PRINCIPLES OF GERIATRIC MEDICINE MEDICINE I

Maria Ligaya Atienza, MD, FPCP, FPCGM || 12 April 2020 LT 06 TRANS 05 V.02
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OUTLINE
● Due to age-associated and disease-associated changes in the
body, older patients progressively become more frail. The body
I. Aging 1
cannot repair itself fully and return to its baseline function
A. Aging & Disease Susceptibility 1
○ A combination of these factors bring about an increase in the risk
B. Demographics 1
of mortality, and increased vulnerability to diseases and
II. Physiologic & Anatomical Changes in Aging 2
intervention as we have seen in this pandemic
A. Vital Signs 2
B. System-specific Changes 3
III. Approach to the Older Adult 6
A. Challenges 6
IV. Comprehensive Geriatric Assessment 7
A. Functional Assessment 8
B. Geriatric Syndromes 9
C. Cognition & Affect 15
D. Social Assessment 18
V. Prevention of Disease in the Elderly 18
A. Screening 18
B. CDC Exercise Recommendations 19
C. Vaccines 19
VI. Fundamentals of Geriatric Medicine 19
Review Questions 20
References 23
Appendix 28

OBJECTIVES
1. Identify the changes in the anatomy and physiology of the older
adult. Figure 1. The rates of most common chronic diseases and related mortality
2. Recognize the challenges in the evaluation of older patients. increased with old age. The mortality to major chronic diseases such as
3. Explain the fundamental concepts of geriatric medicine. cancer, alzheimer’s disease, heart disease, and stroke increases with age [PPPT]
4. Evaluate an elderly patient using the comprehensive geriatric ● Old age (Refer to Figure 1)
assessment. ○ Old age is a major independent risk factor for chronic
5. Formulate plans for preventive care in geriatric patients. diseases and associated mortality
○ Older people typically have multiple comorbidities with an
SUMMARY OF ABBREVIATIONS average 5-10 illnesses per person [Harrison]
3IQ 3 Incontinence Questions ○ Usually, older people consider aging as a disease process or
consider disease-related changes as normal in the aging
ACP American College of Physicians process
○ Aging is not a disease, but it does predispose to the
ACS American Cancer Society
development of different diseases
ADL Activities of Daily Living ○ Many typical aging changes underlie the pathological changes
that occur in the body, making elderly patients more vulnerable
CGA Comprehensive Geriatric Assessment
to diseases
ESR Erythrocyte Sedimentation Rate ■ Aging changes, such as microvascular dysfunction, oxidative
injury, and mitochondrial impairment underlie many of the
GDS-15 Geriatric Depression Scale pathological changes [Harrison]
iADL Instrumental Activities of Daily Living B. DEMOGRAPHICS
MMSE Mini Mental Status Exam
MNA Mini Nutritional Assessment
MOCA Montreal Cognitive Assessment
TUG Timed Up and Go
USPSTF United States Preventive Services Task Force

I. AGING
A. AGING & DISEASE SUSCEPTIBILITY [ , Harrison]

● While it is easy to recognize elderly patients, the exact definition of

aging is quite challenging
● Aging is a progressive process associated with declines in structure
and function, impaired maintenance systems, increased
susceptibility to disease and death, and reduced reproductive
capacity [PPT]
● Structural and functional changes may be due to primary aging
changes or age-related diseases [PPT]

Figure 2. Global population density in terms of percent in 2015 and projected

population density by 2050 [PPT]

MED 6.05 TG Elevazo, Esperancilla, Esteban, Elauria CORE Dealca, Saquing, Mabanta Page 1 of 35
● Refer to Figure 2
○ Elderly population (2015 map)
■ 0-9% (green): Philippines and most of the African continent
■ 10-19% (yellow): China, Korea, and most of the South
America
■ 20-24% (orange): US, Canada, and Russia
■ 25-29% (pink): parts of Europe
■ 30+% (red): Japan
○ While we do not know completely the impact of COVID to the
elderly population in the coming years, the trend for the whole
world is the same
○ There will be a large increase globally in the number of older
persons in 2050
■ Philippines will be under the yellow category by 2050
Figure 3. Population Age Distribution of the Philippines in 2015
Figure 4. Population Age Distribution of the Philippines by 2050
● Refer to Figures 3 and 4
○ In 2015, the population of our country was about 100 million, with
around 7% seniors
○ By 2050, the projected population is about 145 million, with 14%
seniors (around 20 million seniors)
MED 6.05 Principles of Geriatric Medicine
MUST-KNOW
● Aging is a progressive process associated with declines in
structure and function, impaired maintenance systems, increased
susceptibility to disease and death, and reduced reproductive
capacity
● Structural and functional changes may be due to primary aging
changes or age-related diseases
● Old age is a major independent risk factor for chronic diseases
and associated mortality
● Aging is not a disease, but it does predispose to the
development of different diseases
CONCEPT CHECKPOINT
1. T or F. Old age is a minor independent risk factor for chronic
diseases and associated mortality
2. T or F. There will be a large increase globally in the number of
older persons in 2050
ANSWERS:
1. F. Major independent risk factor
2. T
II. PHYSIOLOGICAL & ANATOMICAL CHANGES IN AGING
● Elderly patients represent a heterogeneous population
○ While some of the changes are seen in majority of elderly
patients, this may not be present in all and may not appear in the
same rate in the different elderly age groups
● Primary aging
○ Reflects changes in physiologic reserves over time that are
independent of changes from diseases
■ We know that there are changes in the way the older person
handles periods of significant stress even without
comorbidities
■ Physiologic changes appear most significantly during periods
of stress
● Exposure to extreme temperatures (heat stroke)
[PPT]
○ Decreased cutaneous vasoconstriction and sweat
production = impaired response to heat
● Declined sensation of thirst
○ Delayed detection and recovery from dehydration
● Physiologic changes in cardiac function, including
decreased maximal HR and CO, may impair response to
shock
● Elderly patients represent a heterogenous population = not all 70
or 80 y/o are the same
○ Optimal aging [PPT]
■ Occurs in patients who do not have debilitating diseases and
maintain healthy lives into their 80s and 90s
■ May be determined by genetic influences (20-30%) and
healthy lifestyles (20-30%)
■ Accounts for the probability of a person to reach 100 y/o
○ “Usual” aging [Bates]
■ Complex of diseases and impairments
A. CHANGE IN VITAL SIGNS [PPT]
● Blood pressure
○ Due to atherosclerosis, stiffening of the large arteries, and
increase of the vessel lumen, there is usually a high SBP with a
normal or low DBP = Isolated Systolic Hypertension with
widened pulse pressure
[PPT]
■ BP of 140/60 or 150/70 are common in elderly due to these
changes
■ DBP stops rising at approximately 6th decade [Bates]
○ Refer to Figure 5:
■ Young adults have elastic arteries that would expand during
systole and recoil during diastole = BP doesn’t increase as
much, and pressure is distributed until diastole
■ Older adults have stiffer arteries and less elastic recoil of the
blood vessels due to loss of elastin in the blood vessels
Page 2 of 35
 ● A big spike in the pressure (high SBP) occurs due to the
stiffer arteries
● A large drop in pressure (normal/low diastolic BP) happens
because diameter of the blood vessels remains the same
Figure 5. Intimal changes in arteries and corresponding pressure change
patterns [PPT]
○ Elderly patients are more prone to develop orthostatic
hypotension
■ Defined as a drop in SBP ≥ 20 mmHg or a drop in DBP ≥ 10
mmHg within 3 minutes of standing
■ This is common in patients who are taking antihypertensive
medications and those who have prolonged periods of
inactivity or bedrest (i.e. after being admitted in the hospital
for quite awhile)
● Heart rate and rhythm
○ Resting HR is unchanged, but maximal HR in response to
exercise or physiological stress decreases due to:
■ Loss of pacemaker cells in the SA and AV nodes
■ High levels of circulating catecholamines in the plasma of
older adults due to decreased clearance of these substances
in the bloodstream
● The heart becomes desensitized = decreased
responsiveness to β adrenergic sympathetic activity with
exercise
● 𝐶𝑂 = 𝐻𝑅 × 𝑆𝑉
○ When the maximal HR decreases in the elderly, CO
may become insufficient in times of physiologic stress,
leading to adverse outcomes
○ Older adults are more likely to have abnormal heart rhythms
due to loss of pacemaker cells in the SA and AV nodes
■ It is better to check the apical HR rather than the radial pulse
● Respiratory rate and temperature
○ RR is unchanged
■ RR ≥25 usually denotes pathological conditions
○ Temperature is unchanged
■ There are changes in the temperature regulation leading to
susceptibility to extreme temperatures (hypothermia) and
altered response to infections
● Elderly patients with infections may remain afebrile
B. SYSTEM-SPECIFIC CHANGES [PPT]
EYE AND VISION CHANGES
● Dry eyes due to fewer lacrimal secretions
● Pupils become smaller, making it more difficult to examine the
ocular fundus
● Visual acuity gradually diminishes
○ Constant between 20-50 y/o [Bates]
○ Diminishes gradually until 70 y/o and then more rapidly
● Presbyopia: Progressive loss of accommodation and difficulty
focusing on nearby objects
○ Becomes noticeable during the fifth decade [Bates]
● Increased risk of developing cataracts, glaucoma, and macular
degeneration
○ Thickening and yellowing of lens impairs passage of light to
retina → requires more light for reading and doing fine work →
cataract develops [Bates]
○ Lens continues to expand with aging → pushes iris forward →
narrows angle between iris and cornea → increased risk of
narrow-angle glaucoma [Bates]
MED 6.05 Principles of Geriatric Medicine
HEARING CHANGES
● Early losses start in young adulthood, involving high-pitched
sounds, gradually extending to sounds in the middle and low ranges
● Presbycusis: hearing loss with aging
○ Person fails to hear the higher tones of words but still hears
lower tones = words sound distorted and difficult to understand
[Bates]
○ Usually becomes more evident after age 50
○ You do not necessarily need to shout at them. Instead, modulate
your voice and speak in a deeper voice
MOUTH AND TEETH CHANGES
● There is decreased salivary secretions and loss of taste due to loss
of taste buds
○ Medications that may affect taste
■ Antibiotics like ampicillin, macrolides, and quinolones
■ Antihistamines and many cardiovascular drugs like
captopril, diltiazem, nifedipine, and hydrochlorothiazide
○ Decreased olfaction and increased sensitivity to bitterness and
saltiness affect taste [Bates]
● There is loss of dentition due to dental caries or periodontal disease
○ May lead to malnutrition in this age group
CHEST AND LUNG CHANGES
● Structural changes that lead to an increased work of breathing
○ Chest wall becomes stiffer and hard to move
○ Respiratory muscles weaken
○ Elastic recoil of the lungs decrease
○ Thoracic spine may also develop deformities like kyphosis =
dorsal curve of spine, increases AP diameter of chest
● Coughing becomes less effective
○ Elderlies may have difficulty expectorating sputum
○ Speed of breathing out with maximal effort gradually diminishes
[Bates]
● Lung matures by age 20-25, followed by a progressive decline in
lung function
○ In the elderly, surface area for gas exchange declines while
residual volume increases resulting in a decrease in arterial
pO2, but O2 saturation remains above 90%
● Decreased sensation of dyspnea and diminished ventilatory
response to hypoxia and hypercapnia probably because of neural
changes
○ Causes the elderly to be more vulnerable to ventilatory failure
during high demand states like heart failure and pneumonia →
poor outcomes
CVS CHANGES
● Systolic bruits heard in the middle or upper portions of the carotid
arteries indicate stenosis from atherosclerotic plaques
○ Increases risk for stroke
● Extra heart sounds
○ S3 usually suggests heart failure from volume overload of the
left ventricle in elderly patients
■ May be normal in children and young adults, persisting to 40
y/o, women
○ S4 (atrial gallop) suggests decreased ventricular compliance
and impaired ventricular filling
■ Seldom heart in young adults except well-conditioned athletes
■ Heard in healthy older people
● Cardiac murmurs
○ Aortic sclerosis is the result of fibrosis and calcification of aortic
valve without impeding blood flow
■ Common finding in elderlies
○ Aortic stenosis where valvular changes result in outflow
obstruction
■ Most common clinically significant valvular disorder among
older adults
■ Impedes blood flow
○ To distinguish aortic sclerosis from aortic stenosis: note brisk
carotid upstroke = aortic stenosis has delayed carotid upstroke
[Bates]
Page 3 of 35
 ○ Calcification of the mitral valve annulus may cause the murmur
of mitral regurgitation
■ Become pathologic as volume overload increase in LV [Bates]
■ Calcification impedes normal valve closure during systole
[Bates]
Figure 6. Heart with Diastolic Dysfunction. Normal heart (L). Elderly heart
with a diastolic dysfunction also known as heart failure with preserved ejection
fraction (HFpEF) (R) [PPT]
● Diastolic dysfunction is common among elderly patients =
Age-related changes trigger a cascade of events, leading to this
condition debilitating for elderly
● Refer to Figure 6:
○ Diastolic dysfunction arises from decreased early diastolic filling
and greater dependence in atrial contraction. There is increased
myocardial stiffness and LV hypertrophies
○ Due to the thickening of the blood vessels and other changes in
the large arteries that result in systolic hypertension, the walls of
the LV hypertrophies in response to chronic pressure overload
■ This ventricle becomes stiff which cannot relax normally
during diastole
○ Due to the stiffness, there is a decreased volume of blood
accommodated in the LV of an older adult during the early
filing phase of diastole
■ The LV then becomes more dependent on atrial contraction to
meet the same cardiac output
■ Due to the inherent changes in the atrium itself, dilation of the
LA, and loss of pacemaker cells, the blood supply by atrial
contraction may not be enough to support the needs of the
body, leading to symptoms of heart failure
■ In patients with atrial fibrillation, where the atrium cannot
contract in synchrony with the ventricle, CO becomes
significantly diminished
GASTROINTESTINAL CHANGES
● Normal changing is associated with changes that predispose older
adult to dysphagia
● Oropharyngeal muscle function slows with aging and there is
delayed relaxation of the upper esophageal sphincter, resulting in
slower transfer of food from the pharynx
○ This predisposes patient to aspiration of food to the trachea,
especially to older patients with neurodegenerative diseases like
stroke, Parkinson’s disease, and Alzheimer’s disease
● There is delayed emptying of the stomach, prolonging gastric
contact time with noxious substances like NSAIDs
○ Predisposes elderly to gastric mucosal injury and development of
ulcers
● Increased risk of constipation in the elderly may be due to reduction
and functional impairment of the neurons in the myenteric plexus
● Aging can blunt the manifestations of acute abdominal disease
○ Signs of peritoneal inflammation, like guarding and rebound
tenderness, may be absent/diminished
MED 6.05 Principles of Geriatric Medicine
● Impaired detoxification of the liver may be due to decreased
hepatic blood flow and reduced metabolizing enzymes.
○ These changes impair the metabolism of drugs and may
increase the blood levels of certain medications
■ Thus, lower doses of medications are given to decrease the
risk of adverse events related to toxicity
RENAL CHANGES
● Although baseline homeostasis of fluids and electrolytes is
maintained with normal aging, there is a progressive decline of renal
reserves
● Amount of kidney tissue decreases, causing decline in renal
function. The GFR declines by about 8 ml/min/1.73 m2 per decade
after the fourth decade
○ The loss of reserve manifests clinically in patients being
vulnerable to renal complications during acute illness, like after
MI or during sepsis
● Acceleration of loss renal function
○ Associated with diseases like hypertension, diabetes,
dyslipidemia, smoking, atherosclerotic disease
○ Influences the dosing of certain medications that are metabolized
and excreted by the kidneys
● Urinary incontinence increases with age
● Benign prostatic hyperplasia is common among elderly males
○ Significant enlargement causing urinary hesitancy, dribbling and
incomplete emptying
MUSCULOSKELETAL CHANGES
● Both men and women lose cortical and trabecular bone = cause
fractures
○ Men: more slowly
○ Women: rapidly after menopause
○ Osteoporosis
■ Although common in women, it may also happen to men and
cause fractures
● Loss of height due to thinning of intervertebral discs and
shortening of vertebral bodies in osteoporosis
○ Also due to added flexion at knees and hips
● There is a 30-50% decline in muscle mass
○ Sarcopenia: loss of lean body mass and strength with aging
○ Causes of muscle loss are multifactorial
■ Inflammatory and endocrine changes in the body
■ Sedentary lifestyle
NEUROLOGIC CHANGES
● “Benign forgetfulness” may occur
○ Refers to difficulty recalling names of people or objects or details
of specific events [Bates]
○ Should be differentiated from dementia where the forgetfulness
impairs with the activities of daily living
■ Dementia is not a normal part of aging
● Retrieve and process data more slowly and take longer to learn new
information
○ It is better to encourage elderly to take up a new skill or hobby
like painting as forms of mental exercise
● Have difficulty multitasking and can only focus at one task at a time
○
Assign only one person to ask questions
○
Try to ask one question at a time
○
Focus on doing one thing at a time
○
Avoid getting their BP or auscultating them while getting their
history especially with patients who have cognitive impairment
● May develop benign essential tremors
○ Seen when patient is performing an action
○ Seen in the head, jaw, lips, or hands [Bates]
○ May be confused with Parkinsonism [Bates
■ Benign essential tremors are slightly faster and disappear at
rest and there is no associated muscle rigidity [Bates]
● May lose vibratory sense in the feet and ankles, and position
sense may diminish
Page 4 of 35
● Gag reflex may be decreased
● Reaction times are also impaired
○ Important to assess this especially for older drivers who are
more prone to accidents due to theses changes
IMMUNOLOGIC CHANGES
● “Inflamm-aging” or immunosenescence is seen as increased
background levels of inflammation in the elderly: ESR, CRP, IL-6,
and TNF α
○ Changes brought about by aging in the immune system
○ Refers to the gradual deterioration of the immune system with
aging and involves our capacity to respond to infection
○ Increased IL-6 is associated with dementia and frailty in the
elderly
● T cells become less numerous due to atrophy of the thymus
● B cells may overproduce antibodies, leading to age-related increase
in autoimmune diseases
● We have seen during this pandemic how COVID has greatly
impacted the elderly population due to their poor response to the
disease combined with the multiple comorbidities
MUST-KNOW
● Primary aging
○ Reflects changes in physiologic reserves over time that are
independent of changes from diseases
○ These may appear most significantly during periods of stress
(ex. Exposure to extreme heat, dehydration and shock)
● Optimal aging
○ Occurs in patients who do not have debilitating diseases into
their 80s and 90s
○ May be determined by genetic influences (20-30%) and
healthy lifestyles (20-30%)
● Vital Signs
○ Due to atherosclerosis, stiffening of the large arteries, and
increase of the vessel lumen, there is usually an high SBP
with a normal or low DBP
■ This results to the development of Isolated Systolic
Hypertension with widened pulse pressure
○ Elderly patients are more prone to develop orthostatic
hypotension
■ Defined as a drop in SBP ≥ 20 mmHg or a drop in DBP ≥
10 mmHg within 3 minutes of standing
● Eye and Vision Changes
○ Dry eyes due to fewer lacrimal secretions
○ Pupils become smaller
○ Visual acuity gradually diminishes
○ Presbyopia: there is progressive loss of accommodation and
difficulty focusing on nearby objects
○ Increased risk of developing cataracts, glaucoma, and
macular degeneration
● Hearing Changes
○ Presbycusis: hearing loss with aging
● Mouth and Teeth Changes
○ Decreased salivary secretions and loss of taste
○ There is loss of dentition due to dental caries or periodontal
disease
● Chest and Lung Changes
○ Structural changes lead to an increased work of breathing
■ Chest wall becomes stiffer, respiratory muscles weaken,
and elastic recoil of the lungs decrease
■ Thoracic spine may also develop deformities like kyphosis
■ Coughing becomes less effective
■ Surface area for gas exchange declines; residual
volume increases resulting in a decrease in arterial pO2,
but O2 saturation remains above 90%
● CVS Changes
○ Systolic bruits heard in the middle or upper portions of the
carotid arteries indicate stenosis from atherosclerotic plaques
○ S3 usually suggests heart failure from volume overload of the
left ventricle in elderly patients
MED 6.05 Principles of Geriatric Medicine
■ Normal in young adults
○ S4 usually suggests decreased ventricular compliance and
impaired ventricular filling
○ Aortic sclerosis is the result of fibrosis and calcification of
aortic valve without impeding blood flow
○ Aortic stenosis: where valvula changes result in outflow
obstruction
■ Most common clinically significant valvular disorder among
older adults
● GI Changes
○ Normal changing is associated with changes that predispose
older adult to dysphagia
○ There is delayed emptying of the stomach, prolonging gastric
contact time with noxious substances line NSAIDs which
predisposes elderly to gastric mucosal injury and
development of ulcers
○ Increased risk of constipation in the elderly may be due to
reduction and functional impairment of the neurons in the
myenteric plexus
○ Impaired detoxification of the liver may be due to
decreased hepatic blood flow and reduced metabolizing
enzymes.
● Renal Changes
○ Amount of kidney tissue decreases causing decline in renal
function. The GFR declines by about 8 ml/min/1.73 m2 per
decade after the fourth decade
○ Acceleration of loss renal function
■ Associated with diseases like hypertension, diabetes,
dyslipidemia, smoking, atherosclerotic disease
■ Influences the dosing of certain medications that are
metabolized and excreted by the kidneys
○ The loss of reserve manifests clinically in patients being
vulnerable to renal complications during acute illness like after
MI or during sepsis
○ Urinary incontinence increases with age
○ Benign prostatic hyperplasia is common
■ Significant enlargement causing urinary hesitancy,
dribbling and incomplete emptying
● Musculoskeletal Changes
○ Both men and women lose cortical and trabecular bone
○ Loss of height due to thinning of intervertebral discs and
shortening of vertebral bodies with osteoporosis
○ There is a 30-50% decline in muscle mass.
○ Sarcopenia is the loss of lean body mass and strength with
aging
● Neurological Changes
○ “Benign forgetfulness” may occur
■ Should be differentiated from dementia where the
forgetfulness impairs with the activities of daily living
○ Retrieve and process data more slowly and take longer to
learn new information
○ Have difficulty multitasking and can only focus at one task at
a time
○ May develop benign essential tremors
○ May lose vibratory sense in the feet and ankles, and position
sense may diminish
○ Gag reflex may be decreased
● Immunologic Changes
○ Increased ESR, CRP, IL-6 and TNF α
○ Increased IL-6 is associated with dementia and frailty in the
elderly
○ T cells become less numerous due to atrophy of the thymus
○ B cells may overproduce antibodies, leading to age-related
increase in autoimmune diseases
CONCEPT CHECKPOINT
3. The result of fibrosis and calcification of aortic valve without
impeding blood flow
a. Aortic Sclerosis
Page 5 of 35

b. Aortic Stenosis
c. Mitral Sclerosis
4. Reflects changes in physiologic reserves over time that are
independent of changes from diseases
a. Primary aging
b. Optimal aging
ANSWERS:
3. A.
4. A.
III. APPROACH TO THE OLDER ADULT
● Cognitive Impairment
● Geriatric Syndromes
Figure 7. Approach to Older Adult
[PPT]
● Learn to quickly identify frail elderly patients
○ Usually more weak, easily fatigued, usually thinner, walks slower
compared to their healthier counterparts
○ Most vulnerable to adverse outcomes = greatly benefit from
obtaining a holistic geriatric approach
● Look for common geriatric syndromes, including mood
disorders
● Use efficient assessment tools
○ Assessing these geriatric syndromes utilize assessment tools
that will screen these conditions in elderly patients
● Take into account a patient’s goals, life expectancy and
functional status
● Review advanced directives and goals of care periodically
○ To help guide your therapeutic management
● Be familiar with Beers’ Criteria (Further discussed in later section)
○ Includes medications appropriate/potentially inappropriate for
older patients
○ Medications should be identified and closely reviewed if they
cannot be excluded from the drug regimen
● Adopt evidence-based approach especially to frail elderly who
may be made to undergo invasive procedures despite limited life
expectancy
● Provide caregiver support whenever possible
A. CHALLENGES
● Underreporting
○ Older patients tend to give more positive ratings to their overall
health than younger adults
○ They tend to be reluctant to report symptoms, or may overlook
symptoms as normal part of aging [PPT]
○ Afraid or embarrassed, or try to avoid clinical expenses or
discomforts of diagnosis and treatment [Bates]
○ To address:
■ Ask direct questions
■ Use well-validated geriatric screening tools
■ Consult with family members and caregivers
● Atypical Presentation
○ Note that elderly patients may have atypical presentations. They
lack the usual signs and symptoms characterizing a particular
condition or diagnosis [PPT]
○ Examples:
■ Older adults with infections are less likely to have fever
● Lack of fever despite infections like pneumonia, COVID
and UTI
MED 6.05 Principles of Geriatric Medicine
■ Older adults with hyperthyroidism present with fatigue, weight
loss, and tachycardia
● May not have hyperreflexia or heat intolerance
● Hyperthyroidism increases risk of osteoporosis [Bates]
■ Older adults with MI are less likely to report w/ chest pains
● May present with difficulty of breathing, dizziness,
weakness, or even falls
■ Acute abdomen may be silent
● May be missed because PE findings may be absent
■ Patients may present with vague chief complaints, acute
confusions, or acute functional decline
● Example: Recent onset of incontinence and difficulty
ambulating = Red flags and must be investigated
○ Older adults with mild cognitive impairment may provide
sufficient history
■ Those with severe forms may not be able to give data on the
present illness
■ Use simple sentences with prompts to elicit necessary
information [Bates]
○ For patients with severe impairments, confirm with family
members or caregivers
○ A multifactorial condition that involves interaction between
situation-specific stressors and underlying age-risk related
risk factors, resulting in damage across multiple organ systems
[PPT]
○ Term used to describe clinical condition in a older person that do
not fit into discrete disease categories
○ In current medical usage, syndrome refers to a pattern of signs
and symptoms with a single underlying cause. In geriatric
medicine, it emphasizes multiple causative factors that may
lead to a unified manifestation
○ These are highly prevalent in older adults, especially in frail
elderly
Figure 8. Geriatric Syndrome. A combination of risk factors, including
advancing age, cognitive and functional impairment and decreased mobility,
predispose patients to geriatric syndromes, like incontinence, falls, pressure
ulcers, delirium, and functional decline, all of which make the elderly patients
more frail. When patient becomes more frail, there is worsening of the risk
factors, leading again to the process, whereby the said patient may become
progressively more frail, and eventually leading to poor outcomes, like
dependence to a caregiver to carry out activities of daily living, loss of function
and disability, institutionalization, and death [PPT]
MUST-KNOW
● Approach to older adult
○ Learn to quickly identify frail elderly patients
○ Look for common geriatric syndromes, including mood
disorders
○ Use efficient assessment tools
○ Take into account a patient’s goals, life expectancy and
functional status
○ Review advanced directives and goals of care periodically
○ Be familiar with Beers criteria
○ Adopt evidence-based approach especially to frail elderly
○ Provide caregiver support
● Challenges
○ Underreporting
■ Older patients tend to give more positive ratings to their
health than younger adults. They tend to be reluctant to
Page 6 of 35
 plan with the multidisciplinary team to achieve the best possible
report symptoms, or may overlook symptoms as part of functional status and quality of life of our patients.
aging ○ This care plan is put into action and should be reviewed regularly
○ Atypical Presentation to be modified as the need arises.
■ Note that elderly patients may have atypical presentations. ● The following tables (Tables 1-4) are obtained from Harrison. The
They lack the usual signs and symptoms characterizing a tables below are simply split into parts for easier reading. Refer to
particular condition or diagnosis the appendix (Figure 21) for the combined table.
■ Examples ○ These questions are helpful in conducting annual Medicare
● Older adults with infections are less likely to have fever “Wellness Visits” [PPT]
● Older adults with hyperthyroidism present with fatigue, ○ Positive responses to one or more of the screening questions for
weight loss, and tachycardia each item should prompt consideration of further assessments
● Older adults with MI are less likely to report chest pains [PPT]
● Acute abdomen may be silent
Table 1. Examples of Screening Questions and Tools and Strategies
● Vague chief complaints
for Further Evaluation of Social Support
● Acute confusions
● Acute functional decline Geriatric Assessment Recommended Further Assessment
○ Cognitive Impairment Domains Screens for Positive Screen
■ Older adults with mild cognitive impairment may provide Social Support ● Do you live alone? ● Consider referral to
sufficient history ● Do you have a a social worker
● Those with severe forms may not be able to give data caregiver? ● Refer to Area
on the present illness ● Are you a Agency on Aging
○ Geriatric Syndromes caregiver?
■ A multifactorial condition that involves interaction between
situation-specific stressors and underlying age-risk related Elder Neglect / ● Do you ever feel ● Consider referral to
risk factors, resulting in damage across multiple organ Abuse unsafe where you a social worker
systems live? and/or Adult
■ These are highly prevalent in older adults especially in frail ● Has anyone ever protective services
elderly threatened or hurt
■ A combination of risk factors including advancing age, you?
cognitive and functional impairment and decrease mobility ● Has anyone been
predispose patients to geriatric syndromes like taking your money
incontinence, falls, pressure ulcers, delirium, and functional without your
decline which makes the patients more frail permission?
Advance Directives ● Would you like ● Discuss on
CONCEPT CHECKPOINT information or advance directives
5. Give 3 atypical presentations in the diseases of the elderly forms for a power ● Physician Orders
of attorney for for LIfe-Sustaining
ANSWERS:
health care? Treatment (POLST)
Older adults with infections are less likely to have fever, Older adults with hyperthyroidism
present with fatigue, weight loss, and tachycardia, Older adults with MI are less likely to ● Would you like (or MOLST or
report chest pains, Acute abdomen may be silent, Vague chief complaints, Acute information on a POST)
confusions, Acute functional decline
living will?

IV. COMPREHENSIVE GERIATRIC ASSESSMENT

Table 2. Examples of Screening Questions and Tools and Strategies
● Comprehensive geriartric assessment (CGA) is defined as a for Further Evaluation of Functional Status
multidisciplinary diagnostic and treatment process that identifies
Geriatric Assessment Recommended Further Assessment
medical, psychosocial, and functional capabilities of an older adult
Domains Screens for Positive Screen
in order to develop a coordinated plan to maximize overall health
with aging Functional status ● Do you need ● Instrumental
assistance with Activities of Daily
shopping or Living (ADL) Scale
finances? ● Basic ADL Scale
● Do you need
assistance with
bathing or taking a
shower?
Driving ● Do you still drive? If ● Vision testing
yes: ● Consider
○ While driving, occupational
have you had an therapy and/or
accident in the formal driving
Figure 9. Comprehensive Geriatric Assessment consists of assessments for past 6 months? evaluation
social, functional, cognition and affect, and geriatric syndromes [PPT] ○ Driving concerns
● Besides the medical aspect of caring for the elderly that we by family
focus on as doctors, there are other aspects that contribute to the member?
overall health and quality of life of these patients
○ Functional Vision ● Do you have ● Vision testing
○ Psychosocial trouble seeing, ● Consider referral
○ Cognitive aspects reading, or for eye exam
○ Geriatric syndromes watching TV? (with
● In making the CGA, the different aspects of the health of the older glasses, if used)
person are screened and evaluated with a goal of making a care
MED 6.05 Principles of Geriatric Medicine Page 7 of 35
Hearing ● Do you have ● Check for cerumen few months?
difficulty hearing in ear canals and
Cognition ● Self-reported ● Montreal Cognitive
conversation in a remove if impacted
memory loss? Assessment or Mini
quiet room? ● Hearing Handicap
● Cognitive screen Mental State
● Unable to hear Inventory
positive? (3-item Examination
whisper test 6 ● Consider audiology
recall and clock ● If diagnosis is
inches away? referral
draw test unclear, consider
Table 3. Examples of Screening Questions and Tools and Strategies “Mini-Cog) neuropsychological
for Further Evaluation of Geriatric Syndromes ● Confusion testing
Geriatric Recommended Further Assessment Assessment (CAM)
Assessment Screens for Positive Screen for delirium
Domains NOTE FROM LECTURER: There is no standard form. Different
countries and different institutions would have different questionnaires
Medications ● Do you take 5 or ● Match medications
and screening tools
more routine with diagnoses
medications? ● Consider reducing A. FUNCTIONAL ASSESSMENT
● Do you understand doses, stopping ● The CGA first assesses the functional abilities of a person by asking
the reason for each drugs, adherence if the person can still perform Basic and Instrumental Activities of
of your aides, and/or Living as well as any sensory impairments (e.g.: hearing or visual)
medications? consultation with a ● This allows us to determine the overall functional status of a patient
pharmacist ○ If he is still able to be independent and live alone, or if the
Fall Risk ● Have you fallen in ● “Get up and Go” patient is already dependent on a caregiver to perform tasks
the past year? test such taking medications or moving around
● Are you afraid of ● Consider full Fall ACTIVITIES OF DAILY LIVING
falling? Assessment
● Do you have ● Consider Physical
trouble climbing Therapy Evaluation
stairs or rising from ● Consider Home
chairs? Safety Assessment
Continence ● Do you have any ● Consider full
trouble with your continence
bladder? assessment
● Do you lose urine ● 3 IQ questionnaire
or stool when you (Women)
do not want to? ● American
● Do you wear pads Urological
or adult diapers? Association (ALIA)
7 symptom
inventory (men)
Weight Loss ● Weight <100 ● Assess for common
pounds or risk factors for
● Unintentional malnutrition
weight loss >10 ● Consider referral to
pounds over 6 dietician for
months? nutritional
evaluation
Sleep ● Do you often feel ● Epworth
sleepy during the Sleepiness Scale
day? or Pittsburgh Sleep
● Do you have Index Figure 10. Examples of Activities of Daily Living [PPT]

difficulty falling ● Consider referral ● Patients who become frail and dependent on a caregiver would
asleep at night? for sleep evaluation be unable to perform these activities on their own (Refer to Figure
Pain ● Are you ● Pain assessment 10)
experiencing pain ● Taking a bath, maintaining hygiene, and dressing up may be the
or discomfort? first to be lost when an individual starts to become more dependent
● Transferring or moving in and out of the bed and being mobile may
Alcohol abuse ● Do you drink > 2 ● AUDIT-C also be gradually lost, including toileting and maintaining continence
drinks / day? ● Feeding oneself is usually the last basic activity to be lost, which
Table 4. Examples of Screening Questions and Tools and Strategies makes a person completely dependent on a caregiver in performing
for Further Evaluation of Cognition and Affect the basic activities of daily living
Geriatric Recommended Further Assessment INSTRUMENTAL ACTIVITIES OF DAILY LIVING
Assessment Screens for Positive Screen ● Instrumental activities of daily living allow an individual to live
Domains independently in a community
Depression ● Do you often feel ● PHQ-9 or Geriatric ● While these are not necessary for functional living, the ability to
sad or depressed? Depression Scale perform iADLS improves the quality of life of elderly persons
● Have you lost ● Screen for suicide ● Examples of Activities Daily Living
pleasure in doing risk ○ Cooking
things over the past ○ House cleaning

MED 6.05 Principles of Geriatric Medicine Page 8 of 35

 ○ Taking medications independently
○ Laundry (washing lines, towels and other articles of clothing) MUST-KNOW
○ Shopping (purchasing clothing, groceries and etc) COMPREHENSIVE GERIATRIC ASSESSMENT
○ Managing personal finances (paying bills and proper budgeting) ● A multidisciplinary diagnostic and treatment process that
○ Communication (making & returning phone calls) identifies medical, psychosocial, and functional capabilities of an
○ Transportation (driving a car, calling a cab, using public older adult in order to develop a coordinated plan to maximize
transport) overall health with aging
● It is divided into:
○ Social
○ Functional
○ Geriatric syndromes
○ Cognition and affect
Functional Assessment
● Activities of daily living (ADLs)
● Patients who become frail and dependent on a caregiver would
be unable to perform these activities on their own.
○ Bathing / Hygiene: 1st to be lost
○ Dressing
○ Transferring
○ Toileting
○ Maintaining continence
○ Eating: Last to be lost
● Instrumental activities of daily living (iADLs)
○ Instrumental activities of daily living allow an individual to live
independently in a community
■ Cooking
■ House cleaning
■ Taking medications
■ Laundry (washing lines, towels and other articles of
clothing)
■ Shopping (purchasing clothing, groceries and etc)
■ Managing personal finances (paying bills and proper
budgeting)
■ Communication (making & returning phone calls)
Figure 11. Instrumental Activities of Daily Living [PPT]
■ Transportation (driving a car, calling a cab, using public
transport)
● Deficits in iADLs is a red flag as this may indicate that the patient
○ While these are not necessary for functional living, the ability
may have a dementing disease and should prompt cognitive testing
to perform iADLS improves the quality of life of elderly
VISION persons
● Visual impairment may be asked by simple questions, such as:
○ Do you have trouble seeing, reading, or watching TV? (with CONCEPT CHECKPOINT
glasses, if used) 1.T/F Cooking is an example of an Activity of Daily Living
● Further assessment for positive screen: 2. Give the 4 components of the Comprehensive Geriatric
○ Vision testing: Check visual acuity with a Snellen chart if Assessment
possible
○ If with visual impairment, the patient is referred to ophthalmology ANSWERS:
service to check for possible conditions affecting visual acuity 1. T. It is an example of an instrumental Activity of Daily Living. ADLs include Bathing /
Hygiene, Dressing, Transferring, Toileting, Maintaining continence and Eating
2. Social, functional, cognition and affect, and geriaric syndromes

B. GERIATRIC SYNDROMES
● Fall
● Polypharmacy
● Incontinence
Figure 12. Testing for vision and hearing of elderly patients [PPT] ● Malnutrition
HEARING ● Sleep
● Pain
● Hearing impairment may be assessed using an audioscope, but if
unavailable, it may be assessed by asking: FALL
○ Do you have difficulty hearing conversations in a quiet room? ● A fall occurs when a person’s center of gravity moves outside of
● It can also be assessed by doing a whisper test where you stand their base of support and insufficient, ineffective or no effort is
behind the patient by around an arms length and covering one ear made to restore balance
of the patient ● In community settings, the reported fall incidence rates are 30-40%
○ The examiner whispers a combination of letters and numbers in people aged 65 or more to as much as 40-50% in patients above
and asks the patient to repeat them (done in both ears) 75 y/o.
○ If the patient is unable to do 3 out of 6 trials, hearing impairment ● Fall-related injuries can be severe and lead to a decline in the
is possible and formal hearing tests for further assessment are quality of life of an older person
recommended ● A trigger for a comprehensive assessment
○ Check for cerumen in ear canals and remove if impacted [2022B] ● Because of falls, a patient may suffer from
○ Hearing Handicap Inventory [2022B] ○ Significant morbidity

MED 6.05 Principles of Geriatric Medicine Page 9 of 35

 ■ Fractures: may cause a patient to become bedridden and ■ ECG: In patients suspected of acute coronary syndrome or
eventually have complications of immobility, like pressure with significant known CVD
ulcers ■ X-rays: To exclude fractures
■ Brain, and spinal cord injury ■ Brain imaging: If signs present to exclude subdural
○ It may also cause social isolation and even death hematoma, stroke
● May be divided into two categories: ■ Cardiac monitoring: In patients with history suggestive of
○ Intrinsic: due to gait and balance disorders syncope or near-syncope
○ Extrinsic: due to polypharmacy and environmental factors ■ EEG: In patients with history suggestive of seizure
● History ● Falls Screening (See Appendix for algorithm from Harrison)
○ Always ask the patient about fall history in every hospital or clinic Table 5. The Fall Screening Algorithm
visit
○ Circumstances surrounding the fall Patient answers yes to any key question
■ Was he getting up from bed? Was it while he was going down ● Fell in past year; if yes ask how many times and if there was
the stairs? Did it occur because the patient was rushing to the injury
bathroom? Did it occur in the middle of the night when the ● Feels unsteady when standing or walking
patient got up to urinate? ● Worries about falling
■ Relationship to changes in posture, turning of head, after a
YES = Evaluate Gait, Strength, NO = Low Risk Patient
meal or medication intake, rushing to the toilet, nocturia,
and Balance
straining to urinate or defecate [Harrison]
● Timed up and Go Test Individualized fall
■ Accidental trip or slip = reported “mechanical” fall [Harrison]
● 30 Second Chair Stand interventions
● Older people who trip or slip have a variety of underlying
● 4-stage Balance Test ● Educate the patient
reversible conditions that contributed to the event
● Vitamin D +/- Calcium
■ Hazards in the living environment [Harrison]
If the patient presents with no supplementation
○ Premonitory or associated symptoms
problem, they are considered ● Refer for strength and balance
■ Presence of dizziness or lightheadedness prior to falling?
low risk exercise (community exercise
■ CV or neurological symptoms, symptoms of seizure [Harrison] or fall prevention program)
○ Loss of consciousness or seizure
○ Medication history Patient presents with a gait, strength, and/or balance problem
■ Medications associated with falls ● Ask how many times they fall and the presence of injuries
● Sedatives
● Hyperglycemic agents Patient had no falls or had 1 Patient had 2+ falls or 1 fall
● Antihypertensives fall without injuries with injury
■ Patients who take more than 4 medications usually have a ● Consider as moderate risk ● Consider as high risk patient
higher risk for falls patient
■ A typical scenario is an elderly hypertensive patient Conduct a Multifactorial Risk
maintained on antihypertensive medications who came in Individualized interventions Assessment
after a fall after starting a medication for BPH. ● Educate the patient ● Falls history
● The addition of an alpha blocker for BPH may also lower ● Review and modify ● PE including postural
the patient’s BP, causing episodes of orthostatic medications dizziness and hypotension
hypotension in these patients, leading them to fall. ● Vitamin D +/- Calcium ● Medication review
○ Excessive alcohol intake [Harrison’s,19th ed] supplementation ● Cognitive screen
● Physical Examination ● Refer to physical therapy or ● Feet and footwear
○ Check for physical injury community fall prevention ● Use of mobility aids
■ Check for bruising especially for patients on anticoagulants / program ● Check for visual acuity
platelet inhibitors [2022B]
■ Typically, x-rays are done to rule out fractures, but it is also Individualized interventions
important to work up other causes of falls ● Educate the patient
■ Head trauma, hip range of motion, wrist pain [Harrison] ● Vitamin D +/- Calcium
○ Workup for acute illness (infection? arrhythmia? stroke? etc.) supplementation
■ Patients may become weak due to an ongoing infection or an ● Refer to physical therapy
electrolyte imbalance causing the fall ● Manage and monitor
■ Check vital signs and postural vital signs hypotension
○ Conditions that increase risk for falls (poor visual acuity, ● Modify medications
joint disease, gait and balance problems) ● Address foot problems
■ Footwear and environmental hazards can cause a fall ● Optimize vision
■ Limited range of motion of neck, CV problems, podiatric ● Optimize home safety
conditions, neurological signs [Harrison]
○ Assess fear of falling
■ Cause anxiety and depressive problems in an elderly patient
● Laboratory Tests
○ Should be guided by history and physical exam findings
■ e.g. A weak-looking patient with no appetite may be worked
up for possible electrolyte imbalance like hyponatremia which
may cause falls
○ Falls are multifactorial, workup should be both thorough and
based on your assessment of the patient as most of the time it is
a combination of different factors that put the patient at risk for
falls
○ Typical lab workups done for patients that suffer from falls:
■ CBC: Basic metabolic panel to exclude/verify acute illness
■ Urinalysis: Only when additional symptoms of UTI present Figure 13. Algorithm for Falls Screening in elderly patients (Low Risk) [PPT]

MED 6.05 Principles of Geriatric Medicine Page 10 of 35

● Those who have no history of falls or those who do not have a
sensation of unsteadiness when standing or walking are usually
classified under low fall risk
● Management
○ Individualized fall prevention strategies depending on the
identified risk factors, patient education especially regarding fall
prevention, and review of medication for possible fall triggers are
recommended
○ Vitamin D with at least 800 IU per day with or without calcium
supplementation is also recommended
○ Community rehab programs if available
○ Those with a history of falls should be assessed with a gait,
strength and balance test
■ Timed Up and Go test
Figure 14. Timed Up and Go Test [PPT]
● Timed Up and Go test (TUG)
○ Starts with the patient seated on a chair
○ Allowed to use walking aids, if needed
○ Upon command, the patient stands, walks 3 meters, turns
around, walks back to the chair and sits down
■ Whole process is timed
■ An older adult is considered at risk for falls when he
completes the test in more than 12.6 seconds
○ Normative Reference Values [2022B]
■ 60-69 = 8.1 s
■ 70-79 = 9.2 s
■ 80-99 = 11.3 s
■ >14s = associated with high risk for fall (12.6s in lecture)
Figure 15. Algorithm for Falls Screening in elderly patients (Moderate Risk)
● The presence of a gait, strength, and balance problem with or
without history of a previous fall puts a patient at moderate risk
where, in addition to low risk interventions, a referral to rehab is
done for physical therapy exercises that would improve the
patient’s gait, strength, or balance problem
MED 6.05 Principles of Geriatric Medicine
Figure 16. Algorithm for Falls Screening in elderly patients (High risk) [PPT]
● Those with a history of recurrent falls or those with falls with
injuries should always undergo a thorough screening, including
tests for postural hypotension, a cognitive screen, a visual acuity
check, among others.
● These high risk patients would benefit from medication modification,
changing of footwear and even a home visit to check for the safety
of the patient at home
POLYPHARMACY
● Use of 5 or more drugs simultaneously
● As much as 40% of elderly patients may take around 5-9
medications and around 20% take 10 or more
● A challenge because of the multiple comorbidities of elderly patients
and the tendency to treat all these conditions with medications, in
addition to the widespread use of herbal and vitamin supplements
by older adults
○ Check the medications of the patient including the herbal
supplements that they are taking
● An increase in the number of medications taken increases the
potential of drug-drug and drug-disease interactions
● Predisposes patients to increased risk of adverse drug events
(ADEs)
● Medications commonly implicated in ADEs include:
○ Warfarin and antiplatelet agents (aspirin): bleeding in the elderly
○ Insulin and Oral Hypoglycemic agents (OHAs): cause
hypoglycemic events
○ Drugs promoting electrolyte and volume disturbances: diuretics
○ CNS drugs: sedatives and anticholinergic agents may cause
cognitive slowing
○ Antimicrobials: cause allergic reactions, diarrhea, other ADEs
● When doing the CGA always list down all the medications taken by
the patient = brown bag method
● Brown bag/Medication Reconciliation
○ Done at each clinic visit and especially during transitions of
care (during acute hospitalization, before hospital discharge,
transition to nursing facility etc.)
○ All medications should be considered in terms of unclear
diagnosis or indication (so the medications can be discontinued),
uncertain dose or route of administration, stop date, hold
parameters (e.g. some medications may not be given for a
certain BP level), lab tests needed for monitoring the response or
[PPT]
adverse effect of treatment, dosages different at the last care
setting, medication duplication, medications that should be
restarted, and the potential for drug-drug and drug disease
interactions
○ Check for the possible ADEs, effectiveness of drug therapy,
and adherence to the medications of the patients
● Recommendations for Geriatric Prescribing:
○ Start with non-pharmacologic therapy
■ Use of hot or cold compress, exercise and physical therapy
may be better for those with joint pains instead of taking
NSAIDs
○ Start with smaller doses and gradually increase if needed to
prevent ADEs
○ Renal function influences drug therapy
■ Doses of medications may need to be adjusted
Page 11 of 35
 ○ Make drug regimens as simple as possible so as not to confuse
elderly patients, especially those who do not have a caregiver at ○ Avoid taking:
home ■ Diuretics and hypotensive agents who fall/ have syncope
● Beers Criteria and Deprescribing: ■ Benzodiazepines for sleep problems
○ List of potentially inappropriate medications released by the ■ Anticholinergic medications that increase the risk for
American Geriatric Society cognitive impairment
○ Assess if the benefits of these drugs outweigh the risks ■ PPI for those with unclear indications should be
○ Discontinue drugs that have the lowest benefit to harm ratio and discontinued
the lowest likelihood of adverse withdrawal reactions or disease ■ Hypoglycemic agents in DM patients who have increased
rebound syndromes risk of hypoglycemia
■ These medications are not completely prohibited and may still ■ Statins in patients with chronic illness who are near the
be used if absolutely warranted end of life
■ Patients must be closely followed for development of ADEs
■ Ideally, these medications must be de-prescribed CONCEPT CHECKPOINT
● Must be done carefully, especially at time of care 1.T/F Polypharmacy is defined as the use of 4 or more drugs
transitions, when indications for specific drugs and patient simultaneously
preferences may not be clear [Harrison] 2. Patients with sleep problems should avoid taking what drug
○ Avoid taking: class?
■ Diuretics and hypotensive agents: in patients who fall/ have
syncope ANSWERS:
■ Benzodiazepines: for sleep problems 1. F, It is defined as the use of 5 or more drugs simultaneously
● can lead to dependence 2. .Benzodiazepines

■ Anticholinergic medications: increase the risk for cognitive

impairment
URINARY INCONTINENCE
● Since these drugs block acetylcholine receptors, it can
further worsen cognitive impairment ● Occurs in 1 in 3 older women, and 1 in 5 men
■ Proton pump inhibitors (PPI): for those with unclear ● Due to the embarrassment this condition brings about in elderly
indications because of numerous reported potential ADEs patients, this has been associated with depression and social
■ Hypoglycemic agents: in DM patients who have increased risk isolation in older adults
of hypoglycemia and are not eating well ● Patients may also be prone to develop skin irritations, pressure
■ Statins: in patients with chronic illness who are near the end ulcers, and falls (related to rushing to get to a toilet)
of life ● Curable and controllable in many geriatric patients, especially in
those who have adequate mobility and mental functioning
MUST-KNOW ● Patients may have overactive bladder, which may have symptoms
FALL of urinary urgency with or w/o incontinence, urinary frequency
● A fall occurs when a person’s center of gravity moves outside (voiding every 2 hours or more often) and nocturia
of their base of support and insufficient, ineffective or no effort ○ Pathophysiology, evaluation, and management of overactive
is made to restore balance bladder is the same for urge urinary incontinence
● Significant morbidity: fractures, brain, and spinal cord injury ○ In men, most have symptoms of overactive bladder and voiding
● May be divided into: difficulty (hesitancy, weak stream, post-void dribbling) = overlaps
○ Intrinsic: due to gait and balance disorders with symptoms of disorders of prostate [Harrison]
○ Extrinsic: due to polypharmacy and environmental factors ■ Urinary flow rate
● Timed Up and Go test (TUG) ■ Post-void residual (PVR) determination = for men,
○ Starts with the patient seated on a chair, he is allowed to use diabetics, with neurologic disorders and those with symptoms
walking aids if needed, upon command, the patient stands, of voiding difficulty
walks 3 meters, turns around, walks back to the chair and sits ● Done with full bladder
down ● Normal: 0-100 mL
○ An older adult is considered at risk for falls when he ○ In women, most common symptoms are a mix of urge and stress
completes the test in more than 12.6 seconds incontinence
POLYPHARMACY
● Use of 5 or more drugs simultaneously
● Medications commonly implicated in ADEs include:
○ Warfarin and antiplatelet agents: bleeding in the elderly
○ Insulin and Oral Hypoglycemic agents (OHAs): hypoglycemic
events
○ Drugs promoting electrolyte and volume disturbances:
diuretics
○ CNS drugs: sedatives and anticholinergic agents may cause
cognitive slowing
○ Antimicrobials
● Brown bag/Medication Reconciliation
● Recommendations for Geriatric Prescribing
○ Start with non-pharmacologic therapy
○ Start with smaller doses and gradually increase if needed to
prevent adverse drug events.
○ Renal function influences drug therapy, doses of medications
may need to be adjusted
○ Make drug regimens as simple as possible
● Beers Criteria and de-prescribing:
○ List of potentially inappropriate medications released by the
american geriatric society.
Figure 17. The 3 Incontinence Questions (3IQ) Assessment Tool [PPT]

MED 6.05 Principles of Geriatric Medicine Page 12 of 35

● Evaluation: See Figure 29 in Appendix for algorithm from Harrison
○ The history and physical examination should focus on identifying ○ Stool impaction
potentially reversible causes and contributing factors and ○ Hyperglycemia
identifying the specific lower urinary tract symptoms ○ Excessive caffeine or fluid intake
○ Screened using the 3 Incontinence Questions (3IQ) ○ Delirium
questionnaire (Refer to Figure 17) ○ Depression
■ Aids in identifying if a patient has incontinence, and in ○ Anxiety
classification of the kind of incontinence a patient has ○ Drug side effects( e.g. diuretics and anticholinergics)
○ Clinical forms: ● Interventions:
■ Stress incontinence ○ Kegel exercises
● Occurs when performing physical activity, such as ○ Behavioral interventions: timed voiding and double voiding
coughing, sneezing, lifting, or exercising ○ Intermittent catheterization
● Have the patient stand with a full bladder then ask the ○ Bedside commode
patient to cough, noting the leak of urine upon coughing
CONCEPT CHECKPOINT
[2022B]
■ Urge incontinence
● Urge or feeling that you need to empty your bladder but 6. Type of incontinence that occurs when performing physical
cannot go to the toilet fast enough activity such as coughing, sneezing, lifting, or exercising
● Due to detrusor muscle overactivity caused by loss of 7. T/F Urinary incontinence is more common in males
neurologic control or local irritation
ANSWERS:
■ Mixed incontinence 1.Stress incontinence
● Most common type of urinary incontinence in women 2. .F,1 in 3 older women, and 1 in 5 men
● Have symptoms of both urge and stress incontinence
○ Rule out the possible reversible conditions that contribute to MALNUTRITION
urinary incontinence such as:
● Undernutrition is common in older adults
■ UTI
● Check for factors that affect nutrition, including dentition, oral and GI
■ Stool impaction
disorders, drug regimens that may affect taste and oral secretions
■ Hyperglycemia
○ Often multifactorial
■ Excessive caffeine or fluid intake
● Depression and cognitive disorders
■ Delirium
● Protein- energy malnutrition
■ Depression
○ Occurs when intake is insufficient to meet metabolic demands
■ Anxiety
○ Patient would suffer from loss of muscle mass and weakness
■ Drug side effects (e.g. diuretics and anticholinergics)
○ Patients with this type of malnutrition are associated with
● Management of Urinary Incontinence:
■ Altered immunity
○ Alpha agonist: usually given in women
■ Impaired wound healing
■ Used to treat stress incontinence in women
■ Reduced functional status
○ Alpha blockers: usually given in men
■ Increased healthcare use
■ Used to decrease urethral tone in men with overactive
■ Increased mortality
bladders associated with prostate enlargement
○ Anticholinergic, antimuscarinic agents, and β3 stimulation
● Clinical manifestations of a malnourished patient
inhibit bladder contraction and are used for overactive bladder ○ Insufficient energy intake
and urge incontinence ○ Weight loss
■ These medications predispose patients to cognitive ○ Loss of muscle mass
impairment and may worsen the condition of those who ○ Loss of subcutaneous fat
already have dementing diseases ○ Localized or generalized fluid accumulation (ascites)
○ Decreased functional status
■ Perform cognitive testing beforehand
○ Patients with severe cognitive impairment and immobility can
● Screened using the Mini Nutritional Assessment (MNA) tool [See
Appendix for questionnaire]
generally be managed effectively by prompted voiding and ○ Asks for history of loss of appetite and weight loss, recent
diapers psychological stress or acute illness in past 3 months, presence
○ Interventions for others: of neuropsychiatric conditions, mobility problems, and notes the
■ Kegel exercises
patient’s BMI
■ Behavioral interventions: timed voiding and double voiding
○ Most commonly used screening tool in the elderly to assess risk
■ Intermittent catheterization
for malnutrition
■ Bedside commode
■ Score 12-14: Normal nutritional status
■ Score 8-11: At risk of malnutrition
MUST-KNOW ■ Score 0-7: Malnourished
URINARY INCONTINENCE ○ Patient is classified as malnourished, at risk for malnutrition, or
● Associated with social isolation and depression normal
● Predisposes patients to skin irritations, pressure ulcers and ■ Malnourished and risk for malnutrition: assessed for possible
falls condition causing poor intake, and referred to nutrition service
● Clinical forms:
SLEEP DISORDERS
○ Stress incontinence: Occurs when performing physical
activity such as coughing, sneezing, lifting, or exercising ● Very common among elderly
○ Urge incontinence: Urge or feeling that you need to empty ● Aging is associated with multiple changes in sleep architecture as
your bladder but cannot go to the toilet fast enough well as multiple diseases and disorders that can disrupt sleep
○ Mixed incontinence: Most common type of urinary ● Consequences of sleep difficulty
incontinence in women.Have symptoms of both urge and ○ Lower health-related quality of life
stress incontinence ○ Increased medication use
● Rule out the possible reversible conditions that contribute to ○ More cognitive decline
urinary incontinence such as: ○ Greater health care utilization
○ UTI ● Four main types of sleep disorders in the older adults
○ Insomnia
MED 6.05 Principles of Geriatric Medicine Page 13 of 35
 ■ Inability to fall asleep or stay asleep in a conducive
If unable to fall asleep within 20 min, get out of bed (and bedroom if
environment
possible); while out of bed, do something quiet and relaxing (repeat
■ Associated with depression, anxiety, alcohol intake, and this until you are able to sleep, but set a certain time to wake up every
ingestion of caffeinated beverages later in the day morning, whether or not you got a good sleep)
● Rule out these factors when dealing with insomnia
○ Obstructive sleep apnea (OSA) Only return to bed when sleepy
■ Usually associated with medical comorbidities like obesity and
congestive heart failure If unable to fall asleep within 20 minutes, again get out of bed
■ Occurs around 10% in the elderly
■ Bed partners may complain of loud snoring Repeat these behaviors until able to fall asleep within a few minutes
■ Patients may note headache, feeling of incomplete sleep,
Get up at the same time each morning (even if only a few hours of
daytime fatigue or tiredness
sleep)
○ Restless legs syndrome (RLS)
■ Irresistible urge to move the legs, which may or may not be Avoid naps (gradually lengthens sleep time; goal is to sleep earlier everyday
accompanied by unpleasant sensations in the leg, which is and have complete restful sleep)
relieved by movement
■ Increases in 70 y/o and above Avoid giving benzodiazepine and hypnotics to elderly because It will
■ More common in women not benefit them and may cause dependence
■ Uncomfortable sensation on the legs when not moving
■ Risk factors: PAIN
○ (+) family history
● Pain-related complaints account for up to 80% of clinic visit
○ Iron deficiency
○ Intake of antihistamine and antidepressants
● Usually due to back and joint pain, but headache, neuralgias and
○ Periodic leg movement in sleep (PLMS) cancer pain are also common
■ Flexion movements in the leg, ankle or toes ● Older adults are less likely to report pain or underreport
■ Mainly occurs in the non-REM phase of sleep ○ This can lead to suffering, social isolation, depression, physical
■ Can result to poor sleep and daytime somnolence disability, and loss of function
■ Can be found in up to 45% of older people, but is often of ● It is important to distinguish between acute and chronic pain
unknown clinical significance complaints
● Evaluation of sleep disorders ○ Pain may be accompanied by confusion, fatigue or irritability
Table 6. Evaluation of sleep disorders [PPT] ● Assess the effect of pain on the quality of life, social interactions
and functional level of the patient
Questions to be Conditions that Patients with ● Offer non-pharmacologic therapies
asked can interrupt sleep symptoms of: ○ Tai chi
○ Relaxation techniques
Do you feel sleepy Nocturia Obstructive sleep
○ Massage
during the day? GERD Apnea
○ Acupuncture
Do you have difficulty Chronic pain Restless leg
falling asleep at Caffeine syndrome Periodic
night? Alcohol leg movements in MUST-KNOW
Do you have difficulty sleep should ● Malnutrition
maintaining sleep at undergo sleep study ○ Undernutrition is common in older adults
night? ○ Check for factors that affect nutrition, including dentition, oral
Loud snoring? (OSA) and G.I disorders, drug regimens that may affect taste and
Urge to move legs? oral secretions
(RLS) ○ Depression and cognitive disorders
Kicking a bed ○ Protein-energy malnutrition
partner? (PLMS) ■ Occurs when intake is insufficient to meet metabolic
*Patients with symptoms of OSA, demands
RLS and PLMS should undergo
formal sleep evaluation
○ Screened using the Mini Nutritional Assessment (MNA)
tool
Table 7: Non-pharmacologic Management of Insomnia in Older adults ○ Score 12-14: Normal nutritional status
○ Score 8-11: At risk of malnutrition
Sleep Hygiene Rules
○ Score 0-7: Malnourished
Check effect of medications on sleep and wakefulness ● Sleep disorders
○ Insomnia
Avoid caffeine, alcohol, and cigarettes after lunch ■ Associated with depression, anxiety, alcohol intake,and
ingestion of caffeinated beverages later in the day
Limit liquids in the evening ○ Obstructive sleep apnea
■ Usually associated with medical comorbidities like obesity
Keep a regular bedtime-waketime schedule (sleep and wake up at a set and congestive heart failure
time)
○ Restless leg syndrome
Avoid naps or limit 1 nap a day, not longer than 30 mins (preferable ■ More common in women
in the morning) ● Risk factors:
○ (+) family history
Spend time outdoors (without sunglasses), particularly in the late ○ Iron deficiency
afternoon or early evening (get sunlight to regulate circadian rhythm) ○ Intake of antihistamine and antidepressants
○ Periodic leg movements in sleep
Exercise, but limit exercise immediately before bedtime ■ Can be found in up to 45% of older people, but is often of
unknown clinical significance
Instructions for Stimulus Therapy ● Pain
○ Pain related complaints accounts for up to 80% of clinic visit
Only go to bed when tired or sleepy

MED 6.05 Principles of Geriatric Medicine Page 14 of 35

 ○ Usually due to back and joint pain, but headache, neuralgias
and cancer pain are also common
○ Older adults are less likely to report pain
■ This can lead to suffering, social isolation, depression,
physical disability, and loss of function
○ It is important to distinguish between acute and chronic pain
complaints
○ Asses the effect of pain on the quality of life, social
interactions and functional level of the patient
○ Offer non-pharmacologic therapies
■ Tai chi
■ Relaxation techniques
■ Massage Figure 18. Predisposing and Precipitating factors of Delirium arranged in
■ Acupuncture increasing order of causing delirium (Note: red arrows). Ex: The patient with
high vulnerability (eg. px w severe dementia), may develop delirium even with
just 1 dose of a sleeping pill. Conversely, a patient with a lower vulnerability (eg.
CONCEPT CHECKPOINT Px w functional impairment) will develop delirium with more noxious insults like
8. T/F A score of 12-14 in the MIni Nutritional Assessment tool surgery or ICU stay, and will less likely develop delirium with sleep medications
or sleep deprivation
indicates that the patient is at risk for malnutrition. [PPT]

9. T/F Restless Leg syndrome is more common in Women. ● Risk factors:[Harissons, ]

○ Older adults
○ (+) baseline cognitive dysfunction or those prone to be
ANSWERS:
confused to begin with
6. F. Score 12-14: Normal nutritional status, ○ (+) functional and sensory impairments (hearing or visual)
Score 8-11: At risk of malnutrition, Score 0-7: Malnourished ○ Poor overall health
7. T. Recall.
○ (+) severe illness
C. COGNITION & AFFECT
○ (+) depression
○ (+) history of delirium
DELIRIUM ● Precipitating Factors: [Harissons, ]
● Acute decline in cognition that fluctuates over hours to days ○ Surgery and anesthesia
○ Difficulty in communicating with patient during sundown ○ ICU stay
● INATTENTION ○ Physical restraints
○ Main symptom of patient with delirium ○ Persistent pain
○ Patient is easily distractible and unable to maintain attention ○ Use of medications (eg. opiates, narcotics and
● Altered sleep-wake cycles anti-cholinergic drugs)
○ May present as hyperactive (very agitated) or hypoactive
○ Sleep deprivation
(appear lethargic)
○ Sleep medication
● Hallucinations and delusions common in these patients
○ Immobility
● Affect changes or labile mood
○ Malnutrition
● Considered as a medical emergency
○ Hypoxia and metabolic and electrolyte derangements
○ It is important to identify the actual cause/s of the delirium to
correctly manage the case because it can be the Table 8. The Confusion Assessment Method (CAM) Diagnostic
manifestation of an underlying critical illness [Harissons] Algorithm [Harissons 20th ed, page 148]

○ Common in hospital settings, such as the ER and ICU
○ High rates reported in patients undergoing hip surgery
○ Often unrecognized; failing to recognize upto 70% of affected
patients
○ Refer to Figure 28 in Appendix for an overview of the
assessment and management of impaired mental status and
delirium in older patients
○ Substantial morbidity and mortality
■ Longer length of hospital stay
■ More likely to have subsequent delirium episodes
■ More likely to have cognitive decline
■ Following hospitalization, the 1-yr mortality rate associated
with delirium is around 35-40%
THE CONFUSION ASSESSMENT METHOD (CAM)
DIAGNOSTIC ALGORITHM
The diagnosis of delirium requires the presence of features 1 and 2
and either feature 3 or 4.
Feature 1. Acute Onset and Fluctuating Course
This feature is satisfied by positive responses to the following
questions:
Is there evidence of an acute change in mental status from the
patient’s baseline? Did the (abnormal) behavior fluctuate during the
day, that is, tend to come and go, or did it increase and decrease in
severity?
*Patient may have normal behavior during part of the day, but with changes in
mental status in other parts of the day

Feature 2. Inattention

This feature is satisfied by a positive response to the following

question:
Did the patient have difficulty focusing attention, for example, being
easily distractible, or have difficulty keeping track of what was being
said?
*Patients are easily distractible and can’t focus on questions when doing
history-taking, have a hard time keeping track of the conversation

Feature 3. Disorganized thinking

MED 6.05 Principles of Geriatric Medicine Page 15 of 35

 ○ Daily function is preserved
This feature is satisfied by a positive response to the following
○ Modest cognitive decline in one or more cognitive domains
question:
■ Complex attention, executive function, learning and memory,
Was the patient’s thinking disorganized or incoherent, such as
language, perceptual-motor, or social cognition
rambling or irrelevant conversation, unclear or illogical flow of ideas,
○ Alertness and attention is preserved (unlike in delirium)
or unpredictable switching from subject to subject?
○ Other dementias are unlikely
Feature 4. Altered level of consciousness ○ AD develops at a higher frequency in MCI patients progressing
to AD at a reported rate of 6% to 15% per year
This feature is satisfied by any answer other than “alert” to the ● Normal aging does not cause impairment of cognitive function of
following question: sufficient severity to render an individual dysfunctional
Overall, how would you rate the patient’s level of consciousness: ○ Loss of function is the hallmark of a dementia syndrome
alert (normal), vigilant (hyperalert), lethargic (drowsy, easily ● Slowed thinking and reaction time, mild recent memory loss and
aroused), stupor (difficult to arouse), or coma (unarousable)? impaired executive function can occur with increasing age, but may
not always progress into dementia [Harissons 20th ed]
● Management ● Aspects of cognition affected:
○ Treat underlying cause ○ Memory loss
■ Often, there are a multitude of factors that triggered the ■ Problems with recent memory, while long term memory is
delirium episode and all of them have to be addressed usually intact in mild cases
accordingly ■ Would become repetitive, and asks questions over and over
■ Example: A patient in pain may experience delirium because again
of the pain, the medication for the pain, and the lack of sleep ■ May be unable to plan and perform tasks, even those that
because of the pain. All of these possible factors must be they have performed for many years
considered when addressing the patient’s concerns ○ Language
○ Supportive care: ■ Struggle with word finding, following simple instructions,
■ Use of clocks, calendars, living spaces with windows (to allow difficulty communicating
sunlight), access to one’s own objects (eg. eye glasses, ○ Visuospatial
hearing aids, clothings, pictures), and family visits ■ Can’t make proper abstract connections between 2 things
○ Avoid physical restraints ■ Ex: What is the similarity between a bike and car?
■ Will cause more agitation ● Unable to say that they’re both modes of transportation
○ Chemical restraints must be used, only when they are a threat to ● Answer: Both have wheels; no similarities
self or staff ○ Praxis
■ Typical (Haloperidol), Atypical (Risperidone, Olanzapine), ■ Problem with personal care
Antipsychotics ○ Calculation
○ Judgement
MUST-KNOW ○ Problem-solving
● Delirium ● Dementia is also associated with neuropsychiatric and social
○ Acute decline in cognition that fluctuates over hours to days deficits (behavioral and psychological symptoms of dementia -
○ INATTENTION BPSDs) [PPT]
○ Altered sleep-wake cycles ○ Most of the time patients are brought due to these BPSDs
○ Hallucinations and delusions because these are bothersome to the patient’s family or
○ Affect changes caregiver
○ Medical Emergency ○ The patient may also have:
■ Common in hospital settings, such as the ED and ICU ■ Depression
■ High rates reported in patients undergoing hip surgery ■ Apathy
■ Substantial morbidity and mortality ● May lose their interest
● Longer length of hospital stay ■ Anxiety
● More likely to have subsequent delirium episodes ■ Hallucinations
● More likely to have cognitive decline ● Visual hallucinations are common
● Confusion Assessment Method (CAM) ■ Delusions of persecution, theft, abandonment, or phantom
○ Diagnosis: (+) Features 1 and 2, and either feature 3 or 4 borders
○ Feature 1: Acute Onset and Fluctuating Course ● Phantom borders: They believe there are people in their
○ Feature 2: Inattention house even if no one is there
○ Feature 3: Disorganized Thinking ■ Sleep disturbances
○ Feature 4: Altered Level of Consciousness ■ Compulsions
● Management: ● eg. repeated folding of clothes
○ Treat underlying cause ■ Disinhibitions
○ Supportive care ● They may no longer know what are the socially accepted
○ Avoid physical restraints behaviors
○ Administer chemical restraints only when he/she becomes a ● Dementia may be classified as:
threat to self or the staff ○ Alzheimer’s disease
○ Vascular Dementia
DEMENTIA ○ Parkinson’s disease / Lewy body dementia
● An acquired deterioration in cognitive abilities that impairs the ○ Frontotemporal dementia, etc
successful performance of activities of daily living ● These conditions may present with cognitive decline:
○ Dementia vs Mild Cognitive Impairment = changes in ○ Vitamin deficiencies
cognition, but functional ability is intact ■ Vitamin D and B12
● Age-related Cognitive Decline ○ Hypothyroidism
○ This diagnosis is suggested by mild forgetfulness, difficulty ○ HIV
remembering names, mildly reduced concentration ○ Head trauma
○ Such symptoms are sporadic and do not affect daily function ○ Brain tumors
● Mild Cognitive Impairment (MCI) ○ Degenerative disorders

MED 6.05 Principles of Geriatric Medicine Page 16 of 35

 ○ Work up involves ruling out these conditions and ideally
performing MRI dementia protocol
● Screening tests used to check for dementia:
○ Mini-Mental State Examination (MMSE) (See Appendix)
■ MMSE is a 30-point test of cognitive function, with each
correct answer being scored as 1 point [Harissons, 20th Ed.]
■ It includes tests in the areas of: orientation, registration, recall,
and language
○ Montreal Cognitive Assessment (MOCA) (See Appendix)
■ A bit harder than the MMSE because it test for other aspects
in cognition not tested by the MMSE
■ It requires the patient to memorize 5 objects instead of 3
■ If patient gets a high score in MMSE but you are considering
cognitive impairment, you can verify with MOCA
■ A score of 25 and below may indicate cognitive impairment
○ Mini-Cog
■ Sensitive screening tool for cognitive impairment
■ 3-item recall test and a clock drawing test
■ Ask the patient to memorize 3 objects and proceed to clock
drawing (draw the time 10 minutes past 11 on the clock), then
ask the patient to recall the 3 objects memorized
● 1 point for each object memorized and 2 points for a
correct clock drawing
● Score of 0-2 = possible dementia
Figure 19. Example of abnormal clock-drawing tests [PPT]
● Management for dementia:
○ There is still no treatment for dementia
■ Memantine and cholinesterase inhibitor (Donepezil,
Rivastigmine)
● Only slow down cognitive decline but do not reverse it
○ Optimize the patient’s physical and mental function
○ Identify and manage behavioral symptoms
(non-pharmacologically, if possible)
○ Educate patient and family on how to deal with the patient and
possible prognosis of disease
○ Patients in milder forms of dementia can be included in the
decision making process of their treatment course.
DEPRESSION
● Affects 10% of older men and 18% of older women, but is often
undiagnosed and untreated
○ Numbers may rise due to rise in mental health disorders brought
about by the pandemic
● Elderly patients with depression may report feeling tired, lack of
appetite, have trouble sleeping, and often irritable
● They may also have cognitive problems, such as forgetfulness,
difficulty concentrating, remembering, and making decisions
● Could be a risk factor in developing dementia
● Screening questions:
○ Includes
■ Over the past 2 weeks, have you felt down, depressed or
hopeless?
■ Over the past 2 weeks, have you felt little interest or pleasure
in doing things?
○ Positive initial screening prompts the use of the Geriatric
Depression Scale (GDS-15) See Appendix for questionnaire.
○ A score of 5 and above indicates a possible depression and
warrant referral for further investigation and treatment
MED 6.05 Principles of Geriatric Medicine
MUST-KNOW
DEMENTIA
● An acquired deterioration in cognitive abilities that impairs
the successful performance of activities of daily living
● Age-related Cognitive Decline
○ This diagnosis is suggested by mild forgetfulness, difficulty
remembering names, mildly reduced concentration
● Mild Cognitive Impairment
○ Daily function is preserved, but there is evidence of modest
cognitive decline in one or more cognitive domains
● Classified as:
○ Alzheimer’s disease
○ Vascular Dementia
○ Parkinson’s disease/ Lewy body dementia
● Other conditions that may present with cognitive decline:
○ Vitamin deficiencies (Vitamin D and B12)
○ Hypothyroidism
○ HIV
○ Head trauma
○ Brain tumors
○ Degenerative disorders
● Screening Tests:
○ Mini-Mental State Examination (MMSE)
■ MMSE is a 30-point test of cognitive function, with each
correct answer being scored as 1 point
○ Montreal Cognitive Assessment (MOCA)
■ A bit harder than the MMSE because it tests for other
aspects in cognition not tested by the MMSE
■ It requires the patient to memorize 5 objects instead of 3
■ If the patient gets a high score in MMSE but you suspect
cognitive impairment, you can verify with MOCA
■ A score of 25 and below may indicate cognitive impairment
○ Mini-Cog
■ 3-item recall test and a clock drawing test
■ 1 point for each object memorized and 2 points for a
correct clock drawing
■ Score of 0-2 = possible dementia
● Management for dementia:
○ There is still no treatment for dementia
○ Memantine and cholinesterase inhibitor (Donepezil,
Rivastigmine)
■ Only slow down cognitive decline but do not reverse it
DEPRESSION
● Affects 10% of older men and 18% of older women, but is often
undiagnosed and untreated.
● Elderly patients with depression may report feeling tired, lack of
appetite, and often irritable
● Screening questions:
○ Over the past 2 weeks, have you felt down, depressed or
hopeless?
○ Over the past 2 weeks, have you felt little interest or pleasure
in doing things?
● Geriatric Depression Scale
○ A score of 5 and above indicates a possible depression and
warrant referral for further investigation and treatment
CONCEPT CHECKPOINT
8. T/F Memantine and Rivastigmine can reverse the cognitive
impairment in patients with dementia.
9. All of the following are true of Depression, EXCEPT:
a. It affects 10% of older men and 18% of older women.
b. It is often undiagnosed and untreated
c. A score of 4 and below in the Geriatric Depression Scale
indicates a possible depression and warrant referral for further
investigation and treatment
ANSWERS:
8. F. It can only delay the progression of cognitive impairment
9. C. It should be a score of 5 and above
Page 17 of 35
 D. SOCIAL ASSESSMENT
● Social Support
○ Determine extent of family support
○ Determine the one who finances the patient’s medications
● Elder Neglect/abuse
○ Physical or verbal abuse, deprivation, and isolation should be
referred to social services to ensure patient’s safety
● Advance Directives
○ May guide future diagnostic and therapeutic plans
V. PREVENTION OF DISEASE IN THE ELDERLY
A. SCREENING
● Challenge of age-appropriate screening: Deciding between what
screening tests would offer a cost-effective and reasonable risk:
benefit ratio
○ Test should be done easily and non-invasive as much as
possible
○ Significance of risk:benefit ratio
■ Abnormal results may lead to testing/treatment in patients
who will not suffer morbidity or mortality due to a disease
because of limited life expectancy [PPT]
● Listed screening tests below are just guidelines
○ May proceed or not with the tests depending on the patient’s
clinical status and after informing your patient of the risks and
benefits of these tests so that the patient or the family may be
able to make an informed decision
NOTE: Those marked with an asterisk (*) were not discussed in the
lecture but were mentioned in previous transcriptions. Refer to
appendix for the summary table
COLON/COLORECTAL CANCER
● Recommended in all adults aged 50-75
○ USPSTF does not recommend screening for ages >85
○ ACP does not recommend screening among those with a life
expectancy of <10 years
○ Screening may be discontinued among patients with
comorbidities whose treatment may be hindered by screening
● Screening Tests
○ Annual: Fecal Occult Blood Test or Fecal Immunohistochemical
Test
○ Every 5 years: Sigmoidoscopy
○ Every 10 years: Colonoscopy
BREAST CANCER
● Screening starts at age 40 and continues while the patient is in
good health
○ USPSTF recommend screening up to age 74
■ Benefits and harms are insufficient in those >75y/o
● Screening Test: Mammography every 1-2 years
LUNG CANCER
● Screening is recommended for adults aged 55-74 (up to 80 y/o in
USPSTF guidelines) who are current or former smokers with a
30+ pack year history
○ USPSTF recommends discontinuation of screening if smoking
has been ceased for 15 years or have comorbidities that limits
their ability or willingness to undergo curative surgery
● Screening Test: Low Dose Chest CT Scan annually
PROSTATE CANCER
● ACS recommends screening of men aged 50 and above with a life
expectancy of >10 years ISO-certified, world-class quality
○ After discussion of risks, benefits and uncertainties of PSA
screening
○ USPSTF does not recommend screening with PSA
● Screening Tests: Prostate Specific Antigen every 1-2 years
○ If PSA > 2.5 ng/mL, screen annually
○ If PSA < 2.5 ng/mL, screen every 2 years
MED 6.05 Principles of Geriatric Medicine
OSTEOPOROSIS
● Recommended for women aged 65 and above and men aged 70
and above
○ If risk factors are present or with adult-age fractures, screen
among postmenopausal women and men aged 50-69
● Screening Test: Dual-Energy X-ray Absorptiometry (DEXA) scan
○ After initiating treatment for osteoporosis: every 1-2 years
○ Every 2 years annually after the aforementioned treatment
ABDOMINAL AORTIC ANEURYSM
● Recommend screening among men aged 65-75 with a history of
smoking
● Screening Test: Abdominal Ultrasound (1-time screening) [AAFP]
DIABETES
● Recommended in patients aged 45 and above
○ USPSTF recommends testing from ages 40-70 and in
overweight or obese patients
● Screening Tests: Annual Fasting Blood Sugar (FBS), Glucose
Tolerance Test, HbA1c Test
*CERVICAL CANCER [Harrison]
● Recommended for women aged 21-65, discontinue at age 65 if
adequate prior screening
● Screening Test:
○ Pap smears only every 3 years
○ HPV + Pap smear every 5 years
*CAROTID DISEASE [Harrison]
● Age >65, coronary artery disease, need for coronary bypass,
symptomatic lower extremity arterial occlusive disease, history of
tobacco use and high cholesterol would be appropriate risk factors
to prompt ultrasound in patients with a bruit
● Screening test: Perform a carotid ultrasound once
*CORONARY ARTERY DISEASE [Harrison]
● Screening test: Obtain coronary calcium score (CCS) once
○ CCS of 0 may have a strong negative predictive value for
coronary events in older adults [AHA/ACC]
○ Do not use CCS for patients with known CAD [scct]
B. CDC EXERCISE RECOMMENDATIONS (Older Adults)
● Recommendation 1:
○ At least 2 hours and 30 minutes (150 minutes ) of
moderate-intensity aerobic activity (i.e. brisk walking) every
week
● Recommendation 2:
○ 1 hour and 15 minutes (75 minutes ) of vigorous-intensity
aerobic activity (i.e. jogging/running) every week
● Recommendation 3:
○ An equivalent mix of moderate and vigorous aerobic
activities
● All recommendations must include muscle-strengthening
activities on 2 or more days a week that work all major muscle
groups (legs, hips, back, abdomen, chest, shoulders, and arms)
● Make sure to clear with the patient’s attending doctor before
recommending these exercises
C. VACCINES
Refer to appendix for a summary of the immunization schedule by age (≥19y/o) from CDC
● Aimed at creating immunity against common infections that could
lead to serious complications, as well as for rebuilding previously
obtained immunity [Harrison]
● Flu vaccines are given annually
○ Caregivers must also be given the vaccine[2022]
● Pneumonia: PCV-13 (Pneumococcal conjugate) given once
followed by PPSV-23 (Pneumococcal polysaccharide) after 6
months to 1 year
○ Given at age of 65 [CDC]
● Shingles: Varicella vaccine prevents reactivation of varicella
leading to Herpes zoster
Page 18 of 35
 ○ Given 2 doses at age ≥50 [CDC]
○ Even those who had shingles before must be vaccinated [2022] 10.Queen Elizabeth II (age 94) consults you, a filthy peasant doctor,
for breast cancer. Will you prescribe her breast cancer screening
● Tetanus, Diphtheria, Pertussis (Tdap)
as a precautionary measure?
○ 1 dose Tdap, then Td or Tdap booster every 10 years [CDC]
11.Lippy Dimia brags that she brisk walks for 30 minutes every
● COVID vaccines when available
weekday with strength exercises every Tuesday and Thursday.
Is her exercise regimen appropriate?
MUST-KNOW
SCREENING ANSWERS:
● Screening must balance cost-effectiveness and reasonable 10. No. Breast CA screening is not advised for patients older 74
risk:benefit 11. Yes. 30 minutes * 5 weekdays = 150 minutes per week; appropriate for moderate
intensity exercises, with at least 2 days of muscle strengthening
● Colon Cancer:
○ adults aged 50-75 VI. FUNDAMENTALS OF GERIATRIC CARE
○ Do not screen among ages > 85 or have < 10 yr life
expectancy ● Remember aging is not a disease but it increases susceptibility
○ Discontinue if screening hinders treatment for another to diseases due to reduced physiologic reserves
disease ○ Elderly persons must be educated of this reality
○ Test: ○ Eg. A fall from a younger age group would be most likely
■ Annual fecal occult blood test or immunohistochemistry unremarkable with no lasting consequences because the body
■ Sigmoidoscopy every 5 years, colonoscopy every 10 years still has physiologic reserves available to compensate for the
● Breast Cancer: event. However, a fall in the older age group causes significant
○ adults aged 40-74 stress leading to severe consequences
○ Mammography every 1-2 years
● Lung Cancer:
○ Smokers with current or prior 30+ pack year history and are
aged 55-74
○ No need to screen those who have stopped for > 15 years, or
have comorbidities
○ Test: low dose chest CT scan annually
● Prostate Cancer
○ Men ≥ 50 years and with >10 year life expectancy
○ Test: PSA tests annually if > 2.5 ng/mL or every 2 years if <
2.5 ng/mL
● *Cervical Cancer:
○ Women aged 21-65 Figure 20. Aging increases susceptibility to diseases [PPT]
○ Pap smear every 3 years or HPV+Pap every 5 years
● *Carotid Disease ● Goals of Care: To improve or at least maintain functional ability
○ Age >65, (+)CAD, needs coronary bypass, hx tobacco use, and present quality of life
high cholesterol, (+)bruit ○ Requires inter-professional collaboration (multi-disciplinary
○ Carotid Ultrasonography (taken once) approach)
● *Coronary Artery Disease ■ Doctors, nurses, PT, OT, speech therapists, pharmacists,
○ Coronary calcium score (taken once) social workers, etc
● Osteoporosis ○ Important to open a dialogue with patients to inform them of the
○ Women aged > 65, men aged > 70 risks and benefits of treatment, and make them aware of other
○ Screen postmenopausal women and men aged 50-69 if risk modes of care including palliative and end-of-life care when
factors are observed treatment is no longer the main goal
○ Test: DEXA every 1-2 years ● Emphasis on Person-Centered Care
● Abdominal Aortic Aneurysm ○ Balancing between the following:
○ men aged 65-75 + History of smoking ■ Patient and family’s preferences
○ Test: 1-time abdominal ultrasound ■ Evidence-based medicine, regarding the prognosis, and
● Diabetes risks
○ Adults aged > 45 ○ Focuses on forming individualized and goal-oriented care
○ Screen those who are overweight or obese plans based on stakeholder preferences
○ Tests: Annual FBS, Glucose Tolerance, HbA1c ○ Respecting the patient’s decision to refuse further medical
CDC EXERCISE RECOMMENDATIONS therapy is part as long as the patient made the decision while
● 150 minutes per week of moderate-intensity exercise cognitively able to do so
● 75 minutes per week of vigorous intensity exercise ○ Care plan must often be reviewed to check whether the
● Equivalent mix of both management is in line with the patient’s goals
● All must include muscle strengthening exercises for all major
muscle groups on 2+ days per week NICE-TO-KNOW [Harrison]
VACCINES American Geriatrics Society: Elements to person-centered care
● Annual Flu vaccine for patient and caregivers 1. Individualized, goal-oriented care plan based on the person’s
● Pneumococcal vaccine (PCV-13 followed by PTSV-23) at the preference
age of 65 2. Ongoing review of the person;s goals and care plan
● Shingles vaccine (2 doses) at age 50 3. Continual information sharing and integrated communication
● Tetanus & Diphtheria boosters every 10 years 4. Education and training for providers and, when appropriate, the
● COVID vaccines if available person and those important to the person
5. Performance measurement and quality improvement using
feedback from the person and caregivers
CONCEPT CHECKPOINT

MED 6.05 Principles of Geriatric Medicine Page 19 of 35

RECOMMENDATIONS IN IMPLEMENTING PERSON-CENTERED CARE
IN COMPLEX GERIATRIC PATIENTS (from AGS)[Harrison, PPT]
● Don’t recommend percutaneous feeding tubes (or NGT) in patients
with advanced dementia; instead offer oral assisted feeding
● Don’t use antipsychotics as the first choice to treat behavioral and
psychological symptoms of dementia
● Don’t use benzodiazepines or other sedative-hypnotics in older
adults as first choice for insomnia, agitation or delirium
● Don’t routinely prescribe lipid-lowering medications in individuals
with a limited life expectancy.
○ Avoid use of statins in patients with a limited life expectancy
● Don’t recommend aggressive or hospital-level care for a frail elder
without a clear understanding of the individual’s goals of care and
the possible benefits and burdens
○ Avoid aggressive treatment measures without informing the
patient or their family of the risks and benefits
● Avoid using medications other than metformin to achieve HbA1c
<7.5% in most older adults; moderate control is generally better
○ It is recommended to have less strict HbA1C control in frail
patients
● Don’t use antimicrobials to treat bacteriuria in older adults unless
specific urinary tract symptoms are present
● Don’t recommend screening for breast, colorectal, prostate or lung
cancer without considering life expectancy and the risks of testing,
overdiagnosis and overtreatment
● Don’t prescribe cholinesterase inhibitors for dementia without
periodic assessment for perceived cognitive benefits and adverse
gastrointestinal effects
● Don’t obtain a Clostridium difficile toxin test to confirm “cure” if
symptoms have resolved
REMINDER:
● Care plans for the patient must always be for the patient’s best
benefit
● It must always be aligned to the patient’s goals and values
● The goal is not to add years to life but to add life to those years
○ We want our patient to be as healthy as possible and to be as
functional as long as they can, by assessing medical, functional
and psychosocial conditions so that our patient may maintain or
achieve independence
MUST-KNOW
● Aging increases susceptibility to disease due to reduced
physiologic reserves.
● Goal of care: maintain functional ability and quality of life
● Individualized person-centered care is a core tenet of geriatric
care
● DON’Ts in geriatric care: [PPT]
○ Use of NGT among patients with advanced dementia
○ Use of antipsychotics and benzodiazepines as first-line
treatment
○ Use of statins in patients with a limited life expectancy
○ Aggressive treatment measures without informing the patient
or their family of the risks and benefits
○ Strict HbA1c control in frail patients
○ Antibiotic use for bacteriuria in patients w/o UTI symptoms
○ Screening tests for breast, colorectal, lung or prostate CA w/o
considering life expectancy, over-diagnosis and the risks of
testing
REVIEW QUESTIONS
2022 REVIEW QUESTIONS | Same lecturer
1. Which of the following chronic diseases is associated with
the highest rate of mortality among elderly patients above 85
years old?
a. Cancer
b. Cardiovascular Diseases
c. Alzheimer’s Disease
d. Stroke
MED 6.05 Principles of Geriatric Medicine
2. What is the primary goal of care in elderly patients?
a. Cure of chronic diseases
b. Pain management
c. Maintain functional ability
d. End-of-life-care
3. An 85-year-old man with advanced dementia was brought for
consult due to marked decrease in appetite. What is the
most appropriate thing to do?
a. Insert a PEG and initiate tube feeding
b. Insert an NGT and initiate tube feeding
c. Give food supplements and vitamins
d. Instruct relative regarding hand feeding
4. Which is true about aging process?
a. Aging is considered a disease
b. Homeostenosis is maintained
c. Abnormal laboratory findings may not reflect a disease process
5. An abnormal result in which of the following tests or
procedures would warrant further evaluation in elderly
patients?
a. Thyroid function tests
b. Pulmonary function tests
c. ESR
d. Urinalysis
6. Screening for specific diseases is most appropriate in which
elderly patient?
a. Bone mineral density test in a 70-year old man
b. Pap smear in a 70-year old-woman
c. Low-dose CT scan in a 70-year-old-non smoker
d. Colonoscopy in a 70-year-old man with advanced dementia
7. A healthy 60 year old man requests to be screened for
possible diseases. He has no known comorbids and has a
family history of hypertension. What tests do you
recommend
a. Low dose chest CT scan and PSA
b. Carotid and abdominal ultrasound
c. Bone mineral density test and Colonoscopy
d. FBS and Fecal Occult Blood
8. What is the target systolic blood pressure (in mmHg) in an
elderly with history of postural hypotension?
a. <130
b. <150
c. <140
d. <160
9. An elderly patient came in due to fall. The patient recalls that
he took a new medication a few hours prior to his fall. Which
of the following medications is most likely to be associated
with his fall?
a. Ibuprofen
b. Prednisone
c. Furosemide
d. Metformin
10.A 70/F came in due to a fall. She claims to have weakness
after taking a new medication for diabetes. She also
complains of lightheadedness upon rising from her bed.
What is the most important step in managing her fall?
a. Evaluate patient for osteoporosis
b. Prescribe Vitamin D supplementation
c. Conduct a fall risk assessment
d. Refer patient to physical therapy
11.A 75-year-old patient is about to be discharged from the
hospital. He is presently taking 8 medications while
admitted. What is the most important step to perform when
making him a list of his discharge medications?
a. Instruct caregivers on the correct drug regimen
b. Review all medications and check for appropriateness
c. Revise medications to once daily dosing for easier compliance
d. Check if the patient is cognitively intact to manage his own
medications
12.An 80-year old woman with mild dementia was brought in
due to incontinence. She leaks urine frequently throughout
the day but becomes agitated when told to wear diapers.
Page 20 of 35
 What would be the most appropriate management for this Answer Key:
1C
patient? 2C
a. Prescribe antimuscarinic drugs 3D
b. Prescribe topical estrogen 4C
5A
c. Instruct patient to do kegel exercises
6A
d. Instruct caregiver to do timed voiding 7D
13.What is the most important aspect of the Comprehensive 8B
Geriartric Assessment? 9C - Diuretic use is usually associated with falls because it can cause or worsen orthostatic
hypotension
a. Treatment of underlying medical conditions 10C
b. Primary prevention screening for specific diseases 11B
c. Developing a care to plan to maximize functional status 12B
13C
d. Identifying psychosocial issues in elderly patients 14A
14.Which of the following predispose patients to delirium? 15B
a. Hearing impairment 16B
17C
b. Surgery
18B
c. Immobility 19C
d. Medications 20B
15.An elderly man presents with confusion. He is oriented to
person, but not to time and place. He answers questions but 2021 REVIEW QUESTIONS | Same lecturer
is easily distractible. During the conversation, he is noted to 1. What body changes is expected in a 75 year old man?
have disorganized thinking. What should be established in a. Bone mass is constant
the interview to determine if this is delirium? b. Lean body mass increases
a. Disorganized thinking c. Visceral fat increases
b. Baseline level of cognition d. Weight gain
c. Altered level of consciousness 2. What is the best management for polypharmacy?
d. Inattention a. Ask patient to provide a list of their prescription medications
16.An elderly woman came in due to altered level of b. Check for possible drug interactions
consciousness. She was noted to be well until a day prior to c. Change medications frequently to avoid tolerance
consult when she was noted to be more drowsy than usual d. Medication regimen should address all of the patient’s medical
and refused to eat. Which tests should be done in these conditions
kinds of patients? 3. Who among the following fulfills the frailty phenotype?
a. Cranial CT scan and liver function test a. 60 y.o with dementia and ____
b. Electrolyte panel and urinalysis b. 70 y.o patient with slow gait and decreased physical activity
c. Cranial MRI and chest xray c. 80 y.o. - polypharmacy and comorbidity
d. CBC and blood culture d. 90 y.o. with depression
17.An elderly woman came for consult due to self-reported 4. An 80/M underwent hip surgery and was referred due to
memory loss. She is independent in her ADLs and needs post-op pain and aggressive ___. How can this patient's
assistance only when going out of the house. A battery of delirium be managed?
screening tests was done but the diagnosis remains unclear. a. Ensure adequate pain control
What test can be done to determine if the patient has b. Give haloperidol to control delirium
dementia? c. Give sedative to control delirium
a. Mini-Cog d. Provide physical restraints to avoid injury
b. MMSE 5. A 75/F had a recent fall and reports lightheadedness when
c. Neuropsychological testing she gets out of bed in the morning. What is the most
d. MOCA important step in addressing her fall?
18.An elderly man came in due to difficulty recalling events and a. Conduct fall risk assessment
difficulty learning new tricks. He remains independent in his b. Discontinue any offending medication
functional abilities. What should you tell this patient? c. Prescribe an individualized exercise plan
a. This is a normal part of aging d. Provide calcium supplements
b. He has mild cognitive impairment and should be observed for 6. An elderly male was brought to the hospital due to altered
progression of symptoms mental status. What is one diagnostic clue to confirm that he
c. He may have delirium and should undergo comprehensive has dementia? (Non-verbatim)
tests a. Fluctuations of symptoms
d. He has dementia and should be started on cholinesterase 7. What is the most definitive characteristic of delirium?
inhibitors a. Agitation
19.Which of the following is associated with frailty and b. Inattention
dementia in the elderly? c. Confusion
a. CRP 8. Which among is true about frailty and decreased stress
b. TNF-α response in elderly
c. IL-6 a. Good nutrition can build up muscles in debilitated elderly
d. ESR patients
20.An elderly woman with diabetes and congestive heart failure b. Bed rest should be recommended for hospitalized elderly
maintained on insulin and spironolactone comes due to an patients
acute onset of urinary incontinence. Which of the following c. In absence of stress, mildly frail elderly may appear normal
is important to determine in her history? d. Vaccinations should not be given to frail elderly as they cannot
a. Incontinence triggers mount an immune response
b. Symptoms of UTI 9. What is true regarding the consequences of aging on
c. Diuretic use diabetes?
d. Control of blood sugar a. Elderly individuals have stricter HbA1c target
b. Diet and exercise in the elderly is ineffective in diabetes
management

MED 6.05 Principles of Geriatric Medicine Page 21 of 35

 c. Hypoglycemia symptoms occur at a higher blood sugar levels b. Provide physical restraints to avoid injury
compared to younger patients c. Ensure adequate pain control
d. Medications with high risk of hypoglycemia should be avoided d. Give sedatives to manage agitation
11.What is the most common cause of persistent pain in older
Answer Key:
1C - Systemic effects of aging can be clustered in 4 domains, one of which is change in body
adults?
composition that is characterized by: Decrease in weight, Decrease in lean body mass, a. Cancer pain
Increase in waist circumference, Increase in visceral fat, Bone demineralization. b. Ischemic pain
2B - Place all prescribed medicines in one bag to know the different interactions of each
c. Musculoskeletal pain
3B - Frailty phenotype: weight loss, slow gait, decreased grip, fatigue, decreased physical
activity d. Neuropathic pain
4A - Address the precipitating/underlying factor of the delirium 12.75/F had a recent fall. She reported lightheadedness upon
5A - Conducting fall risk assessment would determine what most likely caused her fall and getting up from her bed in the morning. What is the most
would help address it without any unnecessary actions.
6A important step in addressing the patient’s fall?
7B a. Conduct a fall risk assessment
8C b. Discontinue offending medication
9D
c. Prescribe an individualized exercise program
d. Provide calcium supplementation
2020 REVIEW QUESTIONS | Same lecturer 13.What is the most common form of incontinence seen among
1. Which statement is true regarding population aging? elderly women?
a. Men and women have similar life expectancy a. Mixed
b. The highest percentage of growth is seen among the oldest of b. Overflow
the old (>80 years old) c. Stress
c. The rate of population aging is decreasing d. Urge
d. The rate of population aging is similar in the varying 14.86/M has weight loss of 8 kg over the past year. He has
geographic regions in the world anorexia and depressive symptoms since his wife died 2
2. Which is NOT a part of basic activities of daily living years ago. He is hypertensive and diabetic, and the low salt,
a. Dressing low-calorie meals which he eats minimally. What is the best
b. Maintaining continence plan of management for his malnutrition?
c. Personal hygiene a. Give an antidepressant with weight gain as side effect
d. Taking medications b. Give nutritional supplements
3. What is true of disability seen among older adults? c. Maintain dietary restrictions to prevent complications of his
a. Age is the most important risk factor of functional disability diseases
b. Cognitive impairment limits the functional independence d. Prescribe an antianorexia drug
c. Daily function is impaired even in the early stages of frailty 15.What should be the target A1c level in a frail older diabetic
d. Impairments in performing activities of daily living are more patient?
common among men a. < 9%
4. What body changes is expected in a 75-year-old man? b. < 8%
a. Bone mass is constant c. < 7%
b. Lean body mass increases d. < 6%
c. Visceral fat increases 16.Which screening test is recommended among the elderly?
d. Weight gain a. Annual bones mineral density determination
5. What clinical state does not describe an aging phenotype? b. Annual mammography in patients aged > or = to 60 years
a. Altered response to treatment c. FBS every 5 years in hypertensive patients
b. Classical disease presentation d. Monitor blood pressure at least once a year
c. Emergence of geriatric syndromes 17.What vaccine is NOT recommended for the elderly?
d. Loss of autonomy a. Hepatitis B
6. Which of the following characteristics is NOT included in the b. Herpes Zoster
frailty phenotype? c. Influenza
a. Fatigue d. Pneumonia
b. Impaired grip strength Answer Key:
c. Multiple comorbidity 1B
d. Slow gait 2D
3B
7. What is the best management for polypharmacy? 4C - Decrease in weight, Decrease in lean body mass, Increase in waist circumference,
a. Ask patient to provide a list of their prescription medications Increase in visceral fat, Bone demineralization
b. Check for possible drug interactions 5B
6C - Frailty phenotype: weight loss, impaired grip strength, fatigue, decreased physical activity,
c. Change medications frequently to avoid tolerance slow gait
d. Medication regimen should address all of the patient’s medical 7B - The brown bag test means BRINGING in ALL medications then: See if they can d/c
conditions unnecessary drugs, Simplify regimen, Check for interactions, Px/Caregiver must understand
regimen, Periodically review the medications
8. Which of the following is NOT a characteristic of delirium?
8A - One of the clinical presentations of delirium in Harrison’s states that cognitive change
a. Cognitive change may be explained by dementia NOT explained by dementia
b. Disturbed attention 9D - Predisposing factors – dementia, chronic or transient neurologic dysfunction (caused by
c. Fluctuates during the day diseases, dehydration, alcohol, psychoactive drugs), sensory and hearing deprivation
10C/A - One of the precipitating factors of delirium is surgery and persistent pain, During the
d. Rapid decline in level of consciousness lecture however, it is mentioned: “if it is really needed when the patient is a danger to
9. Which of the following is NOT a predisposing factor for themselves and to others that’s when you give medication which is usually Haloperidol that is
delirium? the usual treatment of choice”
11C
a. Dementia 12A
b. Immobilization 13A - According to Harrison’s older women are more likely to have mixed (urge + stress)
c. Sensory impairment incontinence than any pure form
14B
d. Use of psychoactive drugs
15B - Treatment goals are altered further in frail older adults who have a high risk of
10.80/F underwent hip surgery and was referred due to complications of hypoglycemia and a life expectancy of <5 years. In these cases, an even less
post-operative pain and aggressive behavior. What is the stringent target (e.g., 7–8%) should be considered.
most appropriate management for this patient? 16D
17A - Vaccines: Annual influenza, Herpes zoster once after 50 y/o, Pneumonia vaccine after
a. Give haloperidol to patients at risk for delirium 65 y/o)

MED 6.05 Principles of Geriatric Medicine Page 22 of 35

 REFERENCES
● American Family Physician (2020). Screening for Abdominal Aortic
Aneurysm: Recommendation Statement. Retrieved from:
https://www.aafp.org/afp/2020/0515/od1.html
● Atienza ML. (2021). Lecturer 28 - Principles of Geriatric Medicine. [Lecture
Video]
● Greenberg SA (2012). The Geriatric Depression Scale (GDS). New York:
Hartford Institute for Geriatric Nursing, NYU College of Nursing. Retrieved
from:
https://wwwoundcare.ca/Uploads/ContentDocuments/Geriatric%20Depressio
n%20Scale.pdf
● Jameson JL, Fauci A, Kasper D, Loscalzo J, Longo D, Hauser SL (2018).
Harrison’s Principles of Internal Medicine (20th Ed). NY City, NY: McGraw Hill
Education
● US Preventive Services Task Force (2018). Cervical Cancer: Screening.
Retrieved from:
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervic
al-cancer-screening
● 2022B Lecture Transcriptions
ERRATA

Scan QR code at left or click this link:

MEDICINE I ERRATA SHEET

MED 6.05 Principles of Geriatric Medicine Page 23 of 35

 SUMMARY
MUST KNOW CONCEPTS
I. AGING
● Aging is a progressive process associated with declines in structure
and function, impaired maintenance systems, increased
susceptibility to disease and death, and reduced reproductive
capacity
● Structural and functional changes may be due to primary aging
changes or age-related diseases
● Old age is a major independent risk factor for chronic diseases and
associated mortality
● Aging is not a disease, but it does predispose to the development of
different diseases
II. PHYSIOLOGICAL & ANATOMICAL CHANGES IN AGING
● Primary aging
○ Reflects changes in physiologic reserves over time that are
independent of changes from diseases
○ These may appear most significantly during periods of stress
(ex. Exposure to extreme heat, dehydration and shock)
● Optimal aging
○ Occurs in patients who do not have debilitating diseases into
their 80s and 90s
○ May be determined by genetic influences (20-30%) and healthy
lifestyles (20-30%)
● Vital Signs
○ Due to atherosclerosis, stiffening of the large arteries, and
increase of the vessel lumen, there is usually an high SBP with a
normal or low DBP
■ This results to the development of Isolated Systolic
Hypertension with widened pulse pressure
○ Elderly patients are more prone to develop orthostatic
hypotension
■ Defined as a drop in SBP ≥ 20 mmHg or a drop in DBP ≥ 10
mmHg within 3 minutes of standing
● Eye and Vision Changes
○ Dry eyes due to fewer lacrimal secretions
○ Pupils become smaller
○ Visual acuity gradually diminishes
○ Presbyopia: there is progressive loss of accommodation and
difficulty focusing on nearby objects
○ Increased risk of developing cataracts, glaucoma, and macular
degeneration
● Hearing Changes
○ Presbycusis: hearing loss with aging
● Mouth and Teeth Changes
○ Decreased salivary secretions and loss of taste
○ There is loss of dentition due to dental caries or periodontal
disease
● Chest and Lung Changes
● Structural changes lead to an increased work of breathing
○ Chest wall becomes stiffer, respiratory muscles weaken, and
elastic recoil of the lungs decrease
○ Thoracic spine may also develop deformities like kyphosis
○ Coughing becomes less effective
○ Surface area for gas exchange declines; residual volume
increases resulting in a decrease in arterial pO2, but O2
saturation remains above 90%
● CVS Changes
○ Systolic bruits heard in the middle or upper portions of the
carotid arteries indicate stenosis from atherosclerotic plaques
○ S3 usually suggests heart failure from volume overload of the left
ventricle in elderly patients
■ Normal in young adults
○ S4 usually suggests decreased ventricular compliance and
impaired ventricular filling
○ Aortic sclerosis is the result of fibrosis and calcification of aortic
valve without impeding blood flow
○ Aortic stenosis: where valvula changes result in outflow
obstruction
■ Most common clinically significant valvular disorder among
older adults
● GI Changes
○ Normal changing is associated with changes that predispose
older adult to dysphagia
○ There is delayed emptying of the stomach, prolonging gastric
contact time with noxious substances line NSAIDs which
predisposes elderly to gastric mucosal injury and development of
ulcers
○ Increased risk of constipation in the elderly may be due to
reduction and functional impairment of the neurons in the
myenteric plexus
○ Impaired detoxification of the liver may be due to decreased
hepatic blood flow and reduced metabolizing enzymes.
● Renal Changes
○ Amount of kidney tissue decreases causing decline in renal
function. The GFR declines by about 8 ml/min/1.73 m2 per
decade after the fourth decade
○ Acceleration of loss renal function
■ Associated with diseases like hypertension, diabetes,
dyslipidemia, smoking, atherosclerotic disease
■ Influences the dosing of certain medications that are
metabolized and excreted by the kidneys
○ The loss of reserve manifests clinically in patients being
vulnerable to renal complications during acute illness like after
MI or during sepsis
○ Urinary incontinence increases with age
○ Benign prostatic hyperplasia is common
■ Significant enlargement causing urinary hesitancy, dribbling
and incomplete emptying
● Musculoskeletal Changes
○ Both men and women lose cortical and trabecular bone
○ Loss of height due to thinning of intervertebral discs and
shortening of vertebral bodies with osteoporosis
○ There is a 30-50% decline in muscle mass.
○ Sarcopenia is the loss of lean body mass and strength with
aging
● Neurological Changes
○ “Benign forgetfulness” may occur
■ Should be differentiated from dementia where the
forgetfulness impairs with the activities of daily living
○ Retrieve and process data more slowly and take longer to learn
new information
○ Have difficulty multitasking and can only focus at one task at a
time
○ May develop benign essential tremors
○ May lose vibratory sense in the feet and ankles, and position
sense may diminish
○ Gag reflex may be decreased
● Immunologic Changes
○ Increased ESR, CRP, IL-6 and TNF α
○ Increased IL-6 is associated with dementia and frailty in the
elderly
○ T cells become less numerous due to atrophy of the thymus
○ B cells may overproduce antibodies, leading to age-related
increase in autoimmune diseases
III. APPROACH TO THE OLDER ADULT
● Approach to older adult
○ Learn to quickly identify frail elderly patients
○ Look for common geriatric syndromes, including mood disorders
○ Use efficient assessment tools
○ Take into account a patient’s goals, life expectancy and
functional status
○ Review advanced directives and goals of care periodically

MED 6.05 Principles of Geriatric Medicine Page 24 of 35

 ○ Be familiar with Beers criteria ■ Transportation (driving a car, calling a cab, using public
○ Adopt evidence-based approach especially to frail elderly transport)
○ Provide caregiver support ○ While these are not necessary for functional living, the ability to
● Challenges perform iADLS improves the quality of life of elderly persons.
○ Underreporting Geriatric Syndromes
■ Older patients tend to give more positive ratings to their ● Fall
health than younger adults. They tend to be reluctant to report ○ A fall occurs when a person’s center of gravity moves outside
symptoms, or may overlook symptoms as part of aging of their base of support and insufficient, ineffective or no effort
is made to restore balance
○ Atypical Presentation
○ Significant morbidity: fractures, brain, and spinal cord
■ Note that elderly patients may have atypical presentations.
injury.
They lack the usual signs and symptoms characterizing a
○ May be divided into:
particular condition or diagnosis
■ Intrinsic: due to gait and balance disorders
■ Examples
■ Extrinsic: due to polypharmacy and environmental factors
● Older adults with infections are less likely to have fever
○ Timed Up and Go test (TUG)
● Older adults with hyperthyroidism present with fatigue,
■ Starts with the patient seated on a chair, he is allowed to use
weight loss, and tachycardia
walking aids if needed, upon command, the patient stands,
● Older adults with MI are less likely to report chest pains
walks 3 meters, turns around, walks back to the chair and sits
● Acute abdomen may be silent
down.
● Vague chief complaints
■ An older adult is considered at risk for falls when he
● Acute confusions
completes the test in more than 12.6 seconds
● Acute functional decline
● Polypharmacy
○ Cognitive Impairment
○ Use of 5 or more drugs simultaneously
■ Older adults with mild cognitive impairment may provide
○ Medications commonly implicated in ADEs include:
sufficient history
■ Warfarin and antiplatelet agents: bleeding in the elderly
● Those with severe forms may not be able to give data on
■ Insulin and Oral Hypoglycemic agents(OHAs): hypoglycemic
the present illness
events
○ Geriatric Syndromes
■ Drugs promoting electrolyte and volume
■ A multifactorial condition that involves interaction between
disturbances:diuretics
situation-specific stressors and underlying age-risk related
■ CNS drugs: sedatives and anticholinergic agents may cause
risk factors, resulting in damage across multiple organ
cognitive slowing
systems
■ Antimicrobials
■ These are highly prevalent in older adults especially in frail
○ Brown bag/Medication Reconciliation
elderly
○ Recommendations for Geriatric Prescribing
■ A combination of risk factors including advancing age,
■ Start with non-pharmacologic therapy
cognitive and functional impairment and decrease mobility
■ Start with smaller doses and gradually increase if needed to
predispose patients to geriatric syndromes like incontinence,
prevent adverse drug events.
falls, pressure ulcers, delirium, and functional decline which
■ Renal function influences drug therapy, doses of medications
makes the patients more frail
may need to be adjusted
■ Make drug regimens as simple as possible
IV. COMPREHENSIVE GERIATRIC ASSESSMENT
○ Beers Criteria and de-prescribing:
● A multidisciplinary diagnostic and treatment process that identifies
■ List of potentially inappropriate medications released by the
medical, psychosocial, and functional capabilities of an older adult
american geriatric society.
in order to develop a coordinated plan to maximize overall health
■ Avoid taking:
with aging.
● Diuretics and hypotensive agents who fall/ have syncope
● It is divided into:
● Benzodiazepines for sleep problems
○ Social
● Anticholinergic medications that increase the risk for
○ Functional
cognitive impairment
○ Geriatric syndromes
● Proton pump inhibitors for those with unclear indications
○ Cognition and affect
● Hypoglycemic agents in DM patients who have increased
Functional Assessment
risk of hypoglycemia
● Activities of daily living (ADLs)
● Statins in patients with chronic illness who are near the
● Patients who become frail and dependent on a caregiver would be
end of life
unable to perform these activities on their own.
● Urinary Incontinence
○ Bathing / Hygiene: 1st to be lost
○ Associated with social isolation and depression.
○ Dressing
○ Transferring ○ Predisposes patients to skin irritations, pressure ulcers and
○ Toileting falls
○ Maintaining continence ○ Clinical forms:
○ Eating: Last to be lost ■ Stress incontinence: Occurs when performing physical
● Instrumental activities of daily living (iADLs) activity such as coughing, sneezing, lifting, or exercising
○ Instrumental activities of daily living allow an individual to live ■ Urge incontinence: Urge or feeling that you need to empty
independently in a community. your bladder but cannot go to the toilet fast enough
■ Cooking ■ Mixed incontinence: Most common type of urinary
■ House cleaning incontinence in women.Have symptoms of both urge and
■ Taking medications stress incontinence
■ Laundry (washing lines, towels and other articles of clothing) ○ Interventions:
■ Shopping (purchasing clothing, groceries and etc) ■ Kegel exercises
■ Managing personal finances (paying bills and proper ■ Behavioral interventions: timed voiding and double voiding
budgeting) ■ Intermittent catheterization
■ Communication (making & returning phone calls) ■ Bedside commode
● Malnutrition

MED 6.05 Principles of Geriatric Medicine Page 25 of 35

 ○ Undernutrition is common in older adults ○ An acquired deterioration in cognitive abilities that impairs
○ Check for factors that affect nutrition, including dentition, oral and the successful performance of activities of daily living
G.I disorders, drug regimens that may affect taste and oral ○ Age cognitive decline
secretions ■ This diagnosis is suggested by mild forgetfulness, difficulty
○ Depression and cognitive disorders remembering names, mildly reduced concentration
○ Protein- energy malnutrition ○ Mild Cognitive Impairment
■ Occurs when intake is insufficient to meet metabolic demands ■ Daily function is preserved, but there is evidence of modest
○ Screened using the Mini Nutritional Assessment (MNA) tool cognitive decline in one or more cognitive domains
○ Score 12-14: Normal nutritional status ○ Classified as:
○ Score 8-11: At risk of malnutrition ■ Alzheimer’s disease
○ Score 0-7: Malnourished ■ Vascular Dementia
● Sleep disorders ■ Parkinson’s disease/ Lewy body dementia
○ Insomnia ○ Other conditions that may present with cognitive decline:
■ Associated with depression, anxiety, alcohol intake,and ■ Vitamin deficiencies (Vitamin D and B12)
ingestion of caffeinated beverages later in the day ■ Hypothyroidism
○ Obstructive sleep apnea ■ HIV
■ Usually associated with medical comorbidities like obesity and ■ Head trauma
congestive heart failure ■ Brain tumors
○ Restless leg syndrome ■ Degenerative disorders
■ More common in women ○ Screening Tests:
● Risk factors: ■ Mini-Mental State Examination (MMSE)
○ (+) family history ● MMSE is a 30-point test of cognitive function, with each
○ Iron deficiency correct answer being scored as 1 point
○ Intake of antihistamine and antidepressants ■ Montreal Cognitive Assessment (MOCA)
○ Periodic leg movements in sleep ● A bit harder than the MMSE because it test for other
■ Can be found in up to 45% of older people, but is often of aspects in cognition not tested by the
unknown clinical significance ● It requires the patient to memorize 5 objects instead of 3
● Pain ● If the patient gets a high score in MMSE but you suspect
○ Pain related complaints accounts for up to 80& of clinic visit cognitive impairment, you can verify with MOCA
○ Usually due to back and joint pain, but headache, neuralgias and ● A score of 25 and below may indicate cognitive impairment
cancer pain are also common ■ Mini-Cog
○ Older adults are less likely to report pain ● 3-item recall test and a clock drawing test.
■ This can lead to suffering, social isolation, depression, ● 1 point for each object memorized and 2 points for a
physical disability, and loss of function correct clock drawing
○ It is important to distinguish between acute and chronic pain ● Score of 0-2 = possible dementia
complaints ○ Management for dementia:
○ Asses the effect of pain on the quality of life, social interactions ■ There is still no treatment for dementia
and functional level of the patient ■ Memantine and cholinesterase inhibitor (Donepezil,
Rivastigmine)
○ Offer non pharmacologic therapies
● Only slow down cognitive decline but do not reverse it
■ Tai chi
■ Relaxation techniques
● Depression
■ Massage ○ Affects 10% of older men and 18% of older women, but is often
■ Acupuncture undiagnosed and untreated.
Cognition & Affect ○ Elderly patients with depression may report feeling tired, lack of
● Delirium appetite, and often irritable
○ Acute decline in cognition that fluctuates over hours to days ○ Screening questions:
○ INATTENTION ■ Over the past 2 weeks, have you felt down, depressed or
○ Altered sleep- wake cycles hopeless?
○ Hallucinations and delusions ■ Over the past 2 weeks, have you felt little interest or pleasure
○ Affect changes in doing things?
○ Medical Emergency ○ Geriatric Depression Scale
■ Common in hospital settings, such as the ED and ICU ■ A score of 5 and above indicates a possible depression and
■ High rates reported in patients undergoing hip surgery warrant referral for further investigation and treatment
■ Substantial morbidity and mortality Social Assessment
● Longer length of hospital stay ● Social Support, elder neglect/abuse, advanced directives
● More likely to have subsequent delirium episodes
● More likely to have cognitive decline V. PREVENTION OF DISEASE IN THE ELDERLY
○ Confusion Assessment Method (CAM) ● Screening
■ Diagnosis: (+) Features 1 and 2, and either feature 3 or 4 ○ Screening must balance cost-effectiveness and reasonable
■ Feature 1- Acute Onset and Fluctuating Course risk:benefit
■ Feature 2- Inattention ○ Colon Cancer:
■ Feature 3- Disorganized Thinking ■ adults aged 50-75
■ Feature 4- Altered Level of Consciousness ■ Do not screen among ages > 85 or have < 10 yr life
○ Management: expectancy
■ Treat underlying cause ■ Discontinue if screening hinders treatment for another
■ Supportive care disease
■ Avoid physical restraints ■ Test:
■ Administer chemical restraints only when he/she becomes a ● Annual fecal occult blood test or immunohistochemistry
threat to self or the staff ● Sigmoidoscopy every 5 years, colonoscopy every 10 years
● Dementia ○ Breast Cancer:
■ adults aged 40-74

MED 6.05 Principles of Geriatric Medicine Page 26 of 35

 ■ Mammography every 1-2 years ● CDC Exercise Recommendations
○ Lung Cancer: ○ 150 minutes per week of moderate-intensity exercise
■ Smokers with current or prior 30+ pack year history and are ○ 75 minutes per week of vigorous intensity exercise
aged 55-74 ○ Equivalent mix of both
■ No need to screen those who have stopped for > 15 years, or ○ All must include muscle strengthening exercises for all major
have comorbidities muscle groups on 2+ days per week
■ Test: low dose chest CT scan annually ● Vaccines
○ Prostate Cancer ○ Annual Flu vaccine for patient and caregivers
■ Men ≥ 50 years and with >10 year life expectancy ○ Pneumococcal vaccine (PCV-13 followed by PTSV-23) at the
■ Test: PSA tests annually if > 2.5 ng/mL or every 2 years if < age of 65
2.5 ng/mL ○ Shingles vaccine (2 doses) at age 50
○ *Cervical Cancer: ○ Tetanus & Diphtheria boosters every 10 years
■ Women aged 21-65 ○ COVID vaccines if available
■ Pap smear every 3 years or HPV+Pap every 5 years
○ *Carotid Disease VI. FUNDAMENTALS OF GERIATRIC MEDICINE
■ Age >65, (+)CAD, needs coronary bypass, hx tobacco use, ● Aging increases susceptibility to disease due to reduced physiologic
high cholesterol, (+)bruit reserves.
■ Carotid Ultrasonography (taken once) ● Goal of care: maintain functional ability and quality of life
○ *Coronary Artery Disease ● Individualized person-centered care is a core tenet of geriatric care
■ Coronary calcium score (taken once) ● DON’TS in geriatric care:
○ Osteoporosis ○ Use of NGT among patients with advanced dementia
■ Women aged > 65, men aged > 70
○ Use of antipsychotics and benzodiazepines as first-line treatment
■ Screen postmenopausal women and men aged 50-69 if risk
○ Use of statins in patients with a limited life expectancy
factors are observed
■ Test: DEXA every 1-2 years
○ Aggressive treatment measures without informing the patient or
their family of the risks and benefits
○ Abdominal Aortic Aneurysm
■ men aged 65-75 + History of smoking
○ Strict HbA1c control in frail patients
■ Test: 1-time abdominal ultrasound ○ Antibiotic use for bacteriuria in patients w/o UTI symptoms
○ Diabetes ○ Screening tests (for breast, colorectal, lung or prostate CA) w/o
■ Adults aged > 45 considering life expectancy, over-diagnosis and the risks of
■ Screen those who are overweight or obese testing
■ Tests: Annual FBS, Glucose Tolerance, HbA1c
CONCEPT CHECKPOINT
I. AGING IV. COMPREHENSIVE GERIATRIC ASSESSMENT
1. T or F. Old age is a minor independent risk factor for chronic 6. T/F Cooking is an example of an Activity of Daily Living
diseases and associated mortality ○ Stress Incontinence
○ F. Considered a major independent risk factor 7. T/F Urinary incontinence is more common in males
2. T or F. There will be a large increase globally in the number of ○ F. 1 in 3 older women and 1 in 5 men
older persons in 2050 8. T/F Memantine and Rivastigmine can reverse the cognitive
impairment in patients with dementia.
II. PHYSIOLOGICAL & ANATOMICAL CHANGES IN AGING ○ F. It can only delay improvement
3. The result of fibrosis and calcification of aortic valve without 9. All of the following are true of Depression, EXCEPT:
impeding blood flow ○ It should be a score of 5 and above.
○ Aortic Sclerosis.
4. Reflects changes in physiologic reserves over time that are V. PREVENTION OF DISEASE IN THE ELDERLY
independent of changes from diseases 10. Queen Elizabeth II (age 94) consults you, a filthy peasant doctor,
○ Primary Aging. for breast cancer. Will you prescribe her breast cancer screening
as a precautionary measure?
III. APPROACH TO THE OLDER ADULT ○ No. not advised for ages > 74
5. Give 3 atypical presentations in the diseases of the elderly 11. Lippy Dimia brags that she brisk walks for 30 minutes every
○ Fever weekday with strength exercises every Tuesday and Thursday. Is
○ Fatigue, weight loss, tachycardia in hyperthyroidism her exercise regimen appropriate?
○ Chest pains in post-MI geriatrics ○ Yes. Totals in 150 minutes per week with at least 2 days of
○ Silent Acute Abdomen muscle strengthening
○ Vague chief complaints
○ Acute confusions and functional decline

MED 6.05 Principles of Geriatric Medicine Page 27 of 35

 APPENDIX
NOTE: The following section was lifted from the 2022B transcription. This was not discussed in the 2023 lecture.
TREATMENT OF COMMON DISEASES C. HYPERLIPIDEMIA
● Statin use in elderly is controversial
A. HYPERTENSION
● Typical SE: muscle pain
● CV disease vs adverse effects of antihypertensive drugs ● Risk of myositis and rhabdomyolysis in patients taking high doses
● Person-centered approach ● Healthy older adults >75 with a life expectancy of more than 10
● SBP < 130 mmHG for older patients w/ minimal comorbities, w/o years may benefit
postural hypotension, low risk for falls and volume
D. OSTEOARTHRITIS
● SBP < 150 mmHg for those w/ diabetes, heart failure, stroke and
postural hypotension ● Non-pharmacologic interventions are first line of treatment
○ Hot or cold compress
B. DIABETES
○ Massage
● Uncontrolled DM increase risk of all-cause dementia vs ○ Swimming
hypoglycemic episodes ○ Physical therapy
● Hypoglycemic episodes common in elderly due to medication ○ Acupuncture
errors, decline in renal function, poor oral intake ● Avoid oral NSAIDS
● Hypoglycemic episodes associated with progressive cognitive ○ NSAIDS are associated with GI bleeding, worsening of renal
decline in older adults function, fluid retentions, and exacerbation of hypertension and
○ Uncontrolled diabetes is associated with increased risk of CHF
all-cause dementia ● Proton pump inhibitors (PPI) are associated with increased
● HbA1c 7.5% to 9% is acceptable if harms > benefits incidence of pneumonia, osteoporosis, and possibly dementia
○ HbA1c goals are tailored to the patient’s functional and medical ● Topical NSAIDs are better tolerated in elderly
status, social support, personal goals, perception of risk, and life ○ Lidocaine patches and non-prescription creams may also be
expectancy effective [Harrison’s 20th Ed]
● Metformin is first line drug, but contraindicated for patients with ● Paracetamol 1g up to 4 times daily is recommended for chronic
advanced renal insufficiency or significant heart failure pain
● Use insulin secretagogues with caution ● Tramadol or narcotic agents are recommended for more severe
● Once daily basal insulin therapy is more reasonable; patient must pain
have intact cognition (unless with caregiver)

Undiscussed Section Ends Here

MED 6.05 Principles of Geriatric Medicine Page 28 of 35

Figure 21. Examples of Screening Questions and Tools and Strategies for Further Evaluation of Social Support, Functional Status, Geriatric Syndromes, and Cognition and
Affect [Harrison’s 20th Ed]

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 Figure 22. Algorithm for the Assessment and Management of Falls in Geriatric Patients [Harrison’s 20th Ed]

Figure 23. Sample form of the Mini Nutritional Assessment tool [PPT]

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 Figure 24. Sample form of the Mini Mental State Examination (MMSE) [PPT]

Figure 25. Sample page from the Montreal Cognitive Assessment (MOCA) form [PPT]

MED 6.05 Principles of Geriatric Medicine Page 31 of 35

Table 9. Questions asked in the Geriatric Depression Scale (GDS-15) [Greenberg, 2012]
Question Answer Interpretation
1. Are you basically satisfied with your life? Yes or No No = 1 point

2. Have you dropped many of your activities and interests? Yes or No Yes = 1 point

3. Do you feel that your life is empty Yes or No Yes = 1 point

4. Do you often get bored? Yes or No Yes = 1 point

5. Are you in good spirits most of the time? Yes or No No = 1 point

6. Are you afraid that something bad is going to happen to you? Yes or No Yes = 1 point

7. Do you feel happy most of the time? Yes or No No = 1 point

8. Do you often feel helpless? Yes or No Yes = 1 point

9. Do you prefer to stay at home rather than going out and doing new things? Yes or No Yes = 1 point

10. Do you feel you have more problems with memory than most? Yes or No Yes = 1 point

11. Do you think it is wonderful to be alive now? Yes or No No = 1 point

12. Do you feel pretty worthless the way you are now? Yes or No Yes = 1 point

13. Do you feel full of energy? Yes or No No = 1 point

14. Do you feel that your situation is hopeless? Yes or No Yes = 1 point

15. Do you feel that your situation is hopeless? Yes or No Yes = 1 point
Score > 5 is suggestive of depression (Any score higher than 5 warrants more comprehensive assessment); score > 10 is almost always indicative of
depression [Greenberg, 2012]

Table 10. Questions to be asked in screening for incontinence (3IQ)

1. During the last 3 months, have you leaked urine (even small amounts)?

Yes

No (if this is selected, the screening is complete)

2. During the last 3 months, did you leak urine (check all that apply)

When you were performing some physical activity such as coughing, sneezing, lifting, or exercising

When you had the urge or feeling that you needed to empty your bladder but you could not get to the toilet fast enough?

Without physical activity and without sense of urgency?

3. During the last 3 months, did you leak urine most often (check only one)

When you were performing some physical activity such as coughing, sneezing, lifting, or exercising

When you had the urge or feeling that you needed to empty your bladder but you could not get to the toilet fast enough?

Without physical activity and without sense of urgency?

About equally as often with physical activity as with a sense of urgency

MED 6.05 Principles of Geriatric Medicine Page 32 of 35

 Figure 26. Recommended Screening Tests [Harrison]

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 Figure 27. immunization schedule by age (≥19y/o) [CDC]

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 Figure 28. Algorithm depicting assessment and management Figure 29. Algorithm for the basic evaluation and management of geriatric
of delirium in hospitalized older patients [Harrison] urinary incontinence in outpatient practice [Harrison]

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