geriatrics-knowledge

name

geriatrics-knowledge

description

Project knowledge base for SZMC geriatric medicine clinical practice. Contains Hazzard's Geriatric Medicine, Harrison's Internal Medicine, Washington Manual of Therapeutics, SZMC DAG Antimicrobial Guidelines, Israeli Ministry of Health regulations (ייפוי כוח מתמשך, מקבל החלטות זמני, סיעוד מורכב, driving fitness חוזר מנכ"ל 6/2023), and Israeli 65+ statistics (Brookdale/JDC). Use the inline tables in this file directly (inline-table lookup is not available in this runtime). Trigger on: drug dosing, Beers criteria, geriatric syndromes (falls, delirium, dementia, frailty, incontinence, pressure ulcers, dysphagia, polypharmacy), disease management, antibiotic selection, STOPP/START, AKI/CKD dosing, electrolytes, heart failure, VTE, palliative care, goals of care, functional assessment, nutrition, pain, perioperative risk, capacity assessment, ייפוי כוח מתמשך, מקבל החלטות זמני, driving fitness, נהיגה, כשירות לנהוג, סיעוד מורכב admission criteria. Never answer clinical questions from memory alone — always cite from the inline tables in this file.

Geriatrics Project Knowledge Skill

Purpose

Primary clinical reference corpus for SZMC geriatric ward practice. Search before answering any clinical, pharmacological, legal, or regulatory question.

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Source Hierarchy

Priority	Source	Domain
1	SZMC DAG Antimicrobial Guidelines	Empiric antibiotic selection — always overrides
2	Hazzard's Geriatric Medicine	Geriatric syndromes, pharmacology, aging physiology — authoritative
3	Harrison's Internal Medicine	Pathophysiology, diagnosis, general internal medicine
4	Washington Manual of Therapeutics	Drug dosing, treatment algorithms, electrolyte protocols
5	Israeli MOH Circulars	Capacity law, surrogacy, ward licensing, driving fitness
6	Brookdale/JDC 65+ Statistics	Israeli epidemiology, prevalence, service benchmarks

Rules:

• DAG overrides all for antibiotic selection at SZMC
• Hazzard's overrides Harrison's for geriatric-specific clinical management
• Israeli MOH law overrides textbooks for medico-legal decisions
• GRS removed from hierarchy — superseded by Hazzard's + Harrison's

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Source PDF Chapter References

Canonical TOC files (in the Geri repo, schema-guarded):

• data/hazzard_chapters.json — Hazzard 8e
• data/harrison_22e_toc.json — Harrison 22e

These are the audited source-of-truth for q.ref validation. question_chapters.json (.haz / .har fields) cross-references back into them. Trust the JSON before any in-skill table.

TOC pre-flight is MANDATORY before any web Claude PDF prestage (Bot D cluster-triage workflow): validate the target chapter against the TOC JSON before extracting source quotes from the PDF. Skipping pre-flight risks PDF-scan false positives that match body-text keywords instead of chapter titles (vision_eye batch v1 picked Ch 14 "Models of Hospital Care" because "eye" appeared in body text — title-position match is the fix).

q.ref string format

When constructing or validating a q.ref value, use:

• Hazzard 8e: Hazzard Ch <N> — <TITLE>
• Harrison 22e: Harrison 22e Ch <N> — <Title>

The em-dash — (U+2014) is required by hazzard_chapters.json schema-guard. Hyphen-minus -, en-dash –, trailing space, trailing colon, and abbreviated/paraphrased titles all fail validation. Match the printed chapter title in the PDF — exact case, exact punctuation.

Verified chapters (working subset for fast reference)

This is a working subset surfaced during recent Bot D triage batches. The TOC JSON files above are authoritative; consult them before trusting any entry here.

Hazzard 8e:

• Ch 33 — LOW VISION: ASSESSMENT AND REHABILITATION (PDF p504–523)
• Ch 34 — HEARING LOSS: ASSESSMENT AND MANAGEMENT (PDF p524+)
• Onc block (TOC-verified 2026-05-08):
  • Ch 88 CANCER, Ch 89 BREAST, Ch 90 PROSTATE, Ch 91 LUNG,
  • Ch 92 GI MALIGNANCIES, Ch 93 SKIN CANCER,
  • Ch 94 HEME, Ch 95 HEME MALIGNANCIES

Harrison 22e onc (TOC-verified 2026-05-08):

• Ch 79 Infections in Cancer Patients
• Ch 80 Oncologic Emergencies
• Ch 81 Cancer of the Skin
• Ch 83 Lung Cancer
• Ch 84 Breast Cancer
• Ch 86 Colorectal Cancer

PDF→book page offset for Hazzard 8e: book page = PDF page − 34.

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Search Patterns

Read the inline tables in this file directly. The runtime does not provide search.

Antibiotic:     "SZMC DAG pneumonia empiric"
Drug safety:    "Beers criteria benzodiazepines elderly"
Syndrome:       "delirium prevention nonpharmacologic hospital"
Renal:          "metformin CKD eGFR dosing"
Capacity:       "ייפוי כוח מתמשך רפואי"
Surrogacy:      "מקבל החלטות זמני תהליך"
Driving:        "driving fitness dementia cognitive"
Admission:      "סיעוד מורכב קריטריונים"
Falls:          "falls prevention inpatient geriatric"

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Clinical Domains

Geriatric Syndromes

Falls, delirium (CAM, prevention, management), dementia (types, BPSD, capacity assessment), frailty (CFS, sarcopenia), urinary incontinence, pressure injuries (staging, prevention, grade 3–4 management), dysphagia (aspiration risk, diet modification), malnutrition (MNA, supplementation, refeeding syndrome), sleep disorders, dizziness/vertigo.

Pharmacology

Beers Criteria 2023, STOPP/START, renal dosing (Cockcroft-Gault; actual weight if BMI <30, IBW if obese), anticholinergic burden (ACB scale), drug interactions in polypharmacy, medication reconciliation admission/discharge.

Cardiovascular

HFpEF/HFrEF (SGLT2i, diuretic titration), AF (rate vs rhythm, anticoagulation, CHA₂DS₂-VASc, HAS-BLED), hypertension targets by frailty (SBP 130–150), perioperative cardiac risk (RCRI, Lee index).

Infectious Disease

SZMC DAG: empiric selection by syndrome — CAP, HAP, UTI, SSTI, intra-abdominal, bacteremia, C. diff (fidaxomicin vs vancomycin tiers). Antibiotic renal adjustment. Atypical sepsis presentation in elderly (no fever, AMS as sole sign).

Nephrology / Electrolytes

AKI (KDIGO staging, prerenal vs intrinsic), CKD dosing adjustments, hyponatremia (SIADH vs hypovolemic, correction rate, tolvaptan), hyperkalemia (ECG changes, acute ladder), hypomagnesemia, hypophosphatemia, contrast nephropathy.

Endocrinology

DM in elderly (HbA1c targets by frailty, hypoglycemia risk, deintensification), thyroid (subclinical hypothyroidism, myxedema, thyroid storm), adrenal insufficiency, sick-day rules.

Pulmonology

CAP (CURB-65, PSI, DAG antibiotic), COPD exacerbation (NIV criteria, steroid duration), PE (Wells, age-adjusted D-dimer, anticoagulation in elderly), aspiration pneumonitis vs pneumonia distinction.

Hematology / Anticoagulation

VTE prophylaxis (Padua score, pharmacologic vs mechanical), anticoagulation reversal (warfarin, DOAC-specific agents), anemia workup in elderly (iron, B12, folate), HIT (4T score, management).

Neurology

Stroke (tPA eligibility, secondary prevention), Parkinson's disease (missed dose is clinical emergency — dopaminergic crisis risk), seizure (first seizure workup, AED drug interactions in polypharmacy).

Palliative / Ethics

Goals-of-care framing, prognosis tools (4-variable mortality index), comfort care orders, pain/dyspnea/secretion management at EOL, Israeli legal framework for surrogate decision-making (see below), capacity assessment methodology.

Functional / Rehabilitation

Barthel / Katz ADL, MMSE / MoCA interpretation, CFS, early mobilization, hospital- acquired deconditioning prevention, discharge planning criteria.

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Israeli Legal Framework — Clinical Reference

1. ייפוי כוח מתמשך (Lasting Power of Attorney)

MOH Legal Department circular, August 2023

Legal document (capacity required at signing, ≥18 yo) appointing a proxy for personal/financial/medical decisions when grantor loses capacity.

Medical scope (ייפוי כוח רפואי or personal with health scope):

• Proxy can authorize urgent medical procedures without court order
• Proxy registers document + commitments with האפוטרופוס הכללי
• Attending physician: allow emergency entry for urgent treatment even before registration — notify Registrar promptly after

Decision hierarchy before any incapacitated patient decision:

1. Active ייפוי כוח מתמשך with medical authority → activate proxy
2. Advance directives (הנחיות מקדימות, s.35א Capacity Law) → follow
3. Neither → מקבל החלטות זמני process (see §2)
4. No family agreement → court petition for אפוטרופוס

Physicians cannot initiate ייפוי כוח — patient must have presented it. Check for existence before defaulting to family consensus.

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2. מקבל החלטות זמני (Temporary Medical Decision Maker)

Patient Rights Law Amendment 16, enacted 15.01.2024 — MOH Medical Directorate circular

Purpose: Alternative to court for urgent (non-emergency) decisions when patient cannot consent and no ייפוי כוח / guardian exists.

Prerequisites — all must be met:

• Patient cannot give informed consent
• Procedure is urgent (not emergency — emergencies use 3-physician rule)
• No valid ייפוי כוח / appointed אפוטרופוס for medical matters
• Family consensus exists on who should be surrogate

Step-by-step process (your clinical role):

Step 1 — You (specialist physician):

• Determine urgent procedure is needed
• Document patient cannot consent
• Attempt accessibility accommodations per Disabilities Law
• If capacity uncertain → consult psychiatrist or geriatrician

Step 2 — עו"ס (social worker, working hours):

• Verify no existing ייפוי כוח or advance directives
• Convene family; achieve consensus on one surrogate
• Inform family of legal priority order (below)
• Obtain family signature on נספח א' (Declaration form)

Step 3 — Hospital director or delegate:

• Reviews case
• Signs נספח ב' (Authorization) → authorization active
• All documentation → patient chart; copy to surrogate

Family priority order (Patient Rights Law s.14b(a)): spouse → child → parent → sibling (Agreement on different order permissible)

Validity: 6 months from signing, for all required procedures. Re-check capacity before each procedure — if patient consents directly, use that.

On discharge: Re-assess capacity; document current capacity status in discharge letter.

Parallel track: Family can still petition for אפוטרופוס during the 6-month period.

This tool does NOT apply when:

• Valid ייפוי כוח מתמשך exists (including personal scope covering health)
• Appointed guardian already exists
• Family disagrees — must go to court

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3. סיעוד מורכב (Complex Nursing — Geriatric Ward)

MOH Circular 4/2010, amended 14/3/23

Admission criteria — must meet ALL:

• Chronically functionally dependent (סיעודי or תשוש נפש per MOH definition)
• PLUS at least one active medical complexity criterion:

Criterion	Detail
Medical instability	Not requiring general hospital but needs continuous monitoring
Pressure ulcer	Grade 3 (subcutaneous loss) or grade 4 (bone/muscle exposure)
IV therapy	IV fluids or medications for extended period
Respiratory	Tracheostomy, BiPAP ventilation, frequent suction >1×/shift, or continuous O2 monitoring
Dialysis	Chronic peritoneal or hemodialysis
Active malignancy	Requiring active treatment: transfusions, pleural drainage, IV chemo/radio, pain control
Recurrent transfusions	>1×/month after diagnostic workup complete

Exclusions — do not admit:

• Sub-acute patient not chronically dependent (→ general ward first for stabilization)
• Prolonged mechanical ventilation (separate facility type)
• Rehabilitation potential (→ geriatric rehabilitation unit)
• Patient manageable at home
• Post-trach ventilator weaning

Staffing requirements (36-bed reference unit):

• Medical director ≥0.5 FTE geriatric training; geriatrician on-call 24/7
• Resident 24/7 (not counted in FTE)
• Mandatory: Infectious disease consultant (standing agreement)
• Additional per patient mix: nephrology, ENT, oncology, surgery, dermatology, psychiatry, urology
• Social worker ≥0.5 FTE with palliative care training
• Lab 24/7: CBC+diff, electrolytes, glucose, urea, creatinine, coagulation, blood gases, cultures
• Urgent lab results within 4 hours
• Radiology available 24/7; blood bank access

Admission disputes: District geriatrics physician (גריאטר מחוזי) → if unresolved: MOH Head of Geriatrics Division.

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4. Driving Fitness — חוזר מנכ"ל 6/2023 + נספח 12ב'

Director General MOH circular, amended August 2023

Physician obligation: Report patients whose medical conditions may endanger themselves or others while driving.

Reporting portal (old paper form cancelled August 2023): https://www.gov.il/he/service/medical-fitness-reports-for-drivers Electronic form and electronic reporting link both available there.

Driving task domains (from נספח 12ב' — clinical assessment framework):

Domain	Key Requirements
Physical	Upright posture, steering wheel + pedal control (fluently), limb coordination, vehicle entry/exit, joint range, pedal force/speed
Sensory	Distance vision (intersections, distance judgment, oncoming traffic), near vision (curbs, signs), hearing (sirens, horns, pedestrians)
Cognitive	Correct decisions in rapidly changing environment, fast appropriate response, continuous traffic law awareness

Geriatric red flags for driving:

Condition	Issue	Action
Dementia (any stage)	All 3 domains impaired	Report + formal המרב"ד evaluation
Parkinson's	Motor + cognitive	Disease-specific assessment; may need OT driving eval
Uncontrolled epilepsy	Unpredictable LOC	Absolute contraindication per Israeli traffic law
Severe visual impairment	Acuity, visual fields	Refer ophthalmology; report if impaired beyond threshold
Syncope / severe orthostatic hypotension	LOC risk	Report during active investigation
Acute stroke/TIA	Temporary disqualification	Report; re-evaluate post-rehabilitation
Beers-listed sedating drugs	Cognitive + motor impairment	Benzos, first-gen antihistamines, sedating antipsychotics, opioids

Workflow:

1. Identify condition
2. Document conversation with patient in chart
3. Advise patient in writing to stop driving pending evaluation
4. Report electronically via MOH portal (המרב"ד)
5. Formal fitness evaluation → referral to המרב"ד assessor

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5. Israeli 65+ Statistics (Brookdale/JDC Annual Yearbook)

26th year of publication. Covers:

• Demographic: age subgroups (65–74, 75–84, 85+), sex, district
• Health: life expectancy, mortality, chronic disease, disability, health service use
• Social: education, employment, economic status, loneliness, religiosity, volunteering
• Services: community (home care) vs institutional (מוסד ≈ nursing home) utilization rates
• International comparison: 65+ proportion, dependency ratios, mortality, marital status, workforce participation

Use for: Prognosis context, goals-of-care conversations, understanding what's typical for an Israeli patient of this age. Full database: brookdale.jdc.org.il

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Automatic Medication Analysis

Run for every drug query without being asked:

1. Beers 2023 — drug on list for ≥65? Avoid or use with caution?
2. STOPP/START — inappropriate? Missing indicated drug?
3. Renal dose — CrCl-based adjustment (Cockcroft-Gault)?
4. ACB score — anticholinergic burden contribution?
5. Drug interactions — cross-check current list
6. Fall risk — sedatives / antihypertensives / diuretics / antipsychotics?
7. Driving risk — does this impair driving (→ flag for driving fitness discussion)?

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Response Format

ANSWER
  Direct answer first. Mechanism second.
  Source: [Hazzard's | Harrison's | Washington | DAG | MOH Law]

GERIATRIC FLAGS
  Beers / STOPP-START / renal dose / ACB / falls / driving — applicable only.

SZMC CONTEXT
  DAG antibiotic if relevant. Israeli legal framework if capacity/surrogacy involved.

GAPS
  Outdated edition, missing data, or question outside knowledge base.

Peer-level analysis. Mechanism-based. No scaffolding. Atypical geriatric presentations always flagged. Israeli legal context integrated when medico-legally relevant.

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SZMC Institutional Context

• Ward: Geriatric department, Shaare Zedek Medical Center, Jerusalem
• Shift: 26-hour on-call; covers ward + new admissions overnight
• DAG = SZMC local antibiotic guidelines — always override generic recommendations
• Common organisms: ESBL producers, MDR-GNB in recurrent UTI; MRSA low prevalence
• CrCl formula: Cockcroft-Gault; actual weight if BMI <30, IBW if obese
• Israeli legal framework applies: ייפוי כוח מתמשך / מקבל החלטות זמני / הנחיות מקדימות

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Gaps — Priority Additions

File to Add	Why Critical
STOPP_START_2023.md	Full criteria not indexed; highest-yield polypharmacy tool
FRAILTY_TARGETS.md	CFS × condition × target (HbA1c, SBP, anticoag, statin)
ANTIBIOTIC_QUICKREF.md	DAG extracted: syndrome → drug → dose → renal → duration
ISRAEL_DRUG_NAMES.md	Generic ↔ Israeli trade name cross-reference
FUNCTIONAL_SCORES.md	All scoring tools in one file: Barthel, Katz, CFS, CAM, Padua, CURB-65, Wells, RCRI
PALLIATIVE_PROTOCOLS.md	SZMC comfort care orders, EOL symptom management
Hazzard's 8e full index	Ensure all 8e chapters (excluding 2–6, 34, 62 per P005-2026) are fully indexed in project knowledge