Makindo Medical Notes

📅 4-Month Syllabus in Geriatric Medicine (For Doctors in Training)

Month 1: Foundations

Week 1 – Introduction & Core Concepts

• Biology of Ageing & Geriatric Physiology
  🧬 Normal ageing reduces physiological reserve in cardiovascular, renal, respiratory & neurological systems.
  📌 Example: ↓ baroreceptor sensitivity → orthostatic hypotension; ↓ renal GFR → drug dose adjustments.
  ⚖️ Distinguish ageing from disease (e.g. presbycusis = normal high-frequency loss, vs pathological sensorineural hearing loss).
  🧠 Concept of “homeostenosis” → narrowing of the body’s ability to respond to stress.
• Demographics and Health Systems Impact
  🌍 UK population ≥85 years is the fastest growing group.
  📌 ↑ demand for long-term care, frailty units, and palliative services.
  📊 NHS Long Term Plan & British Geriatrics Society (BGS) guidance shape frailty pathways & integrated care models.
  💷 Socioeconomic costs: falls, dementia, and polypharmacy are leading drivers of hospital admissions and health expenditure.
• Comprehensive Geriatric Assessment (CGA)
  🩺 The cornerstone of geriatric medicine → integrates medical, psychological, functional & social domains.
  📌 Shown in RCTs to reduce mortality, improve quality of life, and delay institutionalisation.
  🧩 Key components: medical review, medication review, cognition, mood, mobility, nutrition, ADLs, social support.
  💡 Remember: CGA is a process not an event — dynamic and repeated as patients’ needs change.
• MDT Working & Communication with Frail Adults
  🤝 Core team = doctors, nurses, AHPs (PT, OT, SLT, dietitian), pharmacists, social workers, and carers.
  📌 Adapt communication for hearing loss (clear voice, visual aids) and cognitive impairment (short phrases, orientation cues).
  👨‍👩‍👧 Family & carers play a crucial role in decision-making, advanced care planning & discharge planning.
  ⚠️ Safeguarding: Always consider elder abuse, neglect, and capacity under the Mental Capacity Act.
• Concept of Frailty
  🧓 Frailty = state of ↑ vulnerability due to cumulative decline across multiple systems.
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Week 2 – Frailty, Falls & Bone Health

• Frailty Models
  🧓 Two main approaches:   • Phenotype (Fried) → ≥3 of: weight loss, weakness (grip strength), exhaustion, slow walking speed, low activity.   • Deficit Accumulation (Rockwood CFS) → frailty as a spectrum, quantified by deficits in function, comorbidities, and cognition.
  📌 Both predict ↑ risk of hospitalisation, institutionalisation & mortality.
  💡 Teaching tip: CFS is quick for bedside use, Fried’s model more research-focused.
• Falls & Balance Disorders
  ⚠️ Falls = leading cause of morbidity, mortality & loss of independence in older adults.
  🔎 Causes are multifactorial → gait/balance impairment, polypharmacy (esp. sedatives, antihypertensives), postural hypotension, visual impairment, neuropathy.
  📌 NICE recommends multifactorial risk assessment & tailored intervention (strength/balance training, home hazard modification, vision/hearing review, medication rationalisation).
  💡 Always ask about “near-miss” falls as a red flag for future events.
• Osteoporosis & Fracture Prevention
  🦴 Osteoporosis = low bone mass + microarchitectural deterioration → ↑ fracture risk.
  💊 1st line: Bisphosphonates (e.g. Alendronate), plus calcium & Vit D supplementation.
  🏃‍♀️ Lifestyle: weight-bearing exercise, smoking cessation, alcohol reduction.
  📌 Assess falls risk & bone health together — many fragility fractures are fall-related.
  💡 Use FRAX/QFracture for 10-year fracture risk assessment.
• Functional Testing
  🚶 Timed Up & Go (TUG): >12 seconds = ↑ falls risk.
  🧾 Berg Balance Scale: assesses static & dynamic balance.
  🏥 Other bedside tools: Chair Stand Test, Gait Speed, Grip Strength.
  📌 These help guide rehab, physio referral & safe discharge planning.
  💡 Mobility = “6th vital sign” in geriatrics — document routinely.

Week 3 – Delirium & Cognition

• Delirium
  🧠 Acute, fluctuating disturbance in attention & cognition (hours–days).
  ⚠️ Causes: infection, new drugs (esp. anticholinergics, opiates, benzodiazepines), pain, constipation, urinary retention, hypoxia, metabolic derangements.
  📌 Reversible if trigger found early. Always look for infection + medication changes first.
  💡 NICE recommends routine use of 4AT for screening in hospitalised older adults.
• Dementia Subtypes
  🧩 Alzheimer’s disease – insidious memory loss, hippocampal atrophy on MRI.
  🌊 Vascular dementia – stepwise decline, focal neuro signs, link with strokes.
  🎭 Lewy body dementia (LBD) – visual hallucinations, Parkinsonism, cognitive fluctuations; antipsychotics contraindicated (risk of neuroleptic sensitivity).
  🗣️ Frontotemporal dementia (FTD) – early personality/behavioural change or expressive aphasia; memory relatively spared early.
  📌 Tailor management: cholinesterase inhibitors for Alzheimer’s & LBD; vascular risk factor control in vascular dementia.
• Cognitive Screening
  📋 Tools:   • AMTS (10 questions) – quick bedside screen, good for acute settings.   • MMSE – widely used, but ceiling effects & licensing issues.   • MoCA – more sensitive for mild cognitive impairment & executive dysfunction.
  📌 Always interpret in context: age, education, culture & language can bias results.
  💡 Screening tools are supportive, not diagnostic — always link back to history, collateral & functional impact.

Week 4 – Polypharmacy & Prescribing

• Pharmacokinetics & Pharmacodynamics in Ageing
  🧪 Ageing → ↓ renal clearance (CKD-EPI more accurate than eGFR in frail adults), ↓ hepatic metabolism, ↑ fat:lean ratio (lipid-soluble drugs accumulate).
  🧠 ↑ CNS drug sensitivity (opiates, benzos, anticholinergics).
  📌 Golden rule: “Start low, go slow, but don’t stop too soon if benefit is likely.”
• STOPP/START Criteria
  📝 STOPP = Screening Tool of Older Persons' Prescriptions (flags potentially inappropriate meds).
  ➕ START = Screening Tool to Alert to Right Treatment (identifies omissions, e.g. missing bisphosphonate in steroid users).
  📌 NICE & BGS recommend structured reviews in frailty, care homes, and hospital discharge planning.
• High-Risk Drug Classes
  💊 Opiates: risk of falls, constipation, delirium.
  💊 Anticoagulants: high bleeding risk vs stroke/VTE prevention; use HAS-BLED/CHA₂DS₂-VASc for balance.
  💊 Sedatives & anticholinergics: worsen delirium, cognitive impairment, falls.
  📌 Always review indication, dose, duration. Consider deprescribing if risks outweigh benefits.
• Practical Prescribing Tips
  📋 Brown bag review (ask patient to bring all meds, incl. OTC & herbal).
  🔄 Check adherence & swallowing ability (liquid or dispersible formulations may help).
  👵 Polypharmacy is not always inappropriate — aim for “appropriate polypharmacy” rather than numerical cut-offs.

Month 2: Common Clinical Problems

Week 5 – Mobility & Falls II

• Syncope vs Falls
  ⚡ Syncope = transient loss of consciousness due to cerebral hypoperfusion (e.g. arrhythmia, orthostatic hypotension).
  🤕 Falls = often mechanical or balance-related, without LOC.
  📌 Key: ECG, lying/standing BP, collateral history (witness accounts often decisive). Holter monitoring if suspicion of arrhythmia.
  🔑 Always ask about prodrome (dizziness, palpitations) vs trip/slip mechanism.
• Parkinson’s Disease & Parkinsonism
  🧠 Motor triad = bradykinesia, rigidity, resting tremor.
  🛑 Non-motor features (often more disabling): depression, constipation, REM sleep behaviour disorder, cognitive decline.
  📌 Parkinsonism can be drug-induced (antipsychotics), vascular, or atypical syndromes (MSA, PSP).
  🤝 MDT approach: physio (gait/balance), OT (home safety), speech therapy (dysarthria, swallow), PD nurse specialist.
  💊 Levodopa responsiveness is a key diagnostic clue.
• Stroke in Older Adults
  🧑‍⚕️ Thrombolysis & thrombectomy can be offered in ≥80s if functional baseline was good and time window criteria are met.
  📌 NICE: Age alone is not a contraindication — assess pre-stroke mRS (Modified Rankin Score).
  🛠️ Rehab planning = early mobilisation, swallow screen, mood/cognition assessment, and family involvement.
  ⚠️ Watch for complications: aspiration pneumonia, post-stroke depression, falls from hemiparesis/visual neglect.

Week 6 – Cardiovascular Disease

• Hypertension
  💉 Common in older adults; vascular stiffness raises systolic BP.
  📌 NICE: • Age <80 → target <140/90 mmHg. • Age ≥80 → target <150/90 mmHg (unless frail or multimorbid).
  ⚠️ Be cautious of postural hypotension → measure lying & standing BP. Falls risk may outweigh benefit of tighter control.
  💊 First-line often thiazide-like diuretics (e.g. indapamide) or calcium channel blockers in >55 yrs.
• Heart Failure
  ❤️ HFpEF (Heart Failure with preserved EF) predominates in older adults; often linked with hypertension, AF, obesity.
  📌 Unlike HFrEF, evidence for mortality benefit of drugs is limited.
  🎯 Focus: symptom control (diuretics for congestion), comorbidity optimisation, exercise rehab.
  🔑 Polypharmacy common → review diuretics & renal function regularly.
  🧠 Prognosis is poor but varies widely; frailty and comorbid burden drive outcomes.
• Atrial Fibrillation (AF)
  🫀 Prevalence ↑ with age; major cause of embolic stroke in elderly.
  📌 Anticoagulation: • Use CHA₂DS₂-VASc to estimate stroke risk. • Use HAS-BLED to estimate bleeding risk.
  ⚖️ Frail patients often under-anticoagulated due to falls risk, but stroke risk usually outweighs bleeding risk (even in fall-prone).
  💊 DOACs (e.g. apixaban) now preferred over warfarin in most, but adjust dose for renal function and age.

Week 7 – Respiratory & Infection

• Pneumonia – CAP vs aspiration.
  📌 “Atypical” presentations: delirium, falls.
• COPD in older adults – frailty complicates NIV decisions.
  📌 Palliative input often needed.
• Sepsis – elderly may be afebrile.
  📌 Always check lactate & urine output.
• UTI vs asymptomatic bacteriuria – treat only if symptomatic.
  📌 Overdiagnosis is common pitfall.
• Vaccines in the Elderly
  • Annual influenza vaccine.
  • Pneumococcal vaccine (≥65 years).
  • Shingles vaccine (offered at age 70, catch-up to 79).
  • COVID-19 boosters per current guidance.

Week 8 – Nutrition & Metabolism

• Malnutrition & sarcopenia – use MUST score.
  📌 Directly impacts falls & mortality.
• Diabetes in elderly – aim for safe, not strict, control.
  📌 Avoid hypoglycaemia at all costs.
• Osteomalacia, Vit D deficiency – common in care homes.
  📌 Screen at-risk patients.
• Dysphagia management – PEG vs NG vs comfort feeding.
  📌 Ethical issues frequent.
• General
  • Screen using MUST tool (Malnutrition Universal Screening Tool).
  • Encourage high-calorie, high-protein diet.
  • Use oral nutritional supplements if needed.
  • Consider NG feeding or PEG in selected cases, but always weigh risks/benefits.

Month 3: Complex Care & Subspecialty

Week 9 – Oncology & Haematology

• Cancer in Older Adults
  🎗️ Common cancers: colorectal, breast, prostate, lung. Presentation may be subtle due to comorbidities or frailty.
  📌 Screening: Controversial in ≥75s — balance early detection vs overdiagnosis, harms of colonoscopy, and limited life expectancy.
  💊 Treatment tolerance: Chemotherapy & radiotherapy carry higher toxicity; renal/hepatic reserve and frailty scores (e.g. Rockwood) should guide decisions.
  🧭 Goals-of-care: Discuss prognosis, quality of life, and patient preferences — shared decision-making is crucial in geriatric oncology.
  👥 MDT input (oncology, geriatrics, palliative care) optimises both survival and comfort.
• Anaemia in the Elderly
  🩸 Common causes: Iron deficiency anaemia (IDA), anaemia of chronic disease (ACD), and bone marrow disorders (e.g. myelodysplasia).
  📌 Always exclude GI blood loss (colorectal cancer, angiodysplasia, ulcers) in IDA.
  🔬 Work-up: FBC, iron studies, B12/folate, reticulocyte count; consider bone marrow biopsy if unexplained.
  ⚠️ Anaemia worsens frailty, falls, and cognitive decline — treat even "mild" anaemia if symptomatic.
  💊 Management: Iron replacement (oral/IV), treat underlying cause, consider ESAs in CKD, supportive transfusions if refractory.

Week 10 – Renal & Urology

• CKD in elderly – eGFR falls with age, interpret carefully.
  📌 Don’t over-diagnose “CKD” in normal ageing.
• Incontinence – urge, stress, overflow.
  📌 Major QoL issue, MDT input vital.
• Prostate disease – LUTS, cancer.
  📌 Balance treatment vs comorbidity.
• Catheter care – last resort, risks: infection, stones.
  📌 Always review indication.

Week 11 – Neurology & Psychiatry

• Advanced Parkinson’s – fluctuations, hallucinations.
  📌 Complex drug titration + palliative overlap.
• Depression in elderly – often masked by somatic complaints.
  📌 SSRIs effective but monitor hyponatraemia.
• Palliative dementia care – behaviour, feeding, capacity.
  📌 Advance planning essential.

Week 12 – Ethics & Law

• Mental Capacity Act, DoLS – assess decision-specific capacity.
  • Balancing autonomy vs. best interests.
  • Consent and capacity issues.
  • Decisions around resuscitation and treatment escalation.
  • Resource allocation and safeguarding concerns.
• Consent in frailty – adapt for hearing/vision impairment.
  📌 Involve advocates if needed.
• Advance care planning, DNACPR – sensitive conversations.
  📌 Use ReSPECT forms.
• Safeguarding older adults – abuse, neglect, financial exploitation.
  📌 MDT responsibility.

Month 4: Integration & Practice

Week 13 – Rehabilitation & Community

• Rehabilitation principles – function, not cure.
  📌 Goal setting with patient/family.
• Community geriatrics – care homes, outreach.
  📌 Interface medicine growing field.
• Discharge planning – early involvement of therapy & social care.
  📌 Prevents “bed-blocking”.

Week 14 – Palliative & End-of-Life Care

• Symptom control – pain, breathlessness, agitation.
  📌 Use “just in case” meds.
• Last days of life – recognise dying, withdraw burdensome interventions.
  📌 Focus on comfort.
• Communication with families – open, honest, supportive.
  📌 Bereavement care matters too.
• • Symptom control: pain (opioids), breathlessness (morphine), secretions (glycopyrronium), agitation (midazolam).
  • DNACPR and ceilings of care discussions.
  • Communication with patient/family is vital.
  • Holistic approach: physical, psychological, spiritual, and social needs.

Week 15 – Acute Geriatrics & Emergencies

• Acute confusion & delirium – commonest emergency.
  📌 Always search for reversible causes.
• Hip fracture – orthogeriatric co-management.
  📌 Improves outcomes.
• Stroke in ≥80s – don’t deny treatment purely by age.
  📌 Consider functional baseline.
• ACS, GI bleed – frailty complicates invasive treatment.
  📌 Discuss ceilings of care early.

Week 16 – Consolidation & Assessment

• Mock OSCEs – delirium, falls, polypharmacy.
  📌 Practise structured assessments.
• Case presentations – CGA, rehab, ethics.
  📌 Develop teaching/leadership skills.
• Portfolio reflection – 2 cases/month + 1 QI project.
  📌 Links practice to curriculum.
• Feedback & next steps – plan CPD, career focus.
  📌 Continuous learning is key.

📌 Teaching Methods

• Weekly tutorials (case-based & guideline review)
• Bedside teaching (CGA, mobility tests)
• OSCE-style assessments every 4 weeks
• Portfolio: 2 reflections/month + 1 QI project
• Reading: BGS curriculum, NICE guidelines, Resus Council UK