Elderly Medicine / Geriatrics Revision Guide ✅

👴 Elderly Medicine / Geriatrics Revision Article — Comprehensive Guide

👴 Geriatrics is complexity medicine. Older adults often present with non-specific syndromes rather than textbook disease: falls, delirium, immobility, incontinence, frailty, reduced appetite, functional decline or “off legs”. For exams and ward work, always ask: what was the baseline?, what has changed?, is this delirium?, are medicines contributing?, what matters to the patient?, and what support is needed for a safe discharge?

✅ 1. Core Principles of Geriatric Medicine

🧓 1.1 Why Older Adults Present Differently

• Reduced physiological reserve: small illnesses can cause large functional decline.
• Atypical presentations: infection may present as delirium or falls rather than fever.
• Multimorbidity: several conditions often interact rather than one neat diagnosis.
• Polypharmacy: medicines can cause, worsen or mask disease.
• Frailty: vulnerability to stressors increases risk of delirium, falls, disability and death.
• Baseline matters: a “normal” test or observation may still represent a major change for that person.

🧠 1.2 The Geriatric Giants

🧠 Exam pearl: “Off legs” is not a diagnosis. It is often a presentation of acute illness, pain, delirium, fracture, medication harm or deconditioning.

🧩 2. Comprehensive Geriatric Assessment

Comprehensive Geriatric Assessment (CGA) is a multidimensional, multidisciplinary process that identifies medical, functional, psychological and social needs in older people, especially those living with frailty. The British Geriatrics Society describes CGA as a coordinated approach used across hospital, community and primary care settings.

📋 2.1 CGA Domains

🏠 2.2 Baseline Function

• Ask what the person could do two weeks ago or before the acute illness.
• Mobility: independent, stick, frame, supervision, one-person assist, two-person assist, hoist.
• Transfers: bed-to-chair, toilet, stairs, bath/shower.
• Personal ADLs: washing, dressing, toileting, feeding.
• Domestic ADLs: cooking, shopping, cleaning, finances, medication management.
• Falls history, fear of falling and confidence outdoors.
• Care package: who comes, how often, what they do, whether it is enough.

👥 2.3 MDT Roles

📌 Clinical reasoning: CGA is not “just social”. It is a diagnostic and therapeutic intervention because it identifies reversible causes of decline, prevents iatrogenic harm and matches treatment to realistic goals.

🧓 3. Frailty

🧬 3.1 What Frailty Means

• Frailty is a state of reduced physiological reserve and increased vulnerability to stressors.
• A minor illness, medication change or fall can cause disproportionate decline.
• Frailty is not the same as age, disability or multimorbidity, although they overlap.
• Frailty can improve or worsen depending on illness, nutrition, exercise, rehabilitation and support.
• Recognition helps tailor treatment intensity, rehabilitation, discharge planning and advance care planning.

📏 3.2 Frailty Tools

💪 3.3 Sarcopenia

• Sarcopenia is loss of muscle mass and strength.
• It contributes to falls, frailty, poor recovery and loss of independence.
• Risk factors: inactivity, malnutrition, inflammation, chronic disease, hospitalisation.
• Management: progressive resistance exercise, protein/nutrition optimisation, vitamin D if deficient, treating underlying disease.

🌱 3.4 Frailty Management

• Identify and treat acute illness promptly.
• Medication review and deprescribing where harms exceed benefits.
• Exercise and strength/balance rehabilitation.
• Nutrition assessment and protein/calorie support.
• Falls prevention and environmental modification.
• Advance care planning and escalation planning based on values and likely benefit.
• Support carers and address loneliness/social vulnerability.

🧠 Exam pearl: Clinical Frailty Scale should reflect the patient’s baseline two weeks or more before the acute illness — not how they look while septic, post-op or delirious.

🚶 4. Falls

NICE NG249, published in April 2025, covers falls assessment and prevention in people aged 65 and over, and people aged 50 to 64 at higher risk. It replaced earlier NICE CG161 and emphasises personalised assessment and interventions.

🔍 4.1 Falls History

• Ask exactly what happened: trip, slip, collapse, dizziness, blackout, legs gave way.
• Ask about prodrome: chest pain, palpitations, breathlessness, dizziness, vertigo, aura, sweating.
• Ask about loss of consciousness and recovery: confusion, tongue biting, incontinence, post-ictal state.
• Ask about injuries, head strike and anticoagulant use.
• Ask about footwear, lighting, stairs, rugs, pets, alcohol and walking aids.
• Ask about previous falls and fear of falling.
• Ask baseline mobility and whether the fall changed function.

🩺 4.2 Falls Assessment

💊 4.3 Medication Causes of Falls

• Benzodiazepines and Z-drugs.
• Antipsychotics and sedating antidepressants.
• Opioids and gabapentinoids.
• Antihypertensives, nitrates, alpha-blockers and diuretics.
• Hypoglycaemic drugs, especially insulin and sulfonylureas.
• Anticholinergic drugs causing confusion and blurred vision.
• Alcohol and illicit drugs.

🏋️ 4.4 Falls Prevention

• Strength and balance training.
• Physiotherapy assessment and appropriate walking aid.
• Home hazard assessment and modifications.
• Vision correction and hearing support.
• Footwear and foot care.
• Medication review and deprescribing.
• Treat postural hypotension, arrhythmia, Parkinsonism, neuropathy and pain.
• Bone protection after fragility fracture or high risk.

🚨 Safety pearl: A fall can be a presentation of syncope, sepsis, stroke, GI bleed, fracture or drug toxicity. Never assume “mechanical fall” without asking what actually happened.

🧠 5. Delirium

NICE CG103 covers prevention, diagnosis and management of delirium in adults in hospital and long-term care. Delirium is common, serious and often missed, especially when hypoactive.

⚡ 5.1 What Delirium Is

• Acute disturbance of attention and awareness.
• Fluctuates over hours to days.
• Usually caused by an underlying medical, surgical, drug or environmental trigger.
• Can be hyperactive, hypoactive or mixed.
• Associated with increased mortality, falls, institutionalisation and longer hospital stay.

🔍 5.2 Delirium Features

🧪 5.3 Delirium Triggers

• Infection: pneumonia, UTI, cellulitis, sepsis.
• Drugs: opioids, benzodiazepines, anticholinergics, steroids, gabapentinoids, polypharmacy.
• Pain, fracture, pressure sores or constipation.
• Urinary retention or catheter problems.
• Dehydration, electrolyte disturbance, AKI, hypoxia, hypercapnia, hypoglycaemia.
• Alcohol withdrawal or sedative withdrawal.
• Environmental factors: sleep deprivation, ward move, sensory deprivation, lack of glasses/hearing aids.

🧯 5.4 Delirium Management

• Identify and treat underlying causes.
• Reorientate regularly: clock, calendar, familiar staff, family presence.
• Ensure glasses, hearing aids and dentures are available.
• Promote sleep: reduce night noise, avoid unnecessary overnight observations where safe.
• Mobilise early and avoid unnecessary lines/catheters.
• Hydration, nutrition and pain control.
• Avoid restraints where possible; use least restrictive measures.
• Medication for agitation only if severe distress or risk and non-drug strategies fail.

🧠 5.5 Delirium vs Dementia vs Depression

🧠 Exam pearl: Acute confusion is delirium until proven otherwise. Dementia is chronic; delirium is acute and fluctuating.

🧠 6. Dementia and Cognitive Disorders

NICE NG97 covers assessment, management and support for people living with dementia and their carers. Dementia care includes diagnosis, function, risk, carer support, medication review and future planning.

🔍 6.1 Dementia Assessment

• Take collateral history from someone who knows the patient well.
• Clarify onset, progression, fluctuations and functional impact.
• Assess memory, language, visuospatial skills, executive function and behaviour.
• Screen for delirium and depression.
• Review drugs, alcohol, sleep, sensory impairment and social function.
• Bloods: FBC, U&E, LFT, calcium, TFT, B12/folate, glucose/HbA1c; others as indicated.
• Brain imaging may identify vascular disease, tumour, subdural haematoma or normal pressure hydrocephalus.

📚 6.2 Dementia Types

💊 6.3 Dementia Treatment and Support

• Cholinesterase inhibitors may be used in Alzheimer’s disease and some Lewy body/Parkinson’s dementia contexts.
• Memantine may be used in moderate-severe Alzheimer’s or when cholinesterase inhibitors are unsuitable.
• Medication benefit is usually modest and should be reviewed.
• Non-drug support: routines, orientation cues, activity, carer support, environmental adaptation.
• Assess driving, finances, cooking, medication management and safeguarding risk.
• Advance care planning should be discussed early while capacity is present.

⚠️ 6.4 Behavioural and Psychological Symptoms

• Agitation, aggression, wandering, hallucinations, sleep disturbance, apathy and disinhibition may occur.
• Look for triggers: pain, infection, constipation, urinary retention, hunger, fear, overstimulation, medication effects.
• Non-pharmacological approaches are first-line where possible.
• Antipsychotics increase stroke and mortality risk in dementia and should be used cautiously for severe distress/risk, especially in Lewy body dementia where sensitivity is high.

⚠️ Safety pearl: New agitation in dementia is often pain, delirium, constipation, urinary retention or fear until proven otherwise.

💊 7. Polypharmacy and Deprescribing

💊 7.1 Why Polypharmacy Matters

• Multiple medicines increase risk of falls, delirium, bleeding, AKI, hypotension and hospital admission.
• Older adults are more sensitive to sedative, anticholinergic, hypotensive and renally cleared medicines.
• Prescribing cascades occur when a drug side effect is misdiagnosed as a new condition and treated with another drug.
• Treatment targets should be individualised according to frailty, life expectancy, patient priorities and treatment burden.

🔍 7.2 Medication Review Framework

• What is each drug for?
• Is it still needed?
• Is it effective?
• Is the dose appropriate for renal/liver function and age?
• Are there interactions or duplicate therapies?
• Is there anticholinergic burden?
• Can the patient take it correctly?
• What can be stopped, reduced or simplified?

⚠️ 7.3 High-Risk Medicines in Geriatrics

🌱 7.4 Deprescribing

• Deprescribing is planned, supervised dose reduction or stopping when harms exceed benefits.
• Prioritise drugs causing current harm, high-risk drugs and drugs without clear indication.
• Consider time-to-benefit: preventive drugs may be less useful in severe frailty/limited prognosis.
• Stop one medicine at a time where possible and monitor for withdrawal or symptom recurrence.
• Discuss with patient/carers to avoid feeling that care is being withdrawn.

🧠 Exam pearl: Medication review is a treatment. In older adults, stopping the wrong drug can be as beneficial as starting the right one.

🚽 8. Continence and Constipation

🚽 8.1 Urinary Incontinence

🧪 8.2 Incontinence Assessment

• Ask onset, pattern, urgency, nocturia, dysuria, haematuria, stream, retention symptoms.
• Review fluids, caffeine, alcohol and diuretics.
• Urinalysis if symptomatic; avoid treating asymptomatic bacteriuria in most older adults.
• Check post-void residual if retention/overflow suspected.
• Assess mobility, cognition, toilet access and constipation.
• Consider red flags: haematuria, recurrent UTI, pelvic mass, neurological symptoms.

🚽 8.3 Constipation

• Common causes: immobility, dehydration, low fibre, opioids, anticholinergics, calcium supplements, iron, hypercalcaemia, hypothyroidism.
• Symptoms: reduced stool frequency, hard stools, straining, abdominal pain, overflow diarrhoea, delirium.
• Assess for obstruction red flags: vomiting, severe pain, distension, weight loss, rectal bleeding.
• Management: fluids, mobility, diet, toileting routine, laxatives matched to stool pattern, treat impaction.
• Opioid-induced constipation requires proactive laxative prescribing.

🧻 8.4 Faecal Incontinence

• Causes: constipation with overflow, diarrhoea, dementia, immobility, sphincter weakness, neurological disease.
• Assess stool consistency, urgency, awareness, rectal loading, diet, medications and functional access to toilet.
• Management depends on cause: treat constipation, manage diarrhoea, toileting routines, continence products, skin care.

🥗 9. Nutrition, Hydration and Swallowing

⚖️ 9.1 Malnutrition

• Older adults are at risk due to poor appetite, illness, dysphagia, dental problems, depression, dementia, poverty and isolation.
• Look for weight loss, loose clothes/rings, low BMI, low intake and muscle wasting.
• Use screening tools such as MUST according to local policy.
• Interventions: food-first approach, fortified diet, snacks, oral nutritional supplements, dietitian referral.
• Refeeding syndrome risk occurs in severe malnutrition; monitor phosphate, potassium, magnesium and thiamine.

💧 9.2 Dehydration

• Causes: poor intake, delirium, dementia, diuretics, fever, diarrhoea, dysphagia, dependency.
• Features: thirst may be absent; look for reduced urine, AKI, postural hypotension, dry mucosa, delirium, constipation.
• Assess swallowing and ability to access drinks, not just fluid prescription.
• IV/subcutaneous fluids may be needed if oral intake is inadequate and clinically appropriate.

🥄 9.3 Dysphagia and Aspiration

• Causes: stroke, Parkinson’s disease, dementia, frailty, head/neck cancer, delirium.
• Signs: coughing on eating/drinking, wet voice, recurrent chest infections, weight loss, prolonged meals, drooling.
• Refer to speech and language therapy when suspected.
• Texture modification, posture, pacing and oral care reduce aspiration risk.
• Feeding decisions in advanced dementia require careful best-interests discussion; tube feeding does not always prevent aspiration.

⚠️ Safety pearl: Recurrent “chest infections” in an older person may be aspiration from dysphagia, reflux, sedation or poor oral hygiene.

🦴 10. Bone Health, Fragility Fracture and Hip Fracture

🦴 10.1 Osteoporosis and Fragility Fracture

• Fragility fracture is a low-trauma fracture from standing height or less.
• Common sites: hip, wrist, vertebra, proximal humerus.
• Risk factors: age, female sex, menopause, previous fracture, parental hip fracture, steroids, smoking, alcohol, low BMI, rheumatoid arthritis.
• Assess fracture risk using local tools such as FRAX/QFracture and DEXA where appropriate.
• Secondary prevention includes falls assessment, vitamin D/calcium optimisation and antiresorptive/anabolic therapy where indicated.

🦵 10.2 Hip Fracture

• Presentation: fall, hip/groin pain, inability to weight bear, shortened externally rotated leg.
• Impacted fractures may have subtle signs and some ability to weight bear.
• Initial management: analgesia, fascia iliaca block where appropriate, X-ray, bloods, ECG, hydration, pressure care, delirium prevention.
• Early surgery is usually preferred after optimisation, because delay increases complications.
• Post-op priorities: mobilisation, VTE prophylaxis, nutrition, analgesia, delirium prevention, continence and discharge planning.
• Hip fracture is a sentinel event — assess osteoporosis and falls risk before discharge.

🧱 10.3 Vertebral Fracture

• May present with acute back pain after minimal trauma or height loss/kyphosis.
• Consider myeloma or metastatic disease if pain is severe, progressive, nocturnal or associated with systemic symptoms.
• Management includes analgesia, mobilisation, osteoporosis treatment and sometimes spinal specialist input.

❤️ 11. Common Acute Medical Problems in Older Adults

🦠 11.1 Infection and Sepsis

• Older adults may have no fever despite serious infection.
• Presentations include delirium, falls, reduced mobility, anorexia, incontinence or functional decline.
• Common sources: pneumonia, UTI/pyelonephritis, cellulitis, biliary sepsis, intra-abdominal infection, pressure sores.
• Do not diagnose UTI from urine dip alone in an asymptomatic older person; asymptomatic bacteriuria is common.
• Assess sepsis risk using observations, perfusion, mental state, urine output and lactate where indicated.

🫘 11.2 AKI

• Common causes: dehydration, sepsis, NSAIDs, ACEi/ARB, diuretics, urinary obstruction, contrast, heart failure.
• Older adults are vulnerable because of reduced renal reserve and polypharmacy.
• Assessment: baseline creatinine, volume status, urine output, urinalysis, medication review, bladder scan/renal ultrasound if obstruction possible.
• Management: treat cause, optimise fluids, stop nephrotoxins, dose-adjust medicines and monitor electrolytes.

🫁 11.3 Breathlessness

• Differentials: heart failure, pneumonia, COPD/asthma, PE, anaemia, arrhythmia, aspiration, metabolic acidosis.
• Older adults may under-report breathlessness due to low activity levels.
• Check oxygen saturation, respiratory rate, chest signs, ECG, CXR, FBC, U&E and BNP/troponin/D-dimer selectively.

🧠 11.4 Stroke and TIA

• Older adults may present with falls, confusion or reduced mobility as well as focal signs.
• Sudden focal neurological deficit is stroke until proven otherwise.
• Check glucose immediately.
• Assess swallowing before oral intake.
• Secondary prevention must account for frailty, bleeding risk, cognition and adherence.

🩸 11.5 Anaemia

• Common causes: iron deficiency, CKD, chronic inflammation, B12/folate deficiency, malignancy, myelodysplasia.
• Symptoms may be falls, breathlessness, angina, fatigue or delirium.
• Iron deficiency in older men/postmenopausal women requires GI blood loss/malignancy consideration.

🛡️ 12. Safeguarding, Capacity and Best Interests

🛡️ 12.1 Safeguarding Concerns

• Physical, emotional, sexual and financial abuse.
• Neglect or self-neglect.
• Domestic abuse and coercive control in older adults.
• Medication mismanagement or withholding care.
• Pressure ulcers, malnutrition, poor hygiene or repeated unexplained injuries.
• Carer stress and inability to cope.

🧠 12.2 Mental Capacity

• Capacity is decision-specific and time-specific.
• Assess ability to understand, retain, use/weigh and communicate the decision.
• Support the person to decide before concluding incapacity.
• An unwise decision does not prove lack of capacity.
• If capacity is lacking, act in best interests using the least restrictive option.
• Involve family/carers, but they do not automatically decide unless legally appointed.

📝 12.3 Best-Interests Decisions

• Clarify the specific decision.
• Assess capacity for that decision.
• Consider past and present wishes, values and beliefs.
• Consult family, carers and relevant professionals.
• Balance benefits and burdens.
• Choose the least restrictive option.
• Document reasoning clearly.

📄 12.4 Advance Care Planning

• Discuss early, not only at crisis point.
• May include treatment escalation plans, DNACPR, ReSPECT/local forms, preferred place of care and advance decisions.
• DNACPR applies to CPR only, not all treatment.
• Conversations should focus on values, outcomes and what matters to the patient.

⚖️ Exam pearl: Capacity is not global. A person may lack capacity for complex discharge decisions but retain capacity to choose food, clothing or visitors.

🏥 13. Discharge Planning and Rehabilitation

🚪 13.1 Safe Discharge Questions

• Is the acute medical problem stable?
• Has delirium improved or is there a safe plan?
• Can the patient transfer and mobilise at the required level?
• Can they manage stairs, toilet, washing, dressing and meals?
• Are medicines reconciled, simplified and supplied?
• Is equipment in place: frame, commode, rails, hospital bed, pressure mattress?
• Is care package adequate and restarted?
• Are follow-up, blood tests, wound care and therapy plans arranged?
• Has the patient/carer received safety-netting?

🏋️ 13.2 Rehabilitation

• Rehabilitation aims to restore function, not simply improve observations.
• Early mobilisation prevents deconditioning, pressure sores, VTE, pneumonia and delirium.
• Rehab potential depends on baseline function, cognition, motivation, nutrition, pain and acute illness recovery.
• Goals should be specific: transfer independently, walk to toilet, manage stairs, prepare drink.
• Community rehab, intermediate care, reablement or inpatient rehab may be needed.

🏠 13.3 Discharge Destinations

📌 Discharge pearl: “Medically fit” is not the same as “safe to go home”. Function, cognition, care, equipment and carer capacity decide discharge safety.

🧑‍🦽 14. Pressure Ulcers, Skin and Immobility

🩹 14.1 Pressure Ulcers

• Pressure ulcers result from pressure, shear and impaired perfusion over bony prominences.
• Risk factors: immobility, poor nutrition, incontinence, frailty, reduced sensation, vascular disease.
• Common sites: sacrum, heels, hips, elbows, occiput.
• Prevention: repositioning, pressure-relieving surfaces, heel protection, skin inspection, nutrition, moisture management.
• Pressure ulcers can become infected and contribute to sepsis.
• Safeguarding consideration is needed if avoidable neglect is suspected.

🛌 14.2 Hazards of Immobility

🏃 14.3 Preventing Deconditioning

• Get dressed, sit out, mobilise early and often.
• Avoid unnecessary catheters, cannulas and bed rails that restrict movement.
• Set daily mobility goals.
• Optimise pain relief before therapy.
• Encourage family involvement where helpful.

👂 15. Sensory Impairment, Communication and Dignity

👂 15.1 Hearing Impairment

• Check hearing aids are present, working and have batteries.
• Face the patient, reduce background noise, speak clearly and do not shout.
• Hearing impairment increases delirium risk and can mimic cognitive impairment.

👓 15.2 Visual Impairment

• Ensure glasses are available and clean.
• Good lighting reduces falls and delirium risk.
• Visual impairment can worsen hallucinations, misinterpretation and anxiety.

🗣️ 15.3 Communication

• Use short sentences and check understanding.
• Allow time for processing.
• Use written information, pictures or family support if appropriate.
• Avoid infantilising language.
• Preserve dignity during personal care, continence care and cognitive assessment.

🚨 16. Geriatric Emergencies

📚 17. OSCE / Exam Pearls

• Always establish baseline function and cognition.
• “Off legs” and “mechanical fall” are not diagnoses.
• Acute confusion is delirium until proven otherwise.
• Hypoactive delirium is common and easily missed.
• Urine dip alone does not diagnose UTI in older adults.
• Medication review is essential after falls, delirium, AKI and syncope.
• Check lying/standing BP in falls and dizziness.
• Frailty should be assessed from baseline, not acute illness state.
• Capacity is decision-specific and time-specific.
• Safe discharge requires function, cognition, care and equipment — not just medical stability.
• Hip fracture may be occult on X-ray; persistent inability to weight bear needs further imaging.
• Deconditioning starts quickly in hospital; mobilise early.

📌 18. Quick Differentials Table

📚 References

• NICE. Delirium: prevention, diagnosis and management in hospital and long-term care. CG103.
• NICE. Falls: assessment and prevention in older people and in people 50 and over at higher risk. NG249.
• NICE. Dementia: assessment, management and support for people living with dementia and their carers. NG97.
• British Geriatrics Society. Comprehensive Geriatric Assessment resources and CGA Hub.
• NICE. Osteoporosis: assessing the risk of fragility fracture. CG146.
• NICE. Hip fracture: management. CG124.
• Local frailty, falls, delirium, dementia, safeguarding, discharge planning, continence, pressure ulcer and end-of-life pathways should always be followed.

⚠️ Disclaimer

This article is for medical education and exam revision. Clinical decisions should follow current local geriatric medicine, frailty, falls, delirium, dementia, safeguarding, rehabilitation, discharge, continence, antimicrobial, prescribing and end-of-life care pathways, formularies, senior advice and national guidance. Geriatric emergencies such as delirium, sepsis, hip fracture, stroke, AKI/hyperkalaemia, GI bleeding, medication toxicity, safeguarding crisis and end-of-life symptom crisis require urgent senior input.