General Internal Medicine and Geriatrics
Core framework
This domain rewards systematic assessment of the complex patient: multimorbidity, polypharmacy, falls, frailty, cognitive impairment and functional decline. Use a structured approach - comprehensive geriatric assessment covering medical, functional, psychological and social domains. For any older patient, ask what matters to them and whether interventions align with goals of care.
Concepts examiners test
Falls assessment and multifactorial intervention; delirium prevention and management (identify and treat cause, avoid restraints and antipsychotics unless dangerous agitation); dementia subtypes and reversible causes; polypharmacy and appropriate deprescribing (anticholinergics, benzodiazepines, sulfonylureas); incontinence; pressure ulcer prevention; and the principles of advance care planning. Also perioperative medical assessment, syncope in the elderly, and the physiology of ageing (reduced renal clearance, altered drug handling).
Traps
- Do not attribute acute confusion to dementia - assume delirium until proven otherwise.
- Antipsychotics in delirium increase mortality and should be reserved for severe distress.
- Tight glycaemic control is often inappropriate in frail elderly; target higher HbA1c and avoid hypoglycaemia.
- Anticholinergic burden worsens cognition and falls - review medications.
- Creatinine may look normal despite poor renal function in low muscle mass; estimate glomerular filtration rate.
Worked rule of thumb
An older patient admitted with a fall and new confusion: treat as delirium, search for triggers (infection, medication, pain, constipation, urinary retention, electrolyte disturbance), stop deliriogenic drugs, and mobilise early. A normal creatinine does not exclude renal impairment in low muscle mass - calculate the estimated glomerular filtration rate.