Master Geriatric Medicine
for MRCP Part 1

What the MRCP Part 1 Tests in Geriatric Medicine

Geriatric Medicine in MRCP Part 1 tests the ability to manage atypical disease presentations, polypharmacy, frailty syndromes, and age-specific pharmacokinetics. Candidates must demonstrate knowledge of validated screening tools (e.g., Rockwood Frailty Score, Barthel Index), diagnostic criteria (e.g., DSM-5 for delirium, NICE guidelines for falls), and evidence-based prescribing adjustments (e.g., renal dose reductions, anticholinergic burden). Emphasis is on distinguishing delirium from dementia, managing osteoporosis and falls risk, recognising elder abuse, and applying deprescribing principles. Questions often present older adults with multimorbidity and require prioritisation of life-saving interventions over routine screening.

High-Yield Concepts

• Delirium vs Dementia vs Depression: Delirium: acute onset, fluctuating consciousness, inattention (CAM criteria). Dementia: insidious, progressive, intact consciousness. Depression: pseudodementia with early mood changes, cognitive testing shows 'don't know' answers. First-line delirium management: haloperidol 0.5–1 mg PO/IM (avoid in Parkinson's, use lorazepam).
• Falls Risk Assessment and Prevention: NICE CG161: multifactorial assessment (gait, balance, vision, medications, postural BP). Offer home hazard assessment and strength/balance training. Syncope workup: carotid sinus massage (contraindicated if >6 months post-stroke/TIA or carotid bruit). Vitamin D 800 IU/day + calcium if deficient.
• Osteoporosis Management: DXA scan T-score ≤ -2.5 or prior fragility fracture. FRAX tool for 10-year fracture probability. First-line: alendronate 70 mg weekly (with calcium/vitamin D). Check renal function (eGFR >35). If intolerance: denosumab 60 mg SC 6-monthly (risk of rebound fractures if stopped).
• Frailty and Comprehensive Geriatric Assessment: Rockwood Clinical Frailty Scale ≥5 (mild frailty). CGA domains: medical, functional (Barthel Index), cognitive (MMSE/MoCA), nutritional (MUST), social. Interventions: deprescribing (STOPP/START criteria), advance care planning. Frailty predicts adverse outcomes (falls, hospitalisation, mortality).
• Urinary Incontinence Types and Management: Stress incontinence: pelvic floor exercises, duloxetine if surgery declined. Urge incontinence (overactive bladder): bladder training, anticholinergics (oxybutynin, but avoid in cognitive impairment; mirabegron as alternative). Overflow: check post-void residual (>200 mL), consider alpha-blockers in men.
• Polypharmacy and Anticholinergic Burden: Anticholinergic Cognitive Burden (ACB) scale: drugs with ACB score ≥3 (e.g., amitriptyline, oxybutynin, paroxetine) increase dementia risk. STOPP criteria: avoid benzodiazepines >4 weeks, duplicate drug classes, NSAIDs in CKD or heart failure. Deprescribe: reduce dose or stop one drug at a time with monitoring.
• Prescribing Adjustments in Older Adults: Use Cockcroft-Gault for drug dosing (e.g., enoxaparin, digoxin, gentamicin). Avoid Beers list drugs: anticholinergics, long-acting sulfonylureas (glibenclamide), meperidine. Start low, go slow: e.g., ramipril 1.25 mg OD, titrate. Monitor electrolytes and renal function 1–2 weeks after dose changes.
• Elder Abuse: Recognition and Response: Types: physical, psychological, financial, neglect. Red flags: unexplained injuries, delayed presentation, conflicting histories, poor hygiene. Mandatory reporting in UK (Care Act 2014): refer to local safeguarding team. Do not confront alleged abuser; ensure patient safety.

Common Traps in Geriatric Medicine Questions

• Assuming confusion in an older patient is dementia without checking for delirium (acute onset, fluctuating course).
• Prescribing standard adult doses without adjusting for renal impairment (e.g., using eGFR instead of Cockcroft-Gault for drug dosing).
• Treating asymptomatic bacteriuria with antibiotics in older adults (screen only if UTI symptoms present).
• Using antipsychotics as first-line for behavioural symptoms in dementia without trying non-pharmacological approaches first.
• Forgetting that falls with syncope require cardiac investigation (e.g., tilt table, loop recorder) not just falls clinic referral.
• Administering the shingles vaccine (Zostavax) in immunocompromised older adults (use Shingrix instead).

How to Revise Geriatric Medicine for the MRCP Part 1

Prioritise memorising the CAM criteria for delirium, STOPP/START criteria, and the Rockwood Frailty Scale. Focus on differentiating delirium, dementia, and depression using clinical vignettes. Know the first-line treatments for osteoporosis, falls prevention, and urinary incontinence by NICE guidelines. Practice calculating creatinine clearance (Cockcroft-Gault) and adjusting common drugs (e.g., enoxaparin, digoxin). Be alert for questions that present an older patient with multiple comorbidities and ask for the most appropriate next step—often this is a comprehensive geriatric assessment or deprescribing, not adding another drug. Review the Beers and STOPP criteria for high-risk medications. Questions frequently test the management of syncope, falls, and polypharmacy, so work through past MRCP Part 1 papers focusing on geriatric scenarios.

Practise it: MedLumen has 50 Geriatric Medicine questions for the MRCP Part 1, each with a full explanation and references.