Medicine of the elderly and rehabilitation
This domain tests a structured, function-centred approach: what matters to the patient, what is reversible, and what should deliberately not be done.
Comprehensive geriatric assessment
CGA is the intervention, not the paperwork. Cover medical, functional (Barthel), cognitive (4AT, MoCA), psychological, social, environmental and goals-of-care domains, delivered by a co-located team. Done properly it reduces mortality and institutionalisation.
Delirium
Screen with 4AT or CAM; hypoactive delirium is the variant most often missed. Hunt for the cause: infection, drugs (opioids, anticholinergics, steroids), pain, constipation, urinary retention, hypoxia, alcohol withdrawal, myocardial infarction, stroke. Non-drug measures come first; antipsychotics are reserved for severe distress or risk to safety, at the lowest dose for the shortest time.
Falls
Ask about syncope, postural symptoms and the circumstances of the fall. Check lying and standing blood pressure, ECG, vision, gait and footwear; review sedatives, antihypertensives, anticholinergics and hypoglycaemics; consider FRAX and vitamin D replacement.
Rehabilitation
Goal setting is patient-led, time-framed and specific; measure with a validated tool at baseline and discharge. Intensity matters - early mobilisation after stroke and hip fracture improves outcome.
Worked example
An 84-year-old becomes confused three days after starting oxycodone for back pain. 4AT is 7/12; BP 118/70 lying and 96/60 standing; sodium 129; urine dip negative. Reasoning: multifactorial delirium - opioid, postural hypotension and hyponatraemia, with sepsis not yet excluded. Action: stop oxycodone, use paracetamol, treat pain, review fluid status, screen for infection and retention, recheck standing BP, rationalise the drug chart, and document capacity and goals of care.
Traps
- Dismissing acute confusion as "just dementia" and discharging the patient.
- Missing constipation or urinary retention as the cause.
- Prescribing benzodiazepines for agitation.
- Ignoring standing blood pressure and sedative burden.
- Writing goals without the patient or family.