Geriatrics Board Prep for Family Medicine

Five-minute daily sessions on falls, deprescribing, dementia, and the care-of-older-adults questions the ABFM actually asks.

The ABFM does not carve out geriatrics as a single blueprint line — instead, older adults are the patients in a large share of vignettes across every organ system. That is exactly how family medicine works: the 78-year-old in the question stem has hypertension, osteoarthritis, and mild cognitive impairment all at once, and the exam wants to know whether you can prioritize. Add the questions that are explicitly geriatric — falls, polypharmacy, dementia workup, incontinence, goals of care — and care of older adults becomes one of the most consequential themes on the test.

Geriatrics questions reward a specific habit of mind: function over chronology. The exam repeatedly tests whether you treat the patient in front of you rather than their birth year — a fit 80-year-old may still benefit from cancer screening or aggressive blood pressure control, while a frail 68-year-old with limited life expectancy may not. Questions about stopping things are as common as questions about starting them: deprescribing per the Beers criteria, discontinuing screening when life expectancy falls below the payoff horizon, and de-escalating care in line with a patient's stated goals.

The high-yield core is compact. Falls are the leading cause of injury death in older adults, and the exam tests the USPSTF position that exercise interventions prevent falls in community-dwelling adults at increased risk. Dementia questions center on the workup (rule out reversible causes, distinguish delirium and depression) more than on drug therapy, because cholinesterase inhibitors have modest benefit and the exam knows it. Urinary incontinence questions almost always hinge on typing the incontinence correctly, because first-line therapy differs for stress, urge, and overflow patterns.

Finally, expect ethics and logistics woven in: decision-making capacity, advance directives, driving safety, elder abuse reporting, and Medicare's Annual Wellness Visit. These are family medicine's home turf, and the ABFM tests them through geriatric vignettes far more often than through abstract policy questions.

High-yield geriatrics topics

• Falls assessment and prevention. Ask about falls annually. For community-dwelling older adults at increased risk, exercise interventions (balance and strength training, tai chi) carry the strongest evidence and a USPSTF grade B. Multifactorial risk assessment is selectively recommended. Review medications — psychotropics are the most modifiable risk factor. Vitamin D supplementation alone is no longer recommended for fall prevention.
• Beers criteria and deprescribing. Know the classic offenders in adults 65 and older: benzodiazepines and non-benzo hypnotics (falls, cognitive impairment), strong anticholinergics like diphenhydramine and oxybutynin, sliding-scale insulin alone, sulfonylureas with long half-lives, NSAIDs with CKD or heart failure, and muscle relaxants. The tested move is usually stopping or tapering a drug, not adding one.
• Dementia evaluation and reversible causes. Initial workup for cognitive decline: structured cognitive testing (MoCA or Mini-Cog), depression screening, TSH, B12, and metabolic panel; neuroimaging for atypical or rapid presentations. Distinguish Alzheimer disease (gradual, memory-first) from vascular (stepwise), Lewy body (fluctuations, visual hallucinations, parkinsonism — avoid antipsychotics), and frontotemporal (behavior and language, younger onset).
• Delirium versus dementia versus depression. Delirium is acute, fluctuating, with impaired attention — search for the precipitant (infection, medications, retention, metabolic derangement) and manage without restraints or sedatives when possible. Depression in older adults can present as pseudodementia with prominent "I don't know" answers and intact attention. Dementia is chronic and progressive with preserved alertness early.
• Urinary incontinence by type. Stress incontinence (leak with cough or lift): pelvic floor muscle training first. Urge incontinence (sudden need, nocturia): bladder training first, then antimuscarinics or mirabegron — prefer mirabegron in patients with cognitive concerns because anticholinergics worsen cognition. Overflow (retention, dribbling): check postvoid residual, consider BPH or neurogenic bladder. Always rule out UTI and medication causes first.
• Osteoporosis screening and treatment. Screen all women 65 and older with DXA (USPSTF grade B); screen younger postmenopausal women with elevated risk. Treat T-score at or below -2.5 or prior fragility fracture with a bisphosphonate first-line. Reassess after 3 to 5 years; drug holidays are appropriate for lower-risk patients on bisphosphonates.
• Goals of care, capacity, and advance directives. Decision-making capacity is task-specific and assessed clinically — a patient with mild dementia may retain capacity for many decisions. Capacity requires understanding, appreciation, reasoning, and a consistent choice. Without capacity, follow the advance directive, then the surrogate hierarchy. Hospice is appropriate at a prognosis of six months or less; earlier palliative care referral improves quality of life.
• Stopping screening at the right time. Colorectal cancer screening is individualized from 76 to 85 and stops after 85. Cervical cancer screening stops at 65 with adequate prior negative screening. Breast cancer screening beyond 74 has insufficient evidence per USPSTF. The unifying rule the exam tests: screening requires roughly a 10-year life expectancy to pay off.

ABFM exam tips

Type the incontinence before you treat it. The vignette gives away the type: leak with cough is stress (pelvic floor training), sudden urge with nocturia is urge (bladder training, then mirabegron or antimuscarinic), dribbling with a large postvoid residual is overflow. Picking a drug before behavioral therapy is usually wrong.

When a question lists an older adult's medications, the answer is often in the list. A fall plus zolpidem, confusion plus oxybutynin, hypoglycemia plus glyburide — the tested move is recognizing and stopping the offending drug per the Beers criteria.

Attention separates delirium from dementia. If the stem says symptoms fluctuate and the patient cannot follow the conversation or count backward, it is delirium — find the cause. Dementia patients early in the course are alert and attentive but cannot store new memories.

Function drives decisions, not age. The exam punishes both overtreatment of the frail (tight A1c goals, continued screening in limited life expectancy) and undertreatment of the fit (withholding surgery or statins from a vigorous 80-year-old solely because of age). Look for functional status cues in the stem.

Loosen glycemic targets in older adults. An A1c goal of 7.5 to 8 percent (or even 8 to 8.5 with limited life expectancy and multimorbidity) is appropriate for frail older adults. Tight control questions in this population are testing whether you know to back off — and to stop sulfonylureas and sliding-scale-only insulin.

Exercise is the answer more often than equipment. For fall prevention, balance and strength training beats vitamin D, beats home modification alone, and beats assistive devices in most question stems. It is the single best-evidenced intervention.

Common pitfalls

Do not give antipsychotics to patients with Lewy body dementia. Severe antipsychotic sensitivity is a hallmark of the disease. Visual hallucinations plus parkinsonism plus fluctuating cognition should make you avoid haloperidol and risperidone; if a drug is unavoidable, low-dose quetiapine or pimavanserin appears in some stems.

Do not treat asymptomatic bacteriuria in older adults. Positive urine cultures without urinary symptoms are common in this population — including patients with chronic catheters — and treatment does not help. New confusion alone in a nursing home resident is not automatically a UTI; look for genuine urinary symptoms or systemic signs before treating.

Cholinesterase inhibitors are not disease-modifying. Donepezil and rivastigmine offer modest symptomatic benefit in Alzheimer disease. Expect questions where the family requests escalating therapy — the honest answer involves goals-of-care discussion, caregiver support, and safety planning, not another prescription.

Restraints and sedatives worsen delirium. First-line delirium management is treating the cause plus non-pharmacologic measures: reorientation, sleep hygiene, glasses and hearing aids, early mobilization, family presence. Antipsychotics are reserved for severe agitation threatening safety.

Benzodiazepines are not a sleep aid in older adults. Neither are diphenhydramine or zolpidem. The tested answer for insomnia is cognitive behavioral therapy for insomnia (CBT-I) and sleep hygiene. This exact scenario — an older adult requesting a sleep medication — is a recurring question.

Do not confuse normal aging with disease. Benign forgetfulness (misplacing keys, slower recall with intact function) is not mild cognitive impairment; MCI (measurable deficit, preserved function) is not dementia (functional impairment). Staging matters because it changes counseling, driving assessment, and planning.

Elder abuse requires reporting, not just documentation. Unexplained bruising in atypical locations, weight loss, missed appointments, or a controlling caregiver should trigger a report to Adult Protective Services. Physicians are mandatory reporters in nearly all states, and the exam tests willingness to act.

Frequently asked questions

How much geriatrics is on the ABFM exam?

The ABFM does not list geriatrics as a single content percentage — older adults appear as the patient population across many organ-system questions. Explicitly geriatric topics like falls, polypharmacy, dementia, incontinence, and end-of-life care appear reliably on every administration, and the demographic weighting of vignettes skews older, so preparing for geriatric decision-making pays off across the whole exam.

What geriatrics topics are most tested on the ABFM?

Falls risk assessment and prevention, the Beers criteria and deprescribing, dementia workup and subtype recognition, delirium evaluation, urinary incontinence typing and first-line treatment, osteoporosis screening and treatment, and goals-of-care conversations including capacity assessment. Medicare Annual Wellness Visit components and elder abuse reporting also appear.

Do I need to memorize the entire Beers list?

No. Focus on the drug classes that recur in questions: benzodiazepines and Z-drugs, first-generation antihistamines, anticholinergic bladder agents in patients with cognitive impairment, long-acting sulfonylureas, NSAIDs in CKD or heart failure, and muscle relaxants. If an older adult in a vignette has a new symptom and one of these on the med list, the medication is usually the answer.

How does the exam test dementia — diagnosis or treatment?

Mostly diagnosis and management strategy: recognizing subtypes from the vignette, ordering the initial reversible-cause workup, distinguishing delirium and depression, and counseling families. Drug questions are usually about limits — knowing cholinesterase inhibitors have modest benefit, avoiding antipsychotics in Lewy body dementia, and managing behavioral symptoms non-pharmacologically first.

When do I stop cancer screening in older adults?

Anchor on life expectancy rather than a single age. USPSTF endpoints: cervical screening stops at 65 with adequate negative prior screening, colorectal becomes individualized at 76 and stops after 85, and breast screening has insufficient evidence beyond 74. A useful exam rule: if life expectancy is under 10 years, screening rarely helps and often harms.

What glycemic target should I use for older adults on the boards?

For healthy older adults, an A1c under 7.5 percent is reasonable. For those with multimorbidity, cognitive impairment, or limited life expectancy, targets relax to 8 percent or looser, and the priority becomes avoiding hypoglycemia — which usually means stopping sulfonylureas and simplifying insulin. Questions in this space almost always reward the less aggressive option.

How should I study geriatrics in five-minute daily sessions?

Geriatrics rewards pattern drilling: incontinence types to first-line treatments, dementia subtypes to their signature features, Beers drugs to their harms. Short spaced sessions build exactly these associations. Mix in vignette practice that forces the function-over-age judgment call, because that framing decides more geriatric questions than any memorized fact.