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Vital Signs

These elderly "actors" may be retired, but they're not retiring

By Matthew C. Wiencke

I'm really looking forward to playing someone with senile dementia," says Joyce Griffen. A retired anthropology professor who lives at Kendal, a retirement community in Hanover, N.H., Griffen spends many hours a week rehearsing and playing roles. She's not involved in theater, however; in fact, she's been in only two plays in her life, back in high school and college. She is, instead, a standardized patient (SP) for Dartmouth's Northern New England Geriatric Education Center (GEC).

She works closely with GEC education specialist Beth Harwood, who provides Griffen with a fictional case history and background on the disease she is playing. Among the conditions she has assumed are alcoholism, congestive heart failure, chronic pain, and heavy smoking.

Marion Grassi, at age 93,
is the GEC's oldest
standardized patient.

Affect: Standardized patients "have to be able to manifest the affect," says Harwood. "I encourage them to get into it and feel it and picture it and say, 'What's missing?' " Griffen preps for her roles by observing people around her. "I've been trying to watch for those subtle symptoms," she says of her current effort to model senile dementia. "There's a certain eye contact which shifts away when they go into another frame of reference."

Griffen is one of the GEC's 15 SPs. They range in age from 68 to 93 and help health professionals in New Hampshire and Vermont train for their work with the elderly. For example, the GEC recently ran an all-day training session for about 50 caseworkers from New Hampshire's Bureau of Elderly and Adult Services, which investigates cases of possible physical neglect and/or financial exploitation among the elderly.

Cases: Before the session, Dr. Stephen Bartels, a professor of psychiatry at DMS and the director of the GEC, had asked the caseworkers for examples of "their most complicated and challenging cases." That feedback was then synthesized into one complex persona for the SPs to play: someone who has numerous medical problems, is developing Alzheimer's, has fallen several times, and isn't taking prescribed medications.

Mock patient Marion Grassi, left, simulates someone with a drinking problem, as geriatrician Steve Bartels demonstrates techniques for interviewing such a patient.

The day of the session, the caseworkers split into groups and each group did several mock home visits on a single SP over a simulated six-month period; on each return "visit," the SP's condition would deteriorate. Even the rooms the interviews took place in mirrored the patient--actors' decline, with alcohol bottles, stale food, and stacks of newspapers strewn around during later visits.

Goals: The caseworkers tried various methods to help the SPs, including motivational interviewing-a form of counseling that guides people toward deciding themselves to change health behaviors based on their own goals and values.

The caseworkers' feedback on the session was overwhelmingly positive; they even gave the SPs a standing ovation at the end of the day. "Some were almost ecstatic with having had a chance to [try] a procedure . . . they could [use] when they went to various houses around the state," says Bill Griffen, Joyce Griffen's husband and an SP himself.

Plans: Bartels and his group have many more plans for using SPs. They have developed a program called eGEM, which stands for Electronic Geriatric Education Module. The web-based

modules show an SP who has assumed a given condition being interviewed by a physician, with training tips inserted at appropriate points. Third-year DMS students are now using eGEMs, followed by one-on-one interviews with SPs. Bartels is also designing eGEMs to help clinicians change their practice settings "to better accommodate older adults," he explains.

As far as Bartels knows, Dartmouth's GEC is the only geriatrics center in the U.S. that makes such heavy use of standardized patients. "We have specialized in the frail, older, at-risk person who has multiple complex problems that are challenging to diagnose . . . and evaluate in the real setting," says Bartels. This is a "huge priority for us," he adds, and "is quite unusual."

Marion Grassi, at age 93, is the GEC's oldest mock patient. Bartels is indebted to her and all the SPs. "They're all just inspirational-incredibly smart, talented people who bring such energy to the role and take it incredibly seriously," he says. "We're only as good as they are, and they are really good."

Grassi, however, makes the job sound like a snap: "You just use your wits," she says wryly.

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