Geriatrics Knowledge Skill

Exam Materials ✓

• Past exam questions: Dec 2021, Jun 2022
• Past exam answers with Hazzard's page citations: Dec 2021, Jun 2022
• Exam source index mapping questions to Hazzard's tables/pages

Board Syllabus Map — P005-2026

Hazzard's 8th Edition — Required: Chapters 2–6, 34, 62

Harrison's 22nd — All Residents

Harrison's 22nd — Base Residents (Additional)

14 Pain | 15 Chest | 16 Abdominal Pain | 17 Headache | 18 Low Back | 20 Fever | 22 FUO | 30 Coma | 39 Dyspnea | 40 Cough | 41 Hemoptysis | 42 Hypoxia | 43 Edema | 48 N/V | 49 Diarrhea/Constipation | 50 Weight Loss | 51 GI Bleeding | 52 Jaundice | 53 Ascites | 55 Azotemia | 56 Electrolytes | 57 Ca | 58 Acid-Base | 66 Anemia | 67 Granulocytes | 69 Bleeding/Thrombosis | 70 Lymphadenopathy | 79 Cancer Infections | 80 Oncologic Emergencies | 102 Iron Deficiency | 120 Platelets | 121 Coagulation | 127 Febrile Patient | 133 Endocarditis | 136 Osteomyelitis | 142 Encephalitis | 143 Meningitis | 147 HAI | 243 Cardiovascular | 247 ECG | 285 NSTEMI | 286 STEMI | 295 Respiratory | 305 Pleura | 311 Critical Illness | 314 Shock | 315 Sepsis | 316 Cardiogenic Shock | 317 Cardiac Arrest | 319 Renal | 321 AKI | 322 CKD | 332 GI Disease | 347 Liver | 355 Cirrhosis | 375 Vasculitis | 379 Sarcoidosis | 384 Gout | 388 Endocrine

Source Hierarchy

Israeli Law Content — Exam Critical

Decision Hierarchy (incapacitated patient)

1. ייפוי כוח מתמשך with medical scope → activate proxy
2. הנחיות מקדימות (s.35א Capacity Law) → follow
3. Neither → מקבל החלטות זמני
4. No family agreement → court (אפוטרופוס)

ייפוי כוח מתמשך

LPA created while patient has capacity. Medical scope = proxy authorizes procedures. Overrides family consensus. Check before defaulting to surrogate process.

מקבל החלטות זמני (Amendment 16, Jan 2024)

Trigger: Urgent non-emergency + cannot consent + no ייפוי כוח/guardian. Exam trap: 3-physician = emergencies. מקבל החלטות זמני = urgent non-emergency. Family priority: spouse → child → parent → sibling. Validity: 6 months. Re-check capacity before each procedure. נספח א' = family declaration. נספח ב' = hospital director authorization → active.

סיעוד מורכב (Circular 4/2010)

Admission = chronically dependent + ≥1 active medical complexity criterion. Criteria: pressure ulcer 3–4, prolonged IV, respiratory (trach/BiPAP/suction), dialysis, active malignancy, recurrent transfusions >1×/month, medically unstable continuous monitoring. Exclusions: sub-acute non-dependent, rehab potential, ventilator-dependent, home-manageable.

מינוי אפוטרופוס באשפוז ממושך (Circular 10/2006)

Applies when: patient cannot consent AND no ייפוי כוח AND prolonged hospitalization. Process via court — not a hospital-level decision. Physician role: assess capacity, document, initiate via social worker and welfare officer.

קביעת מצב תפקודי להעברה (Circular 26/2010)

Defines classification of hospitalized patient for transfer to another facility. Functional status categories: independent / sub-acute / geriatric rehabilitative / geriatric nursing. Required for formal transfer between general hospital and geriatric/rehab settings.

אמות מידה לטיפול שיקומי לקשישים (Circular 4/2009)

Criteria for geriatric rehabilitation admission. Rehabilitation = therapeutic phase in ongoing recovery, targeting motor + cognitive function. Requires: rehabilitation potential (explicit requirement), appropriate facility type. Exclusion: no rehabilitation potential → סיעוד מורכב or nursing setting.

הגדרת מושגים — נהלי רוחב (MOH Geriatrics 0.2.1, updated 2019)

Authoritative definitions for geriatric ward practice (item #1 in exam syllabus). Covers: סיעודי, תשוש, תשוש נפש, נוטה למות, שלב סופי and related classification terms. Search this document for any exam question on geriatric functional definitions.

נוהל התעמרות (Circular 22/03)

5 types: פיזית, נפשית, כלכלית, הזנחה (passive + active), מסגרת (institutional).

Mandatory reporters (חוק העונשין תיקון 26, 1989): רופא, אחות, עובד סוציאלי, פסיכולוג, קרימינולוג, מנהל מוסד + any staff. Failure to report = criminal offense (≤6 months).

Report to: police and/or welfare officer (פקיד סעד).

Hospital procedure: immediate physician exam (no companions), parallel social worker, standardized documentation form, monthly data collection, annual hospital report to MOH.

Discharge: with social worker, welfare officer notified in writing.

PEG לחולה עם קיהיון הנוטה למות (National Committee, 11.8.16, SZMC) ✓

Context: Meeting held at Shaare Zedek Medical Center. Decisions binding on clinical practice.

Legal framework (exam — know these distinctions):

• חולה נוטה למות (s.8a): incurable disease, life expectancy ≤6 months even with treatment.
• שלב סופי (s.8b): multiple organ failure, life expectancy ≤2 weeks even with treatment.
• טיפול נלווה (s.16b): supportive care including nutrition/fluids — mandatory even if patient previously refused. Patient's past wishes CANNOT override duty to provide nutrition in this phase.
• שלב סופי exception (s.17): may withhold ALL treatment including nutrition/fluids IF patient previously expressed wish not to prolong life AND physician determines fluids cause suffering/harm.

Committee decisions (exam-critical rules):

A. חולה נוטה למות עם קיהיון: Must receive food AND fluids, even artificially, UNLESS there is a specific medical contraindication. Ethical arguments based on cognitive status alone are legally prohibited as a basis for withholding nutrition.

B. שלב סופי עם קיהיון: Must receive fluids (NOT necessarily food), even artificially, UNLESS medical contraindication. Law mandates equal right to life regardless of dementia.

C. Medical contraindications only can override — NOT quality-of-life ethical judgments based on cognitive status. Patient's past wish to refuse (when competent) is explicitly overridden by s.16b(2) for nutrition in dying patient phase.

D. Preferred route: oral feeding. Always first — with SLP evaluation, slow careful feeding, aspiration risk reduction. Small volumes orally often sufficient given low caloric needs.

E. PEG vs NGT: No survival difference between PEG, NGT, or IV in dementia patients. BUT PEG is preferred over NGT for comfort/QoL when artificial route is needed. NGT = only temporary bridge. Never as permanent substitute.

F. PEG contraindications in dementia:

• NEVER insert PEG during acute illness (surgical risk outweighs benefit — proven lethal risk)
• NEVER insert PEG in שלב סופי (terminal stage per law definition)
• Consider early PEG insertion when functional decline predictable and patient medically stable

G. When to switch to artificial route: cannot feed orally adequately; recurrent aspirations despite careful feeding; recurrent intercurrent illnesses preventing oral feeding; need for essential medications not giveable orally.

H. Evidence base: RCTs not ethically feasible. No survival difference between methods. Key confounders: dementia severity, disease stage at PEG insertion, nutritional composition, age at dysphagia onset (age 80 = key cutoff), sex (male = risk factor), care setting.

I. Decision-making: multidisciplinary team — physician, nurse, SLP (קלינאית תקשורת), dietitian, OT, PT, social worker. Document all decisions with medical rationale.

J. Prohibited reasoning: quality-of-life judgments based purely on cognitive impairment cannot form basis for withholding nutrition. This is explicitly illegal under חוק החולה הנוטה למות.

SZMC significance: This document was produced AT Shaare Zedek — directly relevant to SZMC practice.

Required Articles — Key Content

AGS Beers Criteria 2023 (JAGS 71:2052–2081) ✓

5 tables: (1) PIMs to avoid, (2) disease/syndrome interactions, (3) drug-drug interactions, (4) use with caution, (5) renal dose adjustments.

Key 2023 changes (exam: know vs 2019):

• Aspirin primary CVD prevention → Avoid (Table 2)
• Rivaroxaban → Avoid long-term AF/VTE; apixaban preferred DOAC
• Warfarin → Avoid initiating for AF/VTE; DOACs preferred (continue if INR well-controlled)
• Dabigatran → Caution (Table 4); higher GI bleeding vs apixaban
• Sulfonylureas → ALL avoid as first/second line (not just long-acting)
• SGLT2 inhibitors → Caution (UTI risk, euglycemic DKA)
• Opioids → added to delirium risk (Table 3)
• Anticholinergics → cumulative burden explicitly flagged (Table 7)
• Baclofen → avoid if eGFR <60 (encephalopathy risk)
• Apixaban → REMOVED from renal table (safe in ESRD)

Exam principles: "Avoid" ≠ absolute contraindication. Criteria do NOT apply to hospice/EOL. Shared decision-making always required. Cost/access barriers acknowledged.

IWG 2024 AD Criteria (JAMA Neurol) ✓

IWG vs AA 2024 (exam-critical distinction):

IWG 2024 Lexicon:

• At-risk: Cognitively normal + amyloid ± T1 tau. NOT AD. Follow up only.
• Presymptomatic AD: Near-deterministic profile — APP/PSEN1/PSEN2 mutation, Down syndrome, homozygous APOEε4/SORL1 LOF, amyloid PET+ with neocortical tau PET+.
• Alzheimer disease: Cognitive symptoms + specific phenotype + pathophysiological biomarkers. Includes prodromal (MCI) and dementia stages.

Key stat: Amyloid+ 65yo man = 21.9% lifetime AD risk = only 1.7× above baseline. Most biomarker+ cognitively normal individuals will NOT develop symptoms.

AA Workgroup 2024 (Alzheimer's & Dementia) ✓

Biological definition — AD defined by biomarkers regardless of cognition. Staging: Stage 1 (biomarker+, cognitively normal), Stage 2 (biomarker+ + subtle symptoms), Stage 3 (dementia). Exam: know this contrasts with IWG (IWG article is the one in syllabus).

VasCog-2-WSO (JAMA Neurol 2025) ✓

Revised criteria for vascular cognitive impairment and dementia (VCID). Delphi consensus, 70 international experts, ≥75% agreement threshold. WSO endorsed. Replaces VasCog 2014. Key change: Temporal relationship between vascular event and cognitive change NO LONGER required. Neuroimaging central. Spectrum: preclinical → mild VCI → major VCID (vascular dementia). Biomarker guidance added (neuroimaging + fluid biomarkers).

Dementia Prevention (JAMA Internal Medicine, Reuben et al) ✓

Dementia = 10% of ≥65yo, 35% of ≥90yo. No RCT has conclusively proven prevention intervention works. But addressing risk factors has other health benefits and should be considered.

Treatment:

• Cholinesterase inhibitors + memantine → modest benefit in AD, DLB, PDD, VaD, TBI dementia
• Anti-amyloid immunomodulators → modestly slow decline in mild MCI/mild AD
• BPSD: nonpharmacologic FIRST (DICE approach). Psychotropics = minimal efficacy + mortality risk

Prevention — modifiable risk factors (Lancet Commission/Livingston framework): Low education, hearing loss (★ dementia link — key exam point), hypertension, obesity (midlife), smoking, depression, physical inactivity, diabetes, social isolation, TBI, alcohol excess, air pollution. 12 factors accounting for ~40% of dementia cases theoretically preventable.

Age-Related Hearing Loss (NEJM 2024, Lin) ✓

Age-related cochlear pathology — most common cause of hearing loss. Sensorineural, bilateral, high-frequency first (presbycusis). Dementia link: Hearing loss = largest modifiable dementia risk factor (Lancet Commission). New: OTC hearing aids now available in US. Management: hearing aids (first-line), cochlear implants (severe/profound). Consequences: cognitive decline, social isolation, depression, falls. Screen with: whispered voice test, handheld audioscope, refer to audiology.

Automatic Medication Analysis

Run for every drug query:

1. Beers 2023 — Table 2 (avoid), Table 3 (disease), Table 4 (caution), Table 6 (renal)
2. STOPP/START — inappropriate or missing drug?
3. Renal dose — Cockcroft-Gault (actual wt BMI <30, IBW if obese)
4. ACB — anticholinergic burden (Table 7)
5. Drug-drug — Table 5 (opioid+benzo, opioid+gabapentinoid, ≥3 CNS agents, anti+anti, warfarin+SSRIs)
6. Fall risk — anticholinergics, benzos, SSRIs/SNRIs, antiepileptics, antipsychotics, opioids
7. Driving risk — מרב"ד reportable condition?

Response Format

Exam questions:

ANSWER — direct, mechanism-based
SOURCE — Hazzard's ch / Harrison's ch / Beers Table / IWG / Israeli law item #
EXAM TRAP — what the exam typically tests

Clinical:

ANSWER + SZMC CONTEXT
DAG if antibiotics. Israeli law if capacity/surrogacy. Auto Beers/renal/ACB.

SZMC Context

Ward: Geriatric department, Shaare Zedek Medical Center, Jerusalem. 26-hour on-call. DAG = override generic for antibiotics. CrCl: Cockcroft-Gault (actual wt BMI <30; IBW if obese). PEG National Committee meeting was held at SZMC — institutional document.

STOPP/START v.3 (O'Mahony 2023) — Exam Reference

Full criteria in knowledge base. Search: "STOPP [section letter]" or "START [system]".

STOPP sections: A Indication · B Cardiovascular · C Coagulation · D CNS · E Renal · F GI · G Respiratory · H Musculoskeletal · I Urogenital · J Endocrine · K Falls-risk drugs · L Analgesics · M Anticholinergic burden

START sections: A Indicated · B Cardiovascular · C Coagulation · D CNS · E Renal · F GI · G Respiratory · H Musculoskeletal · I Urogenital · J Endocrine · K Analgesics · L Vaccines

High-yield STOPP for exam:

• D8: Benzodiazepines ≥4 weeks — taper, never abrupt stop
• D12: Antipsychotics (not quetiapine/clozapine) in Parkinsonism/DLB
• D14: Anticholinergics in delirium/dementia
• D15: Antipsychotics for BPSD >12 weeks without review
• E2: Dabigatran eGFR <30 · E6: Metformin eGFR <30 · E8: Nitrofurantoin eGFR <45
• I8: Antibiotics for asymptomatic bacteriuria — NO indication
• B16: Statins primary prevention ≥85 + frailty + <3yr life expectancy
• K (all 12): Falls-risk drugs in recurrent fallers — benzos, antipsychotics, vasodilators, Z-drugs, AEDs, opioids, antidepressants, alpha-blockers, centrally-acting antihypertensives, antimuscarinics

High-yield START for exam:

• B8: SGLT2i in symptomatic HF regardless of EF or diabetes
• B9: Sacubitril/valsartan in HFrEF on optimal ACEi/ARB
• H4: Bisphosphonate + VitD in osteoporosis (T <−2.5)
• H6: Anti-resorptive after ≥2 denosumab doses stopped (rebound fracture risk)
• L1–4: Vaccines — influenza annual, pneumococcal once, zoster, COVID per guidelines

Exam trap — STOPP vs Beers: STOPP/START is physiological-systems based; Beers is US-focused. Both may be tested. Know which version is in syllabus (STOPP v.3 2023; Beers 2023 JAGS).

FIM — Functional Independence Measure

18 items, 7-point scale (1 = total dependence, 7 = complete independence). Range 18–126. Motor subscale items 1–13; Cognitive subscale items 14–18.

SZMC validation (Harefuah 2020, n=453 hip fracture patients, mean age 82.9):

• FIM=85 cutoff: Best predictor institutional vs home discharge (AUC 0.921, p<0.001)
• FIM=71 cutoff: Best predictor supervised vs independent community living
• Motor subscale plateaus earlier than cognitive; plateau = signal to end active rehab
• Discharge to community: 67.1%; institutional: 25%; self/family: 29.4%

Exam use: FIM quantifies rehabilitation trajectory; discharge planning threshold; documentation for transfer per Circular 26/2010 functional classification.

תומך החלטות / קבלת החלטות נתמכת (MoJ, 27.10.2019)

Conceptually DISTINCT from מקבל החלטות זמני — exam critical.

Types: מתנדב (volunteer) / מקצועי (professional — education + experience in role). Training required; interim provision (Oct 2019): professional תומך may be appointed without completed training if attending orientation + commits to future training. Corporations: pilot program for corporate תומך מקצועי under investigation.

Clinical application: If patient has a תומך החלטות → include them in informed consent discussions as support, not substitute. Do not bypass patient's own signature.

חוק החולה הנוטה למות 2005 — now in knowledge base ✓

Key definitions (exam-critical):

• חולה נוטה למות (s.8a): Incurable illness, life expectancy ≤6 months with treatment
• שלב סופי (s.8b): Multi-organ failure, life expectancy ≤2 weeks with treatment
• הנחיות מקדימות: Advance directives — valid 5 years, renewable; override family/physician
• Nutrition/fluids in חולה נוטה למות: mandatory unless medical CI or שלב סופי + patient previously refused + fluids causing harm
• Withholding vs withdrawing: both addressed; intermittent therapies (dialysis, ventilation cycles) structured so non-renewal ≠ active withdrawal

Search: "חולה נוטה למות" or "שלב סופי" or "הנחיות מקדימות" for full provisions.

Remaining Gaps