    1. Diabetes Case Discussion – 25 minutes
      1. Break participants into small groups (3 to 4). Give each small group note paper to write on and markers. Hand out Diabetes Case (Part 1).  Instruct groups to read case and following questions. Each group should develop a set of history questions, physical exam items and lab studies. Pass out case (Part 2). Groups develop a prioritized assessment and management plan. Each group shares their “findings” with other groups. Ask groups to discuss their rationale for their prioritization of their management list.
    2. Mini-lecture PowerPoint presentation – “Type 2 Diabetes: Prototypical Chronic Illness” – 15 minutes
    3. Mini-lecture: PowerPoint presentation – “Preventing Foot Complications in People with Diabetes”– 15 minutes
      1. Have residents examine each other’s feet, ensuring proper use of monofilament – 5 minutes


Part 3 – 60 to 90 minutes

  1. Prescribing Principles for Older Patients
    1. Mini-lecture: PowerPoint presentation – CHAMP Model – 15 minutes
      1. Review CHAMP model. Use discussion to highlight components of the model.
    2. Cases with discussion
      1. There are a number of cases – select ones you want to do. Allot about 15 minutes for each case discussion. For each case, hand out the learner guide and keep the discussion guide.
      2. Do with entire group (if no larger than 8), otherwise break into groups of manageable size.
      3. Hand out one case at a time. Reader reads case. All write down answers on note cards, pass to reader, who reads them. Facilitate group discussion, using “CHAMP” model to review medication lists and proposed changes.