Care of older people and palliative care
Care of older people and palliative care
This domain tests comprehensive assessment of the older adult and the shift from disease-directed to comfort-directed care. It rewards recognising when the goals of care, not the diagnosis, are the clinical question.
Core rules
- Comprehensive geriatric assessment covers function, cognition, mood, continence, nutrition, falls, social supports and medicines; validated tools include the Mini-Cog, RUDAS or Addenbrooke's, timed-up-and-go, and the falls-risk screen.
- Polypharmacy: review against indication, benefit and time-to-benefit; deprescribe preventive medicines with long lag times (e.g. bisphosphonates, statins in advanced frailty) after discussion. Avoid anticholinergics and sedatives that worsen confusion and falls.
- Delirium is acute, fluctuating inattention - look for infection, constipation, retention, pain and drugs; it is a medical emergency, not “just dementia”.
- Advance care planning records values and preferences; a substitute decision-maker is appointed under state or territory law. Check the legal hierarchy before accepting a relative's consent.
- Palliative care: anticipatory prescribing for pain, dyspnoea, nausea, respiratory secretions and terminal restlessness; recognise the terminal phase using performance status and clinical trajectory; bereavement support for the family.
Worked example
An 84-year-old with advanced dementia has had three admissions for aspiration pneumonia in six months. The family asks for “another course of antibiotics”.
Reasoning: repeated aspiration pneumonia in advanced dementia signals a palliative trajectory. The best action is a structured goals-of-care discussion - what matters to her, what burdens she would accept - leading to an advance care plan, a symptom-focused plan and anticipatory prescriptions, with antibiotics reserved for comfort. Simply repeating antibiotics defers the conversation without changing the outcome.
Traps that cost marks
- Calling delirium “dementia” and not searching for a cause.
- Continuing preventive medicines in advanced frailty without review.
- Accepting a relative's authority without checking guardianship law.