Geriatrics

01 Physiology of Aging

Aging produces predictable physiological changes across every organ system. These changes reduce physiological reserve and narrow the margin between baseline function and clinical decompensation. Understanding normal aging is essential to distinguishing disease from senescence and to anticipating how older adults respond differently to illness, medications, and surgery.

Cardiovascular Changes

The aged heart demonstrates increased left ventricular wall thickness (up to 30% increase by age 80), decreased diastolic compliance, and reduced maximal heart rate (estimated max HR = 220 − age). Arterial stiffening raises systolic blood pressure while diastolic pressure may decrease after age 60, widening pulse pressure. Cardiac output at rest is generally maintained, but maximal cardiac output declines ~1% per year after age 30. Baroreceptor sensitivity diminishes, predisposing to orthostatic hypotension (present in 20–30% of community-dwelling elders ≥65). The conduction system accumulates fibrosis and fat, increasing the prevalence of atrial fibrillation (10% by age 80) and sick sinus syndrome.

Pulmonary Changes

Chest wall compliance decreases (costal cartilage calcification, kyphosis), while lung compliance increases (loss of elastic recoil). FEV1 declines ~30 mL/year after age 30. Residual volume (RV) increases; vital capacity (VC) decreases. FRC and closing capacity converge, leading to airway closure during tidal breathing (particularly in the supine position), which creates ventilation-perfusion mismatch and reduces PaO2. Expected PaO2 ≈ 104 − (0.27 × age) mmHg. Mucociliary clearance slows, and the cough reflex weakens, increasing aspiration pneumonia risk.

Renal Changes

Renal mass decreases ~25–30% by age 80, primarily from cortical nephron loss. GFR declines approximately 1 mL/min/1.73 m² per year after age 40, even without hypertension or diabetes. Serum creatinine may remain normal despite reduced GFR because of decreased muscle mass (reduced creatinine production). The Cockcroft-Gault equation [(140 − age) × weight / (72 × Cr) × 0.85 if female] or CKD-EPI is essential for dosing adjustments. Tubular concentrating ability declines, reducing the ability to conserve sodium and water — older adults are more susceptible to dehydration and hyponatremia.

Neurological Changes

Brain weight declines ~5% per decade after age 40. Cerebral blood flow decreases ~20% by age 80. Processing speed slows, and short-term memory mildly declines, but crystallized intelligence (vocabulary, general knowledge) is preserved. Deep tendon reflexes may diminish; ankle jerks may be absent. Vibratory sensation in the feet decreases. Sleep architecture shifts: total sleep time decreases, sleep latency increases, Stage N3 (slow-wave sleep) decreases, and nighttime awakenings increase.

Musculoskeletal Changes

Muscle mass declines ~3–8% per decade after age 30 (sarcopenia). Type II (fast-twitch) muscle fibers are preferentially lost, reducing power and increasing fall risk. Bone mineral density peaks at age 25–30 and then declines ~0.5–1% per year; in postmenopausal women, loss accelerates to 2–3% per year for the first 5–10 years. Joint cartilage thins, and intervertebral discs lose water content, contributing to height loss (~1 cm per decade after age 40).

Hepatic & GI Changes

Hepatic blood flow decreases ~40–45% by age 65, reducing first-pass metabolism. Phase I metabolism (CYP450 oxidation) declines, while Phase II (conjugation) is relatively preserved. Gastric acid production may decrease (achlorhydria in ~30% of those >80). Colonic transit time increases, contributing to constipation (reported in 30–50% of community-dwelling elders).

Immune System — Immunosenescence

Thymic involution begins in puberty; by age 60–70, the thymus is largely replaced by fat. Naïve T-cell production declines, and the T-cell repertoire narrows. Vaccine response is attenuated — influenza vaccine efficacy drops from 70–90% in young adults to 30–40% in those ≥65 (hence high-dose and adjuvanted formulations). Chronic low-grade inflammation ("inflammaging") contributes to atherosclerosis, sarcopenia, and frailty.

02 Comprehensive Geriatric Assessment

The Comprehensive Geriatric Assessment (CGA) is the cornerstone of geriatric medicine — a multidimensional, interdisciplinary diagnostic process to determine an older person's medical, psychological, social, and functional capabilities and to develop a coordinated care plan. Randomized trials show CGA improves survival, function, and rates of living at home versus usual care (meta-analysis: NNT ~12 to prevent one death or institutional placement at 12 months).

CGA Domains

Screening Tools at a Glance

03 Key Terminology & Abbreviations

Geriatric medicine relies on specific terminology for syndromes, functional measures, prescribing frameworks, and care settings. Mastering these terms is essential for communicating across the multidisciplinary team.

04 Dementia — Alzheimer Disease

Alzheimer disease (AD) accounts for 60–80% of all dementias. Prevalence doubles every 5 years after age 65 (1% at 65, 3% at 70, 6% at 75, 12% at 80, >30% at 85). It is characterized pathologically by extracellular amyloid-beta plaques and intraneuronal neurofibrillary tangles (hyperphosphorylated tau), beginning in the entorhinal cortex and hippocampus before spreading to neocortical areas.

Clinical Presentation

The earliest feature is episodic memory impairment (inability to learn and retain new information) — patients repeat questions and misplace items. Language difficulty (word-finding), visuospatial dysfunction (getting lost in familiar places), and executive dysfunction (impaired planning, judgment) follow. Progression is insidious over 8–12 years. Anosognosia (lack of awareness of deficits) is common and increases with severity.

Diagnosis

Diagnosis is clinical, supported by neuropsychological testing, structural imaging (MRI showing hippocampal & medial temporal lobe atrophy), and biomarkers. CSF biomarkers: decreased Aβ42 and elevated phospho-tau and total tau. Amyloid PET (florbetapir, flutemetamol) positive. FDG-PET shows temporoparietal hypometabolism. Labs to exclude reversible causes: TSH, B12, folate, CBC, CMP, RPR/VDRL, HIV (in appropriate populations).

Pharmacological Management

Non-Pharmacological Management

Structured daily routines, cognitive stimulation therapy, physical exercise (150 min/week moderate aerobic activity associated with slowed decline), caregiver education and support, adult day programs, and environmental safety modifications (remove throw rugs, install grab bars, door alarms for wandering). Music therapy and reminiscence therapy can reduce agitation.

05 Vascular, Lewy Body & Frontotemporal Dementias

Vascular Dementia (VaD)

Second most common cause (~15–20% of dementias). Caused by cerebrovascular disease — large-vessel strokes, small-vessel ischemia (lacunar infarcts, white matter disease), or hemorrhagic events. Classic features: stepwise decline (sudden worsening with new vascular events), executive dysfunction prominent (planning, organization, processing speed impaired more than memory), focal neurological signs (gait abnormality, pseudobulbar affect, urinary urgency). Imaging shows multi-infarct pattern or extensive white matter hyperintensities (Fazekas grade 2–3). Management: secondary stroke prevention (antihypertensives, statins, antiplatelets), control vascular risk factors. AChE inhibitors have limited evidence but are sometimes used.

Dementia with Lewy Bodies (DLB)

Third most common dementia (~5–10%). Core features (2 of 4 = probable DLB): (1) Fluctuating cognition with pronounced variations in attention and alertness; (2) Recurrent visual hallucinations (typically well-formed, detailed — people, animals); (3) REM sleep behavior disorder (acting out dreams, may precede cognitive symptoms by years); (4) Spontaneous parkinsonism (bradykinesia, rigidity, rest tremor). Supportive features: severe neuroleptic sensitivity (can cause NMS or severe EPS), postural instability, repeated falls, autonomic dysfunction.

Frontotemporal Dementia (FTD)

Onset typically age 45–65 (younger than AD). Three clinical variants: (1) Behavioral variant FTD (bvFTD) — the most common; early personality change, disinhibition, apathy, loss of empathy, compulsive behaviors, dietary changes (sweet-food craving), executive dysfunction with relative preservation of memory and visuospatial skills; (2) Semantic variant PPA — loss of word and object meaning, fluent but empty speech; (3) Nonfluent/agrammatic variant PPA — effortful, halting speech with grammatical errors. Imaging: frontal and/or temporal atrophy. Pick bodies (intraneuronal tau inclusions) in some cases. No disease-modifying treatment; SSRIs for behavioral symptoms; AChE inhibitors are NOT effective and may worsen behavior.

06 Delirium

Delirium is an acute, fluctuating disturbance in attention and awareness, with additional cognitive disturbance (memory, orientation, language, visuospatial, perception), that develops over hours to days and is caused by a medical condition, substance, or medication. It occurs in 10–30% of hospitalized older adults and up to 50–80% of ICU patients. It is independently associated with increased mortality (3-fold), prolonged hospitalization, increased institutionalization, and accelerated cognitive decline.

Confusion Assessment Method (CAM)

The CAM is the most widely used bedside delirium screening tool (sensitivity 94%, specificity 89%). Diagnosis requires both of:

(1) Acute onset and fluctuating course — Is there evidence of an acute change in mental status from baseline? Does the abnormal behavior fluctuate during the day?

(2) Inattention — Does the patient have difficulty focusing attention (e.g., easily distracted, difficulty keeping track of what is being said)?

Plus one or more of:

(3) Disorganized thinking — Rambling or irrelevant conversation, illogical flow of ideas, unpredictable switching between subjects.

(4) Altered level of consciousness — Anything other than "alert" (vigilant, lethargic, stuporous, comatose).

Delirium Subtypes

Prevention — HELP Protocol

The Hospital Elder Life Program (HELP) reduces delirium incidence by ~40% (NNT = 6). Key components: (1) Frequent reorientation (calendar, clock, familiar objects); (2) Non-pharmacologic sleep protocol (warm milk, massage, noise reduction, avoid nighttime vitals); (3) Early mobilization; (4) Vision and hearing aids provided; (5) Hydration and nutrition; (6) Avoid deliriogenic medications (benzodiazepines, anticholinergics, meperidine).

Delirium Workup

Systematic evaluation for every new case: (1) Medications review — recent additions, dose changes, or discontinuations (especially opioids, benzodiazepines, anticholinergics, steroids, fluoroquinolones); (2) Infection — CBC, UA with culture, CXR, blood cultures if febrile; (3) Metabolic — BMP (Na, Ca, glucose, BUN/Cr), hepatic panel, TSH; (4) Cardiac/pulmonary — ECG, troponin (if indicated), pulse oximetry, ABG if hypoxic; (5) Urinary/fecal — assess for retention (bladder scan) and impaction; (6) CNS — CT head (if focal signs, on anticoagulation, or history of fall/trauma); lumbar puncture if meningitis suspected; (7) Substance — alcohol level, urine drug screen if appropriate.

Management

First line: Treat the underlying cause. Non-pharmacological interventions (reorientation, de-escalation, family presence, minimize tethers). Pharmacological (only for severe agitation with risk of harm): Haloperidol 0.5–1 mg PO/IM q4h PRN (avoid IV — QTc risk); alternative: olanzapine 2.5–5 mg PO/IM. Avoid benzodiazepines (worsen delirium) except in alcohol/benzodiazepine withdrawal and DLB/Parkinson patients (avoid antipsychotics). Dexmedetomidine for ICU delirium.

Delirium vs Dementia vs Depression

07 Depression & Behavioral Disturbances

Late-Life Depression

Major depression affects 1–5% of community-dwelling elders but 10–15% of hospitalized elderly and up to 25–50% of nursing home residents. Late-life depression often presents differently than in younger adults: somatic complaints predominate (fatigue, pain, GI symptoms, weight loss), cognitive dysfunction is prominent ("pseudodementia" — depressive cognitive impairment that improves with treatment), and patients may deny feeling "sad" but endorse hopelessness, worthlessness, or loss of interest. Suicide risk is highest in white men ≥85 years (rate 4× the national average).

Geriatric Depression Scale (GDS-15)

Treatment: SSRIs are first-line (sertraline 25–50 mg starting dose, target 100–200 mg; escitalopram 5 mg starting, target 10–20 mg). Avoid TCAs in elderly (anticholinergic burden, orthostatic hypotension, cardiac conduction delays). Mirtazapine (7.5–30 mg at bedtime) is useful when insomnia and weight loss are prominent. Bupropion (100–300 mg/day) avoids sexual side effects and sedation; avoid if seizure risk. SNRIs (duloxetine 30–60 mg, venlafaxine 75–225 mg) are helpful with comorbid chronic pain. Start low, go slow — but titrate to adequate dose. Response may take 6–12 weeks in elderly (longer than younger adults).

Behavioral & Psychological Symptoms of Dementia (BPSD)

BPSD affect up to 90% of dementia patients at some point. Includes agitation, aggression, wandering, sundowning, sleep-wake cycle disruption, psychosis (delusions, hallucinations), apathy, and disinhibition.

Management approach: (1) Rule out underlying cause (pain [use PAINAD scale in nonverbal patients], infection, constipation, urinary retention, medication side effect); (2) Non-pharmacological interventions first (music therapy, aromatherapy, structured activities, reduce environmental stimulation, caregiver training — DICE approach: Describe, Investigate, Create, Evaluate); (3) Pharmacological only if non-pharmacological fails and patient is danger to self/others.

08 Falls Assessment & Prevention

Falls are the leading cause of injury, injury-related death, and emergency department visits in adults ≥65. One-third of community-dwelling elders and two-thirds of nursing home residents fall each year. Of those who fall, 20–30% suffer moderate to severe injury (hip fractures, subdural hematomas, lacerations). Fall-related costs in the US exceed $50 billion annually.

Risk Factors for Falls

Falls Assessment Tools

Multifactorial Fall Prevention

Exercise programs are the single most effective intervention (NNT ~10 to prevent 1 fall). Tai Chi reduces falls by 20–40%. The Otago Exercise Programme (strength + balance exercises, 3×/week + walking 2×/week) reduces falls by 35%. Additional interventions: medication review (withdraw sedatives, reduce antihypertensives if orthostatic), home safety assessment, vision correction, vitamin D supplementation (≥800 IU/day if deficient), management of orthostatic hypotension, footwear assessment, and physical therapy referral.

09 Gait Disorders & Assistive Devices

Common Gait Patterns in the Elderly

Assistive Device Selection

10 Hip Fractures

Hip fractures are a geriatric emergency. Over 300,000 occur annually in the US, with 95% in patients ≥65. One-year mortality is 20–30% (higher in men: 37% vs 20% in women). Only 40–60% regain pre-fracture mobility, and 10–20% require long-term institutionalization. Median age at fracture is 80 years.

Classification

11 Osteoporosis

Osteoporosis is defined by the WHO as a DXA T-score ≤−2.5 at the lumbar spine, femoral neck, or total hip. Prevalence: ~25% of women and ~5% of men ≥65. Osteoporosis is responsible for >2 million fractures annually in the US (vertebral compression fractures most common, followed by hip and distal radius fractures).

WHO Diagnostic Criteria (DXA T-score)

FRAX Tool

The FRAX (Fracture Risk Assessment Tool) calculates 10-year probability of major osteoporotic fracture and hip fracture using age, sex, BMI, prior fracture, parental hip fracture, smoking, alcohol (≥3 units/day), glucocorticoids, rheumatoid arthritis, secondary osteoporosis, and femoral neck BMD. Treatment thresholds (US NOF): ≥20% 10-year risk of major osteoporotic fracture OR ≥3% 10-year risk of hip fracture.

Screening Recommendations

USPSTF: DXA screening for all women ≥65 and younger postmenopausal women with risk factors (FRAX equivalent of a 65-year-old white woman). Men: screen at ≥70 or earlier with risk factors (glucocorticoid use, low body weight, prior fracture, hypogonadism).

Pharmacological Treatment

All patients should receive calcium 1,000–1,200 mg/day (diet + supplement) and vitamin D 800–1,000 IU/day (target 25(OH)D ≥30 ng/mL). Weight-bearing exercise and fall prevention are essential non-pharmacological measures.

12 Sarcopenia & Frailty

Sarcopenia

Sarcopenia is the progressive, age-related loss of skeletal muscle mass and function. The EWGSOP2 (2019) definition requires: (1) Low muscle strength (grip strength <27 kg men, <16 kg women; or chair stand >15 sec for 5 rises) for probable sarcopenia; (2) Low muscle quantity (appendicular skeletal muscle mass index by DXA: <7.0 kg/m² men, <5.5 kg/m² women) to confirm; (3) Low physical performance (gait speed <0.8 m/s, SPPB ≤8, TUG ≥20 sec) indicates severe sarcopenia. Prevalence: 5–13% in 60–70 year-olds, 11–50% in those ≥80. Treatment: resistance exercise (most effective), adequate protein intake (1.0–1.2 g/kg/day, ideally 25–30 g per meal), vitamin D supplementation if deficient.

Frailty

Frailty is a clinical syndrome of decreased physiological reserve and increased vulnerability to stressors (illness, surgery, medications), leading to disproportionate adverse outcomes. Two major conceptualizations:

Fried Frailty Phenotype (Physical Frailty)

≥3 of 5 criteria = frail; 1–2 = pre-frail; 0 = robust:

Clinical Frailty Scale (Rockwood, 9-point)

13 Beers Criteria & High-Risk Medications

The AGS Beers Criteria (updated 2023) is the most widely referenced list of potentially inappropriate medications (PIMs) in older adults (≥65). Polypharmacy (≥5 medications) affects >40% of community-dwelling elders and >90% of nursing home residents. The risk of adverse drug reactions (ADRs) increases roughly linearly with the number of medications: 5 drugs = ~50% risk of drug interaction; 8+ drugs = ~100% risk.

Key Beers Criteria Categories (Selected High-Yield)

14 STOPP/START Criteria

The STOPP/START criteria (version 3, 2023) complement the Beers list with a European evidence-based approach. STOPP (Screening Tool of Older Persons' Prescriptions) identifies PIMs to stop; START (Screening Tool to Alert to Right Treatment) identifies beneficial medications that are commonly omitted in older adults.

Selected STOPP Criteria (Medications to Discontinue)

Selected START Criteria (Medications to Consider Starting)

15 Deprescribing & Adverse Drug Reactions

Deprescribing Principles

Deprescribing is the planned, supervised process of dose reduction or stopping medications that are no longer beneficial or may be causing harm. It is not simply "stopping medications" — it requires a systematic approach:

(1) Ascertain all medications (prescription, OTC, supplements, herbals); (2) Identify potentially inappropriate medications using Beers/STOPP criteria and clinical judgment; (3) Determine whether each medication can be discontinued (consider indication, life expectancy, time-to-benefit, goals of care); (4) Plan withdrawal schedule (many drugs require gradual taper: benzodiazepines, SSRIs, beta-blockers, corticosteroids, opioids, gabapentinoids); (5) Monitor for withdrawal syndromes and disease recurrence.

Medications Requiring Gradual Taper

Adverse Drug Reactions in the Elderly

ADRs account for 5–10% of hospital admissions in older adults and occur 2–7× more frequently than in younger adults. The most common culprits: anticoagulants (bleeding), diuretics (electrolyte disturbances, falls), NSAIDs (GI bleed, renal failure), digoxin (toxicity), hypoglycemic agents, and psychotropics. Presentation is often atypical: confusion (anticholinergics), falls (sedatives, antihypertensives), incontinence (diuretics, cholinesterase inhibitors), constipation (opioids, calcium channel blockers), anorexia (digoxin, SSRIs).

16 Renal Dosing & Anticholinergic Burden

Renal Dosing in the Elderly

Age-related GFR decline makes renal dose adjustment critical. Key drugs requiring adjustment in CKD:

Anticholinergic Cognitive Burden (ACB) Scale

The ACB scale assigns points (1–3) to medications based on anticholinergic activity. A total ACB score ≥3 is associated with increased risk of cognitive decline, delirium, falls, hospitalization, and mortality. Each 1-point increase is associated with a 26% increase in mortality risk.

17 Urinary Incontinence

Urinary incontinence affects 30–50% of community-dwelling women ≥65 and 15–30% of men ≥65. Prevalence exceeds 50% in nursing home residents. Despite being common, it is frequently underreported and under-treated. It is a major contributor to social isolation, depression, skin breakdown, falls (rushing to bathroom), and institutionalization.

Types of Urinary Incontinence

Transient Causes — DIAPERS Mnemonic

Delirium; Infection (UTI); Atrophic vaginitis; Pharmaceuticals (diuretics, anticholinergics, alpha-blockers, sedatives); Excessive urine output (hyperglycemia, CHF, hypercalcemia); Restricted mobility; Stool impaction (fecal impaction can cause urinary retention/overflow).

18 Pressure Injuries

Pressure injuries (formerly pressure ulcers or decubitus ulcers) affect ~2.5 million patients annually in the US. Prevalence in acute care: 5–15%; long-term care: 10–25%. They result from sustained pressure over bony prominences that exceeds capillary closing pressure (~32 mmHg), causing tissue ischemia and necrosis. Most common locations: sacrum (28–36%), heels (23–30%), ischial tuberosities (sitting), greater trochanters, lateral malleoli.

NPUAP/EPUAP Pressure Injury Staging (2016)

Prevention — Braden Scale

The Braden Scale assesses pressure injury risk using 6 subscales (each scored 1–4, except friction/shear scored 1–3; total range 6–23):

Risk levels: 19–23 = no risk; 15–18 = at risk; 13–14 = moderate risk; 10–12 = high risk; ≤9 = very high risk.

Norton Scale

Total score range: 5–20. Score ≤14 = at risk; ≤12 = high risk.

Management Principles

Prevention: repositioning q2h, pressure-redistribution surfaces, moisture management, nutrition optimization (protein 1.25–1.5 g/kg/day, vitamin C 500 mg BID, zinc 220 mg daily). Treatment by stage: Stage 1–2: keep moist with appropriate dressings (hydrocolloid, foam, transparent film), relieve pressure. Stage 3–4: debridement (sharp, enzymatic [collagenase], or autolytic), negative-pressure wound therapy (wound VAC), infection management, surgical consultation for closure. Osteomyelitis: suspect if bone visible or probe-to-bone positive; MRI is gold standard; treat with 6–8 weeks IV antibiotics ± surgical debridement.

19 Malnutrition & Failure to Thrive

Malnutrition in the Elderly

Malnutrition affects 5–10% of community-dwelling elders, 30–60% of hospitalized elders, and 35–85% of nursing home residents. Causes include decreased appetite (anorexia of aging), dental problems, dysphagia, depression, dementia, medications (causing nausea, altered taste), social isolation, and poverty. Malnutrition increases mortality (2–3×), hospital length of stay, infection risk, pressure injury risk, and impairs wound healing.

Screening — Mini Nutritional Assessment (MNA)

The MNA-Short Form (MNA-SF) is a validated 6-item screening tool (max 14 points): ≥12 = normal nutritional status; 8–11 = at risk of malnutrition; 0–7 = malnourished. Items: food intake decline, weight loss, mobility, acute disease/stress, neuropsychological problems, BMI (or calf circumference if BMI unavailable).

Laboratory Markers

Failure to Thrive (FTT)

Geriatric failure to thrive is a syndrome of weight loss (>5% in 1 month or >10% in 6 months), decreased appetite, poor nutrition, inactivity, dehydration, depression, and cognitive impairment — leading to progressive functional decline. It represents the convergence of multiple geriatric syndromes. Workup: exclude reversible causes (depression, thyroid disease, malignancy, medication effects, dental disease, dysphagia, social factors). Management is multidisciplinary: treat underlying causes, dietary supplements (oral nutritional supplements add 200–600 kcal/day), appetite stimulants (mirtazapine 7.5–15 mg, megestrol acetate 160–800 mg/day [risk of DVT, adrenal suppression — use cautiously]), physical therapy, and social services.

20 Constipation, Sleep Disorders & Dizziness

Constipation

Affects 30–50% of community-dwelling elders and up to 74% of nursing home residents. Defined as <3 bowel movements per week, straining, hard stools, or sense of incomplete evacuation. Causes: low fiber/fluid intake, immobility, medications (opioids, calcium channel blockers, anticholinergics, iron, aluminum antacids), hypothyroidism, hypercalcemia, colorectal cancer, and neurological disorders (Parkinson disease, spinal cord lesions).

Management ladder: (1) Increase fiber (25–30 g/day) and fluids (1.5–2 L/day); (2) Osmotic laxative: polyethylene glycol (MiraLAX) 17 g daily (safest long-term choice); (3) Stimulant laxative: senna 8.6–17.2 mg at bedtime (safe for chronic use despite old myths); (4) For opioid-induced: methylnaltrexone 8–12 mg SQ or naloxegol 25 mg PO daily. Avoid chronic use of mineral oil (aspiration risk, lipoid pneumonia) and phosphate enemas in CKD (hyperphosphatemia, cardiac arrest).

Sleep Disorders in the Elderly

Sleep complaints affect >50% of older adults. Normal age-related changes: decreased total sleep time (6–7 hours), increased sleep latency, more nighttime awakenings, decreased slow-wave sleep (Stage N3), and advanced sleep phase (earlier bedtime and wake time). Pathological sleep disorders: insomnia, obstructive sleep apnea (OSA; prevalence 20–60% in elderly), restless legs syndrome (RLS; 10–35%), REM sleep behavior disorder (screen for prodromal synucleinopathy), and periodic limb movement disorder.

Insomnia management: First-line: sleep hygiene (consistent bed/wake times, dark/cool/quiet room, avoid screens, limit caffeine after noon, avoid daytime naps >30 min) and CBT-I (cognitive behavioral therapy for insomnia — most effective long-term intervention). Pharmacological (short-term only if non-pharmacological fails): melatonin 0.5–3 mg, suvorexant 10 mg (dual orexin receptor antagonist), low-dose trazodone 25–50 mg. Avoid: benzodiazepines, zolpidem, diphenhydramine (Beers criteria).

Dizziness & Vertigo

Dizziness is reported by 30% of people ≥65 and 50% of those ≥85. Four categories: (1) Vertigo (illusion of movement — BPPV, vestibular neuritis, Meniere disease); (2) Presyncope (lightheadedness — orthostatic hypotension, cardiac arrhythmia, vasovagal); (3) Disequilibrium (unsteadiness — peripheral neuropathy, cerebellar disease, musculoskeletal problems); (4) Non-specific dizziness (multifactorial, anxiety, medications).

BPPV is the most common cause of vertigo in elderly (~50% of cases). Diagnosed by the Dix-Hallpike maneuver (positive = latent-onset, fatigable, upbeating/torsional nystagmus). Treated with the Epley maneuver (canalith repositioning; 80% effective in single session). Meclizine suppresses symptoms but delays central compensation — use only for acute severe episodes (≤3 days).

21 ADLs, IADLs & Functional Scales

Katz Index of Independence in ADLs

Assesses 6 basic activities of daily living. Each activity is scored as independent (1) or dependent (0). Total score: 6 = full independence; 4 = moderate impairment; ≤2 = severe functional impairment.

Lawton Instrumental ADL Scale

Assesses 8 more complex activities that allow independent community living. Each scored 0 (low function, dependent) or 1 (high function, independent). Total: 0 (completely dependent) to 8 (completely independent).

Functional Independence Measure (FIM)

The FIM is an 18-item scale used in rehabilitation settings. Each item scored 1 (total assistance) to 7 (complete independence). Total score range: 18–126. Two subscales: motor FIM (13 items, max 91): self-care, sphincter control, transfers, locomotion; cognitive FIM (5 items, max 35): comprehension, expression, social interaction, problem-solving, memory. FIM score determines rehabilitation intensity needed and is used for Medicare reimbursement in inpatient rehabilitation facilities.

22 Rehabilitation Goals & Settings

Levels of Post-Acute Care

Medicare Requirements for SNF Coverage

The "3-day rule": patient must have a qualifying inpatient hospital stay of ≥3 consecutive midnights (observation status does NOT count) within 30 days of SNF admission. Medicare Part A covers: days 1–20 fully; days 21–100 with daily copay ($204.50/day in 2024); days 101+ not covered. Patient must require daily skilled services (skilled nursing care, PT, OT, or SLP).

Short Physical Performance Battery (SPPB)

The SPPB is a composite measure of lower-extremity function used in geriatric rehabilitation research and clinical practice. Three timed tests, each scored 0–4 (total 0–12):

Interpretation: 0–3 = severe limitation (disability, high mortality); 4–6 = moderate limitation; 7–9 = mild limitation; 10–12 = minimal limitation. A 1-point change is clinically meaningful. SPPB ≤9 is used as a diagnostic criterion for severe sarcopenia.

23 Elder Abuse — Types & Screening

Elder abuse affects an estimated 10% of community-dwelling older adults (≥60) annually, though only 1 in 14 cases is reported. It is associated with 300% increased risk of death within 3 years. Types of elder abuse:

Risk Factors

Victim: cognitive impairment, functional dependence, social isolation, prior history of family violence. Perpetrator: caregiver stress/burnout, substance abuse, mental illness, financial dependence on the elder, history of violence.

Screening & Reporting

Screen with the Elder Abuse Suspicion Index (EASI) (6 yes/no questions, ≥1 positive answer warrants further investigation) or the Vulnerability to Abuse Screening Scale (VASS). All 50 US states have mandatory reporting laws for suspected elder abuse — healthcare professionals must report to Adult Protective Services (APS) even without proof. In most states, reporters are immune from liability for good-faith reports. Patient consent is NOT required to file a report.

24 Capacity, Guardianship & Advance Directives

Decision-Making Capacity Assessment

Capacity is a clinical determination (made by the treating physician); competency is a legal determination (made by a court). Capacity is decision-specific and may fluctuate. The four components of capacity (all must be present):

Guardianship & Conservatorship

Guardianship (of the person) grants authority over personal and healthcare decisions. Conservatorship (of the estate) grants authority over financial decisions. Both require court proceedings and a finding of incapacity. They are measures of last resort — less restrictive alternatives should be explored first (healthcare proxy, power of attorney, representative payee, supported decision-making).

Advance Directives

25 Goals of Care & Hospice Eligibility

Goals of Care Conversations

Goals of care discussions should occur at key transitions: new serious diagnosis, significant functional decline, hospitalization, or when prognosis is <1–2 years. The REMAP framework: Reframe (why the medical situation has changed); Expect emotion (respond with empathy); Map out patient values ("What matters most to you? What are you hoping for? What are you afraid of?"); Align with values; Plan next steps. Document goals clearly: full treatment, limited interventions (e.g., hospitalize but no ICU/intubation), or comfort-focused care.

Hospice Eligibility — General Criteria

Medicare Hospice Benefit requires: (1) Two physicians certify prognosis of ≤6 months if disease follows expected course; (2) Patient (or surrogate) chooses comfort over curative treatment; (3) Covered services: nursing, home health aide, medications for comfort, DME, counseling, spiritual care, respite care (up to 5 days), bereavement support for 13 months after death.

Disease-Specific LCD Guidelines for Hospice

26 Comfort Care & Symptom Management

Pain Management at End of Life

Pain affects 50–80% of patients at end of life. The WHO analgesic ladder (adapted for elderly): Step 1: non-opioids (acetaminophen 325–500 mg q6h, max 2 g/day in frail elderly; topical lidocaine, NSAIDs short-term); Step 2: weak opioids (tramadol 25–50 mg q6h — use cautiously due to seizure and serotonin syndrome risk); Step 3: strong opioids (morphine 2.5–5 mg PO q4h PRN initially, or oxycodone 2.5–5 mg q4–6h; hydromorphone 0.5–1 mg PO q4h for renal impairment). Adjuvants at any step: gabapentin, pregabalin (neuropathic pain); dexamethasone (bone metastases, visceral pain); lidocaine patch (localized pain).

Dyspnea Management

Opioids are first-line for dyspnea at end of life (morphine 2–5 mg PO q4h or 1–2 mg IV q2–4h). Supplemental oxygen only if hypoxic AND symptomatic benefit — a fan directed at the face can be equally effective for the sensation of breathlessness. Benzodiazepines (lorazepam 0.5–1 mg q4–6h) for anxiety-related dyspnea. Nebulized normal saline may help with secretions.

Terminal Secretions ("Death Rattle")

Occurs in 25–50% of dying patients. Caused by pooling of secretions in the hypopharynx. More distressing to family than patient (patient is typically unconscious). Treatment: reposition (lateral with head elevated), gentle oral suctioning (avoid deep suctioning), anticholinergic agents: glycopyrrolate 0.2 mg IV/SQ q4–6h (preferred — does not cross BBB), hyoscine (scopolamine) patch 1.5 mg/72h, or atropine 1% ophthalmic drops 1–2 drops SL q4h.

Nausea & Vomiting

Ondansetron 4 mg IV/PO q6–8h; haloperidol 0.5–1 mg PO/IV q6–8h (useful for opioid-induced and bowel obstruction nausea); prochlorperazine 5–10 mg PO/IV q6h. For bowel obstruction with no surgical option: octreotide 100–300 mcg SQ TID reduces GI secretions; dexamethasone 4–8 mg IV/SQ for partial obstruction.

Delirium at End of Life

Terminal delirium affects up to 88% of dying patients. First: address reversible causes if consistent with goals (medications, urinary retention, fecal impaction, pain). Haloperidol 0.5–2 mg PO/IM/IV q4–6h PRN for agitation. For refractory terminal agitation: palliative sedation with midazolam infusion (0.5–1 mg/hr IV) or phenobarbital (loading 200 mg IV, then 50–100 mg q4–6h) — a last resort for intractable symptoms near death.

Signs of Imminent Death

The following signs indicate death is likely within hours to days: (1) Progressive decrease in consciousness; (2) Mottling of extremities (livedo reticularis); (3) Cool, cyanotic extremities; (4) Decreased or absent urine output; (5) Cheyne-Stokes or agonal breathing; (6) Terminal secretions (death rattle); (7) Loss of ability to swallow; (8) Mandibular breathing (jaw movement with each breath). Educate family about these expected changes. Discontinue unnecessary medications, monitoring, and interventions. Focus on mouth care, positioning, skin care, and emotional/spiritual support.

Medications to Discontinue at End of Life

Statins, antihypertensives (unless symptomatic hypertension), diabetes medications (unless symptomatic hyperglycemia), osteoporosis medications, vitamins/supplements, anticoagulants (unless active DVT/PE causing symptoms), screening medications (aspirin for primary prevention). Continue: analgesics, anticonvulsants (prevent seizures), anxiolytics, anti-secretory agents, antiemetics, and medications providing immediate symptom relief.

27 Prognostication, Caregiver Support & Grief

Prognostication Tools

Caregiver Support

Caregivers of older adults (especially those with dementia) experience high rates of depression (40–70%), anxiety, social isolation, and physical illness. The Zarit Burden Interview (ZBI) is a 22-item tool (0–88 points): 0–20 = little or no burden; 21–40 = mild to moderate; 41–60 = moderate to severe; 61–88 = severe burden. Interventions: respite care (Medicare hospice benefit includes up to 5 days of inpatient respite), support groups (Alzheimer's Association 24/7 helpline: 800-272-3900), psychoeducation, caregiver training in behavioral management techniques, family counseling, adult day programs.

Grief & Bereavement

Normal grief: sadness, yearning, preoccupation with the deceased, sleep disturbance, appetite changes; typically diminishes over 6–12 months with fluctuating intensity ("waves of grief"). Prolonged grief disorder (DSM-5-TR): persistent, pervasive grief lasting ≥12 months in adults (6 months in children) after bereavement, with intense yearning/longing, preoccupation with the deceased, and clinically significant distress or impairment. Affects ~10% of bereaved individuals. Treatment: grief-focused CBT, support groups. Anticipatory grief: grief that occurs before death (during prolonged illness); can facilitate post-death adjustment. Medicare hospice benefit provides 13 months of bereavement support for families.

28 Common Bedside Procedures

Joint Injections & Aspirations

Corticosteroid injections for osteoarthritis in elderly: triamcinolone 40 mg (large joints: knee, shoulder) or 10–20 mg (small joints). Limit to 3–4 injections per joint per year. Contraindications: overlying cellulitis, prosthetic joint (refer to orthopedics), coagulopathy. Hyaluronic acid injections (viscosupplementation) for knee OA: modest evidence; may benefit patients who cannot tolerate NSAIDs or are not surgical candidates.

Urinary Catheterization

Indications for chronic indwelling catheter (Foley) in elderly: urinary retention not amenable to intermittent catheterization, Stage 3–4 sacral/perineal pressure injury with incontinence, comfort care in terminally ill patients, or acute urinary obstruction awaiting surgery. Catheter-associated UTI (CAUTI) risk increases ~5% per day of catheterization. Prevention: insert only for valid indications, remove as soon as possible, nurse-driven removal protocols, maintain closed drainage system. Avoid chronic catheter for convenience or nursing preference. Alternatives: condom catheter (male), intermittent catheterization, prompted voiding.

Paracentesis & Thoracentesis in the Elderly

Procedural considerations: higher bleeding risk with liver disease (but INR and platelet count do NOT reliably predict bleeding in cirrhosis — transfusion thresholds debated). Large-volume paracentesis (>5 L): give albumin 6–8 g per liter removed to prevent post-paracentesis circulatory dysfunction. Thoracentesis: limit to 1–1.5 L per session to reduce re-expansion pulmonary edema risk. Ultrasound guidance is standard of care for both procedures — reduces complications by 50%.

29 Pre-operative Assessment in the Elderly

Patients ≥65 account for ~40% of all surgical procedures but have 2–3× higher perioperative mortality and complications than younger patients. Standard cardiac risk assessment (Revised Cardiac Risk Index, ACC/AHA guidelines) is necessary but insufficient — geriatric-specific risks (frailty, cognitive impairment, functional dependence, polypharmacy, nutritional status) are equally important.

Geriatric-Specific Pre-operative Assessment

ACS-NSQIP Surgical Risk Calculator

The ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) calculator estimates 30-day risk of major complications, mortality, and length of stay based on procedure type and 21 patient variables. Available online at riskcalculator.facs.org. Does not directly measure frailty, so should be combined with frailty assessment for comprehensive risk stratification in elderly surgical candidates.

Post-operative Delirium Prevention

Affects 15–53% of elderly surgical patients (highest after hip fracture and cardiac surgery). Prevention: proactive geriatrics consultation (reduces delirium by 36%), multicomponent non-pharmacological protocols (similar to HELP), avoid benzodiazepines and meperidine, optimize pain control (regional anesthesia when possible, scheduled acetaminophen, low-dose opioids), early mobilization (post-op day 1), sleep promotion, reorient frequently, ensure glasses/hearing aids in place.

30 Feeding Tube Decisions & Wound Care

Feeding Tube Decisions in Advanced Dementia

Dysphagia and aspiration are nearly universal in advanced dementia. Evidence strongly shows that tube feeding in advanced dementia does NOT: prevent aspiration pneumonia, prolong survival, improve nutrition, promote wound healing, improve function, or increase comfort. Tube feeding in advanced dementia is associated with increased agitation (restraints often needed to prevent self-removal), increased aspiration (continued aspiration of oral secretions and gastric reflux), and medical complications (tube site infections, diarrhea, refeeding syndrome).

Wound Care Principles in the Elderly

Aging skin is thinner, less elastic, and heals more slowly (50% slower epithelialization by age 80). Key principles: (1) Moisture balance — wounds heal faster in a moist environment (use appropriate dressings: hydrocolloid for low exudate, foam for moderate, alginate/hydrofiber for heavy); (2) Debridement — remove necrotic tissue (autolytic with moist dressings, enzymatic with collagenase, or sharp debridement); (3) Infection control — distinguish colonization from infection (increasing pain, erythema, warmth, purulence, delayed healing indicate infection); (4) Nutrition optimization — protein 1.25–1.5 g/kg/day, vitamin C 500 mg BID, zinc 220 mg daily; (5) Offloading — pressure redistribution for pressure injuries; therapeutic footwear for diabetic foot ulcers.

Skin Tears

Very common in elderly (fragile skin, anti-coagulant use). Classification (ISTAP): Type 1 — no skin loss (linear or flap tear, flap can be repositioned); Type 2 — partial flap loss; Type 3 — total flap loss. Management: approximate skin flap if present, apply non-adherent dressing (silicone-based dressings preferred), avoid adhesive tape directly on fragile skin (use tubular gauze or paper tape). Prevention: moisturize skin BID, padded bed rails, long sleeves, gentle handling during transfers.

31 Imaging & Diagnostics in the Elderly

Neuroimaging

Brain MRI is the preferred modality for evaluating cognitive decline: hippocampal atrophy (AD), frontal/temporal atrophy (FTD), white matter hyperintensities (vascular disease), normal pressure hydrocephalus (ventricular enlargement disproportionate to sulcal enlargement). CT head (non-contrast) for acute presentations: falls with altered mental status (r/o subdural hematoma — chronic SDH is common in elderly on anticoagulants), acute stroke. FDG-PET: temporoparietal hypometabolism (AD), frontal hypometabolism (FTD), occipital hypometabolism (DLB). DaTscan (I-123 ioflupane SPECT): differentiates DLB (abnormal) from AD (normal); evaluates nigrostriatal dopaminergic integrity.

Bone Densitometry (DXA)

Gold standard for osteoporosis diagnosis. Measures BMD at lumbar spine (L1–L4), femoral neck, and total hip. T-score = number of standard deviations from peak bone mass of a young adult reference. Z-score (compared to age-matched controls) is used in premenopausal women and men <50 — Z-score ≤−2.0 = "below expected range for age." Artifactual elevation of lumbar spine BMD can occur from degenerative changes, compression fractures, and aortic calcification — in these cases, hip BMD is more reliable.

Laboratory Testing Considerations

Age-related reference range changes: BNP increases with age (normal <100 pg/mL in <75 years, <300 pg/mL in ≥75 years); PSA cutoffs may differ; ESR is elevated with age (rule of thumb: upper normal = age/2 in men, (age + 10)/2 in women). D-dimer: age-adjusted threshold (age × 10 ng/mL for patients >50) improves specificity for VTE without reducing sensitivity. TSH: some experts suggest higher target TSH range (0.5–8.0 mIU/L) in very elderly (≥85) to avoid overtreatment of subclinical hypothyroidism.

Echocardiography in the Elderly

Age-related findings that should not be over-interpreted: mild aortic sclerosis (50% of those ≥85; does not necessarily progress to stenosis), mild mitral annular calcification (MAC), basal septal hypertrophy (sigmoid septum), and mild diastolic dysfunction (Grade I is near-universal after age 70). Aortic stenosis prevalence increases dramatically with age (2–5% of those ≥75 have severe AS) and is the most common valvular disease requiring intervention in the elderly.

Cancer Screening Cessation

32 Classification Systems (All)

This section consolidates all major classification and staging systems referenced throughout geriatric medicine.

Mini-Mental State Examination (MMSE) — Score Interpretation

Montreal Cognitive Assessment (MoCA) — Score Interpretation

Note: add 1 point if education ≤12 years (maximum score remains 30). MoCA is more sensitive than MMSE for detecting mild cognitive impairment (90% vs 18% sensitivity for MCI).

Clinical Dementia Rating (CDR)

FAST (Functional Assessment Staging — Reisberg)

Fried Frailty Phenotype

See Section 12 for full criteria. Summary: 0 criteria = robust; 1–2 = pre-frail (intermediate risk); ≥3 = frail (poor outcomes).

Clinical Frailty Scale (Rockwood)

See Section 12 for complete 9-point enumeration.

Braden Scale

See Section 18 for full subscale enumeration. Total 6–23; ≤18 = at risk.

Norton Scale

See Section 18 for enumeration. Total 5–20; ≤14 = at risk.

NPUAP Pressure Injury Staging

See Section 18 for complete staging from Stage 1 through DTPI.

Berg Balance Scale (BBS)

14 items, each scored 0–4 (total 0–56): sitting balance, standing balance, sit-to-stand, standing with eyes closed, tandem standing, picking up object from floor, turning 360 degrees, alternating foot on step, standing on one leg, reaching forward, and more. Scores: 41–56 = low fall risk (independent); 21–40 = medium fall risk (walking with assistance); 0–20 = high fall risk (wheelchair-dependent).

Morse Fall Scale

Total: 0–24 = low risk; 25–50 = moderate risk; ≥51 = high risk.

WHO DXA T-score Classification

See Section 11 for complete classification.

Zarit Burden Interview

See Section 27 for scoring: 0–20 little/none; 21–40 mild-moderate; 41–60 moderate-severe; 61–88 severe.

33 Medications Master Table

Cholinesterase Inhibitors & NMDA Antagonists

Antidepressants in the Elderly

Antipsychotics in the Elderly

Bisphosphonates & Bone Agents

OAB Medications (Non-Anticholinergic Preferred in Elderly)

34 Abbreviations Master List

35 Risk Factors & Comorbidities

Multimorbidity in the Elderly

Approximately 67% of adults ≥65 have ≥2 chronic conditions and 36% have ≥4. The most prevalent chronic conditions in order: hypertension (70%), hyperlipidemia (55%), arthritis (50%), ischemic heart disease (30%), diabetes (27%), CKD (25%), heart failure (15%), COPD (12%), dementia (10%), cancer (various), depression (15–25%). Multimorbidity drives polypharmacy, functional decline, increased healthcare utilization, and mortality. Disease management must be prioritized based on patient values, prognosis, and treatment burden.

Key Risk Factors by Geriatric Syndrome

Preventive Care in the Elderly