Updated April 2025

Elderly Care

Comprehensive clinical guide for UK GP trainees covering frailty assessment, multimorbidity management, and common geriatric presentations

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Executive Summary

1.8M

UK Adults ≥60 with Frailty

Prevalence increases from 6.5% (60-69) to 65% (≥90)

40%

Hospital Admissions

People 65+ account for 40% of admissions, 60% of bed days

210K

Falls Admissions

Emergency hospital admissions for falls in 65+ (2022/23)

66.1%

Dementia Diagnosis Rate

Primary care diagnosis rate (January 2026)

Key Learning Points

Elderly patients often present atypically - confusion, falls, or functional decline may be the only sign of serious illness
Comprehensive Geriatric Assessment (CGA) improves outcomes and reduces hospital admissions
Frailty identification using validated tools enables proactive care planning
Regular medication review using STOPP/START criteria reduces adverse events
Multimorbidity management should focus on patient priorities, not disease-specific targets

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Brainy Bites

Comprehensive Geriatric Assessment

CGA is a multidimensional, interdisciplinary diagnostic process to determine medical, psychological, and functional capabilities. It improves outcomes and reduces hospital admissions.

Frailty Identification

Use validated tools like Clinical Frailty Scale or electronic Frailty Index. Early identification enables proactive care planning and prevents adverse outcomes.

Polypharmacy Review

Regularly review medications using STOPP/START criteria. Deprescribing inappropriate medications reduces falls, confusion, and adverse drug reactions.

Atypical Presentations

Elderly patients often present atypically. Confusion, falls, or functional decline may be the only sign of serious illness like MI, sepsis, or malignancy.

Multimorbidity Management

Focus on patient priorities, not disease-specific targets. Use shared decision-making and consider treatment burden, life expectancy, and quality of life.

The 9 Geriatric Giants — MANIC MOLD

Every elderly patient deserves a check for the 9 Giants: Mobility, Abuse (elder), Nutrition, Incontinence, Cognition/Confusion, Medication problems, Osteoporosis, Loneliness, Depression. They're rarely volunteered. Ask. Treat. Transform lives.

Clinical Pearls & Top Tips

Why These Pearls Matter

Elderly patients often don't volunteer these problems — they think they're just "part of getting old." As the GP, it's your job to ask. Many of these issues are treatable and, when treated, can transform the last years of a patient's life. This section gives you the framework to remember what to look for and how to act on it.

Origin & Context

The Geriatric Giants were first described by Bernard Isaacs in 1965. Originally there were 5, but the concept has grown to 9 as our understanding of elderly care has deepened. These are the most common and most under-reported problems in older adults. They are rarely volunteered — you must ask proactively.

Remember: Finding and treating even one of these can make a huge difference to an elderly person's quality of life.

Mnemonic: MANIC MOLD

Mobility

Includes balance problems, sarcopenia (muscle loss), and falls. Think physio referral, medication review (benzodiazepines? opioids?), and strength training.

Elder Abuse

Including self-neglect. Ask the patient alone. Look at the feet — they often tell the true story of whether a patient is being cared for properly.

Poor Nutrition

Mouth problems, failure to thrive, anorexia of ageing. MUST score if weight is falling. Look at the mouth — ulcers (oral cancer?), denture fit, thrush.

Incontinence

Urinary and faecal. Ask directly — patients are embarrassed to volunteer this. Is confusion increasing alongside it? Rule out UTI.

Confusion / Cognitive Impairment

Dementia or delirium? "Bad behaviour" is often infection, pain, constipation, or depression — not just dementia. Use a memory tool (6-CIT, MMSE).

Medication Problems

Polypharmacy (≥5 drugs). Is the patient refusing or not taking meds? That's a hint — don't ignore it. Review, reduce, deprescribe. Use STOPP/START.

Osteoporosis

FRAX score. DEXA if needed. Calcium + Vitamin D. Falls prevention. Think about this after any low-impact fracture.

Loneliness

One of the most harmful and most overlooked conditions in older people. As harmful as smoking 15 cigarettes a day. Ask about it plainly. Refer to befriending services, community groups.

Depression

Often masked as somatic symptoms or "just old age." Use PHQ-2 or ask: "Do you often feel down or hopeless?" First-line: SSRI (sertraline). Consider behavioural activation too.

💡 AKT Tip

The MANIC MOLD mnemonic is highly AKT-testable. Expect questions about which Giants are commonly missed, and scenarios where one Giant is masking another (e.g. depression presenting as confusion, or pain presenting as "bad behaviour" in a care home resident).

Exam trap: "Bad behaviour" in a care home patient is almost never just dementia. Always rule out infection, pain, constipation, and depression first.

Why Frailty is Not Just "Getting Old"

Frailty usually takes 5–10 years to develop. People with frailty often experience a slow but steady loss of ability. Right now, most frail patients only reach us in a crisis — admitted to hospital when things get very bad. But if we find frailty early and plan ahead, we can slow the decline, reduce hospital admissions, and give patients a much better quality of life in their final years.

Think of it this way: Would you rather decline slowly over 10 years, getting worse each year — or stay well until the last few months of life? Proactive frailty care makes the second option more likely. And yes — frailty can be slowed and sometimes partially reversed.

Fried Frailty Phenotype — Mnemonic: WELSW

Score 0 = Robust | 1–2 = Pre-frail | ≥3 = Frail

Weight Loss

Unintentional loss of >4.5 kg (or >5% body weight) in the past year

Exhaustion

Self-reported low energy or fatigue most of the time (e.g. from CES-D depression scale)

Low Physical Activity

Low weekly kilocalorie expenditure (men <383 kcal/week; women <270 kcal/week)

Slowness

Slow walking speed (timed 4.6 m walk — adjusted for height and sex)

Weakness

Reduced grip strength (measured by dynamometer — adjusted for sex and BMI)

⚠️ Important: Don't Forget the eFI and CFS

In day-to-day primary care, the electronic Frailty Index (eFI) runs automatically from GP records (no action needed — look for the score in the patient summary). For direct assessment, use the Clinical Frailty Scale (CFS) — a quick, validated 1–9 scale.

WELSW/Fried Phenotype is more commonly asked about in exams as the research-based definition of frailty. Know both.

What is Sarcopenia?

Sarcopenia is the age-related, involuntary loss of skeletal muscle mass and strength. It starts as early as age 40, with muscle declining by roughly 1% per year. By age 80, a person may have lost up to 50% of the muscle mass they had at 40. That's enormous — and it directly causes falls, frailty, and loss of independence.

Simple analogy: Think of muscles like a savings account. Every year from 40 onwards, a little money comes out — unless you keep putting some back through exercise.

🚨 We Often Make It Worse Without Realising

Relatives and health professionals sometimes accelerate sarcopenia by being too helpful — taking over tasks the elderly person could still do themselves. A patient who moves from a house to a bungalow loses all those stair climbs that were building muscle. Someone whose family does all the shopping loses that daily walk.

Key principle: Encourage activity appropriate to the patient's ability. Use it or lose it.

Consequences

Falls (weak muscles can't correct balance)
Frailty and functional decline
Longer recovery after illness
Loss of independence
Increased hospitalisation risk

Management

Exercise is the ONLY proven treatment — specifically resistance/strength training
Physiotherapy referral if significant muscle loss
Adequate protein intake (1.0–1.2 g/kg/day)
Treat Vitamin D deficiency (linked to muscle weakness)
Encourage mobility — even small amounts count
Review medications (corticosteroids worsen sarcopenia)

💡 AKT Tip

Sarcopenia is not a diagnosis of exclusion — it is a clinical syndrome. EWGSOP2 (European Working Group on Sarcopenia in Older People) criteria are the reference standard: low muscle strength (primary criterion) + low muscle quantity/quality. Confirmed by measuring grip strength and walking speed or chair stand test. Know that exercise (specifically resistance training) is the only evidence-based treatment. Nutritional supplementation alone is not sufficient.

Why the Feet?

The feet of an elderly patient can tell you more in 30 seconds than some consultations do in 10 minutes. A patient may appear immaculate and well-presented — but the feet reveal the real story. This is especially important in home visits and care home visits.

🚨 What to Look For

Dirty feet, long toenails: Self-neglect or carer neglect — ask more questions, consider safeguarding
Skin changes, colour, temperature: Poor circulation, diabetes, peripheral vascular disease
Ulcers: Diabetic foot, venous, or arterial — needs urgent assessment
Foot deformity: Arthritis, bunions, poor footwear — all increase falls risk
Corns, calluses, ingrown nails: Pain-related mobility reduction and fall risk
Oedema: Cardiac failure, venous insufficiency, DVT, hypoalbuminaemia

Clinical Action

Make it part of every care home visit — a quick look takes 30 seconds
Refer to podiatry for diabetes, nail problems, and mobility-affecting conditions
Address footwear — slippers and improper footwear are a major fall risk
Toenail findings suggestive of neglect → consider safeguarding referral
Foot ulcers in diabetics → urgent diabetic foot pathway activation

💡 SCA Tip

In an SCA scenario involving a care home visit or a frail elderly patient, mentioning that you would examine the feet is an easy way to demonstrate a holistic, person-centred approach. It shows you understand elder care beyond the presenting complaint.

Data Gathering & Examination

Consultation Framework

Elderly patients require a holistic approach that goes beyond disease-focused history taking. Allow extra time and consider cognitive, functional, and social factors.

Build rapport: Speak clearly, face the patient, and check hearing aids are working
Collateral history: Essential for cognitive impairment - speak to family/carers
Functional assessment: Activities of daily living (ADLs) and instrumental ADLs
Social circumstances: Living situation, support network, carers

Fried Frailty Phenotype (WELSW) — The Research Standard

The Fried criteria are the original research definition of frailty and commonly tested in exams. Score each criterion present (1 point each). 0 = Robust | 1–2 = Pre-frail | ≥3 = Frail.

Letter	Criterion	How to Assess
W	Weight loss	Unintentional >4.5 kg or >5% body weight in past year
E	Exhaustion	Self-report: "Do you feel full of energy?" — low energy most of the time
L	Low physical activity	Low weekly energy expenditure or reports very little physical activity
S	Slowness	Slow on timed 4.6 m walk test (cut-off varies by height and sex)
W	Weakness	Low grip strength on dynamometer (adjusted for sex and BMI)

Clinical Frailty Scale (CFS)

9-point scale from very fit (1) to terminally ill (9). Validated for use in primary care and hospital settings.

Score	Category	Description
1-3	Fit to Managing Well	Active, independent, no regular help needed
4	Vulnerable	Slowed up, symptoms limit activities
5-6	Mildly to Moderately Frail	Needs help with IADLs/ADLs
7-9	Severely Frail to Terminally Ill	Completely dependent or end of life

Electronic Frailty Index (eFI)

Automated tool using GP records to identify frailty. Calculates deficit accumulation across 36 variables. Categories: fit (0-0.12), mild (0.12-0.24), moderate (0.24-0.36), severe (>0.36).

Polypharmacy Risks

Polypharmacy (≥5 medications) affects 50% of people >65. Associated with falls, confusion, adverse drug reactions, and non-adherence. If a patient is not taking their medication, it may be a valuable hint — don't ignore non-concordance. Evidence shows 30–50% of people don't take medicines as prescribed.

AKI Sick Day Rules — Mnemonic: SADMAN

When a patient is acutely unwell with vomiting, diarrhoea, fever, or dehydration — STOP these medicines to prevent Acute Kidney Injury (AKI). Restart only after 24–48 hours of eating and drinking normally.

SGLT-2 inhibitors

Drugs ending in "-flozin": canagliflozin, dapagliflozin, empagliflozin. Risk: AKI and euglycaemic DKA when unwell.

ACE inhibitors

Drugs ending in "-pril": ramipril, lisinopril, enalapril, perindopril. Risk: AKI when dehydrated.

Diuretics

Furosemide, bendroflumethiazide, bumetanide. Risk: Worsens dehydration, AKI.

Metformin

Risk: Lactic acidosis in the context of AKI/dehydration. Always stop when unwell.

ARBs (Angiotensin Receptor Blockers)

Drugs ending in "-sartan": losartan, candesartan, valsartan, irbesartan. Risk: AKI when dehydrated.

NSAIDs

Ibuprofen, naproxen, diclofenac. Risk: Renal vasoconstriction → AKI. Avoid in elderly whenever possible.

⚠️ Also remember: Sulphonylureas (e.g. gliclazide, glimepiride) should be stopped/dose-reduced when unwell due to hypoglycaemia risk — not in SADMAN, but equally important. Insulin should NOT be stopped — but doses may need adjusting. Always advise patients to contact their GP/111 if unsure.

STOPP/START Criteria

Screening Tool of Older Persons' Prescriptions / Screening Tool to Alert to Right Treatment

STOPP examples:

Benzodiazepines for >4 weeks (falls risk)
NSAIDs with heart failure or CKD
Anticholinergics with dementia
PPIs for >8 weeks without indication

START examples:

Statin in diabetes or CVD
ACE-I in heart failure
Calcium/vitamin D in osteoporosis
Antiplatelet in AF (if anticoagulation contraindicated)

🚨 Triggers for Urgent Medication Review — Don't Miss These

When any of these happen, it's time to review the whole medication list:

Request for a dosette box — suggests complexity and adherence issues
A fall — review all medications causing dizziness, hypotension, sedation
Increasing confusion or drowsiness — suspect anticholinergic burden
Constipation — check opioids, anticholinergics, iron
Admission to a care home due to increasing frailty
Any new hospital admission or clinic letter
Declining renal function — many drugs need dose reduction or stopping

Tool tip: Use the free Medichec tool to calculate anticholinergic burden from the full drug list. High anticholinergic burden increases fall risk and dementia risk.

⚠️ Nitrofurantoin — Long-Term Use Risk

Long-term use of nitrofurantoin (>6 months) is associated with serious pulmonary toxicity (pulmonary fibrosis, interstitial pneumonitis). This is a commonly missed prescribing error in elderly patients who are left on nitrofurantoin prophylaxis for years without review.

Always review the indication for long-term nitrofurantoin
Monitor for unexplained breathlessness or deteriorating lung function
Also avoid in eGFR <30 (reduced efficacy + increased toxicity)

Hearing Impairment

Face the patient when speaking
Speak clearly, not louder
Reduce background noise
Check hearing aids are working
Use written information

Visual Impairment

Ensure good lighting
Use large print materials
Check glasses are clean
Describe visual information verbally
Consider audio resources

Cognitive Impairment

Use simple language and short sentences
Give one instruction at a time
Allow time to process information
Repeat and reinforce key points
Involve family/carers in discussions
Use visual aids and written summaries

Diagnostic Approach & Investigations

Atypical Presentations

Elderly patients often present with non-specific symptoms rather than classic disease presentations. A high index of suspicion is essential.

Condition	Typical Presentation	Atypical Elderly Presentation
Myocardial Infarction	Chest pain, sweating	Confusion, falls, breathlessness
Pneumonia	Fever, cough, pleuritic pain	Confusion, falls, anorexia
Sepsis	Fever, rigors, tachycardia	Hypothermia, confusion, functional decline
Hyperthyroidism	Weight loss, tremor, anxiety	Apathy, AF, heart failure

Investigating Acute Confusion (Delirium)

Bedside Tests

Vital signs (temperature, BP, HR, RR, O₂ sats)
Capillary blood glucose
Urinalysis (UTI is common trigger)
ECG (arrhythmia, MI)

Blood Tests

FBC (infection, anaemia)
U&Es (AKI, electrolyte disturbance)
LFTs (liver failure, alcohol)
Calcium (hypercalcaemia)
TFTs (thyroid dysfunction)
CRP (infection/inflammation)
B12/folate (if chronic confusion)

Imaging

Chest X-ray (pneumonia, heart failure)
CT head (if focal neurology, head injury, or unexplained)

Falls Investigation (NICE NG249)

⚠️ Medicines & Falls — A Major, Modifiable Risk

30% of people over 65 and 50% of people over 80 fall at least once a year. Medicines are one of the most important modifiable risk factors. Two drug groups cause the most falls:

Psychotropic drugs (sedatives, antipsychotics, antidepressants, opioids) — taking any psychotropic approximately doubles the risk of falling
Cardiovascular drugs (antihypertensives, especially if causing postural hypotension)

Strong evidence: Stopping psychotropic drugs (including opioid analgesics) reduces falls. Always review and attempt to reduce these at falls assessment. Use the STOPPFall criteria to guide deprescribing decisions.

Remember the SADMAN drugs — they may also contribute via orthostatic hypotension (ACE-i, ARBs, diuretics). Review these too.

Multifactorial Risk Assessment

Assess all of the following domains:

Falls history (circumstances, frequency, injuries)
Gait, balance, and mobility assessment
Osteoporosis and fracture risk
Visual impairment
Cognitive impairment and neurological examination
Urinary incontinence
Home hazards
Cardiovascular examination (postural BP, arrhythmia)
Medication review (especially psychotropics, antihypertensives)

Investigations

Lying and standing BP (postural hypotension)
ECG (arrhythmia, heart block)
FBC (anaemia)
U&Es, glucose (metabolic causes)
Vitamin D (if osteoporosis risk)
Consider 24h ECG if syncope

Cognitive Impairment Assessment

Cognitive Screening Tools

Tool	Duration	Use
6-CIT	3-5 min	Quick screening, score ≥8 suggests impairment
MMSE	10 min	Standard assessment, score <24/30 abnormal
MoCA	10 min	More sensitive for MCI, score <26/30 abnormal
ACE-III	15-20 min	Detailed assessment, differentiates dementia types

Dementia Blood Screen

FBC (anaemia, B12 deficiency)
U&Es (renal impairment)
LFTs (liver disease, alcohol)
TFTs (hypothyroidism)
Calcium (hypercalcaemia)
Glucose/HbA1c (diabetes)
Vitamin B12 and folate
Consider syphilis serology if risk factors

Imaging

CT or MRI brain to exclude structural causes (tumour, subdural, normal pressure hydrocephalus) and support dementia subtype diagnosis. MRI preferred if available.

Differential Diagnosis Frameworks

PINCH ME Mnemonic

P	Pain	Uncontrolled pain, urinary retention
I	Infection	UTI, pneumonia, cellulitis, sepsis
N	Nutrition	Dehydration, malnutrition, constipation
C	Constipation	Faecal impaction, urinary retention
H	Hydration	Dehydration, electrolyte imbalance
M	Medication	Anticholinergics, opioids, benzodiazepines, withdrawal
E	Environment	Unfamiliar surroundings, sensory deprivation

Other Important Causes

Cardiovascular: MI, stroke, heart failure
Metabolic: Hypoglycaemia, hypo/hypernatraemia, hypercalcaemia
Neurological: Stroke, subdural haematoma, seizures
Respiratory: Hypoxia, hypercapnia
Endocrine: Thyroid dysfunction, Addison's disease

Intrinsic Factors

Age-related changes (muscle weakness, balance)
Cardiovascular (postural hypotension, arrhythmia, syncope)
Neurological (stroke, Parkinson's, neuropathy)
Musculoskeletal (arthritis, foot problems)
Visual impairment (cataracts, glaucoma)
Cognitive impairment (dementia, delirium)
Medications (sedatives, antihypertensives)

Extrinsic Factors

Poor lighting
Loose rugs or carpets
Clutter and obstacles
Slippery floors
Inappropriate footwear
Lack of grab rails
Stairs without handrails

Common Causes

Category	Causes
Malignancy	GI cancers, lung, haematological, metastatic disease
GI	Malabsorption, IBD, coeliac disease, chronic pancreatitis
Endocrine	Hyperthyroidism, diabetes, Addison's disease
Cardiac	Heart failure (cardiac cachexia)
Respiratory	COPD, TB, lung cancer
Psychiatric	Depression, dementia, anorexia
Social	Poverty, isolation, inability to shop/cook
Medications	Digoxin, metformin, SSRIs, chemotherapy

Type	Features	Causes
Stress	Leakage on coughing, sneezing, exercise	Pelvic floor weakness, prostate surgery
Urge	Sudden urge, frequency, nocturia	Overactive bladder, UTI, BPH
Overflow	Dribbling, incomplete emptying	BPH, neurogenic bladder, constipation
Functional	Normal bladder, can't reach toilet	Immobility, dementia, delirium

Causes of Urinary Retention

Obstructive: BPH, prostate cancer, urethral stricture, constipation
Neurogenic: Spinal cord lesions, MS, diabetic neuropathy
Medications: Anticholinergics, opioids, alpha-agonists
Post-operative: Anaesthesia, pain, immobility
Infection: Severe UTI, prostatitis

Common Conditions in Elderly Care

Multimorbidity Management

Multimorbidity (≥2 chronic conditions) affects 65% of people >65. NICE NG56 recommends a patient-centred approach focusing on quality of life, not disease-specific targets.

Key Principles:

Identify patient priorities and goals
Consider treatment burden and life expectancy
Shared decision-making
Regular medication review
Coordinate care across specialties
Address social and psychological needs

Management in Elderly

Target BP <150/90 if >80 years (NICE 2024)
Consider frailty and comorbidities
Start low, go slow with medications
Monitor for postural hypotension
First-line: ACE-I or ARB + CCB or thiazide

Stroke Risk Assessment (CHA₂DS₂-VASc)

Congestive heart failure	1 point
Hypertension	1 point
Age ≥75	2 points
Diabetes	1 point
Stroke/TIA/thromboembolism	2 points
Vascular disease	1 point
Age 65-74	1 point
Sex (female)	1 point

Score ≥2 (men) or ≥3 (women): Offer anticoagulation (DOAC preferred)

Bleeding Risk (HAS-BLED)

Score ≥3 indicates high bleeding risk but is NOT a contraindication to anticoagulation. Address modifiable risk factors.

Management Principles

Confirm diagnosis with echocardiography and BNP
ACE-I/ARB + beta-blocker (first-line for HFrEF)
Add MRA (spironolactone) if still symptomatic
Consider SGLT2 inhibitor (dapagliflozin, empagliflozin)
Loop diuretic for fluid overload
Annual flu vaccine, one-off pneumococcal vaccine

Symptoms — What to Look For

Core features (memory-based):

Increasing difficulty with tasks requiring concentration and planning
Memory loss (especially short-term — forgetting recent events)
Repeated questioning (e.g. asking the same thing every few minutes)
Getting lost in familiar places; wandering, especially at night
Changes in personality and mood (often depression features)

Additional features (may indicate subtype):

Slow/unsteady gait (vascular, Lewy body, Parkinson's)
Visual hallucinations (Lewy body dementia)
Disinhibition, personality change (frontotemporal)
Urinary incontinence (later stage, normal pressure hydrocephalus)
Stroke-like episodes — muscle weakness (vascular dementia)

Dementia Subtypes

Type	Prevalence	Key Features
Alzheimer's	60-70%	Gradual onset, memory loss, language difficulties
Vascular	15-20%	Stepwise decline, focal neurology, vascular risk factors
Lewy Body	10-15%	Visual hallucinations, parkinsonism, fluctuating cognition
Frontotemporal	5-10%	Younger onset, personality change, disinhibition

⚠️ The Big Blind Spot in Memory Tests (MMSE, 6-CIT)

Standard memory tests like the MMSE, 6-CIT, and AMTS do NOT test the frontal lobe. This means they will MISS:

Frontotemporal dementia (often in patients aged 40–65)
Wernicke-Korsakoff syndrome (alcohol-related frontal lobe damage)
Other dysexecutive syndromes

How do you pick up frontal lobe disorders? Look for a "coarsening of personality" — reported by relatives (often described as "he/she has changed"). Classic signs include:

Loss of social or sexual inhibitions
Irritability, facile humour, abusiveness
Increased accidents, job loss, offending
Family disruption, marital separation

Exam trap: A patient with a normal MMSE but personality change and social disinhibition — think frontotemporal dementia or frontal lobe disorder, not just "it's normal ageing."

Risk Factors — Who to Screen Earlier

Age ≥60 with CVD, stroke, PVD, or diabetes
Age ≥50 with learning disabilities
Age ≥40 with Down's syndrome (screen early — high risk)
Parkinson's disease, MS, MND (neurodegenerative element)
Chronic alcohol use, social isolation, malnutrition, smoking
Depression (bidirectional link with dementia)

Pharmacological Management

Mild-moderate Alzheimer's: Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) — initiated in secondary care
Moderate-severe Alzheimer's: Memantine (NMDA antagonist) — or if AChE-I intolerant
Lewy Body dementia: Rivastigmine preferred. ⚠️ Avoid antipsychotics — high sensitivity, can cause life-threatening reactions
Vascular dementia: Manage vascular risk factors aggressively; consider AChE-I

Monitor for adverse effects of AChE-I:

GI upset (nausea, diarrhoea, weight loss)
Bradycardia / AV node block (possible cause of collapse — do ECG)
Exacerbation of asthma or COPD
Additive effects with beta-blockers (bradycardia) and SSRIs (anorexia)

🚨 Driving & DVLA — Do Not Miss This

A patient diagnosed with dementia MUST inform the DVLA and their car insurance company. This is a legal obligation — not optional.

The DVLA will decide whether the licence can continue, be restricted, or must be revoked
Regular review is usually required (typically 1–3 yearly)
If the patient refuses to stop driving and poses a clear risk, the GMC guidance allows you to break confidentiality and notify the DVLA directly — document this decision carefully

SCA tip: In any dementia scenario, always mention DVLA notification. This is a common exam omission — and a serious real-world safety issue.

Social Interventions & Legal Planning

Lasting Power of Attorney (LPA): Advise early — while the patient still has capacity. Covers property/finances AND health/welfare separately
Advance Decision (Living Will): Legally binding refusal of specific future treatments
Advance Statement: Patient's wishes for future care (not legally binding but must be considered)
Carer support: Alzheimer's Society, Age UK, local carers resource. Formal carer's assessment
Financial support: Benefits advice (Attendance Allowance, Carer's Allowance)
Advanced Care Plan in clinical system: Code and document. If patient declines, code "Advanced Care Plan Declined" in the record

When to Re-refer to the Memory Clinic / Specialist

Disagreement between GP team and carer about stopping medication
Considering switch to memantine in severe dementia
Uncertainty about side effects or benefits
Behavioural and psychological symptoms of dementia (BPSD) requiring specialist input

Motor Features (Triad)

Bradykinesia (slowness of movement)
Resting tremor (4-6 Hz, pill-rolling)
Rigidity (lead-pipe or cogwheel)
Postural instability (later feature)

Treatment Options

Levodopa: Most effective, risk of dyskinesia long-term
Dopamine agonists: Ropinirole, pramipexole (impulse control disorders)
MAO-B inhibitors: Rasagiline, selegiline
COMT inhibitors: Entacapone (with levodopa)

FAST Recognition

Face: Facial weakness, drooping
Arms: Arm weakness, drift
Speech: Slurred speech, difficulty speaking
Time: Time to call 999 immediately

Secondary Prevention

Antiplatelet: Clopidogrel 75mg OD (or aspirin + dipyridamole)
Statin: Atorvastatin 80mg (regardless of cholesterol)
BP control: Target <130/80 (after acute phase)
Anticoagulation if AF (DOAC preferred)
Carotid endarterectomy if >70% stenosis

Click the NEUROLOGICAL section in this segment.

Atypical Presentations in Elderly

Somatic complaints (pain, fatigue, GI symptoms)
Cognitive impairment (pseudodementia)
Anxiety and agitation
Social withdrawal
Reduced self-care

Treatment

First-line: SSRI (sertraline, citalopram) - start low dose
Avoid tricyclics (anticholinergic effects, cardiac risk)
Psychological therapy (CBT, IPT)
Address social isolation and physical health
Monitor for suicide risk

Management

Exclude physical causes (hyperthyroidism, cardiac, respiratory)
Review medications (caffeine, steroids, bronchodilators)
Psychological therapy (CBT) - first-line
SSRI if severe or therapy ineffective
Avoid benzodiazepines (falls, dependence, cognitive impairment)

FRAX Score

10-year probability of major osteoporotic fracture. Consider DEXA scan if intermediate risk.

Risk factors: Age, previous fracture, parental hip fracture, smoking, alcohol, steroids, rheumatoid arthritis, low BMI

Treatment

Calcium 1000-1200mg + Vitamin D 800-1000 IU daily
Bisphosphonate (alendronate 70mg weekly) - first-line
Denosumab if bisphosphonates not tolerated
Weight-bearing exercise
Falls prevention

Definition & Epidemiology

Age-related, involuntary loss of skeletal muscle mass and strength. Loss begins around age 40 at approximately 1% per year. By age 80, up to 50% of peak muscle mass may be lost. Affects up to 50% of people >80 years old.

Diagnosis (EWGSOP2 Criteria)

Primary criterion: Low muscle strength (grip strength or chair stand test)
Confirmed by: Low muscle quantity on DXA or CT/MRI
Severe if also: low physical performance (slow gait, low SPPB score)

Management

Exercise is the only proven treatment — resistance/strength training is essential
Physiotherapy referral
Adequate protein: 1.0–1.2 g/kg/day
Vitamin D supplementation if deficient
Review medications (corticosteroids worsen sarcopenia)
Encourage daily activity — even small amounts help

⚠️ We Often Make It Worse Without Realising

Over-assistance by families and health professionals accelerates sarcopenia. Moving into a bungalow, having all shopping done, ceasing all activities — these all remove the muscle-building stimulus. Encourage appropriate activity. The key message: "Use it or lose it."

Management Ladder

Education, weight loss, exercise (strengthening, aerobic)
Paracetamol (regular dosing)
Topical NSAIDs (first-line for knee/hand OA)
Oral NSAIDs + PPI (short courses, lowest dose)
Intra-articular steroid injection
Referral for joint replacement if severe

Cautions in Elderly

NSAIDs: GI bleeding, renal impairment, heart failure, hypertension
Opioids: Constipation, falls, confusion, dependence
Consider topical capsaicin for knee OA

Inhaler Therapy

SABA (salbutamol) - all patients
LABA + LAMA (e.g., umeclidinium/vilanterol) - if breathless/exacerbations
Add ICS if asthmatic features or frequent exacerbations
Check inhaler technique regularly

Non-pharmacological

Smoking cessation (most important)
Pulmonary rehabilitation
Annual flu vaccine, one-off pneumococcal vaccine
Nutritional support if underweight

CKD Staging (eGFR)

G1	≥90	Normal (with other evidence of kidney damage)
G2	60-89	Mild reduction
G3a	45-59	Mild-moderate reduction
G3b	30-44	Moderate-severe reduction
G4	15-29	Severe reduction
G5	<15	Kidney failure

Management

BP control: Target <140/90 (<130/80 if ACR >70)
ACE-I/ARB if proteinuria or diabetes
Avoid NSAIDs
Adjust drug doses for eGFR
Monitor U&Es, consider nephrology referral if G4-5

Glycaemic Targets in Elderly

Individualise targets based on frailty, life expectancy, and hypoglycaemia risk.

Fit elderly: HbA1c 53-58 mmol/mol (7-7.5%)
Frail/limited life expectancy: HbA1c 58-75 mmol/mol (7.5-9%)
Avoid tight control if high hypoglycaemia risk

Treatment

Metformin - first-line (review at eGFR <45; stop at eGFR <30)
SGLT2 inhibitor if CVD/CKD (cardiovascular benefit)
DPP-4 inhibitor (low hypoglycaemia risk)
Avoid sulphonylureas if possible (hypoglycaemia risk)
Insulin if needed - consider simplified regimen

Red Flags & Conditions Not to Miss

Cancer Warning Signs

General Red Flags

Unexplained weight loss (>5% in 6 months)
Persistent fatigue
Unexplained pain
Night sweats
Lymphadenopathy

Site-Specific

Rectal bleeding (colorectal)
Haemoptysis (lung)
Dysphagia (oesophageal/gastric)
Haematuria (renal/bladder)
Change in bowel habit (colorectal)

4AT Screening Tool

Alertness	Normal (0), Mild sleepiness (0), Clearly abnormal (4)
AMT4	Age, DOB, place, current year (1 point per error, max 4)
Attention	Months backwards (2 if unable, 1 if <7 months, 0 if ≥7)
Acute change	Evidence of fluctuation (4 if yes)

Score ≥4: Possible delirium ± cognitive impairment

Management

Identify and treat underlying cause (see PINCH ME)
Non-pharmacological: Reorient, familiar objects, avoid restraints
Ensure hydration, nutrition, mobilisation
Avoid sedation unless severe agitation/risk to self/others
If medication needed: Haloperidol 0.5mg (avoid in Lewy body dementia)

Types of Abuse

Physical: Bruising, fractures, burns, restraint marks
Psychological: Verbal abuse, threats, isolation, intimidation
Financial: Unexplained transactions, missing money/possessions
Sexual: Unexplained STIs, genital trauma
Neglect: Poor hygiene, malnutrition, pressure sores, missed medications

Red Flags

Injuries inconsistent with explanation
Delay in seeking medical attention
Patient fearful or withdrawn in presence of carer
Carer prevents patient speaking alone
Unexplained deterioration in health/function

Action

Document concerns clearly and objectively
Speak to patient alone if safe to do so
Assess mental capacity
Raise safeguarding alert with local authority
Involve police if immediate danger or crime suspected

Sepsis Recognition (Sepsis 6)

Elderly patients may not mount typical fever response. Consider sepsis if NEWS2 ≥5 or clinical concern.

Give 3:

Oxygen (target 94-98%)
IV fluids
IV antibiotics (within 1 hour)

Take 3:

Blood cultures
Lactate
Urine output monitoring

Acute Coronary Syndrome

30% of elderly MI patients have no chest pain. Atypical presentations:

Acute confusion
Falls
Breathlessness
Syncope
Epigastric pain

Prescribing for the Elderly

Why This Section Matters

Medicines are one of the most powerful tools in medicine — but in older people they can also be one of the most dangerous. Adverse drug reactions cause up to 10% of all hospital admissions in the over-65s, and a large proportion of these are preventable. Getting prescribing right in elderly patients is one of the most impactful skills a GP can develop.

The Core Problem — Bodies Change, but Drug Doses Often Don't

Most drug trials exclude older people, especially those with frailty and multimorbidity. So the evidence we use is often extrapolated from younger, healthier populations. This means the real NNT (Number Needed to Treat) in an 80-year-old is almost certainly worse than the trial suggests — while the risk of harm is higher. Always ask: "Is the benefit/risk balance still right for THIS patient at THIS age?"

⚙️ Pharmacokinetic Changes — How the Body Handles Drugs Differently

Remember: ADME — Absorption, Distribution, Metabolism, Excretion

Stage	Change With Age	Clinical Impact
Absorption	Reduced gastric acid; slower gut motility	Usually minor — most oral absorption unchanged. Slowed onset of some drugs.
Distribution	↓ Total body water; ↑ body fat; ↓ serum albumin	Water-soluble drugs (e.g. digoxin, lithium): higher plasma levels. Fat-soluble drugs (e.g. diazepam): longer duration. Low albumin: more free drug from protein-bound drugs (e.g. warfarin, phenytoin).
Metabolism	↓ Hepatic blood flow; ↓ CYP450 enzyme activity; ↓ first-pass metabolism	Slower breakdown of many drugs → higher levels, longer half-life. Especially relevant for hepatically-metabolised drugs (e.g. statins, beta-blockers, opioids).
Excretion	↓ GFR by ~1 mL/min/year from age 40. Creatinine may look normal despite low eGFR (less muscle mass = less creatinine produced)	Most important change. Accumulation of renally-excreted drugs: digoxin, metformin, lithium, NSAIDs, many antibiotics. Always check eGFR before prescribing.

🔄 Pharmacodynamic Changes — How Drugs Act Differently

Same dose → bigger or different effect

System	Change	Practical Implication
CNS	Increased sensitivity to CNS depressants	Benzodiazepines, opioids, and antihistamines cause more sedation, confusion, and falls at lower doses.
Cardiovascular	Reduced baroreflex sensitivity; arterial stiffness	Antihypertensives and diuretics → postural hypotension → falls. Start low, go slow.
Anticholinergic	Increased sensitivity; reduced ACh reserve	Even mild anticholinergic drugs (e.g. amitriptyline, oxybutynin, promethazine) → confusion, urinary retention, constipation, falls.
Anticoagulants	Increased bleeding risk	Warfarin and DOACs carry a higher bleeding risk in elderly — especially combined with NSAIDs or antiplatelet agents.

The NNT Principle — What It Means for Elderly Prescribing

NNT = Number Needed to Treat. This is how many people need to take a drug for one person to benefit. NNTs in older, frailer patients are higher (fewer benefit) while the Number Needed to Harm (NNH) is lower (more are harmed).

Most evidence comes from younger populations

Trial participants are usually younger, fitter, and have fewer comorbidities than your typical elderly patient. The benefits seen in trials may not apply.

All patients can experience side effects — but fewer benefit

NNTs tell us most people on any drug don't see the target benefit. But everyone can experience adverse effects. This balance tips against treatment as patients get older and frailer.

Focus on person-centred outcomes

What matters to the patient? Not HbA1c targets or cholesterol numbers — but whether they can live well, stay independent, and maintain quality of life. Align treatment goals to what the patient actually values.

The benefit/risk ratio shifts with age

A statin that makes strong sense at age 60 may offer minimal gain at age 90 with severe frailty. Re-evaluate all long-term medications regularly — especially at major life transitions.

✅ The 4 Questions to Ask About Every Drug

What is it for? — Is there a clear, current indication?
Is it still working? — Is the patient getting the expected benefit?
Is it causing harm? — Side effects, falls, confusion, interactions?
Can we stop it or reduce it? — Would the patient agree to try stopping?

🚨 High-Risk Drug Classes in the Elderly

Anticholinergics — confusion, falls, urinary retention, constipation. Use Medichec to calculate cumulative burden.
Benzodiazepines & Z-drugs — sedation, falls, cognitive impairment, dependence
NSAIDs — GI bleeds, AKI, heart failure, hypertension. Avoid if possible.
Opioids — constipation, falls, confusion, respiratory depression
Antipsychotics — falls, stroke risk, Parkinsonism. Avoid in Lewy body dementia.
Digoxin — narrow therapeutic index; accumulates with declining renal function
Anticoagulants — higher bleeding risk; check eGFR for DOAC dosing

💡 AKT Tip — Pharmacokinetics in Elderly

The most commonly tested pharmacokinetic change is reduced renal clearance. Key fact: serum creatinine can look normal in elderly patients despite significantly reduced eGFR — because they have less muscle mass and therefore produce less creatinine. Always use eGFR (not creatinine alone) to guide drug dosing in the elderly.

Classic AKT question pattern: "An 82-year-old on digoxin presents with nausea and bradycardia — what is the most likely cause?" Answer: Digoxin toxicity due to age-related decline in renal clearance.

📋 Don't Leave Patients on Repeats Forever

Every practice should have a system for reviewing repeat prescriptions. A drug may have been perfectly appropriate when started, but with age come declining kidney function, new diagnoses, new drug interactions, and changed goals of care. The indication that existed 10 years ago may no longer be valid — or the risk may now outweigh the benefit.

Key principle: Clarity about the indication and the intended outcome for each medicine is essential — especially now that more colleagues across the team are prescribing.

🔔 Triggers for a Medication Review

When any of these happen, review the whole drug list:

📦 Request for a dosette box — suggests complexity or adherence problems
🪜 A fall — always review all sedating and hypotensive drugs
😵 Increasing confusion or drowsiness — check anticholinergic burden
🚽 Constipation — check opioids, anticholinergics, iron
🏥 Admission to a care home due to frailty
📋 Any new hospital discharge summary or clinic letter
📉 Declining renal function — many drugs accumulate
🎂 A major change in health status or life expectancy

🧭 A System for Medication Review

Use the 7-Step NHS Scotland approach (managemeds.scot.nhs.uk) or the structured approach below:

List all medicines (including OTC, herbal, topical)
Identify the indication for each
Assess effectiveness of each
Identify adverse effects or risks
Assess appropriateness (STOPP/START)
Prioritise changes with the patient
Follow up after changes

💡 Non-Concordance as a Clinical Hint

If a patient is repeatedly not taking their prescribed medication, don't just issue a reminder — think about why. They may be experiencing side effects they haven't told you about. They may have made their own risk-benefit judgment. Evidence shows 30–50% of people don't take medicines as prescribed. Non-concordance is often the patient's way of giving you a valuable signal: "This drug isn't right for me."

One question to ask yourself: "Is this treatment essential?" If not — stop it.

STOPP/START at a Glance

🛑 STOPP — Drugs to Consider Stopping

Screening Tool of Older Persons' Prescriptions

Drug/Class	Reason to Stop
Benzodiazepines >4 weeks	Falls risk, dependence, cognitive impairment
NSAIDs with heart failure or CKD	Fluid retention, AKI
Anticholinergics with dementia	Worsens cognitive impairment
PPIs >8 weeks without indication	C. diff risk, hypomagnesaemia, fractures
Antipsychotics with falls	Increases falls and stroke risk
Long-term oral corticosteroids	Osteoporosis, adrenal suppression, proximal myopathy
Nitrofurantoin >6 months	Pulmonary toxicity, peripheral neuropathy

▶️ START — Drugs to Consider Starting

Screening Tool to Alert to Right Treatment

Drug/Class	Indication
Statin	Established CVD or diabetes (if life expectancy >5 years)
ACE inhibitor / ARB	Heart failure with reduced ejection fraction
Calcium + Vitamin D	Osteoporosis or housebound patients
Bisphosphonate	Osteoporosis on confirmed DEXA or fracture risk
Antiplatelet	AF if anticoagulation contraindicated
DOAC	AF with CHA₂DS₂-VASc ≥2(M) / ≥3(F)
Laxative	If on regular opioids

⚠️ Nitrofurantoin — The Hidden Long-Term Risk

Long-term use of nitrofurantoin (>6 months) is associated with serious pulmonary toxicity — including pulmonary fibrosis and interstitial pneumonitis. This is a commonly missed prescribing error, particularly in older women on long-term prophylaxis for recurrent UTIs who have never been reviewed.

Always review the ongoing indication for prophylactic nitrofurantoin
Investigate unexplained breathlessness or deteriorating pulmonary function in patients on long-term nitrofurantoin
Also avoid if eGFR <30 (reduced urinary drug levels → ineffective; risk of peripheral neuropathy)
AKT tip: The drug most commonly implicated in drug-induced pulmonary fibrosis in a GP setting is nitrofurantoin. Know this one.

What is Deprescribing?

Deprescribing is the planned, supervised process of stopping or reducing medicines that are no longer appropriate, are causing harm, or where the burden of treatment outweighs the benefit. It is not the same as undertreating. Done well, it improves quality of life, reduces falls, and lowers hospitalisation risk.

Key point: Always discuss deprescribing with the patient and carer. Frame it as a positive decision — "we are removing a medicine that is no longer helping you and may be causing harm." Most patients accept this well when it is explained clearly.

About STOPPFall

STOPPFall is a validated tool from the European Geriatric Medicine Society that lists drugs to consider stopping in older people who are at risk of falls. For each drug class, the table below shows: when to consider withdrawing it, whether stepwise withdrawal is needed, and what to monitor afterwards.

Always applies to every drug: Consider withdrawal if there is no current indication, or if a safer alternative is available. Always organise follow-up on an individual basis after stopping any drug.

Drug Class	Consider Withdrawal If…	Stepwise Withdrawal?	Monitor After Stopping
Benzodiazepines (BZD) & Z-drugs	Daytime sedation, cognitive impairment, or psychomotor problems. Also if used for both sleep AND anxiety.	✅ Yes — needed	Anxiety, insomnia, agitation. Consider monitoring: delirium, seizures, confusion.
Antipsychotics	Extrapyramidal or cardiac side effects, sedation, dizziness, blurred vision. If used for BPSD or sleep disorder.	✅ Yes — needed	Return of psychosis, aggression, agitation, hallucinations. Consider: insomnia.
Opioids	Slow reactions, impaired balance, sedation. If used for chronic pain.	✅ Yes — needed	Return of pain. Consider: restlessness, GI symptoms, anxiety, insomnia, diaphoresis.
Antidepressants	Hyponatraemia, orthostatic hypotension, dizziness, sedation, tachycardia/arrhythmia. If used for depression and patient has been symptom-free.	✅ Yes — needed	Recurrence of depression, anxiety, irritability, insomnia. Consider: headache, GI symptoms.
Antiepileptics	Ataxia, somnolence, impaired balance, dizziness. If used for anxiety or neuropathic pain.	⚠️ Consider	Recurrence of seizures. Consider: anxiety, restlessness, insomnia, headache.
Diuretics	Orthostatic hypotension, hypotension, electrolyte disturbance, urinary incontinence.	⚠️ Consider	Heart failure, hypertension, fluid retention signs.
Alpha-blockers (antihypertensive)	Hypotension, orthostatic hypotension, dizziness.	⚠️ Consider	Hypertension. Consider: palpitations, headache.
Alpha-blockers (for prostate — BPH)	Hypotension, orthostatic hypotension, dizziness.	❌ Not generally needed	Return of urinary symptoms.
Centrally-acting antihypertensives	Hypotension, orthostatic hypotension, sedation.	⚠️ Consider	Hypertension.
Sedating antihistamines	Confusion, drowsiness, dizziness, blurred vision. For all indications (hypnotic, itch, allergy).	⚠️ Consider	Return of symptoms. Consider: insomnia, anxiety.
Vasodilators (cardiac)	Hypotension, orthostatic hypotension, dizziness.	⚠️ Consider	Angina symptoms.
Overactive bladder drugs	Dizziness, confusion, blurred vision, drowsiness, prolonged QT.	⚠️ Consider	Return of urinary symptoms.

💡 AKT Tip — Stepwise vs Direct Stop

The drugs requiring stepwise (gradual) withdrawal are: benzodiazepines, antipsychotics, opioids, and antidepressants. These all carry a risk of withdrawal reactions if stopped abruptly. The others listed can generally be stopped directly (with monitoring). Know this distinction for the AKT.

🚨 Who Is STOPPFrail For?

STOPPFrail is specifically designed for patients who meet ALL THREE of these criteria:

Dependent in Activities of Daily Living AND/OR severe chronic disease AND/OR terminal illness
Severe irreversible frailty with high risk of acute complications
You would not be surprised if this patient died in the next 12 months (the "surprise question")

For these patients, the goal shifts from preventing future disease to maximising comfort and quality of life now. Many preventive medicines become inappropriate.

Section	Drugs to Consider Stopping	Rationale
General	Any drug without clear indication; any drug for symptoms that have resolved; any drug the patient persistently fails to tolerate	No benefit without indication
Cardiology	Statins, ezetimibe, fibrates. Antihypertensives if SBP consistently <130 (aim 130–160 in frail). Anti-anginal drugs (nitrates, nicorandil) if no angina symptoms in past 12 months AND no proven CAD	Preventive benefit takes years; short life expectancy means no benefit will be realised
Coagulation	Antiplatelets for primary prevention (no proven CVD benefit in frail elderly). Aspirin for stroke prevention in AF if not a candidate for anticoagulation	Bleeding risk outweighs preventive benefit
CNS	Antipsychotics if used >12 weeks and no current BPSD. Memantine unless it has clearly improved BPSD.	Ongoing sedation risk without demonstrable benefit
GI	PPIs at full dose for ≥8 weeks (reduce dose or stop unless symptomatic). H2 blockers at full dose for ≥8 weeks.	Reduce pill burden; long-term PPI risks (fractures, C. diff, hypomagnesaemia)
Respiratory	Theophylline/aminophylline (narrow TI, doubtful benefit, interactions). Leukotriene antagonists in COPD (not indicated — asthma only).	Risk outweighs benefit; safer alternatives available
Musculoskeletal	Calcium supplements (no proven benefit without symptomatic hypocalcaemia). Bisphosphonates, denosumab, teriparatide. Long-term oral NSAIDs (≥2 months). Long-term oral corticosteroids (reduce/stop carefully).	Fracture prevention takes years — benefit unlikely; risks include GI bleed and fragility fracture from steroids
Urogenital	5-alpha reductase inhibitors and alpha-blockers in catheterised men (no benefit with long-term catheter). Overactive bladder drugs if persistent irreversible incontinence.	No clinical benefit in context of catheterisation or irreversible incontinence
Endocrine	Diabetes drugs — de-intensify therapy. Avoid HbA1c <7.5% (58 mmol/mol) target in frail elderly (associated with net harm). Goal: minimise symptoms of hyperglycaemia only.	Hypoglycaemia risk from tight control; preventive benefits of HbA1c targets require years to accrue
Miscellaneous	Multivitamin supplements (unless treating proven deficiency). Folic acid (stop when treatment course complete). Nutritional supplements (unless treating malnutrition).	Preventive supplements not indicated in end-of-life context

⚠️ Disclaimer

STOPPFrail criteria are evidence-based guidelines, not absolute rules. The final decision to deprescribe any drug always rests with the prescribing clinician, after discussion with the patient and/or carer. Always consider whether the evidence behind any given criterion may have been updated since publication.

🚨 Drugs Requiring Stepwise (Gradual) Withdrawal

Stopping these drugs abruptly can cause serious withdrawal reactions. Always taper gradually:

Benzodiazepines & Z-drugs — e.g. diazepam, lorazepam, zopiclone, zolpidem. Use diazepam equivalent, reduce by ~10% every 2–4 weeks. Refer to specialist if complex.
Antipsychotics — reduce by 10–25% every 4 weeks. Monitor for BPSD relapse.
Opioids — reduce by 10–20% every 1–2 weeks. Monitor for pain return and withdrawal symptoms.
Antidepressants — especially SSRIs/SNRIs. Reduce gradually over weeks to months depending on duration of use. Fluoxetine can often be stopped more quickly due to long half-life.
Corticosteroids (long-term) — reduce slowly to avoid adrenal crisis; monitor for flare of underlying condition.
Beta-blockers — in cardiac patients, never stop abruptly. Taper over 2–4 weeks to avoid rebound tachycardia/angina.

🔗 Useful Deprescribing Resources

KIK Medication Withdrawal Decision Tree — interactive tool for falls-related deprescribing
STOPPFall Full Article — Age & Ageing journal
STOPPFrail v2 Full Criteria
Medichec — anticholinergic burden calculator; also identifies drugs causing dizziness/drowsiness
NHS Scotland 7-Step Medication Review
Canadian Deprescribing Network — patient and clinician resources
Deprescribing Guidelines Video — excellent overview (YouTube)

💡 AKT Tip — Deprescribing Key Facts

Commonly tested deprescribing scenarios in AKT:

Which drugs need stepwise withdrawal? → BZDs, antipsychotics, opioids, antidepressants, corticosteroids, beta-blockers
STOPPFrail: the "surprise question" (would you be surprised if this patient died in the next 12 months?) is a validated clinical tool for identifying end-of-life patients
In frail elderly, HbA1c target <7.5% is associated with net harm — de-intensify diabetes treatment
Antiplatelets for primary prevention have no proven benefit in frail elderly — but those on them for secondary prevention should generally continue

🚨 The Scale of the Problem

Falls are the leading cause of injury-related death in people over 75 in the UK.

30% of people over 65 fall at least once a year
50% of people over 80 fall at least once a year
Falls cause 210,000+ emergency hospital admissions per year in England alone

Medications are one of the most important and modifiable fall risk factors. Unlike slippery floors or poor lighting, we can directly intervene on the drug list.

🧠 Group 1 — Drugs Acting on the Brain

These are the highest-risk group. Taking a psychotropic drug approximately doubles the risk of falling.

Drug Class	Why It Causes Falls
Benzodiazepines / Z-drugs	Sedation, reduced muscle tone, impaired coordination, slowed reaction time
Antipsychotics	Sedation, postural hypotension, extrapyramidal effects (rigidity, shuffling)
Antidepressants (SSRIs, TCAs)	Postural hypotension, sedation, hyponatraemia (especially SSRIs)
Opioids	Sedation, impaired balance, dizziness, confusion
Anticonvulsants / Gabapentinoids	Dizziness, ataxia, somnolence
Antihistamines (sedating)	Sedation, confusion, blurred vision

Strong evidence: Stopping psychotropic drugs (including opioid analgesics) directly reduces falls. This is one of the most impactful single interventions a GP can make.

❤️ Group 2 — Drugs Acting on the Heart & Circulation

These cause falls mainly through postural hypotension and reduced perfusion to the brain.

Drug Class	Why It Causes Falls
Antihypertensives (ACE-i, ARB, CCB)	Postural hypotension — especially on standing
Diuretics	Dehydration → postural hypotension; also electrolyte disturbance (hyponatraemia, hypokalaemia)
Nitrates / Vasodilators	Profound postural hypotension
Beta-blockers	Reduced heart rate response; fatigue; some postural hypotension
Alpha-blockers	Significant postural hypotension
Digoxin	Bradycardia → reduced cardiac output → dizziness/falls

🧪 Polypharmacy Multiplies Fall Risk

The risk from individual drugs compounds when multiple drugs are taken together. Someone on a sleeping tablet (benzodiazepine), a blood pressure drug (antihypertensive), and a painkiller (opioid) simultaneously has a dramatically higher falls risk than someone on just one of these — even though each individual drug might seem like a reasonable dose.

Anticholinergic burden also accumulates across multiple drugs — even those not primarily thought of as anticholinergic (e.g. some antidepressants, bladder drugs, antihistamines, certain antipsychotics). Use the Medichec tool to calculate the total anticholinergic burden from the patient's full drug list.

✅ What to Do at a Falls Assessment — Medicines Review Checklist

List all drugs including OTC, herbal, and PRN
Identify psychotropics — benzodiazepines, Z-drugs, antidepressants, antipsychotics, opioids, gabapentinoids, antihistamines. Aim to reduce or stop.
Lying and standing blood pressure — look for postural hypotension (>20 mmHg systolic drop). If present, review antihypertensives, diuretics, vasodilators, alpha-blockers.
Calculate anticholinergic burden — use Medichec. High burden → cognitive impairment → increased fall risk.
Apply STOPPFall criteria — use the table in the De-Prescribing tab.
Document changes — make a clear plan for stopping/reducing and review in 4–6 weeks.
Refer to physiotherapy for strength and balance training (NICE NG249 — strongest non-pharmacological intervention for falls prevention).

💡 AKT Tip — Medicines & Falls Key Facts

Taking a psychotropic drug approximately doubles the risk of falls — this is a key AKT statistic
The two main drug groups causing falls are: (1) drugs acting on the brain, (2) drugs acting on the heart/circulation
SSRIs can cause hyponatraemia (SIADH) — especially in elderly women — which is itself a falls risk (confusion, dizziness)
Stopping drugs is an intervention in its own right — NICE NG249 explicitly recommends medication review as part of multifactorial falls assessment
For the SCA, always mention medication review when discussing falls — it is a key safety-netting and management point that examiners look for

GP Role in Dementia Medication

Dementia drugs (AChE inhibitors and memantine) are initiated by secondary care (memory clinics). However, once stable, GPs take over prescribing and monitoring. This means you need to know the contraindications, cautions, side effects, interactions, and how to monitor and when to stop. This is heavily tested in both AKT and SCA.

🚫 Absolute Contraindications

Drug(s)	Absolute Contraindication
All AChE inhibitors & Memantine	Known hypersensitivity to the active substance or any excipient
Donepezil	Known sensitivity to piperidine derivatives
Galantamine	Severe hepatic or severe renal impairment, or significant combined hepatic AND renal dysfunction. Also: urinary retention or history of prostatic condition.
Donepezil & Galantamine	Rare hereditary galactose intolerance, Lapp lactase deficiency, or glucose-galactose malabsorption
Rivastigmine	Known hypersensitivity to carbamate derivatives; severe liver impairment
Memantine	Rare hereditary fructose intolerance (oral solution contains sorbitol)

⚠️ Important Cautions — AChE Inhibitors (Donepezil, Galantamine, Rivastigmine)

Caution Area	Detail
Cardiac	AV node block; sick sinus syndrome; concomitant digoxin or beta-blocker therapy (additive bradycardia risk)
Respiratory	Severe asthma; COPD; active pulmonary infections (risk of bronchoconstriction)
GI	Increased risk of peptic ulcers — especially with history of ulcer disease or concomitant NSAID use; epilepsy
Urological	Urinary symptoms — avoid galantamine specifically. Risk of urinary retention.
Neurological	May exacerbate extrapyramidal symptoms. Epilepsy (lowers seizure threshold). CVD history.

⚠️ Cautions — Memantine Specifically

History of convulsions — caution required
Recent MI, uncontrolled hypertension, or uncompensated heart failure — limited safety data; these patients were excluded from trials. Supervise closely.

AChE Inhibitor Side Effects — Two Main Groups to Know

There are two practically important groups of side effects: GI (very common) and Cardiac (uncommon but serious and easily missed).

System	Symptoms	Frequency	Action
GI	Nausea, vomiting, diarrhoea, anorexia, weight loss, abdominal pain	Very common	Generally mild and transient. Take drug after food. If persists: reduce dose. If still persists: switch to alternative AChE inhibitor.
GI — Ulcer	Gastric or duodenal ulceration	Uncommon/rare	Discontinue if ulcer develops. Monitor regularly in at-risk patients. Caution with NSAIDs.
Cardiac 🚨	Bradycardia — possibly collapse, dizziness, syncope	Uncommon/rare	Urgent review. ECG. If PR interval >200 ms → STOP AChE inhibitor. Higher risk if sick sinus, AV block, or on digoxin/beta-blocker.
Neurological	Dizziness, headache, insomnia, somnolence	Very common / common	Mild and transient. Reduce dose if persistent. Consider switching.
Neurological	Syncope	Common / uncommon	Reduce dose. If persistent, consider switch.
Neurological	Extrapyramidal symptoms (worsening Parkinson's)	Rare	Reduce dose. If persistent, switch.
Neurological	Lowered seizure threshold	Rare	Extreme caution in epilepsy.
Psychiatric	Agitation, confusion, insomnia	Common	Reduce dose. If persists, switch.
Respiratory	Bronchoconstriction	Rare	Caution in asthma / COPD / active pulmonary infection.
Skin (galantamine)	Stevens-Johnson Syndrome (SJS), acute generalised exanthematous pustulosis (AGEP), erythema multiforme	Rare	Advise patient/carer to monitor for skin reactions. Stop immediately and seek medical advice if rash develops.
General	Asthenia, fatigue	Common	Mild and transient. Reduce dose or switch if persistent.

🚨 Memantine Side Effects

Memantine appears well-tolerated in practice, but side effects can be missed in patients with severe dementia who may not be able to report them.

System	Symptoms	Frequency	Action
GI	Constipation	Common	Regular or PRN laxative
Cardiovascular	Hypertension	Common	Reduce dose and review BP. Consider stopping.
Neurological	Dizziness, headache, drowsiness	Common	Reduce dose and review. Consider stopping.
Respiratory	Dyspnoea	Common	Reduce dose and review. Consider stopping.

💡 AKT Tip — The Most Dangerous AChE Side Effect

The most serious (and most easily missed) side effect of AChE inhibitors is AV node block / bradycardia leading to collapse. If an elderly patient on donepezil presents with collapse or unexplained falls, do an ECG immediately. PR interval >200 ms → stop the drug. This is a classic AKT scenario.

All AChE Inhibitors

Anticholinergic drugs (e.g. oxybutynin, antipsychotics, tricyclics) — directly antagonise AChE inhibitor effects. Avoid combining.
Synergistic cardiac effects with succinylcholine (suxamethonium), other neuromuscular blocking agents, cholinergic agonists
Beta-blockers — additive bradycardia risk
Digoxin — additive bradycardia and AV block risk
SSRIs — additive anorexia and weight loss

Donepezil & Galantamine Specifically

Both are metabolised via CYP3A4 and CYP2D6 pathways in the liver.

CYP inhibitors → ↑ drug levels → more side effects:

Macrolides: erythromycin, clarithromycin
Azole antifungals: ketoconazole
SSRIs: fluvoxamine, fluoxetine, paroxetine
→ Consider dose reduction if combining

CYP inducers → ↓ drug levels → reduced efficacy:

Rifampicin, phenytoin, carbamazepine
Alcohol (chronic use)
→ Monitor for reduced response

💡 AKT Tip — Interactions to Know

The most AKT-testable interaction is anticholinergic drugs + AChE inhibitors. They directly oppose each other. Prescribing oxybutynin (for overactive bladder) alongside donepezil (for Alzheimer's) is a classic prescribing error — the oxybutynin worsens cognitive function and cancels out the donepezil's effect. Use Medichec to detect these clashes.

Also know: clarithromycin increases donepezil/galantamine levels — if a patient on donepezil is started on clarithromycin (e.g. for CAP), they may suddenly develop more side effects. Be aware of this.

📋 The 5-Point Annual Monitoring Framework

When a patient is stable on dementia medication and handed back to primary care, use this framework for every annual review. It ensures you cover everything the specialist would ask about.

1️⃣ Compliance — Is the Drug Being Taken?

Ask the patient and carer directly — are all doses being taken?
Check the dispensing records (are prescriptions being collected?)
Consider a dosette box or blister pack if adherence is a problem
Non-concordance may indicate intolerable side effects the patient hasn't mentioned

2️⃣ Physical Health Monitoring

Parameter	What to Do
Weight	If weight loss has started or accelerated since starting the AChE inhibitor, the drug may be the cause. Assess further — stop or reduce dose if suspected.
Pulse / BP	If pulse <60 bpm → do an ECG immediately. If PR interval >200 ms → stop drug or discuss urgently with mental health specialist. Increased risk with sick sinus syndrome, AV block, or concomitant digoxin/beta-blocker.
GI tolerance	Ask about anorexia, nausea, vomiting, diarrhoea.
Neurological symptoms	Headaches, dizziness, drowsiness, syncope — reduce dose or switch if persistent.

3️⃣ Impact on Global Functioning

This is best assessed by talking to the carer — it may be worth seeing them separately to get an honest account.

Area	What to Ask / Assess	Action
Functional	Is daily living declining? Can they still dress, wash, eat, walk? Falls risk? Nutritional status? Safety at home?	Review whether referral to Social Services is needed. OT/physio/falls assessment.
Carer impact	Does the carer value the effect of the medication? Are they coping?	Carer's views matter — their assessment of benefit is clinically valid.
Behavioural	New behavioural problems? Signs of BPSD (aggression, wandering, agitation)?	Review whether referral back to the memory clinic is needed.

4️⃣ Cognitive Assessment

Formal cognitive tests are not mandatory at every review — repeated testing can distress patients. Assessment via patient and carer interview is often more valuable. However, a formal test is useful when:

There has been a significant decline in global functioning
You want to assess whether the drug is still working
An unexpectedly large score drop may prompt a conversation about increased care needs

Primary care validated scales to use (if needed):

6-CIT (Six Item Cognitive Impairment Test) — quick, validated in primary care
GPCOG (General Practitioner Assessment of Cognition) — specifically designed for GP use

5️⃣ Is the Medication Still of Overall Benefit?

Stop if: No cognitive, behavioural, functional, or global benefit. OR patient cannot tolerate the side effects.

Continue if: There is still overall benefit AND the patient is tolerating treatment AND there are no contraindications — even if dementia enters the severe stage, provided a carer/relative confirms ongoing benefit to global functioning.

⚠️ Important: Continuing AChE inhibitors in severe Alzheimer's is off-label. If you do so, document clearly that you are aware of this and have accepted responsibility for the off-label prescribing.

How to Stop AChE Inhibitors Safely:

Reduce dose gradually — e.g. if on donepezil 10 mg OD, reduce to 5 mg OD for one month, then stop
Similar step-down approach for other AChE inhibitors
Evidence suggests no withdrawal reaction (AD 2000 trial) but withdrawal reactions have been reported anecdotally — gradual reduction is a reasonable precaution
After stopping, monitor cognition and function for any deterioration — if rapid decline occurs, consider restarting

When to Re-refer to the Memory Clinic:

Disagreement between GP and carer about stopping medication
Considering switch to memantine in severe dementia
Uncertainty about side effects or benefits
New BPSD (behavioural and psychological symptoms of dementia)

💡 AKT Tip — Annual Monitoring Essentials

The most tested monitoring point is pulse/ECG in patients on AChE inhibitors. If pulse <60 → ECG → if PR >200 ms → stop drug. Also know: using 6-CIT or GPCOG (NOT MMSE) as the preferred primary care cognitive tools. And remember: stopping is justified if there is no benefit across any domain (cognitive, behavioural, functional, global).

Care Home & Home Visits

The Three-Part Visit Framework

A good care home visit is not just about fixing the presenting problem. It is a golden opportunity to do a comprehensive geriatric review. Structure every visit in three parts: Before, During, and After. Use the MANIC MOLD framework during the visit itself.

Before You Leave the Practice

Review the Medical Notes First

Before setting off, log into the Electronic Medical Record (EMR). Don't just rely on any printed summary sheet — it may be out of date.

Review previous consultations for the same presenting complaint (use the search box)
Check last entries — from other GPs, OOH, community nurses
Review discharge summaries and hospital letters
Any outstanding recalls, CDM reviews, or pending blood results?
Is there a RESPECT/ReSPECT form and resuscitation status in place? Do you need to set one up?

Think Before You Go

Spend 2 minutes on the journey mentally planning:

What are the possible differentials for this presenting complaint?
What questions will you ask to narrow them down?
What examinations and investigations might you need?
What actions might be required (referral, admission, medication)?

Example: Called for swollen legs? Think: one leg vs two? One leg → DVT (Wells score, D-dimer), cellulitis (antibiotics — any allergies?), Baker's cyst. Both legs → likely cardiac (check for AF, consider BNP, gentle diuretics).

⚠️ Confidentiality — Destroy All Paperwork

Any printed patient summary sheet or handwritten notes must be destroyed by shredding after the visit. Do NOT throw in a bin, leave in your car, or take home. Tearing is NOT enough. Use the practice shredder. This is a serious breach of confidentiality if not done.

Digital access: Ask your practice about apps like Brigid for secure mobile EMR access — much safer than printed sheets.

The 3-Step Visit Structure

STEP 1 — The Presenting Problem (Always First)

Deal with the acute problem they called you for
Always check vital signs: pulse, BP, temperature, O₂ saturations
Address any immediate safety concerns

STEP 2 — The 9 Geriatric Giants Review (MANIC MOLD)

After dealing with the presenting problem, run through the Giants. Use direct, kind questions — patients will rarely volunteer these.

Mobility

Is mobility deteriorating? Consider stopping benzodiazepines or unnecessary antipsychotics. Try reducing opioids if pain controlled. Refer to physio for sarcopenia/strengthening. Check footwear.

Elder Abuse / Self-Neglect

Ask the patient ALONE: "How are you doing here?" / "How are they treating you here?" Look for unusual bruising. Always look at the feet — they reveal neglect when everything else looks fine.

Nutrition

Look in the mouth — poor dentures, ulcers (oral cancer?), thrush. Assess body habitus. Ask about food intake. Request the patient's weight — MUST score if falling. Look at the feet for peripheral oedema (hypoalbuminaemia).

Incontinence

Ask directly. Is confusion increasing alongside it? Is there a strong smell suggesting UTI? Dip urine / send MSSU. Are they drinking enough?

Confusion / Cognition

Dementia or delirium? "Bad behaviour" is often infection, pain, constipation, or depression — not dementia. Use 4AT (delirium) or 6-CIT/MMSE (dementia). Treat the cause first.

Medication Problems

Ask if refusing or not taking meds. Review the full list. Remove what is not needed. Refer to pharmacy if complex. Check SADMAN (see Sick Day Rules tab).

Osteoporosis

Has FRAX been calculated? DEXA if appropriate. Calcium + Vit D prescribed? Falls prevention in place?

Loneliness

Ask plainly: "Often as people age, they feel more lonely. Are you experiencing that?" Discuss with care home about befriending, group activities. Signpost to local services.

Depression

"You seem a bit down to me — are you feeling low in your spirits a lot?" Consider antidepressant (SSRI at low dose) and behavioural activation.

STEP 3 — Advanced Care Planning

Does the patient have a DoLS (Deprivation of Liberty Safeguards) in place if they lack capacity and are being deprived of liberty? Code in notes.
RESPECT/ReSPECT form — consider for all frail or elderly patients. Discuss sensitively with patient and family. Complete if appropriate.
Is the patient on the palliative care register? Should they be?
If end of life:
- Start anticipatory medications ("just in case" box: opioid, antiemetic, anxiolytic, antisecretory)
- Stop unnecessary medications
- Involve palliative care team / Gold Line (out-of-hours palliative support)
- Complete DNACPR/RESPECT form — discuss with patient/family
- Keep care home staff fully informed

Back at the Practice

Documentation & Admin

Write up the home visit clearly — include the presenting reason and what you found/did
Use appropriate clinical templates (e.g. Ardens, SystmOne, EMIS) for CDM, medication reviews, etc.
Tidy up the repeat medication list — reduce polypharmacy where possible
Move on recall dates — keep recalls to a minimum to reduce appointment burden

Prescriptions & Follow-Up

Issue prescriptions electronically when you return (not handwritten — higher error risk)
Let the care home know when the prescription will be ready
Liaise with community phlebotomy for follow-up blood tests
Inform Community Matrons / Care Coordinators / District Nurses of any issues needing follow-up

🚨 If End of Life — Do Not Leave Without Doing This

Start anticipatory medications if not already in place
Stop unnecessary medications (simplify the drug list)
Contact palliative care / Gold Line if needed
Complete DNACPR/RESPECT form — discuss with patient/family; document conversation
Ensure care home staff know the plan and who to call out of hours

AKI Sick Day Rules — SADMAN

🚨 When to Use Sick Day Rules

Give this advice to patients (or care home staff) when a patient is acutely unwell with:

Vomiting or diarrhoea (unless only minor)
Fever, sweats, and shaking — e.g. with chest infection, UTI, flu
Any illness where they are not eating or drinking normally

STOP These Medicines When Acutely Unwell — SADMAN

SGLT-2 inhibitors

Canagliflozin, dapagliflozin, empagliflozin ("-flozins") — risk of AKI and euglycaemic DKA

ACE inhibitors

Ramipril, lisinopril, enalapril ("-prils") — risk of AKI when dehydrated

Diuretics

Furosemide, bendroflumethiazide — worsen dehydration and AKI risk

Metformin

Risk of lactic acidosis in the context of AKI/dehydration

ARBs

Losartan, candesartan, valsartan ("-sartans") — risk of AKI when dehydrated

NSAIDs

Ibuprofen, naproxen, diclofenac — renal vasoconstriction → AKI

Also Remember

Sulphonylureas (gliclazide, glimepiride): stop or reduce during illness — hypoglycaemia risk when not eating
Insulin: Do NOT stop — but doses may need adjusting. Advise patient/carer to monitor blood glucose closely (at least 4x daily when unwell)
Restart SADMAN drugs after 24–48 hours of eating and drinking normally. If in doubt, call GP or 111.

General Sick Day Advice to Give Patients/Carers

Rest and drink plenty of sugar-free fluids (aim 3 litres/day — UNLESS heart failure: stick to 1.5–2 litres and weigh daily; if weight up >2 kg in 3 days → call 111)
Try to maintain normal eating. If not managing meals, replace with carbohydrate-containing drinks/snacks (yoghurt, fruit juice, Lucozade)
Avoid excess caffeine
Take paracetamol for pain/fever as needed
Contact GP/111 if vomiting uncontrollably, unable to keep fluids down, or any doubt about medicines

💡 AKT Tip — This is Highly Testable

SADMAN is one of the most tested prescribing safety topics in the AKT. Expect scenarios such as: "An 80-year-old on ramipril, furosemide and metformin develops D&V. Which medications should be stopped?" — Answer: All three (A, D, and M from SADMAN).

Common trap: Insulin should NEVER be stopped — even if not eating. This is a very common AKT distractor.

Additional Domains

Key Team Members

Geriatrician	Specialist assessment, CGA, complex multimorbidity
Community Nurse	Wound care, medication support, monitoring
Physiotherapist	Mobility, falls prevention, rehabilitation, sarcopenia
Occupational Therapist	ADL assessment, home adaptations, equipment
Pharmacist	Medication review, deprescribing, SADMAN counselling, anticholinergic burden
Social Worker	Care package, safeguarding, benefits advice, LPA advice
Dietitian	Nutritional assessment, malnutrition management, sarcopenia support
Podiatrist	Foot care, diabetic foot, nail problems, footwear advice

Mental Capacity Assessment

Mental Capacity Act 2005: Assume capacity unless proven otherwise. Capacity is decision-specific and time-specific.

4-stage test:

Understand the information
Retain the information
Weigh up the information
Communicate the decision

Advance Care Planning

Advance Decision (Living Will): Legally binding refusal of specific treatments
Advance Statement: Preferences for future care (not legally binding)
Lasting Power of Attorney (Health & Welfare): Appointed decision-maker
DNACPR/ReSPECT: Do Not Attempt CPR - discuss sensitively, document clearly

Best Interests Decision-Making

If patient lacks capacity, decisions must be made in their best interests:

Consider patient's past and present wishes
Consult family, carers, and healthcare team
Consider beliefs, values, and cultural factors
Choose least restrictive option
Document decision-making process

Vaccinations

Annual influenza vaccine (all ≥65)
Pneumococcal vaccine (one-off at 65, or if immunosuppressed)
Shingles vaccine (70-79 years, catch-up to 80)
COVID-19 booster (as per national programme)

Screening

AAA screening (men aged 65)
Bowel cancer screening (60-74, FIT test)
Breast screening (50-70, mammography every 3 years)
Cervical screening (up to 64, then stop if previous screens normal)

Lifestyle Interventions

Smoking cessation (benefits at any age)
Physical activity (150 min/week moderate intensity) — especially resistance training for sarcopenia prevention
Healthy diet (Mediterranean diet, reduce salt, adequate protein 1.0–1.2 g/kg/day for muscle maintenance)
Alcohol within guidelines (≤14 units/week)
Social engagement (reduce isolation — as harmful as 15 cigarettes/day)
Cognitive stimulation (reading, puzzles, social activities)

You've Got This!

Elderly care is complex but incredibly rewarding. Remember: every patient is an individual with their own story, priorities, and goals. Use your clinical knowledge, but never forget the person behind the diagnosis.

"The art of medicine consists of amusing the patient while nature cures the disease." - Voltaire

In elderly care, we add: while optimising function, quality of life, and dignity.

Elderly Care

Executive Summary

Key Learning Points

Downloads & Resources

Quick Navigation

Brainy Bites

Comprehensive Geriatric Assessment

Frailty Identification

Polypharmacy Review

Atypical Presentations

Multimorbidity Management

The 9 Geriatric Giants — MANIC MOLD

Clinical Pearls & Top Tips

Why These Pearls Matter

Origin & Context

Mnemonic: MANIC MOLD

💡 AKT Tip

Why Frailty is Not Just "Getting Old"

Fried Frailty Phenotype — Mnemonic: WELSW

⚠️ Important: Don't Forget the eFI and CFS

What is Sarcopenia?

🚨 We Often Make It Worse Without Realising

Consequences

Management

💡 AKT Tip

Why the Feet?

🚨 What to Look For

Clinical Action

💡 SCA Tip

Data Gathering & Examination

Consultation Framework

Fried Frailty Phenotype (WELSW) — The Research Standard

Clinical Frailty Scale (CFS)

Electronic Frailty Index (eFI)

Polypharmacy Risks

AKI Sick Day Rules — Mnemonic: SADMAN

STOPP/START Criteria

🚨 Triggers for Urgent Medication Review — Don't Miss These

⚠️ Nitrofurantoin — Long-Term Use Risk

Hearing Impairment

Visual Impairment

Cognitive Impairment

Diagnostic Approach & Investigations

Atypical Presentations

Investigating Acute Confusion (Delirium)

Bedside Tests

Blood Tests

Imaging

Falls Investigation (NICE NG249)

⚠️ Medicines & Falls — A Major, Modifiable Risk

Multifactorial Risk Assessment

Investigations

Cognitive Impairment Assessment

Cognitive Screening Tools

Dementia Blood Screen

Imaging

Differential Diagnosis Frameworks

PINCH ME Mnemonic

Other Important Causes

Intrinsic Factors

Extrinsic Factors

Common Causes

Causes of Urinary Retention

Common Conditions in Elderly Care

Multimorbidity Management

Management in Elderly

Stroke Risk Assessment (CHA₂DS₂-VASc)

Bleeding Risk (HAS-BLED)

Management Principles

Symptoms — What to Look For

Dementia Subtypes

⚠️ The Big Blind Spot in Memory Tests (MMSE, 6-CIT)

Risk Factors — Who to Screen Earlier

Pharmacological Management

🚨 Driving & DVLA — Do Not Miss This

Social Interventions & Legal Planning

When to Re-refer to the Memory Clinic / Specialist

Motor Features (Triad)

Treatment Options

FAST Recognition