Geriatrics and Palliative Care
This domain tests comprehensive assessment of the older adult, deprescribing, recognition of delirium, and safe, humane end-of-life care including opioid prescribing in organ failure.
Core rules
- Comprehensive geriatric assessment covers function (activities of daily living), cognition, mood, nutrition, continence, falls, medication and social support; the plan follows from that, not from the diagnosis alone.
- Falls: multifactorial assessment - medications, vision, gait and balance, postural blood pressure, footwear, home hazards. Offer strength and balance exercise and check vitamin D.
- Polypharmacy: review against STOPP/START or Beers criteria. Anticholinergics, benzodiazepines, long-term NSAIDs, sulfonylureas and sedating antihistamines are the usual culprits.
- Delirium: use a validated tool such as the 4AT, then look for cause - infection, new drug, urinary retention, constipation, pain, hypoxia, electrolyte disturbance. Non-drug measures come first; antipsychotics only for severe distress, at the lowest dose, briefly.
- Dementia: assess cognition and function, address driving, finances, safety and caregiver strain.
- Palliative care: follow the WHO analgesic ladder, treat total pain (physical, psychological, social, spiritual), and prescribe anticipatory medication for pain, breathlessness, agitation and secretions.
- Opioids in renal impairment: avoid morphine (active metabolites accumulate); use fentanyl or hydromorphone with dose adjustment.
Worked example
An 82-year-old with three falls in 6 months takes amitriptyline, zopiclone, ibuprofen and gliclazide, and has a postural drop of 25 mmHg. Reasoning: the falls are largely iatrogenic. Stop amitriptyline and zopiclone, replace ibuprofen with paracetamol and topical treatment, review glycaemic control, and address postural hypotension before ordering more imaging.
Traps that cost marks
Labelling acute confusion as dementia; sedating delirium before searching for a cause; prescribing morphine in advanced kidney disease; ignoring caregiver burden.