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Bradford VTS The GP Training website for everyone, not just Bradford Created by Dr Ramesh Mehay (est. 2002)
Updated Guidelines 2026:
  • NICE NG28 Type 2 diabetes (medicines update, February 2026): modified-release metformin plus an SGLT2 inhibitor is now first-line for most adults — but frailty has its own treatment track. In frail older people, only add the SGLT2 inhibitor if their frailty does not put them at risk of hypotension or volume depletion; prescribe the fewest medicines at the lowest effective doses. Sick day rules must be written into every treatment plan.
  • NICE Osteoporosis: risk assessment (July 2026, replaces CG146): assess fracture risk in everyone 50+ (and post-menopausal women) with a previous fragility fracture or significant steroid use; consider assessment in all women 65+, all men 75+, and in people aged 50–74 with risk factors such as 2 or more falls in the past year. Treatment recommendations are due in a second part (expected 2027).

Elderly Medicine for GPs: Your Essential Guide

Nine giants, fourteen tablets and one very patient patient — the real diagnosis is often hiding in the slippers

☕ Tea-Friendly Learning⏰ For GP Trainees Short on Time🚩 Red Flag Focused

Last Updated: 20 September 2026

Executive Summary: What You'll Master Today

Because you have 47 other things to do before lunch, and that's just the morning list

Quick Facts at a Glance:

1 in 3
people aged 65+ fall every year
NICE, 2024
210,000
falls admissions (65+), England
NICE, 2022/23 data
Up to 1 in 3
die within a year of hip fracture
18–33% — NICE, 2024
1 in 3
people with dementia (65+) still undiagnosed
66.1% diagnosed — NHS England, Jan 2026

📥 Downloads & Resources

Useful downloads and web links for elderly medicine

📥 Downloads

path: ELDERLY MEDICINE

This shortcode is replaced automatically by WordPress. Memory assessment tests (6CIT, GPCOG etc.) live here.

🌐 Web Resources

📚 Quick Navigation

🧠 Brainy Bites 🏆 Geriatric Giants & Top Tips ⚖️ Frailty & Assessment 🔍 Atypical Presentations 🔀 Differential Diagnosis 🧩 Dementia at a Glance 🩺 Common Conditions 🚩 Red Flags & Safeguarding 💊 Prescribing & Deprescribing 🏠 Care Home & Home Visits 🤝 Team, Ethics & Prevention 💪 You've Got This

🧠 Brainy Bites: Essential Elderly Medicine Wisdom

The stuff seasoned GPs wish someone had told them sooner

💡
New symptom? Suspect a tablet first — In an older person, every new symptom is a side effect until proven otherwise. Ask one question before anything else: "What was started, stopped or changed in the last few weeks — including anything from the chemist?"
🎯
"Bad behaviour" is a symptom, not a diagnosis — Think PICD before blaming dementia: Pain, Infection, Constipation, Depression (and drugs). The resident who shouts when moved is often in pain — watch for grimacing.
⚠️
The surprise question changes everything — "Would I be surprised if this person died in the next 12 months?" If the honest answer is no, it is time for advance care planning, the palliative care register and a STOPPFrail review — not another statin titration.
💊
Start low, go slow — but do go — Under-treatment is also harm. Age alone is not a reason to withhold an anticoagulant in AF or a bisphosphonate after a hip fracture. Weigh benefit, harm and what the patient wants.
🩺
Lie them down, then stand them up — Lying and standing BP is the most skipped examination in general practice. Measure it in anyone who falls, feels dizzy or is 80+ on antihypertensives. If there is a real postural drop, NICE NG136 says treat to the standing reading.
🔑
30 seconds: shoes off, mouth open — Feet and mouth reveal neglect, nutrition and infection faster than any blood test. An immaculate cardigan can hide overgrown toenails and ill-fitting dentures.
📋
A deprescribing script that works — "This tablet was the right choice ten years ago. Your body has changed since then, and now it may be doing more harm than good. Shall we try reducing it and see how you feel?" Framing stopping as good care (not giving up) makes patients far more willing.
🏥
The carer is your best investigation — A collateral history from a daughter, neighbour or care worker picks up the frontal-lobe change, the night-time wandering and the untaken tablets that the memory score misses. Try to see the carer alone for a few minutes.

1️⃣ Geriatric Giants & Top Tips

MANIC MOLD, sarcopenia, why frailty matters, and why you should always look at the feet

🏆 The 9 Geriatric Giants — MANIC MOLD

The common, treatable problems that older people rarely volunteer — so you have to ask

Where it came from: In 1965 Bernard Isaacs coined the term "geriatric giants". The original five were falls, poor nutrition, incontinence, confusion and polypharmacy. Two were widened: Falls → Mobility (because it is more than falls) and Polypharmacy → Medication problems (because many tablets are simply not taken). Today there are nine.

🧠 Mnemonic: MANIC MOLD — the 9 Geriatric Giants

M
Mobility — balance problems, sarcopenia (age-related muscle loss) and falls.
A
Abuse (elder) — including self-neglect.
N
Nutrition (poor) — mouth problems, failure to thrive, the "anorexia of ageing".
I
Incontinence — urinary and faecal; embarrassing, so rarely mentioned.
C
Confusion / Cognition — dementia or delirium?
M
Medication problems — polypharmacy, side effects, tablets not taken.
O
Osteoporosis — fracture risk, falls prevention.
L
Loneliness — common, harmful and very easy to miss.
D
Depression — often disguised as tiredness, pain or "just getting old".

Tap each card below for what to actually do about each giant.

M
Mobility
tap to flip
If deteriorating: physio for sarcopenia and strength/balance; stop unnecessary benzodiazepines or antipsychotics (discuss with psychiatry if needed); trial opioid reduction if pain is controlled; ask the pharmacy team to optimise medicines; check footwear.
A
Abuse & self-neglect
tap to flip
Ask alone: "How are you doing here? How are they treating you?" Look for unusual bruising. Look at the feet — they often tell you whether someone is being cared for.
N
Nutrition
tap to flip
Look in the mouth: dentures, ulcers (beware oral cancer), thrush. Ask about intake. Ask for the weight — use the MUST score (Malnutrition Universal Screening Tool) if it is falling.
I
Incontinence
tap to flip
Ask directly: all or some of the time? New confusion with it? Drinking enough? Strong smell? In people over 65, don't use a urine dipstick to diagnose UTI (UKHSA guidance) — send an MSU if you suspect infection. Check for constipation and retention.
C
Confusion / Cognition
tap to flip
Dementia or delirium? "Bad behaviour" may be infection (history, examination, bloods), pain (grimacing, calling out on moving), constipation or depression. Use 4AT for delirium; a memory tool (6CIT, GPCOG) for dementia.
M
Medication problems
tap to flip
Review and remove anything not needed. Ask if any tablets are refused or not taken — that is a clue, not a nuisance. Reduce polypharmacy and avoid creating new polypharmacy.
O
Osteoporosis
tap to flip
Fracture risk: FRAX or QFracture; DXA if it will change management (NICE 2026 risk assessment guideline). Falls prevention in place? See Common Conditions → Musculoskeletal.
L
Loneliness
tap to flip
Ask plainly: "Often, as people get older, they feel more lonely. Are you experiencing that too?" Agree a plan with the care home or family: befriending, group activities (the Thursday singing session counts), social prescribing.
D
Depression
tap to flip
Ask kindly: "You seem a bit down to me. Do you find you are low in your spirits a lot?" Consider talking therapy, behavioural activation (planning small enjoyable activities) and, where appropriate, an antidepressant.
✅ Why it matters: Once you find and treat these, you can transform an older person's life — moving more easily, falling less, feeling better in mood. Our job is to help older people live a better life, not just a longer one.

⚖️ Why Frailty Matters

Frailty is a long-term condition — so manage it like one

The problem: We tend to treat frailty as an inevitable part of old age. Yet it usually develops over 5–10 years. At the moment many people with frailty only reach us when things go badly wrong and they are admitted.
✅ The opportunity: If we find frailty early and plan care, we reduce the chance of serious illness, help people recover faster when they do get ill, and slow their decline. Frailty can be slowed — and sometimes partly reversed.
⚠️ Ask yourself (and your patient): In the last 10 years of life, would you prefer Option 1 — declining a little more each year until you die — or Option 2 — staying reasonably well until the final year? Proactive frailty care makes Option 2 more likely.

🧠 Mnemonic: WELSW — the 5 Fried frailty criteria

W
Weight loss — unintentional.
E
Exhaustion — self-reported low energy.
L
Low physical activity
S
Slowness — slow walking speed.
W
Weakness — poor grip strength.

Fried phenotype: 0 criteria = robust; 1–2 = pre-frail; 3 or more = frail. This is the research definition — in day-to-day practice use the Clinical Frailty Scale (see section 2).

💪 Sarcopenia — The Muscle Loss That Sneaks Up On Everyone

Age-related, involuntary loss of skeletal muscle mass and strength

The numbers: Evidence suggests muscle mass and strength fall by around 1% a year from age 40 in a roughly linear way. By 80, that adds up to a very large loss compared with age 40. Think of muscle as a savings account: from 40 onwards a little comes out every year unless you keep paying in.
⚠️ We make it worse: Families and professionals often take over tasks the older person could still do. They may not manage the big weekly shop — but why not take them along, or do a small shop each day? Moving someone with good mobility into a bungalow removes every stair climb that was keeping their legs strong.
✅ The key message: Exercise — particularly strength (resistance) training — is the main intervention shown to help sarcopenia. Yes, there is a risk of falls when people stay active, but falls are more likely when muscles are weak. "Use it or lose it."

👟 Always Look at the Feet!

A 30-second window into what is really going on

What the feet can tell you
  • •Self-neglect or care neglect: someone can look immaculate, but dirty feet and long toenails reveal the real story.
  • •Skin, temperature, colour, ulcers: diabetes and circulation problems.
  • •Deformity: arthritis or poor footwear.
  • •Corns, calluses, bad shoes: all increase falls risk.
  • •Ankle swelling: heart failure, venous disease, low albumin, calcium-channel blockers.
What to do
  • •Make it routine on every home and care home visit.
  • •Podiatry for nail problems, diabetes and mobility-limiting foot problems.
  • •Address footwear — loose slippers are a classic falls risk.
  • •Signs of neglect → explore further and consider a safeguarding referral.
  • •New ulcer in someone with diabetes → urgent diabetic foot pathway.
🎓 SCA tip: In any frail-patient or care-home consultation, saying you would examine the feet (and look in the mouth) shows the examiner a genuinely holistic approach.

2️⃣ Frailty & Comprehensive Assessment

Consultation framework, frailty tools that actually work in primary care, and communication tips

🗂️ The Consultation Framework

Allow extra time. Think function, cognition and social context — not just the disease.

  • Rapport: face the patient, speak clearly (not louder), check the hearing aid is in and switched on.
  • Collateral history: essential if there is any cognitive impairment — family, carers, care home staff.
  • The 9 Giants: run through MANIC MOLD — people rarely volunteer them.
  • Full drug history: including over-the-counter, herbal, eye drops, inhalers and "the ones I don't take".
  • What matters to you? NICE NG56 (multimorbidity) puts the person's own priorities at the centre.
  • Vital signs: pulse, BP (lying and standing), temperature, oxygen saturations, respiratory rate.
  • Gait and balance: watch them get up from the chair and walk — the "get up and go".
  • Mouth and feet: dentures, ulcers, thrush; nails, ulcers, footwear.
  • Skin: pressure areas, unexplained bruising.
  • Weight: a single weight is useful; a trend is gold.
  • ADLs (activities of daily living): washing, dressing, toileting, eating, transferring.
  • IADLs (instrumental ADLs): shopping, cooking, finances, medicines, transport — these slip first.
  • Living situation: stairs, who else lives there, carers, care package.
  • Carer strain: is the carer coping? Offer a carer's assessment.
✅ Hearing:
  • Face them, reduce noise
  • Speak clearly, not louder
  • Check hearing aids work
  • Write key points down
Vision:
  • Good lighting
  • Large-print materials
  • Clean glasses on
  • Describe visual info aloud
Cognition:
  • Short sentences
  • One instruction at a time
  • Allow processing time
  • Involve carers; written summary

🔎 Frailty Tools in Primary Care

Use an electronic index to find people; use clinical assessment to confirm

eFI2 — electronic Frailty Index 2: A new version developed in 2025 (using Bradford and Welsh data). GP record systems in England are replacing the original eFI with eFI2, and NHS England recommends it for proactive care. It weights conditions by their contribution to risk and predicts outcomes such as serious falls, new home care and care home admission better than the original eFI.Source: BJGP 2025; Age & Ageing 2025
⚠️ Remember: An electronic score identifies people who may be frail — it is a population search tool, not a diagnosis. Follow a high score with a brief clinical assessment such as the Clinical Frailty Scale.

Clinical Frailty Scale (CFS) — version 2.0

ScoreCFS 2.0 labelWhat it looks like
1Very fitRobust, active, energetic; among the fittest for their age
2FitNo active disease symptoms but less fit than level 1
3Managing wellMedical problems well controlled; not regularly active beyond walking
4Living with very mild frailty (previously "vulnerable")Not dependent, but symptoms limit activities; "slowed up"
5Living with mild frailtyNeeds help with higher-level IADLs: finances, transport, heavy housework
6Living with moderate frailtyNeeds help with all outside activities and housekeeping; help with bathing
7Living with severe frailtyCompletely dependent for personal care, but stable
8Living with very severe frailtyCompletely dependent, approaching end of life
9Terminally illLife expectancy under 6 months, not otherwise severely frail

Source: Rockwood & Theou, CFS version 2.0 (Dalhousie University, 2020). Score the person's baseline over the last 2 weeks — not how they look on the day they are acutely ill.

Fried Frailty Phenotype (WELSW) — the research definition

LetterCriterionHow it is assessed in studies
WWeight lossUnintentional weight loss over the past year
EExhaustionSelf-reported low energy most of the time
LLow physical activityLow weekly activity / energy expenditure
SSlownessSlow timed walk (adjusted for height and sex)
WWeaknessLow grip strength on a dynamometer (adjusted for sex and BMI)
✅ Then what? For people with moderate or severe frailty, the useful actions are a structured medication review, a falls conversation, an advance care planning discussion and — where complex — a Comprehensive Geriatric Assessment (CGA: a multidisciplinary review of medical, functional, psychological and social needs).

3️⃣ Atypical Presentations & Investigations

Older bodies whisper instead of shouting — confusion, falls and "off legs" may be the only clue

🕵️ Atypical Presentations

Keep a high index of suspicion — "just not herself" is a legitimate presenting complaint

ConditionTextbook presentationHow it may present in an older person
Myocardial infarctionCentral chest pain, sweatingConfusion, falls, breathlessness, collapse, epigastric pain
PneumoniaFever, productive cough, pleuritic painConfusion, falls, off food, raised respiratory rate
SepsisFever, rigors, tachycardiaLow temperature, new confusion, sudden loss of function
UTIDysuria, frequencyNew incontinence, new or worse delirium, functional decline
HyperthyroidismWeight loss, tremor, anxietyApathy ("apathetic thyrotoxicosis"), new AF, heart failure
DepressionLow moodPhysical complaints, poor memory ("pseudodementia"), withdrawal
⚠️ Care-home dipstick trap: A "positive dip" in someone who is "a bit off" is not a diagnosis. Up to half of older adults in care have bacteria in their urine without infection (asymptomatic bacteriuria). UKHSA advises not using dipsticks to diagnose UTI in over-65s — look for new urinary symptoms, think of other causes (PINCH ME), and send urine for culture if UTI is genuinely suspected.Source: UKHSA diagnostic decision tool for suspected UTI in adults over 65

🧪 Investigating the Big Three

Acute confusion, falls and cognitive impairment

Bedside:
  • Full observations incl. temperature, respiratory rate, sats — calculate NEWS2
  • Capillary glucose
  • 4AT delirium screen
  • Look for urinary retention and constipation
  • ECG if cardiac cause possible
Bloods:
  • FBC, CRP
  • U&Es (AKI, sodium)
  • LFTs, calcium, glucose
  • TFTs
  • B12/folate if a subacute or chronic picture
⚠️ Imaging: Chest X-ray if chest signs or heart failure suspected. CT head needs same-day hospital assessment — e.g. head injury (especially on an anticoagulant), new focal neurology, or unexplained decline.
💊 Prescribing Pearl: Review every drug started or changed recently. Anticholinergics, opioids, benzodiazepines, Z-drugs, and steroids are frequent culprits — as is sudden withdrawal of alcohol or benzodiazepines.
Who needs a comprehensive falls assessment? NICE NG249 (2025) says offer a comprehensive falls assessment and management to people who have fallen in the past year and who:
  • are living with frailty, or
  • were injured and needed medical treatment, or
  • had a loss of consciousness related to the fall, or
  • could not get up independently, or
  • have had 2 or more falls in the last year.
Everyone else who has fallen: assess gait and balance.Source: NICE NG249, recommendation 1.1.3–1.1.5
✅ Comprehensive assessment includes:
  • Falls history and fear of falling
  • Gait, balance, mobility
  • Lying and standing BP; ECG
  • Medication review
  • Neurological examination
  • Osteoporosis risk assessment
  • Continence, vision, cognition, feet
  • Long-term conditions (arthritis, dementia, diabetes, Parkinson's)
⚠️ Tests to consider:
  • FBC (anaemia), U&Es, glucose
  • ECG — arrhythmia, heart block
  • Ambulatory ECG if syncope suspected
  • Vitamin D if fracture risk / housebound
💊 Prescribing Pearl: Medicines are one of the few falls risk factors you can change today. Taking a psychotropic drug roughly doubles the risk of falling, and there is good evidence that stopping psychotropics (including opioids) reduces falls. See Prescribing → Medicines & Falls.
✅ Interventions: Falls-prevention exercise (strength and balance) is the cornerstone. NICE NG249 also says consider a home hazard assessment — this can be done by an OT or appropriately trained staff.
ToolTimeNotes
6CIT3–4 minPrimary-care validated, open access. 0–7 normal; 8–9 mild; 10+ significant impairment
GPCOG~5 minDesigned for GPs; includes an informant section
MoCA~10 minMore sensitive for mild cognitive impairment
ACE-III15–20 minDetailed; mainly used in memory clinics
Dementia blood screen (NICE NG97):
  • FBC, ESR or CRP
  • U&Es, calcium, LFTs
  • HbA1c
  • TFTs
  • B12 and folate
  • Syphilis or HIV test only if history suggests risk
✅ Also:
  • Urine culture only if infection suspected
  • ECG / X-ray as clinically indicated (ECG is useful before AChE inhibitors)
  • Imaging is arranged by the memory service to exclude structural causes and help with subtype

4️⃣ Differential Diagnosis Frameworks

Four common presentations and how to think them through

🔀 Common Presentations

Open each panel for a structured differential

🧠 Mnemonic: PINCH ME — causes of delirium

P
Pain — including urinary retention and fractures.
I
Infection — chest, urine, skin, abdominal; sepsis.
N
Nutrition — poor intake, low glucose, deficiencies.
C
Constipation — and faecal impaction.
H
Hydration — dehydration, sodium problems.
M
Medication — anticholinergics, opioids, benzodiazepines; alcohol or drug withdrawal.
E
Environment — new surroundings, sensory loss (glasses and hearing aids!).
🛑 Don't forget the serious ones:
  • Cardiovascular: MI, stroke, heart failure
  • Metabolic: hypoglycaemia, hypo/hypernatraemia, hypercalcaemia
  • Neurological: subdural haematoma, seizures
  • Respiratory: hypoxia, hypercapnia
  • Endocrine: thyroid disease, Addison's
Intrinsic (inside the person)
  • •Muscle weakness (sarcopenia), balance problems
  • •Postural hypotension, arrhythmia, syncope
  • •Stroke, Parkinson's, neuropathy
  • •Arthritis, foot problems
  • •Visual impairment (cataract, glaucoma)
  • •Dementia, delirium; urgency/incontinence (rushing)
  • •Medicines — psychotropics, antihypertensives
Extrinsic (the environment)
  • •Poor lighting
  • •Loose rugs, clutter, trailing wires
  • •Slippery floors, no grab rails
  • •Stairs without handrails
  • •Loose slippers, poor footwear
  • •Pets under foot
CategoryCauses to consider
MalignancyGI, lung, haematological, metastatic disease
GastrointestinalMalabsorption, coeliac disease, IBD, pancreatic insufficiency, dental/swallowing problems
EndocrineHyperthyroidism, uncontrolled diabetes, Addison's
CardiorespiratoryHeart failure (cardiac cachexia), COPD, TB
Psychiatric / cognitiveDepression, dementia, bereavement
SocialPoverty, isolation, unable to shop or cook
MedicinesAChE inhibitors, metformin, SGLT2 inhibitors, GLP-1 agonists, SSRIs, digoxin
⚠️ Suspected cancer: Use NICE NG12 for site-specific referral criteria — unexplained weight loss is a feature of many pathways.
TypeFeaturesCommon causes
StressLeaks on coughing, sneezing, exertionPelvic floor weakness, post-prostatectomy
UrgeSudden urgency, frequency, nocturiaOveractive bladder, UTI, bladder irritants
OverflowDribbling, incomplete emptyingBPH, constipation, anticholinergics, neuropathy
FunctionalNormal bladder, can't get to the toilet in timeImmobility, dementia, delirium
🛑 Causes of retention:
  • Obstructive: BPH, prostate cancer, stricture, constipation
  • Neurogenic: spinal cord lesions (think cauda equina), diabetic neuropathy
  • Medicines: anticholinergics, opioids, tricyclics
  • Infection: UTI, prostatitis
Painful retention is an emergency — catheterise or refer the same day.

5️⃣ Dementia at a Glance

Spotting it, working it up, referring it, and supporting the whole family — NICE NG97

🧩 Dementia — The Essentials

Basically: increasing difficulty with tasks and activities that need concentration and planning

Common features
  • •Memory loss — especially recent events
  • •Periods of confusion; low attention span (e.g. repeatedly asking the time)
  • •Wandering, especially at night
  • •Changes in personality
  • •Changes in mood — often depressive features
Additional features (may hint at subtype)
  • •Slow, unsteady gait
  • •Stroke-like symptoms — weakness on one side (vascular)
  • •Visual hallucinations (Lewy body)
  • •Urinary incontinence
  • •Disinhibition, personality change (frontotemporal)
SubtypeClues
Alzheimer's diseaseGradual onset; early short-term memory loss; word-finding problems
Vascular dementiaStepwise decline; focal neurology; vascular risk factors
Dementia with Lewy bodiesFluctuating cognition, visual hallucinations, parkinsonism; very sensitive to antipsychotics
Frontotemporal dementiaOften younger onset; personality change, disinhibition, language problems; memory relatively spared early
Age and higher-risk groups:
  • 60+ with cardiovascular disease, stroke, peripheral vascular disease or diabetes
  • 50+ with a learning disability
  • 40+ with Down's syndrome
Existing conditions:
  • Chronic disease — depression, hypothyroidism, HIV
  • Neurodegenerative conditions — Parkinson's, MND, MS
  • Learning disability (especially Down's syndrome)
⚠️ Other factors: social isolation, long-term heavy alcohol use, malnutrition, smoking.
  • Good history with specific examples of behaviour — from the patient and family or carers. Specifically ask about aggression, agitation and wandering.
  • Consider a home visit to see how they are really managing.
  • Medicines review: is anything impairing cognition? (anticholinergics, sedatives, opioids)
  • Mental state: is this delirium, depression or psychosis? Exclude acute reversible causes first.
  • Physical examination including neurological examination — look for infection, constipation, thyroid disease, diabetes and other reversible problems.
  • Cognitive test: 6CIT or GPCOG in primary care.
⚠️ The big blind spot of memory tests: AMTS, MMSE and 6CIT do not test the frontal lobe. They can miss frontotemporal dementia (often in younger people) and frontal damage such as Wernicke–Korsakoff syndrome.
🛑 Spotting frontal lobe disorders — "coarsening of personality": usually reported by relatives, or noticed by a GP who knows the patient well.
  • Loss of social (sometimes sexual) inhibitions
  • Irritability, facile jokiness, abusiveness
  • Leading to: family disruption (violence, separation), more accidents at home, work and on the road, absence from work, job loss, offending
  • Sometimes impotence or "morbid jealousy" (irrational belief that a partner is unfaithful)
  • A "dysexecutive syndrome" picture — poor planning, organising and judgement
  • In alcohol-related disorders this is not just acute intoxication
Bloods (NICE NG97):
  • FBC, ESR or CRP
  • U&Es, calcium, LFTs
  • HbA1c
  • TSH / thyroid function
  • B12 and folate
  • Syphilis serology or HIV test only if history suggests risk
✅ Other:
  • Cognitive test (6CIT or GPCOG)
  • Urine culture if infection suspected
  • ECG / chest X-ray depending on presentation
  • Stop or reduce medicines that impair cognition.
  • Refer to the memory assessment service. NICE emphasises timely diagnosis so people can access support, plan ahead and be considered for medication.
  • Review the social situation — mobility, carer and family support and concerns, including the potential for abuse or neglect.
  • Once the diagnosis is confirmed: offer advance care planning information. Code it in the record — if the person does not wish to engage, record that the advance care plan was declined.
  • Keep doing primary and secondary prevention (BP, lipids, diabetes) as appropriate to the person's goals and life expectancy.
  • Annual dementia review — see the aide memoire below.
✅ What the memory service does: confirms the diagnosis and subtype; decides suitability for medication; helps manage behavioural and psychological symptoms; assesses safety risk; and supports the patient and carer.

🔀 Suspected cognitive impairment — what next?

START: Memory or behaviour concern raised
↓
❓ Acute onset, fluctuating, drowsy or 4AT ≥4?
YES ↓NO ↓
Treat as delirium: find the cause (PINCH ME), same-day assessment if unwell. Reassess cognition once recovered.
History + collateral, exam, 6CIT/GPCOG, NG97 bloods, med review → exclude depression → refer to memory service
When to re-refer someone already diagnosed:
  1. Difference of opinion between the practice and the carer about stopping medication
  2. Considering a switch to memantine in severe dementia
  3. Uncertainty about side effects or benefits
  4. Behavioural problems needing the community mental health team — whether or not the person is on anti-dementia medication

💊 Dementia Medicines — What NICE Says (NG97)

Usually started on specialist advice — but GPs continue, monitor and sometimes add memantine

SituationNICE NG97 recommendation
Mild to moderate Alzheimer'sAChE inhibitor monotherapy: donepezil, galantamine or rivastigmine — start with the lowest acquisition cost option
Moderate Alzheimer's, AChE-I not tolerated / contraindicatedMemantine monotherapy
Severe Alzheimer'sMemantine monotherapy is an option
Already on an AChE inhibitorConsider adding memantine in moderate disease; offer it in severe disease. Primary care prescribers may start memantine here without specialist advice
Disease becoming severeDo not stop AChE inhibitors because of disease severity alone
Dementia with Lewy bodiesOffer donepezil or rivastigmine (mild–moderate); galantamine only if those are not tolerated; memantine if AChE-Is not tolerated or contraindicated
Vascular dementiaOnly consider AChE-I/memantine if suspected mixed Alzheimer's, Parkinson's dementia or Lewy body disease
Frontotemporal dementiaDo not offer AChE inhibitors or memantine
💊 Prescribing Pearl — doses (NICE TA217, from product licences):
  • First-line — donepezil: 5 mg once daily at bedtime; assess after 1 month and increase to a maximum of 10 mg once daily if needed.
  • Second-line / add-on — memantine: 5 mg once daily, increased in 5 mg steps at weekly intervals to a maximum of 20 mg daily.
  • Galantamine and rivastigmine (oral or patch): doses vary by formulation — not verified for this page; check the BNF and the specialist's plan.
Treatment continues while there is benefit and it is tolerated — no fixed duration.
🛑 Antipsychotics in dementia: Only for people at risk of harming themselves or others, or with agitation, hallucinations or delusions causing severe distress. Discuss the increased risk of stroke and death first, use the lowest effective dose for the shortest time, and review regularly. In Lewy body dementia or Parkinson's, antipsychotics can cause severe, even life-threatening reactions — seek specialist advice.
⚠️ Updated since the old page: Earlier local guidance suggested considering stopping AChE inhibitors once Alzheimer's becomes severe. NICE NG97 now says not to stop them because of severity alone — stop if there is no benefit or they are not tolerated. Continuing an AChE inhibitor in severe disease is outside some product licences, so document your reasoning.

🤝 Social Interventions, Legal Planning & Driving

Often more life-changing than any tablet

  • Carer support and assessment: Alzheimer's Society, local carers' services (in Bradford, for example, Carers' Resource and Making Space).
  • Community care: home care, day care, respite care.
  • Money: benefits advice via Citizens Advice or DWP (e.g. Attendance Allowance, Carer's Allowance).
Lasting Power of Attorney (LPA): two separate types — property and financial affairs; health and welfare (which covers healthcare and treatment decisions).
✅ Advance decision to refuse treatment: legally binding refusal of specified future treatments if the legal requirements are met.
Also: advance statement of wishes (not legally binding but must be considered); making a will — the Alzheimer's Society can signpost to solicitors experienced in dementia.

You might say: "While things are still clear for you, it's a good time to put your wishes on paper — then your family never has to guess."

🚩 Red Flags — Do Not Miss

🚩

A diagnosis of dementia — the patient must tell the DVLA and their car insurer. The DVLA decides whether the licence continues, is restricted or needs regular review.

🚩

Unsafe driver who will not stop or will not tell the DVLA — GMC confidentiality guidance allows you to disclose to the DVLA after you have tried to persuade them and told them you intend to. Document every step.

🎓 SCA tip: DVLA advice is one of the most commonly forgotten points in dementia consultations.

6️⃣ Common Conditions in Older People

Multimorbidity, by system — with NICE targets adjusted for age and frailty

🧮 Multimorbidity — The Mindset (NICE NG56)

Two or more long-term conditions — the norm, not the exception, in older age

The approach:
  • Find out what matters most to the person
  • Consider treatment burden, not just disease targets
  • Weigh likely benefit against life expectancy and frailty
  • Regular structured medication review
  • Coordinate care — one plan, not five clinic letters
✅ Try saying: "If we could only work on one or two things together this year, what would make the biggest difference to your day-to-day life?"

🩺 Condition-by-Condition

Choose a system, then open a condition

Targets: Under 80: clinic BP below 140/90. 80 and over: clinic BP below 150/90. Use clinical judgement for people with frailty or multimorbidity.Source: NICE NG136
⚠️ Postural hypotension: Measure standing as well as seated BP in people 80 and over, people with type 2 diabetes, and anyone with postural symptoms. With a significant postural drop, treat to a target based on standing BP.
💊 Prescribing Pearl:
  • First-line (aged 55+ or of Black African/African-Caribbean family origin) — calcium-channel blocker: amlodipine 5 mg once daily, increased to a maximum of 10 mg once daily if needed. Increase with care in older people.
  • Second-line — add an ACE inhibitor (or ARB if not tolerated): ramipril 2.5 mg once daily, doubled at 2–4-week intervals to a maximum of 10 mg once daily. Check U&Es before and after starting and after each dose increase.
Long-term treatment; review at least annually.Sources: NICE NG136 (step choice); UK product SmPCs on medicines.org.uk (doses)
Stroke risk — CHA₂DS₂-VASc:
  • Congestive heart failure — 1
  • Hypertension — 1
  • Age 75+ — 2
  • Diabetes — 1
  • Stroke / TIA / thromboembolism — 2
  • Vascular disease — 1
  • Age 65–74 — 1
  • Sex category (female) — 1
✅ NICE says:
  • Offer a DOAC if CHA₂DS₂-VASc is 2 or more, taking bleeding risk into account
  • Consider a DOAC for men with a score of 1
  • Assess bleeding risk with the ORBIT score (NICE prefers it to HAS-BLED)
  • A high bleeding score is a prompt to fix modifiable risks (BP, alcohol, NSAIDs) — not an automatic reason to withhold
💊 Prescribing Pearl:
  • First-line — apixaban: 5 mg twice daily, long-term. Reduce to 2.5 mg twice daily if at least two of: age 80+, weight 60 kg or less, serum creatinine 133 micromol/L or more.
  • Alternatives: dabigatran, edoxaban or rivaroxaban (all NICE-recommended DOACs) — doses depend on renal function (use creatinine clearance); check the BNF.
  • If DOACs are contraindicated or unsuitable: warfarin (vitamin K antagonist).
Sources: NICE NG196; apixaban UK SmPC
⚠️ Common trap: Aspirin is not a stroke-prevention option in AF. Falls risk and older age on their own are not good reasons to leave someone unprotected.
Diagnosis: Symptoms plus NT-proBNP, then echocardiogram and specialist assessment. In practice: NT-proBNP over 2,000 ng/L → urgent (2-week) referral; 400–2,000 ng/L → referral within 6 weeks; below 400 → heart failure less likely.
✅ HFrEF — the "four pillars": NICE now promotes all four together as first-line:
  1. ACE inhibitor (or ARB if not tolerated; ARNI in specialist-defined situations)
  2. Beta-blocker licensed for heart failure
  3. Mineralocorticoid receptor antagonist (MRA)
  4. SGLT2 inhibitor (dapagliflozin or empagliflozin)
HFpEF: consider an MRA and an SGLT2 inhibitor.Source: NICE NG106 (2025 update) and NICE indicator IND317
💊 Prescribing Pearl: Loop diuretics (e.g. furosemide) relieve congestion but do not improve survival. Four-pillar drugs are usually started and titrated with the heart failure team — individual starting doses and titration steps are not listed here; follow the BNF and the heart failure service plan. In frail older people, titrate slowly and watch standing BP, potassium and renal function.
⚠️ Sick days: ACE inhibitors, ARBs, diuretics and SGLT2 inhibitors all feature in sick day rules (SADMAN) — see Care Homes → Sick Day Rules.
Dementia has its own section — see 5️⃣ Dementia at a Glance and the dementia medicines tab in 8️⃣ Prescribing.
Key motor features:
  • Bradykinesia (slowness) — essential for diagnosis
  • Rest tremor ("pill-rolling")
  • Rigidity (lead-pipe or cogwheel)
  • Postural instability — later
✅ GP role:
  • Refer suspected Parkinson's untreated to a specialist
  • Watch for falls, postural hypotension, constipation, depression, hallucinations, swallowing problems
  • Involve the Parkinson's nurse, physio, OT, speech and language therapy
🛑 Never stop Parkinson's medicines suddenly: Abrupt withdrawal (e.g. nil by mouth, vomiting, admission) risks a dangerous rigid, feverish state. Get medicines given on time, every time. Avoid dopamine-blocking antiemetics (metoclopramide, prochlorperazine) and most antipsychotics.
💊 Prescribing Pearl: Levodopa, dopamine agonists and MAO-B inhibitors are started by the specialist — doses are individual and not listed here. Know the classic side effects: dopamine agonists → impulse control disorders (gambling, shopping, hypersexuality) — ask about them at every review.

🚩 Red Flags — Do Not Miss

🚩

FAST — Face, Arms, Speech, Time — suspected acute stroke: call 999 immediately.

🚩

Suspected TIA (symptoms resolved) — give aspirin 300 mg immediately unless contraindicated, and refer for specialist assessment within 24 hours.

💊 Prescribing Pearl — secondary prevention:
  • Antiplatelet — first-line: clopidogrel 75 mg once daily, long-term.
  • If clopidogrel is unsuitable: aspirin plus modified-release dipyridamole — check BNF for doses.
  • Statin: atorvastatin 80 mg once daily (use a lower dose if drug interactions or high risk of adverse effects).
  • AF: anticoagulate instead of antiplatelet (DOAC as above).
Sources: NICE NG128, NICE TA210, NICE NG238
✅ BP after stroke: Aim for a clinic systolic below 130 mmHg — except in severe bilateral carotid stenosis, where 140–150 mmHg is appropriate. In frail older people use judgement and watch the standing BP.
⚠️ Carotid disease: Symptomatic carotid stenosis of 50–99% (NASCET criteria) after a non-disabling stroke or TIA → urgent assessment for carotid endarterectomy.
⚠️ Atypical features:
  • Physical complaints — pain, tiredness, bowel symptoms
  • Poor memory and concentration ("pseudodementia")
  • Anxiety, agitation, withdrawal, poor self-care
  • Weight loss and poor sleep blamed on "old age"
✅ Non-drug first: Talking therapy, behavioural activation, tackling loneliness and physical health problems. Always ask about suicidal thoughts — older men living alone are a higher-risk group.
💊 Prescribing Pearl:
  • First-line — SSRI, e.g. sertraline: 50 mg once daily; if needed, increase in 50 mg steps at intervals of at least 1 week to a maximum of 200 mg daily. Continue for at least 6 months after symptoms resolve.
  • Second-line — mirtazapine (can help poor sleep and appetite): dose not verified for this page — check the BNF.
  • Check sodium before and a few weeks after starting an SSRI in older people — hyponatraemia can cause confusion and falls.
  • Citalopram: MHRA warning on dose-dependent QT prolongation; lower maximum doses apply in older people — check the BNF.
  • Avoid tricyclics — anticholinergic effects, falls, and dangerous in overdose.
Source: sertraline UK SmPC (dose); MHRA Drug Safety Update (citalopram)
First: Exclude physical causes (thyroid, arrhythmia, hypoxia, hypoglycaemia) and medicines (steroids, salbutamol, caffeine, withdrawal).
✅ Treatment: Psychological therapy (e.g. CBT) first. If a drug is needed, an SSRI such as sertraline (dosing as above — note sertraline is not licensed for generalised anxiety disorder in the UK, although NICE recommends it).
🛑 Avoid benzodiazepines: falls, fractures, confusion, dependence. If someone is already on one long-term, plan a slow taper (see Prescribing → Deprescribing).
Who to assess (NICE, July 2026):
  • Assess everyone 50+ (and post-menopausal women) with a previous fragility fracture, or current/frequent systemic steroids (e.g. prednisolone 5 mg or more daily for over 3 months)
  • Consider assessing all women 65+ and all men 75+
  • Consider 50–74-year-olds with risk factors: 2+ falls in the last year, parental hip fracture, BMI below 18.5, smoking, alcohol over 14 units a week
✅ DXA: Offer DXA to people 30+ with a previous hip or vertebral fragility fracture, a major osteoporotic fracture in the last 2 years, or 2+ fragility fractures. Consider DXA if 10-year major osteoporotic fracture risk is 10% or more. Don't let a DXA delay stop antiresorptive treatment starting in someone likely to need it.Source: NICE Osteoporosis: risk assessment (2026). Treatment recommendations are due in part 2 (expected 2027).
💊 Prescribing Pearl:
  • First-line — alendronic acid 70 mg once weekly. Take on an empty stomach with a full glass of water, stay upright for 30 minutes before food or other medicines. Review need for treatment after about 5 years.
  • Second-line — risedronate (if alendronate not tolerated or cannot be taken correctly): weekly dose not verified for this page — check the BNF.
  • Make sure calcium and vitamin D intake is adequate (diet first; supplement if low) — check the BNF for combined products.
  • Denosumab is usually specialist-guided — never let it lapse without a plan, as stopping can cause rebound vertebral fractures.
Sources: NICE TA160/TA161 (alendronate as first choice; 70 mg weekly preparation)
Recognising it (EWGSOP2 approach):
  • Low muscle strength (grip strength or chair-rise test) — the main criterion
  • Confirmed by low muscle quantity/quality (specialist tests)
  • "Severe" if physical performance is also poor (slow walking)
✅ Management:
  • Resistance (strength) exercise — the core treatment
  • Physiotherapy referral
  • Adequate protein and energy intake — dietitian if weight falling
  • Treat vitamin D deficiency
  • Review steroids and other contributors
✅ Core treatment: Therapeutic exercise (tailored), weight loss if overweight, information and support. Walking aids if needed. Refer for joint replacement if symptoms substantially affect quality of life and non-surgical care hasn't worked — don't exclude people because of age or comorbidities.
💊 Prescribing Pearl:
  • First-line — topical NSAID (offer for knee OA; consider for other joints), e.g. ibuprofen 5% gel applied to the affected joint (check local formulary).
  • Second-line — oral NSAID at the lowest effective dose for the shortest time, with a PPI for gastroprotection, e.g. naproxen 250–500 mg twice daily (total 500 mg–1 g daily in 2 divided doses; start at the lowest dose in older people). Check renal function, BP and heart failure status first.
  • Intra-articular steroid injection: consider for short-term relief (2–10 weeks) when other treatments are ineffective or to support exercise.
Sources: NICE NG226; naproxen UK SmPC
🛑 NICE NG226 — do NOT routinely offer: paracetamol or weak opioids (unless used infrequently for short-term relief and everything else is unsuitable); never strong opioids, glucosamine or hyaluronan injections. This replaces the old "paracetamol first" ladder on the previous version of this page.
What changed in 2026: NICE now offers metformin modified-release (MR) plus an SGLT2 inhibitor first-line for most adults, with seven treatment tracks depending on comorbidity — one of which is frailty. Targets and treatment should be individualised and agreed with the person.Source: NICE NG28 (February 2026 update), summarised in Diabetes & Primary Care
⚠️ Frailty track:
  • Offer metformin MR; only add an SGLT2 inhibitor if frailty doesn't put the person at risk of hypotension or volume depletion
  • Prescribe the fewest medicines at the lowest effective doses
  • If more glucose lowering is needed: DPP-4 inhibitor first, then pioglitazone, a sulfonylurea or insulin — mindful of hypoglycaemia
  • Relax HbA1c targets; STOPPFrail notes that an HbA1c below 58 mmol/mol is associated with net harm in people near the end of life
✅ HbA1c targets (fitter adults): Usually 48 mmol/mol on lifestyle or a single drug not linked to hypos; 53 mmol/mol if on a drug that can cause hypos (e.g. sulfonylurea) or more than one drug. Relax these for frailty, hypo risk and limited life expectancy.
💊 Prescribing Pearl:
  • First-line — metformin MR: 500 mg once daily with the evening meal; increase by 500 mg every 10–15 days as tolerated to a maximum of 2 g once daily. (People already stable on standard-release can stay on it; standard-release suits people who need tablets crushed or liquid.)
  • Renal function: reduce metformin to 1 g a day if eGFR is below 45; do not start, and stop, if eGFR is below 30.
  • Second agent (with metformin) — SGLT2 inhibitor, e.g. empagliflozin: 10 mg once daily; can increase to 25 mg once daily only if eGFR is 60 or more and tighter control is needed. Before starting: check for previous DKA, dehydration risk, very low-carbohydrate diets; don't start during intercurrent illness.
  • DPP-4 inhibitors (e.g. sitagliptin) have a low hypo risk and suit frailty — dose depends on eGFR; check the BNF.
Sources: NICE NG28 (2026); metformin MR and empagliflozin UK SmPCs
🛑 Sulfonylureas and insulin — hypos are dangerous in older people: If starting a sulfonylurea, counsel and document: hypo symptoms and treatment; driving and hypos — tell the car insurer (and the DVLA if they hold an HGV/PSV licence — check current DVLA guidance); make sure they have a glucose meter, test strips, lancets and a sharps bin on repeat.
Practical admin: Everyone 60+ already gets free NHS prescriptions in England. For patients under 60 starting glucose-lowering medicine, complete the medical exemption certificate application. Always give written sick day rules.
✅ Non-drug (biggest wins):
  • Stop smoking — benefits at any age
  • Pulmonary rehabilitation
  • Vaccinations (flu, pneumococcal, COVID-19, RSV if eligible)
  • Nutrition support if underweight
  • Personalised self-management plan
Inhalers — the steps:
  • Short-acting bronchodilator for everyone
  • No asthmatic features, still breathless or exacerbating → LAMA + LABA
  • Asthmatic/steroid-responsive features → LABA + ICS
  • Check inhaler technique every time — arthritis, grip and cognition matter
💊 Prescribing Pearl: Inhaler doses depend on the specific device — choose by what the patient can actually use (a spacer, or a device needing less inspiratory effort) and follow the BNF/local formulary. Doses not listed here.
StageeGFRDescription
G190 or moreNormal — CKD only with other kidney damage markers
G260–89Mildly reduced
G3a45–59Mildly to moderately reduced
G3b30–44Moderately to severely reduced
G415–29Severely reduced
G5Below 15Kidney failure
Management:
  • BP below 140/90; below 130/80 if ACR 70 mg/mmol or more
  • ACE inhibitor/ARB if albuminuria (or diabetes with raised ACR)
  • SGLT2 inhibitor where NICE criteria are met
  • Statin for cardiovascular protection
⚠️ Prescribing:
  • Avoid NSAIDs
  • Adjust doses for eGFR (DOACs, metformin, gabapentinoids, antibiotics)
  • Nitrofurantoin: avoid if eGFR below 45
  • Remember a "normal" creatinine can hide a low eGFR in someone with little muscle

7️⃣ Red Flags, Delirium & Safeguarding

The conditions you must not miss — and the patients who cannot always speak up for themselves

🚩 Must-Not-Miss in Older People

Atypical presentations make these easy to miss

🚩 Red Flags — Do Not Miss

🚩

Suspected sepsis (new confusion, fast breathing, low BP, mottled skin, low temperature) — calculate NEWS2 and arrange emergency transfer if high risk. Older people often don't mount a fever.

🚩

"Silent" MI — collapse, sudden breathlessness, new confusion or epigastric pain may be the only signs: 12-lead ECG, 999 if acute coronary syndrome suspected.

🚩

Head injury on an anticoagulant — needs same-day hospital assessment for CT, even if they "seem fine".

🚩

Long lie (on the floor for hours) — rhabdomyolysis, pressure damage, hypothermia, AKI: same-day assessment.

🚩

Collapse on an AChE inhibitor (donepezil etc.) — check pulse and ECG for bradycardia or heart block.

🚩

Unexplained weight loss, new iron-deficiency anaemia, change in bowel habit, haematuria, dysphagia, haemoptysis — follow NICE NG12 suspected cancer pathways. Older age is the biggest risk factor for cancer.

🚩

Acute painful urinary retention — same-day catheterisation.

🌀 Delirium — Spot It, Screen It, Sort It

An acute, fluctuating disturbance of attention and awareness — a medical emergency in disguise

ItemHow to score
1. AlertnessNormal, or mild sleepiness under 10 seconds after waking = 0 · Clearly abnormal = 4
2. AMT4 (age, date of birth, place, current year)No mistakes = 0 · 1 mistake = 1 · 2 or more mistakes / untestable = 2
3. Attention — months of the year backwards from December7 or more correct = 0 · Starts but fewer than 7, or refuses = 1 · Untestable = 2
4. Acute change or fluctuating courseChange in alertness, cognition or other mental function in the last 2 weeks, still present in the last 24 hours: No = 0 · Yes = 4
🛑 4 or more: possible delirium (± cognitive impairment)
⚠️ 1–3: possible cognitive impairment
✅ 0: delirium or severe cognitive impairment unlikely (unless item 4 information is incomplete)

Source: the4AT.com user guide. The 4AT supports — it does not replace — clinical judgement.

  • Find and treat the cause — PINCH ME, plus sepsis, hypoxia, glucose, sodium, retention, drugs.
  • Decide the setting: many people can be managed at home or in the care home with a clear plan; admit if the cause needs hospital treatment or they are unsafe.
  • Non-drug care: familiar people and objects, clocks and calendars, glasses and hearing aids on, good lighting, hydration, nutrition, sleep, mobilising, avoid moving rooms.
  • Tell the family it is common and usually temporary: "Your mum's brain is reacting to being unwell. As we treat the cause, we expect the confusion to settle — though it can take days to weeks."
  • Follow up: delirium can unmask dementia — reassess cognition once recovered.
💊 Prescribing Pearl:
  • First, stop or reduce culprit drugs (anticholinergics, opioids, sedatives).
  • If distressed or a risk to themselves or others and de-escalation has failed, NICE CG103 says consider short-term haloperidol (usually 1 week or less), starting at the lowest clinically appropriate dose and titrating cautiously. NICE does not state a specific starting dose — seek senior or specialist advice and check the BNF.
Source: NICE CG103, recommendation 1.6.4
🛑 Avoid antipsychotics (or use only with specialist advice) in Parkinson's disease and dementia with Lewy bodies — risk of severe reactions. Avoid benzodiazepines unless treating alcohol or benzodiazepine withdrawal.

🛡️ Elder Abuse & Safeguarding

Older adults at risk are protected by the Care Act 2014 (England)

TypeWhat you might see
PhysicalBruising in odd places, fractures, burns, restraint marks
PsychologicalFearful, withdrawn, threatened, isolated
FinancialUnexplained money problems, missing possessions, sudden changes to wills
SexualUnexplained genital injury or infection
Neglect / self-neglectPoor hygiene, dirty feet and long nails, weight loss, pressure sores, missed medicines
⚠️ Warning signs:
  • Injuries that don't match the story; delays in seeking help
  • Patient seems fearful around a carer
  • Carer won't let you see the patient alone
  • Unexplained deterioration
Action:
  • See the person alone if safe: "Is anyone hurting you or making you feel frightened?"
  • Document clearly and objectively (body maps help)
  • Assess capacity for the decisions involved
  • Raise a safeguarding concern with the local authority; discuss with your practice safeguarding lead
  • Police or 999 if there is immediate danger or a crime

8️⃣ Prescribing & Deprescribing for Older People

Why older bodies handle drugs differently, how to review, what to stop — and monitoring dementia medicines

💊 The Prescribing Toolkit

Five tabs — work through them like a medication review

How to decide whether to prescribe:
  • Remember the NNT (number needed to treat) behind the evidence — trial results are often extrapolated to older age groups with no direct evidence of benefit.
  • NNTs tell us most medicines don't produce the target benefit in most people — but everyone can get the side effects.
  • Focus on person-centred outcomes. The benefit–risk balance changes as we age.
⚠️ The body changes (pharmacokinetics):
  • Kidneys: GFR tends to fall with age, so renally cleared drugs accumulate (DOACs, metformin, digoxin, lithium, gabapentinoids). A "normal" creatinine can hide a low eGFR in someone with little muscle.
  • Body composition: more fat, less water — fat-soluble drugs (e.g. diazepam) last longer; water-soluble ones reach higher levels.
  • Liver: slower metabolism for some drugs.
✅ The response changes (pharmacodynamics):
  • The brain is more sensitive to sedatives, opioids and anticholinergics → confusion and falls.
  • Blunted blood-pressure reflexes → postural hypotension with antihypertensives and diuretics.
  • Higher bleeding risk with anticoagulants plus NSAIDs or antiplatelets.
1
What is it for?
tap to flip
Is there a clear, current indication? "Started in hospital in 2014" is not an indication.
2
Is it working?
tap to flip
Is the patient getting the benefit we hoped for — measured in ways that matter to them?
3
Is it harming?
tap to flip
Falls, confusion, constipation, dizziness, interactions, pill burden, cost to the patient's day.
4
Can we stop or reduce?
tap to flip
Would the patient like to try? "Is this treatment essential? If not — stop it."
🛑 High-risk drug groups in older people: anticholinergics; benzodiazepines and Z-drugs; NSAIDs; opioids; antipsychotics; digoxin; anticoagulants (dose by renal function); sulfonylureas and insulin (hypos).
Don't leave patients on repeats forever: Have a practice system for reviewing repeats. A drug may be necessary — but it can also become a risk as renal function declines and pharmacokinetics change. Be clear about the indication and intended outcome of each medicine, especially now that more colleagues across the team prescribe.
Aide memoire

🔔 Triggers for a medication review

  • Request for a dosette box / blister pack
  • A fall
  • Increasing confusion or drowsiness
  • Constipation
  • Care home admission due to increasing frailty
  • Hospital discharge or new clinic letter
  • Falling eGFR
  • Major change in health or life expectancy
Aide memoire

🧭 A 7-step structured review (NHS Scotland)

  • 1. Aims — what matters to the patient?
  • 2. Need — which drugs are essential?
  • 3. Need — are any unnecessary?
  • 4. Effectiveness — are targets being met?
  • 5. Safety — adverse effects, interactions, falls, renal dosing
  • 6. Cost-effectiveness
  • 7. Adherence and patient-centredness — agree the plan
⚠️ Non-concordance is a clue: If a patient isn't taking a medicine, they may be giving you a valuable hint — side effects, doubts, or their own benefit–risk judgement. Evidence suggests 30–50% of people do not take medicines as prescribed. Iatrogenic illness causes significant harm.
🛑 Nitrofurantoin long-term: Chronic pulmonary reactions (pulmonary fibrosis, interstitial pneumonitis) can develop insidiously, especially in older people on long-term therapy — plus liver reactions and peripheral neuropathy. Review every long-term prophylaxis prescription, ask about breathlessness and cough, and remember it is contraindicated if eGFR is below 45 (short courses at eGFR 30–44 only for resistant organisms).Source: nitrofurantoin UK SmPC

STOPP/START — examples

🛑 STOPP (consider stopping):
  • Long-term benzodiazepines — falls, dependence, cognition
  • NSAIDs with heart failure or CKD
  • Strongly anticholinergic drugs in dementia or delirium
  • Full-dose PPI long-term without a clear indication
  • Antipsychotics in people who fall (unless essential)
✅ START (consider starting):
  • Anticoagulant in AF (unless contraindicated)
  • Bone protection after a fragility fracture
  • ACE inhibitor/four pillars in HFrEF
  • Laxative with regular opioids
  • Statin in established CVD when life expectancy and wishes support it
What deprescribing is: The planned, supervised stopping or reducing of medicines that are no longer appropriate or where harm outweighs benefit. It is not "giving up" — frame it positively and agree it with the patient and carer.
For every drug: consider withdrawal if there is no indication or a safer alternative exists. After deprescribing, monitor fall incidence and symptoms (e.g. orthostatic hypotension, blurred vision, dizziness) and arrange follow-up individually.
Drug classConsider withdrawal if…Stepwise withdrawal?Monitor after stopping
Benzodiazepines & Z-drugsDaytime sedation, cognitive or psychomotor impairment; sleep and anxiety indicationsIn general neededAnxiety, insomnia, agitation (consider: delirium, seizures, confusion)
AntipsychoticsExtrapyramidal or cardiac side effects, sedation, dizziness, blurred vision; given for BPSD or sleepIn general neededReturn of psychosis, aggression, agitation, hallucinations (consider: insomnia)
OpioidsSlow reactions, impaired balance, sedation; chronic (possibly acute) painIn general neededReturn of pain (consider: restlessness, GI symptoms, anxiety, insomnia, sweating)
AntidepressantsHyponatraemia, orthostatic hypotension, dizziness, sedation, arrhythmia; depression now symptom-free, sleep disorderIn general neededRecurrence of depression, anxiety, irritability, insomnia (consider: headache, GI upset)
AntiepilepticsAtaxia, somnolence, poor balance; given for anxiety or neuropathic painConsiderSeizures (consider: anxiety, restlessness, insomnia, headache)
DiureticsOrthostatic hypotension, hypotension, electrolyte disturbance; possibly incontinenceConsiderHeart failure, hypertension, fluid retention
Alpha-blockers (for BP)Hypotension, orthostatic hypotension, dizzinessConsiderHypertension (consider: palpitations, headache)
Alpha-blockers (for BPH)Hypotension, orthostatic hypotension, dizzinessIn general not neededReturn of urinary symptoms
Centrally acting antihypertensivesHypotension, orthostatic hypotension, sedationConsiderHypertension
Sedating antihistaminesConfusion, drowsiness, dizziness, blurred vision — for all indicationsConsiderReturn of symptoms (consider: insomnia, anxiety)
Vasodilators (cardiac)Hypotension, orthostatic hypotension, dizzinessConsiderAngina
Overactive bladder / incontinence drugsDizziness, confusion, blurred vision, drowsiness, prolonged QTConsiderReturn of symptoms

Source: STOPPFall expert consensus (Seppala et al., Age & Ageing 2021). "In general needed" = >70% of experts; "Consider" = 30–70%.

🛑 Who it is for — must meet ALL three:
  1. Dependent for activities of daily living and/or severe chronic disease and/or terminal illness
  2. Severe irreversible frailty — high risk of acute complications
  3. The doctor would not be surprised if the patient died in the next 12 months
The goal shifts to quality of life and avoiding drug harm. Agree changes with the patient and/or family.
SectionConsider stopping / reducing
A: GeneralAny drug persistently not taken or tolerated despite support; any drug without a clear indication; drugs for symptoms that have resolved (pain, nausea, vertigo, itch)
B: CardiologyLipid-lowering drugs. Antihypertensives if systolic persistently below 130 (appropriate target in frailty 130–160) — check what else the drug is doing first (e.g. rate control, heart failure). Nitrates, nicorandil, ranolazine if no angina for 12 months and no proven coronary disease
C: CoagulationAntiplatelets for primary prevention; aspirin for AF stroke prevention in people not suitable for anticoagulation
D: CNSAntipsychotics in dementia used for over 12 weeks with no current BPSD; memantine in moderate–severe dementia unless it has clearly improved BPSD
E: GIReduce full-dose PPIs or H2-antagonists used 8 weeks or more, unless symptoms persist at lower dose
F: RespiratoryTheophylline/aminophylline; leukotriene antagonists (montelukast) in COPD
G: MusculoskeletalCalcium supplements (unless symptomatic hypocalcaemia); vitamin D (unclear evidence for preventing falls/fractures in this group); bisphosphonates, denosumab, teriparatide, strontium; long-term oral NSAIDs (2 months+); long-term oral steroids (careful reduction)
H: UrogenitalBPH drugs in catheterised men; overactive bladder drugs with persistent irreversible incontinence
I: EndocrineDe-intensify diabetes treatment; avoid HbA1c targets — HbA1c below 58 mmol/mol is associated with net harm here. Aim to prevent symptomatic hyperglycaemia
J: MiscellaneousMultivitamins and nutritional supplements given as prophylaxis; folic acid once the course is complete (usually 1–4 months)
⚠️ Disclaimer: STOPPFrail supports — never replaces — the prescriber's decision, and its evidence base may change after publication.
🛑 Taper gradually (STOPPFall "in general needed"): benzodiazepines and Z-drugs, antipsychotics, opioids, antidepressants.
⚠️ Also never stop abruptly: long-term oral corticosteroids (adrenal insufficiency), beta-blockers in heart disease (rebound angina/tachycardia), Parkinson's medicines, antiepileptics used for epilepsy.
💊 Prescribing Pearl: Tapering speed depends on the drug, dose and how long it has been taken — use NICE CKS, the BNF or the KIK decision tree for drug-specific schedules, and agree review dates. Specific tapering percentages are not given here.
🛑 The scale: Around a third of people 65+, and half of people 80+, fall at least once a year — so reduce polypharmacy and avoid unnecessary medicines.Source: NICE (NG249 consultation, 2024)
🧠 Group 1 — drugs acting on the brain:
  • Benzodiazepines, Z-drugs
  • Antipsychotics
  • Antidepressants (SSRIs → hyponatraemia; tricyclics)
  • Opioids
  • Antiepileptics and gabapentinoids
  • Sedating antihistamines
Taking a psychotropic roughly doubles the risk of falling — and there is good evidence that stopping psychotropics (including opioids) reduces falls.
❤️ Group 2 — drugs acting on heart and circulation:
  • Antihypertensives (ACE-i, ARB, CCB)
  • Diuretics — dehydration, low sodium/potassium
  • Nitrates and vasodilators
  • Alpha-blockers
  • Beta-blockers, digoxin — bradycardia
These mainly cause falls through postural hypotension.
⚠️ Burden adds up: A sleeping tablet plus a blood pressure tablet plus a painkiller is far riskier than any one alone. Use Medichec to see total anticholinergic burden and drugs that cause dizziness and drowsiness — high anticholinergic burden is linked to cognitive impairment, dementia and early death.
Aide memoire

✅ Falls review — medicines checklist

  • List every drug — including over-the-counter, PRN and herbal
  • Flag every psychotropic — can it be reduced or stopped?
  • Lying and standing BP — postural drop? Review antihypertensives, diuretics, nitrates, alpha-blockers
  • Check anticholinergic burden (Medichec)
  • Apply STOPPFall (Deprescribing tab)
  • Write a clear plan with a review date
  • Refer for strength and balance exercise (NICE NG249)
Your role: AChE inhibitors and memantine are usually started on specialist advice, then continued and monitored in primary care. The most relevant problems to monitor are: worsening asthma or COPD; anorexia and weight loss; GI ulcer or bleed; AV node block as a cause of collapse; and additive effects (beta-blockers → bradycardia; SSRIs → anorexia).
DrugAbsolute contraindications
AllHypersensitivity to the active substance or excipients
DonepezilKnown sensitivity to piperidine derivatives
GalantamineSevere hepatic or renal impairment, or significant combined renal and hepatic dysfunction; urinary retention or history of prostatic condition
Donepezil & galantamineRare hereditary galactose intolerance, Lapp lactase deficiency or glucose–galactose malabsorption
RivastigmineHypersensitivity to carbamate derivatives; severe liver impairment
MemantineHereditary fructose intolerance — avoid the oral solution (contains sorbitol)
⚠️ Cautions — AChE inhibitors:
  • AV node block, sick sinus syndrome; concurrent digoxin or beta-blocker
  • Severe asthma, COPD, active chest infection
  • Peptic ulcer risk (history of ulcer, NSAIDs)
  • Urinary symptoms (avoid galantamine)
  • Epilepsy; cardiovascular disease
  • May worsen or cause extrapyramidal symptoms
⚠️ Cautions — memantine:
  • History of convulsions
  • Recent MI, uncontrolled hypertension or uncompensated heart failure — excluded from trials, limited data; supervise closely
AChE inhibitor effectFrequencySuggested action
GI: anorexia, nausea, vomiting, diarrhoeaVery commonUsually mild and transient; take after food. If persists, reduce dose; then consider switching AChE inhibitor
GI: gastric/duodenal ulcerationUncommon/rareStop if ulcer develops; monitor those at risk
🚨 Bradycardia / heart blockUncommon/rareUrgent review and ECG. Collapse or dizzy spells with PR interval over 200 ms → stop. Higher risk with sick sinus, SA/AV block, digoxin or beta-blockers
Dizziness, headache, insomnia, somnolenceVery common/commonUsually transient; reduce dose or switch if persistent
SyncopeCommon/uncommonReduce dose; consider switching
Extrapyramidal symptoms (incl. worse Parkinson's)RareReduce dose; consider switching
Lower seizure thresholdRareExtreme caution in epilepsy
Skin (galantamine): SJS, AGEP, erythema multiformeRareWarn patient and carer; stop and seek advice if a rash develops
Asthenia, fatigueCommonUsually transient; reduce dose or switch
BronchoconstrictionNo dataCaution in asthma, COPD, pneumonia
Agitation, confusion, insomniaCommonReduce dose; consider switching
Memantine effectFrequencySuggested action
ConstipationCommonPRN or regular laxative
HypertensionCommonReduce dose and review BP; consider stopping
Dizziness, headache, drowsinessCommonReduce dose and review; consider stopping
BreathlessnessCommonReduce dose and review; consider stopping
⚠️ Memantine looks well tolerated — but in severe dementia people may not be able to tell you about distressing side effects. Ask carers specifically.
All AChE inhibitors:
  • Anticholinergics (oxybutynin, some antipsychotics, tricyclics) directly oppose them — a classic prescribing clash
  • Synergy with suxamethonium and other neuromuscular blockers, cholinergic agonists, and beta-blockers affecting cardiac conduction
  • Additive effects: beta-blockers → bradycardia; SSRIs → anorexia
Donepezil and galantamine (CYP3A4 and CYP2D6):
  • Inhibitors raise levels: erythromycin, clarithromycin, ketoconazole, fluvoxamine, fluoxetine, paroxetine — dose reduction may be needed
  • Inducers lower levels: rifampicin, phenytoin, carbamazepine, alcohol
Aide memoire

📋 Annual review of dementia medication

  • 1. Compliance — is it being taken properly? Check collection records; consider blister packs
  • 2. Physical health — weight (loss started or sped up after starting?); pulse and BP — if pulse under 60, do an ECG; PR over 200 ms → stop or discuss with mental health specialist; GI and neurological tolerance
  • 3. Global functioning — daily living, falls, nutrition, safety at home (social services, OT, physio, falls assessment); does the carer value the medicine?; new behavioural problems or BPSD → consider referral to the older people's mental health team (see the carer alone if needed)
  • 4. Cognition — formal scores aren't mandatory and can distress; use 6CIT or GPCOG when function has deteriorated significantly
  • 5. Still of overall benefit? — see below
  • 6. Review other long-term conditions at the same visit
✅ Continue if: there is cognitive, behavioural, functional or global benefit, it is tolerated and there are no contraindications. NICE NG97: don't stop AChE inhibitors because of disease severity alone. Use in severe disease may be outside the licence — document your reasoning.
🛑 Stop if: no cognitive, behavioural, functional or global benefit; side effects not tolerated; or it has become inappropriate (e.g. extreme frailty, end of life).
💊 How to stop: Reduce gradually — e.g. donepezil 10 mg → 5 mg once daily for a month, then stop; similar step-downs for other agents. The AD2000 trial did not find a withdrawal reaction, but reactions have been reported anecdotally, so tapering is a sensible precaution. Watch for rapid decline afterwards.
When to re-refer: disagreement with the carer about stopping; considering memantine in severe dementia; uncertainty about side effects or benefit; behavioural problems needing the community team.

9️⃣ Nursing & Care Home Visits — What To Do

Before you go, when you get there, back at the practice — and sick day rules

🏠 The Three-Part Visit

Every visit is a chance for a mini geriatric review — not just a fix for today's problem

Review the medical notes first:
  • Previous consultations about the same complaint (use the search box)
  • The last few entries — other GPs, out-of-hours, community nursing
  • Discharge summaries and hospital letters
  • Outstanding recalls, chronic disease reviews, blood results
  • ReSPECT form and resuscitation status — in place? Do you need to start one?
✅ Before you get there… think! Mull it over on the journey — don't overthink: the differentials, the questions that will narrow them, and what you might need to do.

🔀 Worked example: called out for "swollen legs"

START: Care home reports swollen legs
↓
❓ One leg or both?
ONE LEG ↓BOTH LEGS ↓
DVT (Wells score, D-dimer), cellulitis (antibiotics — any allergies?), ruptured Baker's cyst
More likely heart failure: examine chest, check for AF, NT-proBNP; consider a diuretic. Also think drugs (amlodipine), low albumin, venous disease
⚠️ The printed summary sheet: Useful for repeats and recent bloods — but log into the electronic record for the full picture. You are responsible for destroying any paperwork with patient information: don't bin it, don't leave it in the car — shred it at the practice (tearing is not enough). Leaving it lying around is a serious confidentiality breach.
💡 Leadership idea: Many practices now offer secure mobile access to records on home visits. If yours doesn't, exploring it could make a great quality improvement or leadership project.
🛑 FIRST — the acute problem: Deal with what they called you for. Always do vital signs: pulse, BP, temperature, sats (and respiratory rate).
SECOND — the 9 Geriatric Giants (MANIC MOLD): See the flip cards in section 1. The quick version:
  • Mobility — deteriorating? Physio, stop unnecessary sedatives/antipsychotics, trial opioid reduction, pharmacy review
  • Abuse — ask 1:1; bruising; look at the feet
  • Nutrition — mouth (dentures, ulcers, thrush), body habitus, intake, weight and MUST
  • Incontinence — all or some of the time? New confusion? Drinking enough?
  • Confusion — dementia or delirium? Pain, infection, constipation, depression?
  • Medication — refusing any? Remove what isn't needed
  • Osteoporosis — fracture risk assessed?
  • Loneliness — befriending, home activities
  • Depression — ask; behavioural activation; antidepressant?
THIRD — Advance care planning:
  • Is a DoLS (Deprivation of Liberty Safeguards) authorisation in place? Code it and add to the problem list and summary
  • Consider resuscitation status / ReSPECT for everyone — use the template
  • Palliative care register — should they be on it?

🚩 If this is end of life — don't leave without:

🚩

Anticipatory medicines ("just in case") prescribed if appropriate

🚩

Unnecessary medicines stopped

🚩

Palliative care team involved if needed (and your local out-of-hours palliative advice line)

🚩

DNACPR / ReSPECT discussed with the patient and relatives, completed and documented

🚩

Care home staff kept in the loop — who to call out of hours

Aide memoire

🗒️ Back at the practice

  • Write up the visit, including why you were called
  • Tidy the repeat list — reduce polypharmacy
  • Use templates (e.g. Ardens, SystmOne, EMIS) for everything else you reviewed — medication review, chronic disease, bloods
  • Move recall dates on — keep recalls to a minimum
  • Arrange follow-up bloods with community phlebotomy / observation team
  • Tell community matrons, care coordinators or district nurses about issues needing follow-up
💊 Prescriptions: Unless it's very urgent, issue prescriptions electronically when you're back — errors are less likely than with handwritten ones. Tell the home or patient what you have done and when the item will be ready.
Tell the patient (or care home) — when you are unwell with:
  • Vomiting or diarrhoea (unless only minor)
  • Fevers, sweats and shaking (unless only minor) — e.g. flu, chest infection, water infection
…then: 1) STOP the medicines I have written down for you; 2) restart them when well — after 24–48 hours of eating and drinking normally; 3) if in doubt, contact the pharmacist, doctor, nurse or 111.

🧠 Mnemonic: SADMAN — medicines to pause on sick days

Tap each card for examples.

S
SGLT2 inhibitors
tap to flip
Names ending in "-flozin": canagliflozin, dapagliflozin, empagliflozin. Risk: dehydration, AKI and ketoacidosis — which can occur with a normal glucose. MHRA advises checking blood ketones during serious illness.
A
ACE inhibitors
tap to flip
Names ending in "-pril": ramipril, lisinopril, enalapril, captopril, perindopril. Risk: AKI when dehydrated.
D
Diuretics
tap to flip
Furosemide, bumetanide, bendroflumethiazide, indapamide. Risk: worse dehydration and AKI.
M
Metformin
tap to flip
Risk: lactic acidosis if the kidneys are struggling from dehydration.
A
ARBs
tap to flip
Names ending in "-sartan": losartan, candesartan, valsartan, irbesartan. Risk: AKI when dehydrated.
N
NSAIDs
tap to flip
Ibuprofen, naproxen, diclofenac, ketoprofen. Risk: reduced kidney blood flow → AKI.
✅ General sick day advice:
  • Rest
  • Drink plenty of sugar-free fluids — around 3 litres (5 pints) a day unless advised otherwise. Heart failure: ask your heart failure nurse or GP (you may need to stick to about 1.5–2 litres); weigh yourself daily and call the GP or 111 if you gain more than 2 kg in 3 days
  • Keep to your meal pattern; if you can't, swap meals for carbohydrate snacks or drinks (yoghurt, milky drinks, fruit juice, non-diet fizzy drinks — letting them go flat can help)
  • Avoid too much caffeine
  • Take painkillers at the recommended doses (avoiding NSAIDs)
  • Contact the GP if you think you need antibiotics; call GP or 111 if vomiting uncontrollably
⚠️ If on insulin or diabetes medicines:
  • Never stop insulin, even if not eating — doses may need adjusting; get advice
  • Pause metformin and SGLT2 inhibitors; sulfonylureas may need reducing or pausing because of hypo risk if not eating
  • Check blood glucose more often — at least four times a day and overnight if on insulin or very unwell — and write results down (ask someone to help if too unwell)
  • Ketones: people with type 1 diabetes should check ketones if glucose is 15 mmol/L or higher (or as their team advises); anyone on an SGLT2 inhibitor should check blood ketones when seriously unwell, even with normal glucose. Positive ketones → contact GP or diabetes team immediately
Sources: MHRA Drug Safety Update (SGLT2 inhibitors and ketones); NICE NG28 (sick day rules in every plan)
🎓 AKT tip: "An 80-year-old on ramipril, furosemide and metformin has diarrhoea and vomiting — which to stop?" All three. And the classic distractor: insulin is never simply stopped.

🔟 Team Working, Ethics & Prevention

The multidisciplinary team, mental capacity, advance care planning, vaccines and screening

🤝 The Wider Picture

Elderly care is a team sport

Team memberHow they help
Geriatrician / frailty teamComprehensive Geriatric Assessment, complex multimorbidity, frailty virtual wards
Clinical pharmacistStructured medication reviews, deprescribing, sick day counselling, anticholinergic burden
PhysiotherapistStrength and balance, falls prevention, sarcopenia
Occupational therapistDaily living assessment, equipment, home hazard assessment
District nurse / community matronWounds, monitoring, housebound chronic disease care
Social workerCare packages, safeguarding, carers' assessments
DietitianMalnutrition, weight loss, sarcopenia
PodiatristNails, diabetic feet, footwear
Social prescriber / care coordinatorLoneliness, community groups, practical support
Mental Capacity Act 2005 (England & Wales): Assume capacity unless shown otherwise. Capacity is decision-specific and time-specific. A person lacks capacity for a decision if, because of an impairment of mind or brain, they cannot:
  1. understand the relevant information
  2. retain it
  3. use or weigh it
  4. communicate their decision
✅ Best interests:
  • Past and present wishes, beliefs and values
  • Consult family, carers, LPA and the team
  • Least restrictive option
  • Document the process
Planning ahead:
  • Advance decision: legally binding refusal of specified treatment
  • Advance statement: wishes and preferences (not binding, but must be considered)
  • LPA (health & welfare): a chosen decision-maker
  • ReSPECT / DNACPR: discuss sensitively, document clearly
✅ Routine for older adults:
  • Flu: every autumn for 65+
  • COVID-19: seasonal boosters for eligible older groups, per the national programme
  • Pneumococcal: one-off at 65
  • Shingles (Shingrix, 2 doses): people turning 65 (since September 2023) and those aged 70–79, until their 80th birthday; severely immunosuppressed adults 18+
RSV — recently extended: Offered to people turning 75 and those aged 75–79 since 2024. From April 2026, people aged 80 and over and all residents of older adult care homes are also eligible, with no upper age limit.Source: British Geriatrics Society; UKHSA Green Book
ProgrammeWhoNote
Bowel (FIT)50–74, every 2 yearsAge lowered to 50 (completed 2025). 75+ can request a kit
BreastWomen 50 up to their 71st birthday, every 3 yearsAfter 71 they can self-refer every 3 years
Cervical25–64Invitations stop after 64 if previous screens were normal
AAAMen in the year they turn 65Older men can self-refer
Healthy ageing: stop smoking (benefits at any age); strength and balance activity; enough protein and calories; alcohol within 14 units a week; social connection — loneliness is a genuine health risk; keep the mind active.

💪 You've Got This!

A final word of encouragement before you head back to the coalface

You've Got This! 💪

Remember: you don't need to be a geriatrician to provide excellent care for older people. You just need to know when to worry, when to treat, when to stop — and when to refer.

You can confidently run a medication review, check the nine giants, look at the feet, measure a standing blood pressure and start an honest conversation about what matters most. Refer when the picture is complex, the dementia diagnosis is uncertain, or behaviour has outgrown what the home can manage.

The one thing never to miss? The quiet older person who is "just not themselves" — delirium, sepsis or a silent heart attack may be hiding behind that phrase. Take the carer seriously when they say something has changed.

☕ Now go reward yourself with that well-deserved coffee

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