Geriatric Medicine
The lens
Geriatric questions reward restraint. Aging changes drug handling - reduced renal clearance, lower albumin, more adipose tissue - so start low and go slow. Review every medication against the Beers criteria; anticholinergics, benzodiazepines, sulfonylureas, and first-generation antihistamines are frequent offenders.
Geriatric syndromes
- Falls: ask annually, assess gait and balance (Timed Up and Go), and address vision, footwear, home hazards, and vitamin D.
- Delirium versus dementia: delirium is acute, fluctuating, with inattention; dementia is insidious and progressive. Always hunt for a cause - infection, medication, pain, constipation, urinary retention.
- Urinary incontinence: stress, urge, overflow, functional. Check a postvoid residual before starting a drug.
- Polypharmacy and deprescribing: for each drug, ask what goal it serves and whether that goal still applies.
Traps
- Attributing new symptoms to "normal aging." Weight loss, incontinence, and confusion are never normal.
- Tight glycemic control in a frail patient with limited life expectancy - an A1c target of 7.5–8.0% or simply avoiding symptomatic hyper- and hypoglycemia is often right.
- Missing depression that presents as somatization, insomnia, and anorexia.
- Skipping advance care planning and capacity assessment.
Rule of thumb
Before adding a drug for a new symptom in a patient over 75, ask which existing drug could be causing it.
Worked example: an 82-year-old on 12 medications presents with dizziness and a fall. The culprits are a sedative-hypnotic plus an alpha-blocker; deprescribe rather than adding meclizine, which is itself anticholinergic and on the Beers list.