ABFM Geriatric Medicine common mistakes
ABFM Geriatric Medicine · Understand the traps and how to avoid them.
Dismissing a presenting complaint - fatigue, unintentional weight loss, new incontinence, cognitive slowing, or gait decline - as 'just part of getting older' and closing the visit without a differential.
Candidates over-learn the list of normal age-related physiologic changes (reduced thirst, decreased renal reserve, presbycusis, slower processing) and then anchor every nonspecific symptom to that list, especially when the vignette gives an age over 75 and no dramatic red flags.
What to do instead
Memorise an explicit 'never normal aging' list - involuntary weight loss, urinary or faecal incontinence, falls, acute confusion, pain, depression, and new focal deficits - and force yourself to name at least three treatable causes for each symptom before selecting an answer. When an option says 'reassurance only,' treat it as a distractor unless a documented workup is already negative.
Accepting the vignette's statement that the patient 'lives independently' or 'is doing well' and answering the question without performing any structured functional assessment of ADLs and IADLs.
Function is usually implied rather than stated in stems, and under time pressure candidates jump to the diagnosis or drug choice instead of asking whether the patient can manage finances, medications, shopping, cooking, driving, and telephone use.
What to do instead
In every geriatric vignette, explicitly ask yourself the IADL set (money, medications, transportation, shopping, meals, housework, phone) and the ADL set (bathing, dressing, toileting, transferring, feeding). Tie the answers to the decision at hand - IADL loss drives need for supervision, ADL loss drives placement level - and pick the option that reflects the documented deficit rather than the reassuring sentence.
Not asking about falls at routine visits, and after a reported fall, ordering only an x-ray and discharging without orthostatic vitals, medication review, vision and footwear assessment, home hazard review, or a gait and balance test.
Falls are treated as an unavoidable consequence of age, so screening is skipped; after a fall, the visit narrows to ruling out fracture and the multifactorial causes are never enumerated.
What to do instead
Ask every patient 65 and older annually about falls and fear of falling. For any fall, run a fixed checklist: orthostatic blood pressure and pulse, medication review for sedatives, antihypertensives, anticholinergics and hypoglycaemics, visual acuity and cataract status, footwear, home hazards, vitamin D, and a gait/balance measure such as the Timed Up and Go or 30-second chair stand - then match the intervention to the deficits found.
Attributing acute or fluctuating confusion in a patient with known dementia to 'progression of dementia' and missing delirium, or failing to look for the precipitating cause.
Symptoms overlap heavily and the existing dementia diagnosis becomes an anchor; acute change from baseline and inattention are not assessed, and the stem's familiar history feels explanatory.
What to do instead
Use a structured delirium tool (CAM or 4AT) and explicitly establish the baseline and the time course. Any acute change or fluctuation in attention means delirium until proven otherwise - then search systematically for triggers: infection, new medications or anticholinergics, urinary retention, constipation, pain, dehydration, hypoxia, and sensory deprivation. Choose the option that identifies and treats the cause rather than one that increases the antipsychotic dose.
Missing depression in an older adult because the presentation is somatic (pain, insomnia, appetite loss, vague GI complaints) or because the low mood is written off as an understandable reaction to illness, bereavement, or institutionalisation.
Geriatric depression is frequently atypical and the classic neurovegetative features are attributed to comorbid medical illness, so validated screening is never performed and the diagnosis is made only when psychosis or suicidality appears.
What to do instead
Screen with PHQ-2 and escalate to PHQ-9, and screen specifically whenever there is new functional decline, weight loss, or cognitive complaint. Ask directly about anhedonia, hopelessness, and suicidal ideation, and remember that anhedonia and hopelessness are more discriminating in older adults than sadness. Distinguish depression with cognitive impairment from dementia by treating the depression and re-testing cognition.
Adding a new medication to treat a symptom that is actually an adverse effect of an existing drug - for example, starting an antidepressant for fatigue caused by a beta-blocker, an antiparkinsonian for tremor caused by a neuroleptic, or a laxative for constipation caused by an anticholinergic.
Each new complaint is evaluated in isolation in a problem-oriented note, the medication list is reviewed only for allergies and interactions rather than for causality, and the visit ends with a prescription because that feels active.
What to do instead
Before adding any drug, ask one question: 'Could an existing medication be causing this?' Review the full list including over-the-counter anticholinergics, sedative-hypnotics, NSAIDs, sulfonylureas and proton pump inhibitors against Beers criteria, calculate an anticholinergic burden, and prefer a trial of stopping or dose-reducing the likely culprit with a defined review date over adding a new agent.
Treating urinary incontinence with pads, fluid restriction, or an immediate antimuscarinic without first classifying the type (stress, urge, overflow, mixed, functional) or checking post-void residual and urinalysis.
Incontinence is embarrassing for both patient and candidate, is assumed to be an inevitable aging change, and the urge-type presentation dominates memory, so the workup is skipped and a drug is chosen reflexively.
What to do instead
Classify first: obtain a bladder diary, post-void residual, urinalysis, and medication review (diuretics, anticholinergics, sedatives, caffeine). Reserve antimuscarinics or beta-3 agonists for documented urge incontinence after behavioural therapy, screen for constipation and reversible causes, and always consider functional contributors such as immobility, delirium, and inaccessible toilets before labelling it a bladder problem.
Deciding a patient is 'too old' or 'too frail' for rehabilitation and recommending custodial care or SNF placement without a therapy trial, or conversely ordering an unrealistic intensive programme without assessing endurance and cognition.
Ageism and prognostic pessimism bias the estimate of recovery, and rehabilitation potential is judged from the diagnosis and the patient's age rather than from current function, premorbid status, cognition, and motivation.
What to do instead
Base the recommendation on premorbid and current function, cognition, endurance, social support, and the patient's own goals, never on chronological age. Involve physical and occupational therapy early for a documented trial, set measurable functional goals, and select the least restrictive setting that can deliver the needed intensity; document the functional trajectory as the justification.
Choosing the most aggressive treatment option in a seriously ill older patient without first establishing goals of care, or failing to identify the appropriate surrogate decision-maker and the correct standard (substituted judgment versus best interests).
Candidates are trained to treat disease, prognostication feels uncertain, and discussions about dying are uncomfortable; when a surrogate is present, the temptation is to accept the family's preference rather than the patient's previously expressed values.
What to do instead
Before selecting a management option in advanced illness, ask what matters most to the patient, what functions are unacceptable to lose, and whether an advance directive or health care proxy exists. Apply substituted judgment when the patient lacks capacity, use best interests only when prior wishes are unknown, and remember that palliative care is appropriate alongside disease-directed therapy, not only after it is withdrawn.
Confusing payer rules - assuming a prolonged hospital stay automatically qualifies for skilled nursing facility care, that home health requires no homebound status, or that hospice requires stopping all treatment - and then giving an incorrect disposition or coverage answer.
Coverage and eligibility rules are administrative, rarely encountered in daily clinical work, and are learned as fragments, so plausible-sounding but wrong statements feel correct under exam pressure.
What to do instead
Memorise the key thresholds as discrete facts: the qualifying inpatient hospital stay required before SNF coverage, the homebound requirement and skilled-need requirement for home health, and the hospice eligibility criteria (prognosis of six months or less if the disease runs its usual course, with palliative rather than curative intent for the terminal diagnosis). Link every disposition choice to the functional and skilled-need documentation that justifies it.