Geriatrics
Core concepts
Geriatric medicine centers on function, not just disease. The geriatric syndromes-falls, delirium, incontinence, frailty, and polypharmacy-drive most exam questions. Understand comprehensive geriatric assessment and the 4Ms framework (What Matters, Medication, Mentation, Mobility). Distinguish delirium (acute, fluctuating attention) from dementia (chronic, progressive) and depression (pseudodementia). Know Beers criteria for potentially inappropriate medications in older adults (e.g., benzodiazepines, anticholinergics, long-acting sulfonylureas). Advance care planning and goals-of-care discussions are core competencies.
Traps
- Attributing acute confusion in an older adult to dementia rather than looking for delirium triggers (infection, medications, dehydration, pain, constipation).
- Missing that falls warrant a multifactorial assessment: vision, gait/balance, medications, orthostatics, home hazards.
- Using tight glycemic control in frail older adults; individualized A1c targets (often 7.5–8%) reduce hypoglycemia.
- Forgetting that constipation and urinary retention are common, reversible causes of agitation.
Worked example / rule of thumb
An 82-year-old with new confusion after starting oxybutynin: anticholinergic burden is a likely delirium trigger. Stop the drug, evaluate for infection and dehydration, and reassess. Rule of thumb: when an older adult changes acutely, look at the medication list first.
Prevention
Screen for fall risk annually, review medications at every visit, and discuss advance directives early, before crisis.