Medicine — Geriatric Medicine, NMC MBBS licence examination syllabus (Nepal Medical Council).
Geriatric medicine: falls, frailty and the drug chart
The presenting complaint is rarely the diagnosis, and the drug chart is part of the examination.
Older patients break the pattern that the rest of medicine teaches. Disease presents non-specifically, several problems occur at once, the treatment for one worsens another, and the presenting complaint — a fall, confusion, "off legs" — is a symptom of something else entirely rather than a diagnosis in itself.
That produces a recognisable failure mode. A patient is admitted with a label like "social admission" or "acopia", the underlying infection or drug effect is never identified, they deteriorate in a hospital bed, and the deterioration is attributed to age. Almost every step of that sequence is preventable.
🩺 Where this lives: "Acopia" and "social admission" are not diagnoses — they are unfinished assessments. An older person who was managing at home last week and cannot manage today has something wrong: an infection, a new drug, retention, constipation, pain, a fracture, a myocardial infarction. Labelling the change as social failure closes the inquiry precisely when it should open, and the treatable cause is then never found. The label also quietly determines how the patient is treated by everyone who reads it afterwards.
💡 A note on scope. This chapter gives no doses, no frailty scoring instruments and no postural hypotension thresholds — instruments and thresholds differ between services and guidelines, so use the tool in local practice. Delirium is covered in full in the Delirium chapter, prescribing safety and the prescribing cascade in Prescribing Safety, femoral neck fracture in Orthopaedics, and capacity in the Ethics chapter.
Atypical presentation
The rule to internalise is that in older people, the presenting complaint is a symptom of something else. New confusion, a fall, immobility, incontinence or not eating are not diagnoses — they are the non-specific ways in which infection, myocardial infarction, drug effects, retention, constipation, pain and electrolyte disturbance announce themselves. And as in the newborn, fever and a raised white cell count are frequently absent in serious infection; a hypothermic confused older patient may be profoundly septic.
THE SYSTEMATIC SEARCH IN A NON-SPECIFIC PRESENTATION
When an older person is "not themselves", work through:
INFECTION — chest, urine, skin, abdomen. Remember fever
may be absent, and a positive urine dipstick in an
older person does not prove urinary infection is the
cause of confusion.
DRUGS — anything started, stopped or changed recently.
This is the highest-yield question on the list.
RETENTION and CONSTIPATION — both cause confusion,
agitation and immobility, and both are found by
examining rather than by testing.
PAIN — often unreported, particularly where cognition is
impaired. Look for a fracture after a fall.
METABOLIC — glucose, sodium, calcium, renal function,
thyroid.
CARDIAC and NEUROLOGICAL — myocardial infarction and
stroke both present atypically, frequently without
chest pain or classical focal signs.
HYPOXIA and anaemia.
AND ALWAYS: a full physical examination including the
skin, the abdomen and the feet, and a COLLATERAL HISTORY.
What could this person do a week ago? The rate of change is
the most informative single piece of information you can
obtain, and the patient often cannot supply it.
For the management of delirium itself, see the delirium
chapter — this is about finding what caused it.
Falls
💡 Exam angle: the first question in any fall is whether consciousness was lost, because a collapse belongs to an entirely different differential — syncope, arrhythmia, seizure — from a trip. After that, falls are multifactorial by definition, and the highest-yield intervention is reviewing the drug chart. The examination point most often omitted in practice is the lying and standing blood pressure: postural hypotension is common, frequently drug-induced, easily corrected, and almost never measured.
Polypharmacy
DEPRESCRIBING IS PRESCRIBING
THE GOVERNING QUESTION
For every new symptom in an older person: COULD A DRUG BE
CAUSING THIS? Falls, confusion, constipation,
incontinence, dizziness, low mood, weight loss and
reduced appetite are all common drug effects.
THE CLASSES THAT CAUSE MOST HARM
SEDATIVES and hypnotics — falls, confusion, dependence
ANTICHOLINERGIC drugs — confusion, retention,
constipation, dry mouth, blurred vision. Their effects
are ADDITIVE, and many drugs have anticholinergic
activity without being thought of that way.
OPIOIDS — confusion, constipation, falls
ANTIHYPERTENSIVES and DIURETICS — postural hypotension,
falls, electrolyte disturbance, incontinence
ANTIPSYCHOTICS — falls, and increased mortality in
dementia
WHY THIS GETS WORSE WITH AGE
Renal function declines, so renally cleared drugs
accumulate at doses that were previously safe.
Body composition changes.
Sensitivity to sedatives and anticholinergics increases.
More drugs mean more interactions — see the prescribing
safety chapter.
THE PRESCRIBING CASCADE is especially common here: a drug
causes a symptom, the symptom is treated as a new disease,
and another drug is added. Breaking it requires reviewing
the whole chart rather than the newest complaint.
STOPPING A DRUG IS A TREATMENT, and frequently the most
effective one available. Review indication, benefit,
ongoing need and the patient's own priorities — a drug
preventing an event in ten years may not serve someone
whose priority is not falling this month.
Frailty
Frailty is loss of physiological reserve, not a synonym for age. A frail person responds to a small insult — a urinary infection, a new tablet, a night without sleep — with a disproportionate decline in function. That is why two people of the same age can be entirely different patients, and why age alone should never determine treatment. What matters is function: what could this person do a month ago, and what can they do now?
The harms of hospital
💡 Exam angle: hospital is not a neutral environment for an older person. Deconditioning from days in bed costs muscle that takes weeks to regain, and the ward brings delirium, falls, hospital-acquired infection, pressure ulcers and malnutrition. The interventions are unglamorous and effective: get patients up and dressed, restore glasses and hearing aids, protect sleep, encourage family presence, and remove the catheter, the cannula and every unnecessary drug.
Clinical reasoning: four presentations
🔍 Case 1 — the social admission
PresentationAn 84-year-old who was shopping independently last week is brought in unable to stand, mildly confused and incontinent. She is admitted as a "social problem" pending a care assessment. No examination beyond observations is recorded.
ErrorA label instead of an assessment.
ReasoningSomeone who was independent a week ago and is not now has an acute problem. Infection, drugs, retention, constipation, pain, fracture and myocardial infarction all present exactly like this in older people.
AnswerFull examination including abdomen and skin, check for retention and constipation, review the drug chart, basic tests including glucose, and take a collateral history establishing the rate of change.
🔍 Case 2 — falls and a new tablet
PresentationA man has fallen three times in a month. He had an antihypertensive added six weeks ago and takes a sedative at night. He is referred for physiotherapy. His lying and standing blood pressure is not measured.
Missed stepsThe drug review and the postural blood pressure.
ReasoningFalls are multifactorial, and drugs are the most modifiable factor. Antihypertensives and sedatives are among the classes most strongly associated with falls, and postural hypotension is common and easily demonstrated.
AnswerMeasure lying and standing blood pressure, review every drug with a view to stopping or reducing, assess vision, gait and the home environment. Physiotherapy is useful but is not a substitute for removing the cause.
🔍 Case 3 — treated for the side effect
PresentationAn older woman is started on a drug, becomes constipated, is given a laxative, then develops confusion and is given a sedative at night. She then falls. Each prescription was reasonable in isolation.
PatternA prescribing cascade.
ReasoningEach new symptom was treated as a new disease rather than as a possible drug effect, and each addition created the next problem. The sedative that followed is a well-recognised cause of falls.
AnswerReview the entire drug chart from the beginning, identify the original culprit, and stop rather than add. See the prescribing safety chapter.
🔍 Case 4 — too old to treat
PresentationAn 82-year-old who walks to market daily and lives independently is deemed "too old" for a treatment offered routinely to younger patients. No functional assessment is recorded and she is not asked her view.
ErrorUsing age as a proxy for reserve.
ReasoningFrailty rather than age determines physiological reserve, and two people of 82 may be entirely different patients. Her described function suggests she is not frail.
AnswerAssess frailty and function rather than age, discuss benefits, burdens and her own priorities with her, and decide together. She has capacity and the decision is hers — see the Ethics chapter.
Commonly confused
Confusion
The distinction
Why it matters
Presenting complaint vs diagnosis
Falls and confusion are symptoms
The cause is elsewhere.
"Social admission" vs assessment
It is an unfinished assessment
The treatable cause is never found.
Fever vs infection
Fever is often absent in the elderly
A hypothermic patient may be septic.
Fall vs collapse
Was consciousness lost?
Entirely different differential.
Physiotherapy vs drug review
Drugs are the most modifiable factor
Both are needed; one is skipped.
New symptom vs drug effect
Ask whether a drug caused it
Prevents the prescribing cascade.
Age vs frailty
Frailty is loss of reserve
Age alone decides nothing.
Admission vs safety
Hospital itself causes harm
Deconditioning is fast and hard to reverse.
Rapid revision
MUST-KNOW FACTS
1. In older people the PRESENTING COMPLAINT IS RARELY THE DIAGNOSIS.
2. Confusion, falls, immobility and incontinence are SYMPTOMS.
3. "ACOPIA" and "SOCIAL ADMISSION" are NOT diagnoses.
4. FEVER AND LEUCOCYTOSIS ARE OFTEN ABSENT in serious infection.
5. A hypothermic confused older patient may be septic.
6. Search systematically: infection, DRUGS, retention, constipation, pain.
7. Also metabolic, cardiac, neurological, hypoxia and anaemia.
8. Myocardial infarction and stroke present atypically in the elderly.
9. A positive urine dipstick does not prove UTI is causing confusion.
10. Take a COLLATERAL HISTORY — establish the RATE OF CHANGE.
11. FALLS: first ask whether CONSCIOUSNESS WAS LOST.
12. A collapse is a different problem from a trip.
13. Falls are MULTIFACTORIAL — drugs, vision, blood pressure, weakness, environment.
14. MEASURE LYING AND STANDING BLOOD PRESSURE.
15. Postural hypotension is common, drug-induced and rarely looked for.
16. A fall predicts the next fall — and the next may break a hip.
17. EVERY NEW SYMPTOM IS A DRUG EFFECT UNTIL PROVEN OTHERWISE.
18. Highest-harm classes: SEDATIVES, ANTICHOLINERGICS, opioids, antihypertensives.
19. Also diuretics and antipsychotics.
20. Anticholinergic effects are ADDITIVE across many drugs.
21. RENAL FUNCTION DECLINES WITH AGE — safe doses may become unsafe.
22. The PRESCRIBING CASCADE is especially common in this group.
23. STOPPING A DRUG IS A TREATMENT.
24. FRAILTY is loss of PHYSIOLOGICAL RESERVE, not age.
25. A small insult causes a disproportionate decline.
26. Two people of the same age may be entirely different patients.
27. NEVER withhold treatment on the basis of AGE ALONE.
28. Assess FUNCTION — what could they do a month ago?
29. HOSPITAL ITSELF CAUSES HARM.
30. DECONDITIONING is fast and hard to reverse — get patients UP AND DRESSED.
31. Hazards: delirium, falls, infection, pressure ulcers, malnutrition.
32. Restore GLASSES and HEARING AIDS — they prevent delirium.
33. Remove the catheter, the cannula and unnecessary drugs.
💡 Exam angle: three habits answer most questions here — treat the presenting complaint as a symptom and search for its cause, review the drug chart before adding anything, and judge the patient by function rather than by age.
Syllabus points
Why presentation is atypical
Why 'social admission' is not a diagnosis
Absent fever in serious infection
The systematic search for a cause
Collateral history and rate of change
Was consciousness lost?
Falls as multifactorial
Lying and standing blood pressure
Every symptom as a possible drug effect
The classes that cause most harm
Declining renal function and dosing
Deprescribing as treatment
Frailty versus age
The harms of hospital admission
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