geriatrics-knowledge

name

geriatrics-knowledge

description

PRIMARY: Israeli geriatrics board exam (שלב א' גריאטריה, P005-2026) study platform. SECONDARY: SZMC ward clinical decision support. Contains: Hazzard's 8th ed (Ch 2-6, 34, 62), Harrison's 22nd ed (board chapters), SZMC DAG Antimicrobial Guidelines, Washington Manual of Therapeutics, AGS Beers Criteria 2023 (JAGS 71:2052-2081) ✓, IWG Alzheimer disease clinical-biological construct (JAMA Neurol 2024) ✓, AA Workgroup revised Alzheimer criteria (Alzheimer's & Dementia 2024) ✓, VasCog-2-WSO criteria (JAMA Neurol 2025) ✓, Dementia Prevention narrative review (JAMA IM, Reuben et al) ✓, Age-Related Hearing Loss (NEJM 2024, Lin) ✓, נוהל התעמרות בזקנים (MOH circular 22/03) ✓, חוזר מנכ"ל 6/2023 + report form נספח א' ✓, ייפוי כוח מתמשך (MOH Legal Dept Aug 2023) ✓, מקבל החלטות זמני (Amendment 16, Jan 2024) ✓, סיעוד מורכב (MOH Circular 4/2010) ✓, PEG לחולה עם קיהיון הנוטה למות — National Committee (11.8.16) ✓, מינוי אפוטרופוס באשפוז ממושך (Circular 10/2006) ✓, קביעת מצב תפקודי להעברה (Circular 26/2010) ✓, אמות מידה לטיפול שיקומי לקשישים (Circular 4/2009) ✓, הגדרת מושגים — נהלי רוחב (MOH Geriatrics Division 0.2.1) ✓, Brookdale 65+ Statistics Israel 2024 ✓, Driving license fitness domains נספח 12ב' ✓, Past exam questions + answers Dec 2021, Jun 2022 ✓, Exam source index (Hazzard's page citations per question) ✓. חוק החולה הנוטה למות 2005 ✓, STOPP/START v.3 (O'Mahony 2023) ✓, FIM assessment (SZMC validation, Harefuah 2020) ✓, קבלת החלטות נתמכת / תומך החלטות (MoJ 27.10.2019) ✓, ALWAYS use project_knowledge_search FIRST on any clinical or exam question. Trigger on: any exam topic, Hazzard's, Harrison's chapter, Beers 2023, STOPP/START v.3, IWG/AA AD, VasCog, dementia, hearing loss, FIM, Israeli law, driving fitness, נהיגה, ייפוי כוח, מקבל החלטות, תומך החלטות, סיעוד מורכב, חולה נוטה למות, PEG, התעמרות, שיקום, העברה, מושגים גריאטריים, past exam, שאלות בחינה. Never answer from memory alone — always search first.

Geriatrics Knowledge Skill

Israeli Board Exam שלב א' (P005-2026) + SZMC Clinical Reference

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Document Index — Complete Status

Articles ✓ All indexed

Article	Journal	Status
AGS Beers Criteria 2023	JAGS 71:2052–2081	✓ Full text
IWG AD: Clinical-Biological Construct	JAMA Neurol 2024	✓ Full text
AA Workgroup: Revised AD Criteria & Staging	Alzheimer's & Dementia 2024	✓ Full text
VasCog-2-WSO Revised VCID Criteria	JAMA Neurol 2025	✓ Full text
Dementia Prevention and Treatment	JAMA Internal Medicine	✓ Full text
Age-Related Hearing Loss	NEJM 2024	✓ Full text

Israeli Laws & MOH Regulations

#	Document	Status
1	MOH Geriatrics definitions — נהלי רוחב 0.2.1 (updated 2019)	✓
2	Circular 26/2010 — functional status for transfer	✓
3	Circular 4/2009 — rehabilitation criteria for elderly	✓
4	חוק החולה הנוטה למות 2005	✓
5	National Committee: PEG in terminal dementia (11.8.16, SZMC)	✓
6	Circular 10/2006 — guardian appointment (prolonged hospitalization)	✓
7	ייפוי כוח מתמשך — preparation/registration	✓
8	ייפוי כוח מתמשך — activation in hospital emergencies	✓
9	מקבל החלטות זמני (Amendment 16, Jan 2024)	✓
10	קבלת החלטות נתמכת / תומך החלטות (MoJ circular 27.10.2019)	✓
11	סיעוד מורכב (Circular 4/2010, amended 14/3/23)	✓
12	נוהל התעמרות (Circular 22/03)	✓
13	Driving fitness 6/2023 + report form + נספח 12ב'	✓
14	Brookdale 65+ Stats 2024 (pp.33–43, 47–55, 131–140)	✓
15	FIM assessment (Harefuah 2020, SZMC hip fracture cohort n=453)	✓

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

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Board Syllabus Map — P005-2026

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

Harrison's 22nd — All Residents

Ch	Topic
26	Neurologic Causes of Weakness/Paralysis
382	Articular/Musculoskeletal Disorders
387	Periarticular Disorders of the Extremities
433	Approach to Patient with Neurologic Disease
436	Seizures and Epilepsy
437	Introduction to Cerebrovascular Diseases
438	Ischemic Stroke
439	Intracerebral Hemorrhage
458	Guillain-Barré / Immune-Mediated Neuropathies
459	Myasthenia Gravis / Neuromuscular Junction

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

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Source Hierarchy

Priority	Source	Domain
1	SZMC DAG	Empiric antibiotics — always overrides
2	Hazzard's 8th	Geriatric syndromes — authoritative
3	Harrison's 22nd	Internal medicine chapters per syllabus
4	Washington Manual	Drug dosing, electrolytes
5	Required articles	Beers 2023, IWG/AA AD, VasCog, dementia, hearing
6	Israeli MOH laws	Medico-legal, regulatory — exam section
7	Brookdale stats	Israeli epidemiology

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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.

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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):

	AA 2024	IWG 2024
Definition	Biological only	Clinical-biological
Cognitively normal + biomarker+	Diagnosed as AD	"At-risk" only
Biomarker primary endpoint trials	Yes	No — clinical required

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.

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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?

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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.

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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.

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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).

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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):

Setting	Mean FIM	IQR
Admission	39	29–58
Discharge from rehabilitation	72	58–87
Community (plateau)	100	92–111

• 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.

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תומך החלטות / קבלת החלטות נתמכת (MoJ, 27.10.2019)

Conceptually DISTINCT from מקבל החלטות זמני — exam critical.

	תומך החלטות	מקבל החלטות זמני
Capacity	Patient RETAINS capacity (supported)	Patient LACKS capacity
Role	Supports patient's own decision	Makes decision on behalf of patient
Authority	Court-appointed	Hospital director authorized
Consent	Patient still consents	Surrogate consents

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.

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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.

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Remaining Gaps

Missing	Priority
קבלת החלטות נתמכת — full law text (תיקון 18 לחוק הכשרות)	Medium
Hazzard's 8e full index — ensure all 8e chapters (excluding 2–6, 34, 62 per P005-2026) are fully indexed in project knowledge	High
FRAILTY_TARGETS — CFS × condition × target (HbA1c, SBP, anticoag, statin)	Medium