NCCPA CAQ Geriatrics cheat sheet

Beers Criteria: potentially inappropriate medications in adults ≥65 include benzodiazepines, Z-drugs, first-generation antihistamines, anticholinergics, long-acting sulfonylureas, and NSAIDs (especially chronic use); risk is falls, delirium, and hypoglycemia.

Atypical antipsychotics in dementia carry a boxed warning for increased mortality (≈1.6–1.7× placebo); use only for severe agitation or psychosis after nonpharmacologic measures fail, at the lowest dose for the shortest time.

Polypharmacy rule: perform a full medication reconciliation at every transition of care; apply the prescribing cascade concept-a new drug may be treating a side effect of an existing one (e.g., antiparkinsonian drug for metoclopramide-induced parkinsonism).

Delirium is a medical emergency: acute onset, fluctuating course, inattention plus disorganized thinking or altered level of consciousness. The Confusion Assessment Method (CAM) is the standard bedside screen; treat the underlying cause, not the behavior.

Dementia workup: reversible causes to exclude include hypothyroidism, B12 deficiency, depression (pseudodementia), medication effects, subdural hematoma, and normal pressure hydrocephalus (gait apraxia, urinary incontinence, cognitive decline).

Falls: screen annually with gait/balance assessment (Timed Up and Go, ≥12 seconds suggests increased fall risk); multifactorial intervention includes medication review, vision, footwear, home hazards, and strength/balance exercise.

Urinary incontinence types: stress (leak with cough/sneeze; pelvic floor therapy), urge (overactive bladder; behavioral therapy then antimuscarinic or beta-3 agonist), overflow (retention; consider obstruction or anticholinergic burden), functional (environment/mobility).

Elder mistreatment: screen for physical, emotional, sexual, financial exploitation, neglect, and self-neglect; report per state mandatory reporting law. Signs include unexplained injuries, dehydration, and caregiver stress.

Advance care planning: assess decision-making capacity; if absent, identify the health care proxy per state hierarchy. POLST/MOLST documents are for seriously ill patients and travel with the patient; advance directives name a surrogate and preferences.

Pharmacokinetic aging: decreased gastric acid and splanchnic blood flow, reduced hepatic first-pass metabolism, decreased renal clearance (use Cockcroft-Gault creatinine clearance, not eGFR alone, for drug dosing), and decreased total body water with increased fat-prolonging half-life of lipophilic drugs.

Anticholinergic burden (e.g., diphenhydramine, oxybutynin, amitriptyline) is associated with cognitive decline, falls, constipation, and urinary retention; use the Anticholinergic Cognitive Burden scale to quantify.

Hypertension in older adults: treat to <130/80 when tolerated (per ACC/AHA), but avoid orthostatic hypotension; measure BP seated and standing. Deprescribing may be appropriate in frail patients with limited life expectancy.

Diabetes in older adults: relax A1c targets to 7.5–8.0% (or higher) for those with multiple comorbidities, functional or cognitive impairment, or limited life expectancy; avoid sulfonylureas and insulin regimens that risk hypoglycemia.

Osteoporosis: DXA screening for women ≥65 and men ≥70 (or earlier with risk factors); FRAX estimates 10-year fracture risk. Treat with bisphosphonate, denosumab, or anabolic agent based on fracture risk; ensure calcium and vitamin D adequacy.

Pressure injuries: stage by depth (Stage 1 nonblanchable erythema; Stage 2 partial-thickness; Stage 3 full-thickness; Stage 4 to bone/tendon; unstageable if eschar; deep tissue injury). Prevention: repositioning, support surfaces, nutrition, moisture management.

Hospice eligibility generally requires prognosis ≤6 months if disease runs its normal course; Medicare Hospice Benefit covers interdisciplinary care, medications related to the terminal diagnosis, and bereavement support.

Pain in older adults: start low, go slow; acetaminophen is first-line for mild-moderate musculoskeletal pain; avoid chronic NSAIDs; opioids require bowel regimen and fall monitoring.

Capacity vs. competence: capacity is a clinical determination (understanding, appreciation, reasoning, expressing a choice); competence is a legal determination made by a court.