Geriatric Medicine
This domain tests whether you can recognize how aging changes the presentation and management of common diseases, and whether you can act on functional status, cognition, and goals of care rather than on a single abnormal number. Questions cluster around atypical presentation, the geriatric syndromes, safe prescribing, falls, delirium, incontinence, pressure injury, elder mistreatment, and advance care planning.
Atypical presentation and the geriatric giants
Older adults may have infection without fever or leukocytosis, myocardial infarction with dyspnea or confusion rather than chest pain, and depression with somatic complaints. Delirium is often the first sign of illness. The geriatric giants-immobility, instability, incontinence, intellectual impairment, and iatrogenic harm-are interrelated; a fall may be the presenting symptom of a urinary tract infection, constipation, medication effect, or environmental hazard.
Function, cognition, and mood
Assess ADLs and IADLs, gait and balance, vision, hearing, and home safety. Screen cognition with a validated tool and distinguish delirium from dementia: delirium has acute onset, fluctuating course, and inattention. Depression can mimic dementia. Delirium workup includes medication review, infection, urinary retention, constipation, pain, hypoxia, and metabolic derangement.
Prescribing and transitions
Aging reduces renal clearance and lean mass while increasing body fat, prolonging half-life of lipophilic drugs. Start low, go slow, review Beers criteria, and deprescribe anticholinergics, sedative-hypnotics, and long-acting sulfonylureas when possible. Reconcile medications at every transition.
Worked example
An 84-year-old woman presents with 2 days of confusion and a fall. She has urinary frequency but no fever, dysuria, or leukocytosis. Medications include oxybutynin and diphenhydramine. Reasoning: new confusion with inattention is delirium until proven otherwise. Do not anchor on urinary tract infection; asymptomatic bacteriuria is common and treatment does not improve delirium. Check bladder scan for retention, review anticholinergics, assess pain and constipation, and obtain urinalysis only if symptoms suggest infection. Stop the anticholinergic burden and address fall risk.
Traps
Calling cognitive change 'normal aging'; treating asymptomatic bacteriuria; using restraints for agitation; missing depression or sensory impairment; continuing a drug because 'it was started for a reason' without reviewing benefit.