⭐ Anticholinergics for Urge UI in ElderlyOxybutynin: avoid immediate-release formulation in elderly (high anticholinergic burden → confusion, dry mouth, constipation, urinary retention). Prefer extended-release formulations or trospium, solifenacin, or mirabegron (β3-agonist — no anticholinergic effects).
Pressure Ulcers — Staging
Stage I
Non-blanchable erythema. Intact skin. Area may be painful, firm, soft, warmer/cooler than adjacent skin.
Stage II
Partial-thickness loss. Shallow open wound with red/pink wound bed. May look like intact blister. No slough.
Stage III
Full-thickness skin loss. Subcutaneous fat may be visible. No bone/tendon/muscle exposed. Slough may be present.
Stage IV
Full-thickness with exposed bone, tendon, or muscle. Often includes undermining/tunneling. High infection risk → osteomyelitis.
Unstageable
Full-thickness. Base obscured by slough (yellow/tan) or eschar (brown/black). Can't assess depth. Remove eschar to stage (except heel).
DTI
Deep Tissue Injury. Purple/maroon localized area. Intact or non-intact skin. Pressure and/or shear. May evolve rapidly.
⭐ Braden ScalePredicts pressure ulcer risk. Lower score = HIGHER risk. Domains: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction/Shear. Score ≤18 = at risk; ≤12 = high risk. Heel pressure ulcers: DO NOT remove stable eschar (acts as natural cap).
✅ Management: Offload pressure (repositioning q2h), wound care (moisture-retentive dressings), optimize nutrition (protein 1.2–1.5g/kg/day, zinc, Vitamin C), debridement if necrotic tissue, treat infection. Wound consult or surgery for Stage III/IV.
Falls — Assessment & Prevention
⚠️ #1 Cause of Injury Death in Adults 65+ in the United States. 30% of adults 65+ fall each year. 50% of nursing home residents fall annually.
3-Question Fall Screen
Have you had any falls in the past year?
Do you feel unsteady when standing or walking?
Are you worried about falling?
Any "yes" → Comprehensive fall assessment including medication review, orthostatic vitals, cognitive screen, gait/balance assessment, home safety evaluation.
Finisterre / Unknown — Idiopathic (15–25% of cases never find a cause)
⭐ Syncope Red Flags → Cardiac Workup!Exertional syncope (HCM, AS), syncope during exercise, syncope preceded by palpitations, family history of sudden cardiac death, new LBBB/QTc prolongation on EKG, structural heart disease. Workup: EKG (always), orthostatic vitals, Holter monitor, echocardiogram.
Orthostatic Hypotension: ↓SBP ≥20 mmHg or ↓DBP ≥10 mmHg within 3 min of standing. Causes: Dehydration, medications (antihypertensives, diuretics), autonomic dysfunction (DM, Parkinson's). Treatment: ↑fluid/salt, compression stockings, fludrocortisone, midodrine.
Frailty — Fried Phenotype
WESLP — Fried Frailty Criteria (≥3/5 = FRAIL)
W
Weight loss — Unintentional loss of >10 lbs (4.5 kg) in past year OR >5% body weight
ChEI (can help hallucinations), dopamine agonists for Parkinsonism. AVOID antipsychotics!
Frontotemporal (FTD)
5–10%
TDP-43 or tau deposits, frontal/temporal atrophy
Personality/behavior changes FIRST (disinhibition, apathy, hypersexuality), language problems, younger onset (50s–60s), memory relatively spared early
Symptomatic: SSRIs for behavioral sx, no FDA-approved disease-modifying tx
⚠️ Lewy Body Dementia: Antipsychotics (haloperidol, risperidone) cause severe neuroleptic sensitivity reactions (acute EPS, rigidity, cognitive decline, death). Use with extreme caution or avoid entirely. Quetiapine is relatively safer if needed.
Safety: Driving assessment, medication management, fall prevention
Wandering: Door alarms, GPS tracking
Caregiver education and respite care
Advance care planning early
Adult day programs
Simplify medication regimen
Structured daily routine
Delirium — Medical Emergency
⚠️ Delirium = Medical Emergency. NOT a normal part of aging. Always indicates an underlying medical cause that must be found and treated. Increased mortality, longer hospitalizations, increased nursing home placement.
DELIRIUM — Causes
D
Drugs — Most common cause! Anticholinergics, benzos, opioids, polypharmacy, recent medication changes, alcohol/benzo withdrawal
Agitation, combative, pulling out lines, loud, disoriented
Easiest to recognize
Hypoactive
Somnolent, withdrawn, quiet, slowed speech
Most common, most missed
Mixed
Fluctuates between hyper and hypo
Also common
CAM (Confusion Assessment Method)
Delirium diagnosed if features 1 AND 2 plus either 3 OR 4:
Acute onset AND fluctuating course
Inattention (can't focus, easily distracted)
Disorganized thinking (rambling, incoherent)
Altered level of consciousness (anything other than alert)
Sensitivity 94–100%, Specificity 90–95%. Gold standard for delirium screening.
Management: Treat underlying cause (PRIORITY). Reorientation (clock, calendar, family). Restore sleep-wake cycle. Provide glasses/hearing aids. Avoid restraints. Early mobilization. IV fluids if dehydrated. Only use low-dose haloperidol if patient is a safety risk (does NOT reduce duration). Avoid benzos unless withdrawal delirium.
Depression in the Elderly
Geriatric Depression Scale (GDS)
15-item or 30-item scale. 15-item most common in clinical practice.
Pseudodementia: Depression can mimic dementia (memory complaints, difficulty concentrating). Key: patients with pseudodementia often COMPLAIN about memory loss; those with true dementia often downplay it. Treat depression first, reassess cognition.
⭐ Mini Nutritional Assessment (MNA)Screening tool for malnutrition risk in elderly. MNA short form (6 questions). Score: ≥12 = normal; 8–11 = at risk; 0–7 = malnourished. Goal protein intake in elderly: 1.0–1.2 g/kg/day (frail or ill: 1.2–1.5 g/kg/day). Vitamin D supplementation (600–800 IU) recommended for all elderly.
Patient appears fearful or anxious around caregiver
Caregiver speaks for patient; doesn't allow private interview
Inconsistent history for injuries
Poor hygiene/nutrition despite having family
Unexplained financial transactions
Repeated "accidents" or ED visits
Delayed presentation for injuries
⚠️ MANDATORY REPORTING: All 50 states require healthcare providers to report suspected elder abuse to Adult Protective Services (APS). Document carefully (photos of injuries, exact quotes). Interview patient ALONE — never with suspected abuser present.
Beers Criteria — Medications to Avoid in Elderly (≥65)
⚠️ American Geriatrics Society Beers Criteria: List of potentially inappropriate medications (PIMs) in older adults due to ↑risk of adverse events. Know what to AVOID and WHY.
Medication
Category
Risk in Elderly
Alternative
Diphenhydramine (Benadryl)
First-gen antihistamine
Highly anticholinergic → confusion, delirium, urinary retention, constipation, falls, sedation
Mirabegron (β3-agonist), ER oxybutynin, trospium, solifenacin
Glyburide
Sulfonylurea
Long half-life → prolonged hypoglycemia (hepatically cleared)
Glipizide (shorter acting); SGLT2i, GLP-1 for T2DM
Meperidine (Demerol)
Opioid
Active metabolite (normeperidine) accumulates → seizures, neurotoxicity
Morphine, hydromorphone, oxycodone
Muscle relaxants (Cyclobenzaprine, Methocarbamol)
Skeletal muscle relaxant
Anticholinergic, sedating, poor evidence for efficacy in elderly
PT, heat/cold therapy, acetaminophen
Anticholinergic Burden
Anticholinergic Burden: The cumulative effect of multiple drugs with anticholinergic properties. Even "mild" anticholinergic drugs combined can cause significant cognitive and physical toxicity.
High Anticholinergic Drugs to Avoid
Diphenhydramine (Benadryl)
Hydroxyzine
Oxybutynin (IR)
Tricyclic antidepressants
Scopolamine
Benztropine
Promethazine
Chlorpheniramine
Anticholinergic Toxidrome
"Mad as a hatter, blind as a bat, dry as a bone, red as a beet, hot as a hare, full as a flask"
Mad as a hatter: Confusion, delirium, agitation
Blind as a bat: Blurred vision, mydriasis
Dry as a bone: Dry mouth, dry skin, urinary retention, constipation
Red as a beet: Flushing
Hot as a hare: Hyperthermia (no sweating)
Full as a flask: Urinary retention, distended bladder
Comprehensive Geriatric Assessment (CGA)
ADLs (Basic)
Impairment → need for personal care assistance
Bathing
Dressing
Eating
Toileting
Transferring (bed/chair)
Continence
Mnemonic: BDETC
IADLs (Instrumental)
Impairment → need for home support/assistance
Shopping
Housekeeping
Accounting (finances)
Food preparation
Telephone use
Transportation
Medications
Mnemonic: SHAFTM
⭐ ADL vs IADL Key PointADLs (Basic self-care): impaired in moderate-severe dementia, severe physical illness. IADLs: impaired first in MCI and early dementia. IADL impairment distinguishes MCI from normal aging, and dementia from MCI. Always assess BOTH in geriatric patients.
Master Mnemonic Reference
DIAPPERS — Reversible Causes of UI
D
Delirium / Dementia
I
Infection (UTI)
A
Atrophic vaginitis/urethritis
P
Pharmaceuticals (diuretics, sedatives)
P
Psychological (depression)
E
Excess urine output (CHF, DM)
R
Restricted mobility
S
Stool impaction
DELIRIUM — Causes of Delirium
D
Drugs / Alcohol withdrawal
E
Electrolyte disorders
L
Lack of drugs (withdrawal)
I
Infection (UTI, pneumonia, sepsis)
R
Reduced sensory input
I
Intracranial (stroke, bleed, seizure)
U
Urinary retention / Fecal impaction
M
Metabolic (thyroid, hepatic, hypoxia)
WESLP — Fried Frailty Criteria (≥3 = Frail)
W
Weight loss (unintentional >10 lbs/year)
E
Exhaustion (self-reported, ≥3 days/week)
S
Slowness (gait speed <0.8 m/s)
L
Low activity (<383 kcal/week men, <270 women)
P
Poor grip strength (bottom 20%)
HPBMF — Syncope Causes
"Happy People Bring More Food"
H
Heart / Vascular (cardiac — most dangerous)
P
Pressor reflex / Vagal (vasovagal — most common)
B
Basilar artery TIA
M
Metabolic / Drugs
F
Finisterre / Unknown (idiopathic)
9 D's of Weight Loss in Elderly
1. Dementia
2. Depression
3. Dysphagia
4. Dysgeusia
5. Diarrhea
6. Disease (cancer, CHF)
7. Drugs
8. Dysfunction
9. Dentition
Anticholinergic Toxidrome
M
Mad as a hatter — Confusion, delirium
B
Blind as a bat — Blurred vision, mydriasis
D
Dry as a bone — Dry mouth, no sweating, constipation
R
Red as a beet — Flushed skin
H
Hot as a hare — Hyperthermia
F
Full as a flask — Urinary retention
CAM Criteria (Delirium Diagnosis)
Need features 1 + 2 + (3 OR 4)
1
Acute onset + Fluctuating course (ask family/nurses about change from baseline)
2
Inattention (digit span, MOCA attention items, ask to name months backward)
3
Disorganized thinking (rambling, irrelevant answers, unclear thought process)
4
Altered LOC (anything other than "alert" — drowsy, stuporous, hypervigilant)
Pressure Ulcer Staging Quick Reference
1
Stage I: Non-blanchable RED — intact skin
2
Stage II: Partial thickness — shallow wound or blister
3
Stage III: Full thickness — fat visible, no bone
4
Stage IV: Full thickness — BONE/TENDON/MUSCLE exposed
U
Unstageable: Covered by slough or eschar
D
DTI: Purple intact skin — deep tissue
UWorld-Style Practice Vignettes
An 82-year-old woman is brought to the ED by her daughter. The daughter says, "Mom was completely fine yesterday but this morning she's not making any sense and keeps falling asleep." The patient has type 2 diabetes, hypertension, and osteoarthritis. Medications include metformin, lisinopril, and ibuprofen (recently started for knee pain). Vitals: T 38.2°C, BP 102/64, HR 102, RR 20. Urinalysis shows pyuria and bacteriuria. Mental status: inattentive, alternating between somnolence and agitation.
Q: What is the diagnosis, and what is the most likely precipitating cause?
✅ Diagnosis: Delirium — precipitated by UTI (Infection)
Why delirium? CAM criteria met: • Acute onset (overnight, fine yesterday) • Fluctuating course (alternating somnolent/agitated) • Inattention (not making sense) • Altered LOC
Precipitant: UTI — Atypical UTI presentation in elderly. Instead of dysuria/frequency, she has delirium + low-grade fever + UA positive.
Contributory factors: • NSAIDs (ibuprofen) → renal dysfunction → drug toxicity, AKI → electrolyte disturbance • Fever → metabolic stress
Management: 1. Treat the UTI (IV antibiotics for altered MS, TMP-SMX or fluoroquinolone or nitrofurantoin when improved + eating) 2. STOP ibuprofen (Beers Criteria — avoid NSAIDs in elderly; risk of AKI, GI bleed, HTN) 3. IV fluids (dehydrated) 4. Reorientation, minimize anticholinergics and sedatives 5. Correct any electrolyte abnormalities
A 78-year-old man is evaluated in clinic. He reports no memory problems but his wife says he often misplaces items and has missed two medical appointments. Neuropsychological testing shows 1.5 standard deviations below age-matched norms on episodic memory tasks. He manages his own medications, drives safely, and pays his bills independently. He lives alone. MMSE is 26/30, MoCA is 23/30.
Q: What is the diagnosis, and what is the risk of progression to Alzheimer's disease?
Why MCI and not dementia? • Objective cognitive impairment (neuropsych testing, MoCA 23/30) • ADLs are INTACT — manages medications, drives, pays bills independently • This is the critical distinguishing feature: MCI = impaired cognition + INTACT ADLs
Why amnestic MCI? Memory is the primary domain affected (misplacing items, appointment, episodic memory testing). Amnestic MCI has the highest risk of converting to Alzheimer's disease.
Conversion risk: 10–15% per year convert from MCI to AD (vs 1–2%/year in general elderly population).
Treatment: • Cholinesterase inhibitors: NOT proven to prevent conversion to AD • Monitor annually (repeat cognitive testing) • Vascular risk factor management (HTN, DM, dyslipidemia) • Exercise (1–2h aerobic/week) • Cognitive engagement, social activity • Advance care planning discussion
A 75-year-old nursing home resident develops a 3cm dark purple area of intact skin over her sacrum. She has been bedbound for 6 weeks following a hip fracture and hip replacement. The area is firm and painful to touch. There is no overlying skin break.
Q: How is this pressure injury classified, and what is the appropriate management?
✅ Classification: Deep Tissue Pressure Injury (DTI)
Why DTI? • Purple/maroon color of intact or non-intact skin • Intact skin (no open wound) • Over a bony prominence (sacrum) • Firm and painful • History of prolonged pressure (6 weeks bedbound)
DTI ≠ Stage I: Stage I = non-blanchable red. DTI = purple/maroon, deeper tissue damage underneath intact skin. DTI can rapidly evolve to Stage III or IV!
Management: 1. Immediately offload the area (special pressure-relieving mattress, reposition q2h with turning schedule) 2. Do NOT massage the area (can worsen damage) 3. Keep skin clean and dry; protect from shear 4. Optimize nutrition (protein 1.2–1.5g/kg/day, Vitamin C, zinc) 5. Monitor closely — DTI can evolve within days 6. Wound care consult 7. Address underlying risk factors (incontinence management, pain management to allow repositioning)
A 79-year-old man falls and fractures his wrist at home. Review of his medication list reveals: atenolol, amlodipine, furosemide, alprazolam (for sleep, 5-year history), oxybutynin, and metoprolol. He reports 3 falls in the past 6 months. He scores 26/30 on MMSE. His daughter is concerned about his polypharmacy. TUG test: 18 seconds.
Q: Which TWO medications should be prioritized for deprescribing to most significantly reduce his fall risk?
✅ Deprescribe: Alprazolam (benzodiazepine) AND Oxybutynin (anticholinergic)
Alprazolam (Benzodiazepine): • Beers Criteria — strongly avoid in elderly • ↑Fall risk 50–60% (impairs balance, reflexes, reaction time) • Sedation, paradoxical agitation, cognitive impairment • Must TAPER slowly (do not abruptly discontinue — withdrawal risk, seizures) • Goal: CBT-I for insomnia; consider low-dose trazodone or mirtazapine short-term
Oxybutynin IR (immediate-release): • Beers Criteria — highly anticholinergic • Crosses blood-brain barrier → confusion, memory impairment, delirium, falls • Switch to: Mirabegron (β3-agonist — no anticholinergic SE), solifenacin, or trospium
Also consider: • Has BOTH atenolol AND metoprolol — duplicate BB therapy! Reduce to one agent • Furosemide → dehydration, orthostatic hypotension, frequent urination (fall risk getting to bathroom at night)
Note: TUG of 18 sec = moderate-high fall risk. Refer to PT for gait/balance training. Home safety evaluation.
An 84-year-old woman is brought to the ED by her son. She has dementia and lives with him. Exam reveals multiple bruises in different stages of healing on her upper arms and thighs, a healing burn on her forearm, and poor hygiene. She appears fearful and looks to her son before answering questions. Her son answers questions on her behalf, saying she "falls a lot." When alone with the clinician, she says "I don't want to go home with him."
Q: What is the suspected diagnosis, what type specifically, and what is the appropriate next step?
Red flags present in this case: • Bruising in unusual locations (upper arms/thighs) + multiple stages of healing • Unexplained burn injury • Poor hygiene despite living with family member (suggests neglect) • Patient appears fearful around caregiver/son • Caregiver speaks for patient, doesn't allow independent answers • When alone: patient expresses fear of going home • Dementia = vulnerability factor (cognitive impairment = #1 risk factor for elder abuse)
Management: 1. Interview patient ALONE — you already did this, and got crucial information 2. Mandatory report to APS (all 50 states require mandatory reporting) 3. Do NOT confront the abuser at this time 4. Photograph and document ALL injuries (with patient consent) — include color, size, stage of healing 5. Admit to hospital if immediate safety risk 6. Social work referral + geriatric social services 7. Assess capacity (dementia affects decision-making capacity) 8. Develop safety plan
Most common perpetrator: Family members (adult children #1). Most common type: Neglect, then financial abuse.
A 71-year-old man presents with a 4-month history of sadness, anhedonia, difficulty concentrating, poor sleep, and weight loss of 12 pounds. He recently retired and his wife passed away 6 months ago. He scores 9/15 on the GDS and 24/30 on the MMSE. His primary care provider is concerned about whether this is depression or early dementia.
Q: What is the most likely diagnosis and how do you differentiate from dementia?
✅ Geriatric Depression (with features of Pseudodementia)
| Feature | Depression (Pseudodementia) | True Dementia | |---|---|---| | Onset | Identifiable (grief, life event) | Gradual, insidious | | Chief complaint | Patient complains about memory | Patient minimizes/unaware | | Mood | Clearly depressed | May not have depressed mood | | Cognitive fluctuation | Variable — worse some days | Progressive decline | | History of depression | Common | Less typical | | Response to antidepressant | Improves cognitive function | Cognitive deficits persist |
Key teaching point: In depression, patients COMPLAIN about their cognitive symptoms. In dementia, patients often DENY or are UNAWARE of their deficits.
Management: 1. Start antidepressant: Sertraline or Escitalopram (preferred in elderly — fewest drug interactions, best tolerated) 2. Reassess cognition in 3–6 months after treatment 3. Psychotherapy (CBT, grief counseling) 4. Address social isolation (support groups, senior center) 5. Avoid TCAs, MAOIs, and paroxetine in elderly 6. If cognition doesn't improve with antidepressant → true dementia more likely
Matching Practice
Match the Mnemonic Letter to its Meaning in DELIRIUM
Ask anything about geriatric syndromes, mnemonics, clinical presentations, or medications. Try: "What are the stages of pressure ulcers?", "Explain the difference between delirium and dementia", "What is the Fried frailty phenotype?", "Which medications should I avoid in elderly?"
🎯 Geriatrics Final — Practice Quiz
⏱️ Timed Vignette-Style Test
UWorld-style second-order vignettes at ~60 seconds each. Choose Practice or Timed Exam mode, set the pacing timer and length, then work through the hard question bank with per-topic scoring and full answer review.