Master Geriatric Medicine
for MRCP Part 1

Core Concepts

Geriatric medicine focuses on the health and well-being of older adults, recognizing age-related physiological changes and the prevalence of multi-morbidity and geriatric syndromes. Chronological age (usually >65 years) differs from biological age, which reflects functional capacity.

• Physiological Changes with Age:
  • **Cardiovascular:** Decreased arterial compliance (increased SBP), reduced baroreflex sensitivity, reduced cardiac reserve.
  • **Renal:** Decline in GFR (approx. 1ml/min/year after 40), reduced drug clearance.
  • **Respiratory:** Decreased lung elasticity, reduced FEV1, impaired cough reflex.
  • **Neurological:** Brain atrophy, neuronal loss, slower processing speed, reduced neurotransmitter levels.
  • **Endocrine:** Impaired glucose tolerance, reduced thyroid hormone production (though TSH may be normal), vitamin D deficiency.
  • **Musculoskeletal:** Sarcopenia (muscle loss), osteopenia/osteoporosis, reduced joint cartilage.
  • **Immune:** Immunosenescence (impaired immune response, increased susceptibility to infections, reduced vaccine efficacy).
• Geriatric Syndromes ("Geriatric Giants"): Multifactorial health conditions prevalent in older adults, often impacting function and quality of life. Key examples include: Frailty, Falls, Delirium, Dementia, Polypharmacy, Incontinence, Pressure ulcers, Malnutrition, Failure to thrive, Immobility.
• Comprehensive Geriatric Assessment (CGA): A multidimensional, interdisciplinary diagnostic process to determine a frail older person's medical, psychosocial, and functional capabilities and problems. Aims to develop a coordinated plan for treatment and follow-up.

Clinical Presentation

• Atypical Presentation: Illnesses in older adults often present non-specifically or without classic symptoms due to blunted physiological responses and multi-morbidity.
  • E.g., Myocardial Infarction without chest pain (presenting as confusion, dyspnea, fatigue).
  • E.g., Infection without fever or leukocytosis (presenting as delirium, falls, functional decline).
  • E.g., Depression without sadness (presenting as anhedonia, fatigue, somatic complaints).
  • E.g., Hyperthyroidism without tachycardia or tremor (presenting as apathy, weight loss, fatigue).
• Non-Specific Symptoms: Falls, confusion (delirium), functional decline, weakness, fatigue, loss of appetite are common presenting complaints for a wide range of underlying acute or chronic conditions.
• Threshold Phenomenon: Older, frail individuals have diminished physiological reserve; a minor stressor (e.g., UTI, minor injury, new medication) can precipitate a major decline in function or a geriatric syndrome.

Diagnosis (Gold Standard)

Diagnosis in geriatrics relies heavily on a holistic approach, often incorporating functional and cognitive assessments alongside standard medical investigations.

• Comprehensive Geriatric Assessment (CGA): The cornerstone for managing complex older adults. Involves detailed assessment of:
  • Medical status (comorbidities, medications).
  • Functional status (ADLs: personal care; IADLs: instrumental activities like managing meds, shopping).
  • Cognitive function (MMSE, MoCA, AMT).
  • Mood (Geriatric Depression Scale - GDS).
  • Social circumstances and support.
  • Nutritional status (MUST, MNA).
  • Mobility and falls risk.
  • Sensory impairments (vision, hearing).
• Frailty Assessment: Clinical Frailty Scale (CFS) is commonly used. Fried's Frailty Phenotype identifies ≥3 of: unintentional weight loss, self-reported exhaustion, weakness (grip strength), slow walking speed, low physical activity.
• Delirium: Confusion Assessment Method (CAM) for diagnosis; requires acute onset/fluctuation, inattention, plus either disorganized thinking or altered level of consciousness.
• Dementia: Clinical diagnosis based on cognitive decline interfering with independence in ADLs/IADLs, confirmed by neuropsychological testing and ruling out reversible causes.
• Polypharmacy Review: Utilizing tools like STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria to identify potentially inappropriate medications and omitted beneficial drugs. Beers Criteria also widely used.

Management (First Line)

Management focuses on patient-centered goals, maintaining functional independence, improving quality of life, and preventing further decline.

• Polypharmacy Management: Regular medication review (at least annually), deprescribing (systematic withdrawal of inappropriate medications), use of STOPP/START criteria. Aim to simplify regimens.
• Falls Prevention: Multifactorial approach including: exercise programs (balance, strength), medication review (sedatives, antihypertensives), home hazard assessment, vision correction, vitamin D supplementation.
• Delirium Management: Identify and treat underlying cause (infection, dehydration, medication side effect). Non-pharmacological interventions are first-line: reorientation, maintaining sleep-wake cycle, adequate hydration/nutrition, minimizing restraints, avoiding unnecessary sedatives.
• Dementia Management:
  • Non-pharmacological: Cognitive stimulation therapy, memory aids, routine, environmental modifications, caregiver support.
  • Pharmacological: Acetylcholinesterase inhibitors (Donepezil, Rivastigmine, Galantamine) for mild-moderate Alzheimer's disease. Memantine for moderate-severe Alzheimer's disease.
• Incontinence: Bladder/bowel training, pelvic floor exercises, fluid management. Pharmacotherapy (antimuscarinics, beta-3 agonists) or surgical options are secondary.
• Malnutrition: Nutritional assessment and supplementation, dietary modification, feeding assistance, oral hygiene.
• Immobility/Deconditioning: Early mobilization, physical therapy, strength and balance training.
• Advance Care Planning: Discussion and documentation of patient's wishes regarding future medical treatment (e.g., DNR, power of attorney for health care) is crucial.
• Multidisciplinary Team (MDT) Approach: Essential, involving physicians, nurses, occupational therapists, physiotherapists, social workers, dieticians, pharmacists.

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