Step 2 CK · Family & Preventive Medicine

Geriatrics & Chronic Care

Name: Geriatrics & Chronic Care
Creator: Veli Bakalov, MD

Falls, pills, and function — the levers that keep elders independent

Family & Preventive Medicine·Family Medicine·5 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Falls are the leading cause of injury and accidental death at 65+: screen yearly; a Timed Up-and-Go of 12 seconds or more flags high risk.
Fall prevention: deprescribe sedatives and review antihypertensives, strength and balance exercise (PT, tai chi), vitamin D if deficient, vision correction, treat orthostasis, home safety.
Beers list: avoid benzodiazepines and Z-drugs, diphenhydramine and other anticholinergics, sulfonylureas (especially glyburide and glimepiride), muscle relaxants, and chronic NSAIDs in older adults.
Delirium = acute onset, fluctuating course, inattention, clouded consciousness (CAM); find the trigger (e.g., UTI). Dementia = chronic, progressive, alert; depression = poor effort, "I don't know."
Fried frailty: weight loss, exhaustion, weak grip, slow gait, low activity; ≥3 = frail, 1–2 = pre-frail.
IADLs (SHAFT) decline before basic ADLs (DEATH); losing ADLs signals a higher care need.
Incontinence: urge → bladder training, then β3 agonist (mirabegron, vibegron) or antimuscarinic; stress → Kegels, pessary, sling; overflow → relieve obstruction or catheterize; functional → scheduled voids.
Pressure injuries (ulcers): stage 1 nonblanchable erythema, stage 2 partial thickness/blister, stage 3 into fat, stage 4 exposed bone/muscle/tendon; plus unstageable and deep tissue pressure injury; reposition every 2 hours.
A durable power of attorney for healthcare names the surrogate, who uses substituted judgment; a POLST converts goals into portable orders.

Falls and frailty

Ask every year. Falls are the leading cause of injury and of accidental death in adults 65 and older. Screen annually by asking about falls and observing gait and balance. A Timed Up-and-Go (stand from a chair, walk 3 meters, return, and sit) taking 12 seconds or longer flags high fall risk. Causes are usually multifactorial: medications, poor vision, orthostatic hypotension, weakness or gait disorders, and environmental hazards.

Prevention that works. Combine interventions aimed at the patient's specific risks:

Review and reduce culprit medications, especially sedatives and antihypertensives
Strength, gait, and balance exercise (physical therapy, tai chi)
Vitamin D if deficient
Vision correction (glasses, cataract surgery)
Treat orthostatic hypotension
Home-safety changes: grab bars, lighting, removing loose rugs

Exercise has the strongest trial evidence for preventing falls in community-dwelling older adults (USPSTF). In an older adult who is falling, pair it with a medication review that deprescribes sedating drugs.

Frailty (Fried phenotype). Five criteria: unintentional weight loss, exhaustion, weak grip strength, slow walking speed, and low physical activity. Three or more criteria means frail; one or two means pre-frail. Frailty predicts falls, disability, hospitalization, and death, and it should shape how aggressive care plans are.

≥12 sTimed Up-and-Go that flags high fall risk

≥3 of 5Fried criteria = frail (1–2 = pre-frail)

5+ drugspolypharmacy

Medications: Beers criteria and deprescribing

Polypharmacy. Taking five or more medications raises the risk of drug interactions, falls, and adverse events, and each new symptom tempts a prescribing cascade (a new drug to treat the side effect of an old one). Review the list at every visit and deprescribe drugs without a clear current indication or benefit.

Beers criteria. The Beers criteria list medications that are potentially inappropriate in older adults because safer alternatives exist.

High-yield Beers medications

Drug class	Examples	Main harm
Benzodiazepines and Z-drugs	Lorazepam, diazepam, zolpidem	Falls, fractures, delirium
First-generation antihistamines	Diphenhydramine, hydroxyzine	Anticholinergic: confusion, urinary retention
Other anticholinergics	Oxybutynin, tricyclic antidepressants	Confusion, constipation, falls
Sulfonylureas (avoid as first- or second-line)	Glyburide, glimepiride highest risk; glipizide if one must be used	Prolonged hypoglycemia
Skeletal muscle relaxants	Cyclobenzaprine, methocarbamol	Sedation, anticholinergic effects
Chronic NSAIDs	Ibuprofen, naproxen	GI bleeding, kidney injury, fluid retention
Antipsychotics in dementia	Any, for behavior alone	Stroke and increased mortality

For insomnia, prefer sleep hygiene and CBT for insomnia over diphenhydramine or benzodiazepines.

Cognition: the 3 Ds

Rule out delirium first. Delirium is a medical emergency with an underlying trigger (infection such as UTI, drugs, metabolic derangement, urinary retention, pain, sleep loss). Dementia is itself a major risk factor for delirium, so a sudden decline in a patient with dementia is delirium until proven otherwise. The hypoactive form, with a quiet and withdrawn patient, is the one most often missed.

Delirium vs dementia vs depression

Feature	Delirium	Dementia	Depression ("pseudodementia")
Onset	Acute, over hours to days	Insidious, over months to years	Subacute, often with a mood change
Course	Fluctuating	Chronic, progressive	Tracks mood
Attention and consciousness	Inattention; clouded consciousness	Alert until late	Alert
Testing behavior	Cannot sustain attention	Tries, confabulates, or covers gaps	Poor effort; "I don't know" answers
Reversibility	Often reversible; find the trigger	Usually irreversible; check B12 and TSH for reversible mimics	Improves with treatment

Confusion Assessment Method (CAM). Delirium requires an acute onset or fluctuating course plus inattention, and either disorganized thinking or an altered level of consciousness. Manage by treating the cause, then use nonpharmacologic measures: reorientation, glasses and hearing aids, sleep protection, early mobilization, and avoiding restraints. Reserve low-dose antipsychotics for dangerous agitation, and avoid benzodiazepines except in alcohol or sedative withdrawal.

Dementia screening. Use the Mini-Cog (clock draw plus 3-word recall), the MoCA (more sensitive for mild cognitive impairment), or the MMSE.

Function, continence, and skin

ADLs vs IADLs. Basic ADLs (DEATH) are Dressing, Eating, Ambulating, Toileting, and Hygiene. Instrumental ADLs (SHAFT) are Shopping, Housekeeping, Accounting (finances), Food preparation, and Transportation. IADLs decline first; loss of basic ADLs signals a need for more care.

Urinary incontinence. Check a urinalysis and post-void residual, and look for reversible contributors (UTI, diuretics, anticholinergics, hyperglycemia, constipation). Then match therapy to the mechanism.

Four types of incontinence

Type	Mechanism	Clue	Treatment
Urge	Detrusor overactivity	Sudden urgency, large leaks	Bladder training first, then antimuscarinics (oxybutynin, tolterodine) or a β3 agonist (mirabegron, vibegron), preferred when anticholinergic or cognitive risk is a concern
Stress	Urethral hypermobility	Leaks with cough, laugh, or exertion; no urgency	Pelvic floor (Kegel) exercises, pessary, midurethral sling
Overflow	Retention (BPH, neurogenic bladder)	Dribbling, high post-void residual	Relieve obstruction (tamsulosin for BPH) or catheterize
Functional	Normal tract; cannot reach the toilet (mobility or cognition)	Dementia or immobility	Scheduled voiding, improved access

Antimuscarinics add anticholinergic burden in older adults (oxybutynin most of all); β3 agonists (mirabegron, vibegron) avoid it.

Pressure injuries (pressure ulcers). Prevent them by repositioning at least every 2 hours, offloading the heels and sacrum, using pressure-redistributing surfaces, managing moisture, and optimizing nutrition. Assess risk with the Braden scale.

Stage 1Intact skin with nonblanchable erythema.
Stage 2Partial-thickness loss: blister or shallow ulcer, no fat visible.
Stage 3Full-thickness loss into subcutaneous fat; no bone, muscle, or tendon exposed.
Stage 4Exposed bone, muscle, or tendon.

Pressure injury staging (NPIAP)

A wound base hidden by slough or eschar is unstageable until it is cleared. Intact purple or maroon skin is a deep tissue pressure injury.

Advance care planning and chronic care

Documents. A living will states which treatments the patient would or would not want. A durable power of attorney for healthcare (healthcare proxy) names a surrogate decision-maker and is broadly authoritative, covering situations no document anticipated. A POLST turns goals into portable medical orders that follow the patient across settings.

Surrogate standards. Surrogates use substituted judgment (what the patient would have wanted), not their own preferences. When the patient's wishes are unknown, they fall back on the patient's best interests. Without an appointed proxy, the next of kin serves in the order set by state law.

Supporting caregivers. Assess caregiver burden routinely and connect families to respite care and community support. This prevents burnout, which is a risk factor for elder neglect.