ABIM Geriatric Medicine common mistakes
ABIM Geriatric Medicine · Understand the traps and how to avoid them.
Attributing a new or progressive symptom such as weight loss, fatigue, incontinence, confusion, or falls to 'normal aging' and closing the differential without further evaluation.
Trainees learn predictable age-related changes and may overgeneralize them; older adults often present atypically, and labeling a symptom as aging is cognitively efficient but diagnostically unsafe.
What to do instead
Treat any new, progressive, or functionally important symptom as pathologic until proven otherwise; distinguish expected aging changes from disease and document a differential with targeted testing.
Taking a disease-focused history without objectively screening ADLs, IADLs, mobility, cognition, home safety, and caregiver strain, or accepting 'doing fine' as a functional assessment.
Time pressure and the biomedical model favor problem-based history; patients and families often underreport decline unless asked about specific tasks and recent changes.
What to do instead
Use a structured functional screen such as Katz ADL, Lawton IADL, Timed Up and Go, and a validated cognitive screen; ask about recent changes, caregiver burden, and home environment, and document baseline function.
Treating a fall as a single-event injury and discharging the patient without orthostatic vital signs, gait and balance testing, medication review, vision assessment, or foot examination.
The acute visit focuses on injury and 'no injury' provides false reassurance; falls are multifactorial and the contributing factors are not apparent from the injury alone.
What to do instead
Manage the fall as a geriatric syndrome: perform multifactorial risk assessment including orthostatics, gait/balance testing, medication review for sedatives and antihypertensives, vision, feet, home hazards, and arrange exercise-based follow-up.
Relying on a single cognitive score such as the MMSE to diagnose or exclude dementia, without functional assessment, informant history, education/language adjustment, or evaluation for reversible contributors.
Cognitive screening scores are influenced by education, language, sensory impairment, and mood; clinicians may anchor on a 'normal' score and miss mild cognitive impairment or early dementia.
What to do instead
Combine cognitive testing with functional assessment and an informant report, use education-adjusted norms, assess depression and delirium, and check targeted reversible causes such as TSH, vitamin B12, metabolic abnormalities, and medications.
Attributing acute confusion or agitation in a hospitalized older adult to known dementia or a primary psychiatric disorder and starting an antipsychotic before evaluating for delirium and its underlying cause.
A baseline dementia label and behavioral framing can lead to anchoring; antipsychotics are sometimes used quickly for agitation without first identifying infection, medication effects, pain, retention, constipation, hypoxia, or withdrawal.
What to do instead
Screen for delirium with a validated tool such as the CAM or 4AT, establish baseline and fluctuation, search for precipitating causes, use nonpharmacologic measures first, and reserve antipsychotics for dangerous agitation at the lowest effective dose.
Continuing all home medications across acute illness and care transitions without reconciliation, or adding a new drug without considering renal/hepatic function, falls risk, cognition, and anticholinergic burden.
Fragmented records, prescribing inertia, and the prescribing cascade make it easy to carry forward inappropriate medications; older adults have altered pharmacokinetics and are vulnerable to drug interactions.
What to do instead
Reconcile medications at every transition, use Beers criteria and STOPP/START as prompts rather than rules, adjust doses for renal function, review OTC products and supplements, and actively deprescribe when harms outweigh benefits.
Dismissing urinary incontinence as inevitable aging or treating it only with pads without classifying the type or evaluating reversible causes; similarly missing pressure injury risk, sensory impairment, sleep problems, or elder mistreatment.
Embarrassment, normalization of symptoms, and time constraints reduce inquiry; clinicians may not ask privately about incontinence, mistreatment, or sensory and sleep problems.
What to do instead
Classify incontinence as stress, urge, overflow, or functional; check postvoid residual, medications, infection, and constipation; screen pressure injury risk, vision and hearing, sleep, and ask privately about mistreatment with a safety plan when indicated.
Applying adult thresholds and symptom patterns to older adults, such as waiting for chest pain to diagnose myocardial infarction or treating blood pressure and glucose to tight adult targets in frail patients.
Guidelines are often extrapolated from younger populations, and older adults commonly present with atypical symptoms such as delirium, falls, or functional decline rather than classic complaints.
What to do instead
Maintain a broad differential for atypical presentations, use age-appropriate and individualized targets with shared decision-making, and avoid intensive glycemic or blood pressure control when it increases fall, hypoglycemia, or polypharmacy risk.
Recommending cancer screening, tight preventive targets, or long-term preventive medications without considering life expectancy, time to benefit, goals, and the care setting, or omitting vaccination and fall prevention in long-term care.
Disease-specific quality metrics and guidelines encourage automatic screening; clinicians may not routinely estimate life expectancy or match prevention to the patient's goals and setting.
What to do instead
Individualize screening and prevention by life expectancy, time to benefit, and patient goals; ensure appropriate vaccination, exercise, advance care planning, and medication review across ambulatory, hospital, home, and long-term care settings.
Deferring goals-of-care conversations until a crisis or documenting code status by asking only 'full code or DNR' without exploring the patient's values, prognosis understanding, and preferred surrogate.
Clinicians may feel uncomfortable with prognostic uncertainty, fear causing distress, or allow family dynamics to substitute for the patient's own values; code status alone is not a goals-of-care discussion.
What to do instead
Initiate structured goals-of-care conversations early, assess decision-making capacity, identify the surrogate, explore values and acceptable outcomes, document specific preferences and code status, and involve palliative care when symptoms or conflict are complex.