ABPS Geriatric Medicine common mistakes
ABPS Geriatric Medicine · Understand the traps and how to avoid them.
Treating a 'normal' screening lab or imaging result as ruling out disease in an older adult without adjusting for age-specific thresholds (e.g., accepting a creatinine within the reference range as excluding renal impairment, or a normal TSH as excluding thyroid disease in a patient on amiodarone).
Candidates memorize adult reference ranges and apply them verbatim; they forget that creatinine reflects muscle mass and that eGFR must be calculated, and that reference ranges were derived in younger populations.
What to do instead
For every lab, ask 'what is the age- and physiology-adjusted interpretation?' Calculate eGFR/Cockcroft-Gault for every renally cleared drug, and interpret creatinine in the context of frailty, sarcopenia, and amputation. State the adjusted threshold explicitly in your reasoning.
Attributing new confusion or functional decline to 'just aging' or to a known dementia diagnosis, rather than working up a superimposed delirium.
Baseline cognitive impairment anchors the clinician; delirium is under-recognized when the patient is already confused, and the fluctuating course is mistaken for dementia progression.
What to do instead
For any acute change in mentation or function, apply the Confusion Assessment Method (acute onset/fluctuation, inattention, disorganized thinking, altered consciousness) and actively hunt for precipitants: infection, medications, pain, constipation, urinary retention, dehydration, hypoxia, metabolic derangement, sensory deprivation. Document baseline cognition to detect change.
Prescribing or continuing a medication without deprescribing review, i.e., failing to apply Beers/STOPP criteria to anticholinergics, benzodiazepines, sulfonylureas, NSAIDs, and sedative-hypnotics in a patient with falls, confusion, or incontinence.
Candidates focus on 'what to add for the new problem' and treat each symptom with a new drug rather than reviewing the existing regimen as the cause (prescribing cascade).
What to do instead
Before adding any drug for a geriatric syndrome, review the full list against Beers/STOPP and ask whether an existing drug is the culprit. Practice stating a deprescribing plan with taper schedules and monitoring for withdrawal.
Missing the reversible or treatable contributors to a fall or 'frailty' presentation, and instead labeling the patient as an inevitable faller without a multifactorial assessment.
Falls are framed as a single event rather than a syndrome; candidates jump to gait aids and move on without addressing orthostatics, vision, footwear, home hazards, vitamin D, arrhythmia, neuropathy, and medications.
What to do instead
Systematically enumerate and address each modifiable domain: orthostatic vitals, vision, gait/balance testing, medication review, vitamin D, home safety, continence, cognition, footwear, and cardiac evaluation when indicated. Name the specific intervention for each contributor.
Under-treating pain or over-restricting analgesia in older adults out of opioid fear, or conversely using meperidine/NSAIDs and fixed high starting doses.
Candidates conflate 'opioid caution' with 'opioid avoidance' and default to subtherapeutic acetaminophen or unsafe NSAIDs; they also fail to adjust starting doses for renal function and frailty.
What to do instead
Use a stepwise approach: scheduled acetaminophen as foundation, topical agents where appropriate, cautious opioids ('start low, go slow') with bowel regimen, and avoid NSAIDs/meperidine. Reassess function and side effects, not just pain scores.
Failing to distinguish delirium, depression, and dementia when a patient presents with cognitive or behavioral change, and therefore missing a treatable depression or an acute delirium.
The three overlap in presentation; candidates anchor on the most familiar diagnosis and do not systematically screen with validated tools or assess time course and attention.
What to do instead
Use a structured differential: assess attention/fluctuation (delirium), mood/anhedonia with cognitive complaints (depression, e.g., PHQ-2/9, and pseudodementia features), and chronic progressive decline (dementia, e.g., MoCA/MMSE). Treat and reassess; document the time course.
Recommending aggressive disease-specific treatment or screening without weighing goals of care, prognosis, and time-to-benefit in a patient with limited life expectancy.
Candidates apply guideline-directed care uniformly without integrating life expectancy, functional status, and patient preferences; they also overestimate benefit of cancer screening in the very old.
What to do instead
For each intervention, state the time-to-benefit versus the patient's estimated prognosis and goals. Use shared decision-making framing and explicitly justify deprescribing or forgoing screening when benefit is unlikely within the remaining lifespan.
Misjudging capacity and consent, or defaulting to surrogate decision-making when the patient can still decide, and failing to apply substituted judgment/advance directives correctly.
Candidates equate cognitive impairment or a dementia diagnosis with incapacity, and they do not separate decision-specific capacity from global competence.
What to do instead
Assess capacity for the specific decision (understanding, appreciation, reasoning, choice). If impaired, identify the appropriate surrogate and apply substituted judgment using advance directives and known values; document the reasoning.
Missing atypical presentations of common acute illness in older adults, e.g., sepsis or MI presenting as confusion or falls without fever or chest pain, or UTI diagnosed on culture alone without clinical signs.
Candidates rely on classic textbook presentations and forget that older adults blanch symptoms; conversely they over-diagnose UTI from asymptomatic bacteriuria.
What to do instead
For acute decline, maintain a broad differential and lower the threshold for cultures, ECG, and imaging. Do not treat asymptomatic bacteriuria; require clinical signs plus urinalysis/culture correlation before treating UTI.
Failing to address nutrition, sarcopenia, and functional status as part of health maintenance, and missing weight loss as a red flag rather than a benign aging change.
Candidates treat preventive care as a checklist of vaccines and screening and overlook nutrition, strength, and function; unintentional weight loss is dismissed as expected in aging.
What to do instead
Include weight trend, appetite, dentition, dysphagia, and functional assessment in every older-adult review. Work up unintentional weight loss and prescribe resistance exercise plus protein-adequate nutrition for sarcopenia.