Geriatrics, Palliative Care, and General Internal Medicine
This section tests atypical presentation in older adults, deprescribing, and the communication skills that define goals of care.
Delirium
Acute fluctuating inattention and altered awareness, identified with the Confusion Assessment Method. Hunt for the cause: infection, anticholinergic and sedative drugs, constipation, urinary retention, pain, hypoxaemia, and withdrawal. Non-drug measures come first; antipsychotics are reserved for severe agitation with risk of harm, at the lowest dose for the shortest time.
Falls
Screen annually. Assess gait and balance, orthostatic blood pressure, vision, footwear, home hazards, vitamin D, and the medication list. Medication review is the highest-yield single intervention.
Polypharmacy
Apply explicit criteria such as Beers or STOPP/START: avoid benzodiazepines, long-acting sulfonylureas, strongly anticholinergic drugs, and NSAIDs in frail patients with chronic kidney disease. Taper rather than stop abruptly.
Palliative care
Ask about symptoms, understanding, and goals before discussing interventions. For pain, use stepwise opioids with laxative prophylaxis; morphine metabolites accumulate in renal failure, so switch to hydromorphone or fentanyl. For dyspnoea, opioids help, with oxygen only if hypoxaemic. Discuss CPR and ventilation explicitly - a do-not-resuscitate order never means withholding other treatment. Prescribe anticipatory medications for pain, dyspnoea, and terminal secretions.
Worked example
An 84-year-old with dementia becomes acutely confused after starting oxybutynin. The drug is the likely precipitant: stop it, check for urinary retention and constipation, and use non-drug measures. Adding a benzodiazepine for agitation would deepen the delirium and increase fall risk. Reasoning: in delirium, subtract causes before adding drugs.
Traps that cost marks
- Attributing acute confusion to underlying dementia.
- Using antipsychotics as first-line delirium treatment.
- Reading a DNR order as a limit on antibiotics, fluids, or analgesia.