Guidelines for Geriatric Care

1. Comprehensive Geriatric Assessment (CGA)

• Evaluate Activities of Daily Living (ADLs): bathing, dressing, toileting, transferring, continence, feeding
• Evaluate Instrumental ADLs (IADLs): managing finances, medications, telephone, transportation, shopping, cooking
• Decline occurs at ~1% per year per organ system after age 30

• Review of all medical conditions (average elderly patient has 4-6 diagnosable disorders)
• Focus on common geriatric syndromes: pressure ulcers, incontinence, falls, functional decline, and delirium
• Four shared risk factors for all five syndromes: older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility
• Medication review (all prescribed + OTC)
• Nutritional evaluation
• Sensory screening (vision, hearing)

• Cognitive testing (e.g., Mini-Cog, MMSE, MoCA)
• Depression screening (e.g., Geriatric Depression Scale)
• Competency evaluation (decision-making capacity)

• Social support, living arrangements
• Identify informal (unpaid) caregivers
• Financial screening: "Do you have enough money for food, housing, medications?"
• Determine who holds durable power of attorney for health and finances

Sources: Goldman-Cecil Medicine, Ch. 23; Textbook of Family Medicine 9e, Ch. 4

2. Frailty

• Pre-frail: 1-2 criteria; Frail: 3-5 criteria
• Prevalence: ~10% community-dwelling adults >65 years; 25-56% in older surgical patients

• Physical exercise is the primary intervention
• Nutritional supplementation (protein, vitamin D)
• Team-based approach: patient + family + caregivers + social workers
• Consider palliative care framework when appropriate
• Targeted prevention of iatrogenic injury and recurrent hospitalization

Sources: Goldman-Cecil Medicine, Ch. 24; Harrison's Principles of Internal Medicine 22E

3. Falls Prevention - AGS/BGS Clinical Practice Guideline

• "Have you fallen in the last year?"
• "Are you afraid of falling?"

• Any fall in the past year
• Difficulty with walking or balance
• Poor performance on gait/balance test

• Discontinue or reduce medications affecting balance, alertness, or judgment
• Exercise programs (especially balance and strength training)
• Vitamin D supplementation (if deficient)
• Home hazard modification
• Visual correction

• Hip fracture: 14% mortality at 6 months, ~25% at 1 year; 5x more likely to require institutionalization
• Rib fractures (>3): in-hospital mortality doubles; risk of pneumonia up to 33%
• Pelvic fractures: in-hospital mortality ~8%, 27% die within 1 year
• Cervical fractures: 20-30% 1-year mortality

Sources: Mulholland & Greenfield's Surgery 7e, Ch. 30; Goldman-Cecil Medicine

4. Clinical Pharmacology in the Elderly (Polypharmacy)

• Less muscle mass + more fat → greater sensitivity to water-soluble drugs; prolonged effect of lipophilic drugs
• Reduced renal and hepatic clearance of most drugs (except drugs undergoing conjugation/glucuronidation)
• Increased risk of orthostatic hypotension, falls, delirium, and bleeding

• Evidence-based, patient-centered process to identify and eliminate unnecessary or inappropriate medications
• Use tools like the Beers Criteria (AGS) and STOPP/START criteria to identify inappropriate prescribing
• In dialysis patients: consider deprescribing quinine, diuretics, and alpha-1 blockers

• Non-adherence due to: number of medications, cost, cognitive impairment, and side effects

Sources: Goldman-Cecil Medicine, Ch. 25; Comprehensive Clinical Nephrology 7e

5. Specific Geriatric Syndromes and Their Management

Cognitive Impairment / Dementia

• Screen annually using validated tools (Mini-Cog, MMSE, MoCA)
• Assess functional impact; evaluate for reversible causes (hypothyroidism, B12 deficiency, depression, medications)
• Recent 2024 guideline on behavioral/psychological symptoms of dementia (BPSD): Watt et al., J Am Med Dir Assoc 2024 recommends individualized, non-pharmacologic approaches first

Delirium

• Prevention-focused: the HELP (Hospital Elder Life Program) strategy remains standard
• American Geriatrics Society guidelines: multicomponent non-pharmacologic interventions; avoid benzodiazepines; use antipsychotics only when required for safety
• Postoperative delirium is particularly common; strongly associated with worse long-term cognitive trajectories

Urinary Incontinence

• Present in ~33% of older women; urinary frequency/nocturia in ~75% of older men
• Ask every patient: "Have you had urinary incontinence to the extent that it is bothersome?"
• Determine pattern: overflow, urge, stress, or mixed
• Behavioral interventions (pelvic floor, bladder training) before pharmacologic

Pressure Ulcers

• Prevention: safe positioning, regular turning, pressure-reducing beds (advanced static mattresses preferred; alternating-air not recommended)
• Treatment: wet-to-dry or semiocclusive dressings; protein/zinc/antioxidant supplementation; débridement as needed; surgical repair if not healing in 6 months

Malnutrition / Weight Loss

• Common and often overlooked; contributes to sarcopenia, frailty, and poor wound healing
• Screen using MNA (Mini Nutritional Assessment)
• Protein and nutritional supplementation can improve outcomes across the frailty spectrum

6. Musculoskeletal Considerations

• Bone mass decreases ~1%/year; up to 2-3%/year in early post-menopausal women
• Bisphosphonate therapy (e.g., zoledronate 5 mg IV every 18 months) in osteopenic older women significantly reduces vertebral and non-vertebral fractures within 1 year - warranted if life expectancy >1 year
• Sarcopenia: muscle mass declines ~25% by age 70 and 30-40% by age 80 without exercise; resistance training is the key intervention

7. Sensory Changes

• Screen for hearing loss using audioscope or HHIE-S (10-item questionnaire, 75% accuracy)
• Screen for vision with standard acuity charts; refer for formal ophthalmologic evaluation as indicated

8. Prognosis and Goals of Care

• Life expectancy calculators (e.g., ePrognosis: https://eprognosis.ucsf.edu) can refine estimates beyond actuarial tables
• Time to benefit concept: Treatments taking 5-10 years to show benefit (e.g., cancer screening, statins in primary prevention) are unlikely to benefit patients with <3-year life expectancy
• Advance care planning should be revisited annually and after major health events
• Always clarify patient goals and preferences before initiating aggressive treatments

9. Elder Abuse - Red Flags

10. Key Organizations and Frameworks

1. Function first - maintain independence and quality of life, not just disease control
2. Multidisciplinary - physician, nurse, pharmacist, social worker, physio/OT all have a role
3. Patient goals - always align treatment plans with patient values and preferences
4. Polypharmacy vigilance - review and deprescribe at every encounter
5. Time to benefit - weigh each intervention against realistic life expectancy and prognosis

Geriatric Guidelines: Dementia / Alzheimer's Disease

Overview

1. Pathophysiology (What You Must Know Clinically)

• Core pathology: Amyloid-beta (Aβ) neuritic plaques + neurofibrillary tangles (NFTs) of hyperphosphorylated tau + Aβ in vessel walls
• Atrophy pattern: Starts in medial temporal lobes → inferior temporal → lateral/medial parietal → dorsolateral frontal cortices
• Key genetic risk factor: ApoE ε4 allele - one copy increases risk 2-3x in women; two copies increases risk 10-15x in both sexes
• Cholinergic deficit is the primary neurotransmitter abnormality targeted by approved therapies

2. Clinical Staging

3. Diagnostic Evaluation (2024 NIA-AA / Alzheimer's Association Guidelines)

Step 1 - Thorough Clinical Assessment

• Detailed history from patient AND a reliable informant (family/caregiver)
• Characterize: onset, progression, symptom pattern, impact on daily function
• Risk profile: age, family history of dementia, hypertension, smoking, head trauma, sleep apnea
• Full medication review (many drugs can cause cognitive impairment)
• Neurologic and mental status examination

Step 2 - Cognitive Testing

Step 3 - Laboratory Workup (to exclude reversible causes)

Step 4 - Neuroimaging

• MRI brain (preferred): medial temporal / hippocampal atrophy, posterior-predominant cortical atrophy in AD; exclude vascular disease, normal pressure hydrocephalus (NPH), tumors, subdural hematoma
• CT brain: acceptable if MRI unavailable
• FDG-PET: shows posterior temporoparietal hypometabolism in AD; useful when diagnosis is uncertain
• Amyloid PET: positive = amyloid plaques present; now considered a "core 1" diagnostic biomarker by the 2024 NIA-AA revised criteria
• CSF biomarkers: Aβ42, Aβ42/40 ratio, p-Tau181 - abnormal ratios confirm AD pathology
• Blood-based biomarkers (emerging): plasma p-Tau217 is highly predictive of AD pathology; rapidly entering clinical use

2024 NIA-AA Revised Diagnostic Criteria

• Core 1 biomarkers (amyloid): amyloid PET, CSF Aβ42/40, plasma p-Tau217 - necessary and sufficient for biological diagnosis
• Core 2 biomarkers (tau): tau PET, CSF p-Tau - indicate neurodegeneration/staging
• Allows diagnosis even in preclinical (asymptomatic) stage

Differential Diagnosis Clues

4. Treatment Guidelines

A. Pharmacologic - Neurotransmitter-Based (Symptomatic)

• Dose escalation over 4-6 weeks for each drug to minimize side effects
• AChEIs: maintain MMSE score for ~1 year vs. 2-3 point decline with placebo
• Common approach: Start AChEI at mild stage → add memantine when patient enters moderate stage
• AChEIs may help treat delusions and hallucinations; memantine can reduce agitation
• AChEIs not proven efficacious in MCI (though prior trials lacked biomarker confirmation)
• Memantine not approved for mild AD

B. Disease-Modifying Therapies (Anti-Amyloid Immunotherapy) - 2023-2024 Approvals

• Phase 3 RCTs showed ~25-35% slowing of clinical decline vs. placebo
• ARIA (Amyloid-Related Imaging Abnormalities) is the key safety risk - occurs in 20-35% on MRI; can be asymptomatic, or cause headache, confusion, seizures in severe cases; higher risk in ApoE ε4 carriers
• MRI monitoring is required before and during treatment
• Patient selection: biomarker-confirmed early-stage AD only (MCI or mild dementia); moderate-severe AD is NOT an indication
• ApoE ε4 homozygotes have higher ARIA risk; risk-benefit discussion is mandatory
• Aducanumab was removed from clinical use (ambiguous clinical benefit)

C. What Does NOT Work (Evidence-Based)

• Estrogen hormone replacement therapy
• Statins (for AD prevention)
• Vitamin E
• Ginkgo biloba

5. Managing Behavioral and Psychological Symptoms of Dementia (BPSD)

Step 1 - Non-Pharmacologic First (Guideline Recommendation)

• Identify and treat underlying causes (pain, infection, constipation, urinary retention, sensory impairment)
• Structured activities, music therapy, reminiscence therapy, validation therapy
• Environmental modifications (adequate lighting, familiar objects, reduce noise/clutter)
• Caregiver education and support
• Regular exercise programs

Step 2 - Pharmacologic for BPSD (Use with Caution)

6. General Dementia Care Principles

Driving Safety

• All dementia patients should be assessed for driving safety
• Moderate-severe dementia: driving should cease
• Refer to occupational therapy driving evaluation for mild dementia

Advance Care Planning

• Initiate early, while patient still has decision-making capacity
• Establish: power of attorney for health and finances, healthcare proxy, living will/advance directive
• Revisit at every stage transition

Nutrition

• Screen with Mini Nutritional Assessment (MNA)
• High-protein oral supplements for weight loss and sarcopenia
• Per ESPEN 2024 guideline: oral nutritional supplements are recommended over tube feeding in advanced dementia - tube feeding does not improve survival or prevent aspiration in end-stage AD

Physical Activity

• Per international collaborative guideline (2023) (Veronese et al., Eur Geriatr Med): structured exercise is recommended for both prevention and management of MCI and dementia
• Aerobic exercise + resistance training: 150 min/week moderate intensity
• Benefits: slows cognitive decline, reduces BPSD, improves function and mood

Caregiver Support

• Up to 80% of caregivers develop depression or burnout
• Refer to support groups (Alzheimer's Association), respite care
• Educate about disease progression, safety at home (locks, stove guards, tracking devices)

Safety at Home

• Home safety assessment by occupational therapy
• Fall prevention measures
• Driving cessation planning
• Wandering prevention (door alarms, GPS devices)
• Medication management (locked pill boxes, blister packs)

7. Monitoring and Follow-Up

8. Summary of Key Guidelines by Organization

Sources: Harrison's Principles of Internal Medicine 22E (2025); Goldman-Cecil Medicine; Textbook of Family Medicine 9e; Stahl's Essential Psychopharmacology; The Maudsley Prescribing Guidelines 15e; PubMed PMID 38640961, 37768499, 38772068, 39761441