Geriatric Medicine and Palliative Care
What this domain tests
Frailty, falls, polypharmacy and delirium, plus symptom control, advance planning and care in the last days of life.
Core rules
- Frailty changes thresholds. Use a clinical frailty scale; in moderate or severe frailty, symptom control and function outrank tight numerical targets for blood pressure, glucose and lipids.
- Falls. Ask about the circumstances, blackouts, medication and alcohol; check lying and standing blood pressure, vision, gait and cognition; review sedatives, antihypertensives and anticholinergics.
- Polypharmacy. Apply STOPP/START criteria; consider anticholinergic burden, which contributes to falls, confusion and constipation. Deprescribe one drug at a time with a review date.
- Delirium versus dementia. Delirium is acute, fluctuating and inattentive; look for pain, constipation, urinary retention, infection, drugs and hypoxia. Dementia is progressive and does not fluctuate hour to hour.
- Advance care planning. Capacity is decision-specific; a person with capacity may refuse treatment even if that refusal seems unwise. Document discussions and resuscitation preferences.
- Symptom control. Follow the analgesic ladder, converting opioids correctly and prescribing a laxative with any opioid. For the dying patient, use a syringe driver when oral route fails; prescribe anticipatory medication for pain, agitation, respiratory secretions, nausea and breathlessness.
Worked example
An 88-year-old with moderate frailty on eight medicines is admitted after a fall with new confusion. You screen for infection, check for urinary retention and constipation, review the anticholinergic load, and stop two contributing drugs with a review in a week. The reasoning: the fall and delirium are iatrogenic until the medication list is examined.
Traps
- Tightening glycaemic or blood pressure control in frailty.
- Missing delirium because the patient "has dementia anyway".
- Starting an opioid without a laxative.
- Assuming a patient lacks capacity because the decision seems risky.