General Internal Medicine and Geriatrics
The final domain rewards holistic reasoning: multimorbidity, polypharmacy, falls, delirium, and the atypical presentation of common disease in older adults. Questions often give a frail patient with several drugs and ask which change reduces harm most.
Atypical presentation and frailty
- Older adults may present with confusion, falls, or functional decline rather than fever or pain; infection, myocardial infarction, and hypothyroidism can all appear this way. Measure temperature, glucose, oxygen saturation, and an electrocardiogram early.
- Frailty predicts outcome better than chronological age. Use a simple screening tool and consider rehabilitation potential before aggressive intervention.
Polypharmacy and prescribing
- Review every drug for indication, dose, interaction, and anticholinergic burden. Beers criteria list potentially inappropriate drugs in older adults, including benzodiazepines, long-acting sulfonylureas, and anticholinergics.
- Start low and go slow; deprescribe when benefit is absent. A falls history with sedatives is an indication to stop them, not to add another drug.
Falls, delirium and continence
- Falls: assess gait and balance, vision, postural blood pressure, medication, footwear, and home hazards; check vitamin D and bone health. Syncope with injury requires cardiac assessment.
- Delirium: use a validated tool such as the 4AT or confusion assessment method; treat the cause and use non-pharmacological measures first. Antipsychotics are reserved for severe distress and used briefly at low dose.
- Urinary incontinence: exclude infection, constipation, and drugs; consider post-void residual and prostate disease in men.
Capacity and prevention
- Assess capacity by the four abilities: to understand, retain, weigh, and communicate a decision. Capacity is decision-specific.
- Prevention: vaccination, blood pressure control, osteoporosis treatment, and venous thromboembolism prophylaxis in immobile inpatients.
Worked example
An 84-year-old on amitriptyline, zopiclone, and glyburide is admitted after a fall with a fractured wrist and new confusion. The priorities are to treat pain, screen for infection and electrolyte disturbance, stop the sedative and anticholinergic drugs, switch the sulfonylurea to a safer agent, assess gait and bone health, and arrange a medication review with the family before discharge, rather than adding a new drug for dizziness.
Traps
Attributing confusion in an older patient to dementia without looking for delirium; continuing sedatives after a fall; and discussing capacity as a global label rather than a decision-specific judgement.