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How do you teach about the 3Ds? Delirium, Dementia and Depression

In this and upcoming posts, we will review some educational products in both geriatrics and palliative care.

For many of us, it is the beginning of the academic year, and it is our best chance to have an impact on the care of our GeriPal patients. Some of us are already cringing at the notion of walking in to discover that one of our GeriPal patients has received benzodiazepines overnight for behavioral problems likely related to delirium. Now is the best time to think about education interventions for our various trainees regarding the 3Ds!

To start, the Portal of Geriatric Online Education (POGOe) has excellent resources.

The 3D’s of Cognitive Impairment: An interactive card-sorting exercise”. This is a fun and easy to play game. Once you print out the cards and cut up, you can easily carry around with you and no technology is needed to play! We have played this with all levels of learners-- medical students, residents, and even fellows. We have had great success playing this game with our hospital ward-teams and other student disciplines (i.e. nursing, pharmacy). There are 3 categories-- Dementia, Delirium and Depression. You divide your learners into two teams and each takes turn placing the cards (i.e. attention normal, lasts days to weeks, progressive, Mini-cog) into the correct category. Each team gets a point for placing it correctly. You discuss why it belongs under Dementia/Delirium/Depression, so they are all learning with each turn. Some cards do cross into more than one category, but this makes discussion interesting and ultimately you choose which is best (there is also a scoring sheet to help you!). In the end, one team wins, but all have learned. Don't forget that candy, snacks and prizes always help make any game more fun. (REF: Paniagua, M, van Zuilen, M, Pua, R, Mintzer, M and Silver, I. (2009). The 3D's of Cognitive Impairment: An interactive card-sorting exercise. POGOe - Portal of Geriatric Online Education. Retrieved July 02, 2012)

Another educational activity, “The Three D's Worksheet”, covers a hospitalized older adult case utilizing PowerPoint slides with prompting questions provided in the facilitator guide. Learners get to think through a worksheet individually and it takes about 20minutes. This educational activity is also great for varying levels of trainees and disciplines. (REF: Wen, A. (2010). The Three D's Worksheet. POGOe - Portal of Geriatric Online Education. Retrieved July 02, 2012)

There are many more great teaching resources out there, so please help us discuss and share those that you find helpful in the GeriPal comment section.

Wishing you all the best in your teaching adventures.

by: Amy M. Corcoran and Rachel K. Miller


Bruce Scott MD said…
I thought I'd looked fairly carefully through the POGOE website. I'd missed the Three D's Worksheet. There's some good stuff to steal here. I look forward to further posts in this series, in case I've missed some other pearls. (There's a wealth of good stuff there.)

They've foolishly let me help revise the curriculum for the third year clerks in Internal Medicine. I'm putting together the finishing touches on the geriatrics session right now, in fact. I'll have a heavy emphasis on these three Ds.

The clerkship director has been using a form of Team Based Learning (see for a general idea). I was skeptical at first, but have been watching it in action for three months now, and I like it. I've conned her into adopting even more of the typical TBL approach.

Students (30 or so) are put into groups of 5-7 students at the beginning of their (12 week) clerkship, and will stay in these groups throughout.

Give them prereading, which they actually DO, since it will impact their success.

2.5 to 3 hour session.

Start with individual 10 item multiple choice test, which they turn in. Then they repeat same test in their small groups, with a consensus answer. (Using a neat instant feedback scratchoff card, that gives them a chance to take a second shot at the question for partial credit.) Both tests count for their grade for the clerkship. These tests are closed book.

They then get a chance to formulate an appeal on any of the questions they got wrong, which may get them partial credit as well. This is open book, internet, whatever. (This is ingenuous, by the way, it gets them back into the source material. The whole structure really helps the students teach each other.) They have to appeal on either question format, i.e. the question was poorly written in some which case they have to propose a rewrite. Or they appeal on question content, in which case they have to show their source.

Then we discuss the questions one by one, asking the group members to explain why they picked the choices they did and to help clear up any questions that remain. Instructor(s) walk around during the group test, so we know what is being discussed. Thus we know if there are certain areas that need a bit more discussion from us. Usually we have a tiny bit to say about the question no matter what, but if the students understand it well, we spend relatively less time there.

After going through the questions, we have further group exercises. I'm planning to present two different cases. First with an outpatient memory loss workup. They have to decide as a group based on the information given what the most likely etiology is. Making the stem such that several different etiologies are plausible. We poll the groups simultaneously for their answer choices. They then explain/defend their choices.

Second case will cover decision making capacity, autonomy, and issues of potential self-neglect.

At the end of the course, they give written feedback to the other students in their group. We will be experimenting with adding an anonymous evaluation portion that allows them to give a numerical score to the other group members, which we plan to incorporate into their grade as well. This is new, and we haven't exactly decided how we are going to do it yet. I've still got two weeks before this has to be ready for the next set of students. Plenty of time. :)

As I said, I was quite skeptical about the approach when I first heard it described. I'm close to becoming a proselytizing convert, however. They really do a lot of the teaching themselves. In a way, I suppose I miss the "sage on the stage" element of didactic teaching. The data are pretty stunning for my school for the improvement they've had on their shelf exam since the adoption of this style of teaching. It's also a lot of fun, even though they haven't yet been my questions or my exercises. I suspect that it will be even more fun as I get to incorporate some of my own ideas.

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