ABPN Geriatric Psychiatry common mistakes
ABPN Geriatric Psychiatry · Understand the traps and how to avoid them.
Choosing the antidepressant with the best evidence in a healthy adult when the vignette specifies late-life comorbidity, then defending it on efficacy grounds.
Training and everyday practice emphasize efficacy trials in younger adults; geriatric-specific cautions (orthostasis, anticholinergic load, hyponatremia, QT, fall risk, CYP interactions) get treated as afterthoughts rather than as the discriminator the item is testing.
What to do instead
Before selecting any psychotropic, list the patient's specific vulnerabilities (falls, hyponatremia risk, cardiac conduction, renal/hepatic clearance, polypharmacy) and eliminate options that aggravate them; then choose among survivors on efficacy.
Diagnosing major depressive disorder in an older adult with low mood plus weight loss, fatigue, and poor concentration without first checking for a medical or substance cause in the stem.
Pattern-matching to the depression template fires before the candidate inventories the medical contributors embedded in the history (hypothyroidism, anemia, B12 deficiency, occult malignancy, medication effects).
What to do instead
Run a fixed medical-mimic checklist on every mood vignette: thyroid, B12/folate, CBC, metabolic panel, medication review, substance use, and pain; only then commit to a primary psychiatric diagnosis.
Treating a new cognitive complaint as delirium only if the patient is agitated or hyperactive.
The hyperactive stereotype dominates teaching examples, so hypoactive delirium (withdrawal, quiet confusion, decreased oral intake) is read as depression or 'just dementia.'
What to do instead
Apply the acute onset plus fluctuating course plus inattention triad regardless of motor subtype, and actively look for hypoactive presentations in hospitalized or post-operative older adults.
Labeling cognitive decline as Alzheimer disease without checking whether the pattern is stepwise, focal, or accompanied by parkinsonism, hallucinations, or executive-predominant deficits.
Alzheimer disease is the base rate, so the candidate stops at the most common cause and ignores the discriminating features that point to vascular, Lewy body, or frontotemporal pathology.
What to do instead
For each dementia vignette, explicitly test the competing diagnoses against their signature features (stepwise/vascular, fluctuation and visual hallucinations and REM behavior disorder for Lewy body, early behavioral change for FTD) before selecting.
Prescribing donepezil or memantine for mild cognitive impairment or for a non-Alzheimer dementia without noting the indication mismatch.
Familiarity with these agents plus pressure to 'do something' overrides the evidence base, which does not support routine use in MCI and is weaker outside Alzheimer disease.
What to do instead
Tie each cholinesterase inhibitor or memantine choice to a stated indication (mild-to-moderate Alzheimer, moderate-to-severe Alzheimer for memantine) and be prepared to say no drug when the stem describes MCI.
Starting an older patient on a standard adult dose of a benzodiazepine or z-drug for insomnia and moving on without addressing the fall and cognitive risk.
Insomnia complaints invite a quick pharmacologic fix, and the adult dosing reflex carries over despite age-related changes in clearance and sensitivity.
What to do instead
Default to CBT-I and sleep hygiene first; if a drug is unavoidable, use the lowest dose for the shortest time, avoid long-acting agents, and document the fall/cognitive risk discussion the item is probing.
Missing that a new behavioral change in a dementia patient is delirium or pain rather than progression of the dementia itself.
Once a dementia diagnosis is in the stem, every subsequent change gets attributed to the underlying disease, and the reversible superimposed cause is overlooked.
What to do instead
Treat any acute change in function or behavior in a dementia patient as delirium until proven otherwise; search for infection, medication change, pain, constipation, and metabolic derangement.
Failing to screen for and act on suicide risk in older adults, especially men with recent loss, chronic illness, or a recent healthcare contact.
The intuition that older adults 'don't attempt' or that talk of death is normal aging suppresses the risk assessment the vignette is set up to elicit.
What to do instead
Screen explicitly with a validated tool, treat passive ideation and hopelessness as meaningful, and remember that older white men have the highest completed-suicide rate; ask about access to lethal means.
Attributing psychotic symptoms in an older adult to schizophrenia when the onset is late, without considering dementia-related psychosis, delirium, or a medical/medication cause.
The schizophrenia frame is overlearned, and late-onset psychosis is uncommon as primary schizophrenia, so the differential is truncated.
What to do instead
For any first-episode psychosis in late life, work the secondary-psychosis differential first (delirium, dementia, medication, metabolic, neurologic, sensory impairment) and reserve primary psychotic disorders for cases that survive that screen.
Choosing a medication regimen that ignores age-related pharmacokinetics and drug-drug interactions, then missing the interaction the item plants in the medication list.
Candidates focus on the psychiatric target symptom and skim the accompanying medication list, forgetting that reduced hepatic/renal clearance and polypharmacy make interactions the point of the question.
What to do instead
Before finalizing any answer, scan the full medication list for CYP interactions, QT prolongation, anticholinergic burden, and serotonergic combinations, and adjust dose or choice accordingly.