Geriatric Medicine & Frailty
A board-focused walkthrough of frailty as a syndrome of lost physiologic reserve — the Fried phenotype, the 5 Ms, and the geriatric giants (falls, delirium, polypharmacy) — with next-best-step deprescribing and function-focused management for Step 2 CK.
What frailty is (and why boards care)
Frailty is a clinical syndrome of decreased physiologic reserve and reduced resistance to stressors from cumulative decline across multiple organ systems. It overlaps with — but is distinct from — comorbidity and disability. The hallmark boards test: a frail elder decompensates disproportionately after a minor stressor (a UTI, one new drug, minor surgery), presenting with delirium, falls, or acute functional decline rather than classic disease signs.
Frame every geriatric patient with the 5 Ms: Mind (cognition/mood/delirium), Mobility (gait/falls), Medications (polypharmacy/Beers), Multicomplexity (multimorbidity + psychosocial context), and what Matters most (goals of care).
Recognizing frailty changes management — lower thresholds for harm, active deprescribing, and function-focused rather than disease-focused goals. Life expectancy, not chronologic age, drives decisions to stop cancer screening (generally when estimated life expectancy is <10 years).
- Fried frailty phenotype — frail if ≥3 of 5; pre-frail if 1–2:
- Unintentional weight loss (≥10 lb or ≥5% body weight in the past year)
- Self-reported exhaustion
- Weakness (low grip strength)
- Slow gait speed
- Low physical activity
- Sarcopenia (loss of muscle mass + strength) is the biologic substrate of physical frailty
- Falls are the leading cause of injury death in adults ≥65 — screen for falls annually
- Best bedside mobility screen: Timed Up-and-Go; ≥12 sec = elevated fall risk (CDC STEADI)
- Every faller: check orthostatic vitals, review meds, assess gait, vision, feet, footwear
- Strength/balance exercise (PT, Tai Chi) is the best-proven intervention to reduce falls; routine vitamin D does NOT prevent falls (USPSTF) — replete only if deficient
- "Start low, go slow" — reduced renal/hepatic clearance and ↑ drug sensitivity in elders
Vignette: An 82-year-old woman presents after her third fall in 6 months. Medications: lorazepam for sleep, oxybutynin for urinary urgency, lisinopril. Exam: BP 138/80 supine → 118/68 standing with dizziness; Timed Up-and-Go 18 sec; no focal neuro deficits.
- Diagnosis: multifactorial fall risk — orthostatic hypotension (≥20 systolic / ≥10 diastolic drop with symptoms), culprit medications, and gait impairment.
- Next best step: perform a multifactorial falls assessment and deprescribe high-risk drugs — stop lorazepam and oxybutynin (both Beers-listed; a benzodiazepine and an anticholinergic each raise fall/confusion risk). Add PT for gait/balance training, check vitamin D (replete if deficient), and arrange a home-safety evaluation.
- Test link: recurrent falls + sedating/anticholinergic meds → deprescribe first; don't merely add a mobility aid or start a new drug.
Vignette: A 78-year-old man, cognitively intact on admission, becomes acutely agitated and inattentive on postoperative night 2 after hip-fracture repair, with waxing-and-waning alertness and visual hallucinations.
- Diagnosis: delirium — acute onset, fluctuating course, inattention (the hallmark), plus altered consciousness → CAM-positive.
- Next best step: identify and treat the underlying cause — screen for infection/UTI, hypoxia, uncontrolled pain, urinary retention, constipation, electrolyte/glucose derangement, and offending drugs (opioids, anticholinergics, benzodiazepines).
- Management: nonpharmacologic first — reorient, restore the sleep-wake cycle, mobilize early, remove tethers (lines/catheters), correct sensory deficits (glasses/hearing aids). Reserve a low-dose antipsychotic only for severe agitation threatening safety. Avoid benzodiazepines except in alcohol/benzodiazepine withdrawal.
ADLs = DEATH (basic self-care):
- Dressing, Eating, Ambulating, Toileting, Hygiene
IADLs = SHAFT (independent-living skills):
- Shopping, Housekeeping, Accounting (finances), Food preparation, Transportation
Delirium causes = "I WATCH DEATH":
- Infection, Withdrawal, Acute metabolic, Trauma, CNS pathology, Hypoxia, Deficiencies (B12/thiamine), Endocrinopathy, Acute vascular, Toxins/drugs, Heavy metals
IADLs are lost before ADLs — the earliest functional decline shows up in finances, medications, and driving.
The 3 Ds — delirium vs dementia vs depression
| Feature | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Acute (hrs–days) | Insidious (mo–yr) | Weeks |
| Course | Fluctuating | Progressive, steady/day | Diurnal (worse AM) |
| Attention | Impaired (hallmark) | Normal early | Usually intact |
| Consciousness | Altered/clouded | Clear until late | Clear |
| Reversible? | Yes — find the cause | Usually no | Yes (treat) |
| Memory complaint | Disorganized thinking | Denies / confabulates | Emphasizes ("I don't know") |
High-yield Beers drugs → safer alternative
| Drug (class) | Why avoid in elders | Prefer |
|---|---|---|
| Diphenhydramine / 1st-gen antihistamines | Anticholinergic → confusion, falls, retention | Loratadine, cetirizine |
| Benzodiazepines (lorazepam, diazepam) | Falls, delirium, sedation | Sleep hygiene; treat cause |
| Oxybutynin (anticholinergic OAB agent) | Confusion, dry mouth, retention | Behavioral therapy; mirabegron |
| Tertiary TCAs (amitriptyline) | Anticholinergic, orthostasis | SSRI |
| NSAIDs (chronic use) | GI bleed, AKI, HF, ↑BP | Acetaminophen |
| Glyburide (long-acting sulfonylurea) | Prolonged hypoglycemia | Shorter-acting agent (glipizide) |
| Muscle relaxants (cyclobenzaprine) | Anticholinergic, sedation | PT, acetaminophen |
| Sliding-scale insulin (sole regimen) | Hyper/hypoglycemia swings | Scheduled basal + correction |
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