The Elderly Patient

Last updated 1 Jun 2026 · Geriatrics

📋 Key Information Summary

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Ageing is not a disease but involves progressive physiological decline (reduced organ reserve, sarcopenia, osteoporosis, immunosenescence) that lowers the threshold for clinical decompensation.
Dementia affects ≥400,000 Australians; Alzheimer disease accounts for ~70%, vascular dementia ~17%, and Lewy body dementia ~5%. Early diagnosis enables access to cholinesterase inhibitors, carer support, and advance care planning.
Falls are the leading cause of injury-related death in Australians ≥65 years. Multifactorial risk assessment (gait, balance, vision, medications, cognition, home hazards) is the cornerstone of prevention.
Polypharmacy (≥5 medicines) affects ~40% of Australians ≥75 years and is the strongest modifiable risk factor for adverse drug reactions (ADRs), falls, and hospitalisation.
Depression is under-recognised in the elderly; the Geriatric Depression Scale (GDS-15) is the validated screening tool. SSRIs (sertraline, escitalopram) are first-line; avoid tricyclics and benzodiazepines.
Cognitive screening with the MMSE (≥24/30 normal) or MoCA (≥26/30 normal) should be offered when dementia is suspected; refer to a specialist or memory clinic for formal diagnosis.
Donepezil, galantamine, and rivastigmine are PBS-listed for mild-to-moderate Alzheimer disease; memantine is PBS-listed for moderate-to-severe Alzheimer disease (authority required).
A home medicines review (HMR, MBS item 900) should be offered to all patients on ≥5 medicines or at risk of ADRs; a residential medication management review (RMMR, MBS item 903) is available for permanent RACF residents.
The STOPP/START criteria and Beers Criteria are validated tools to identify potentially inappropriate medicines in older adults.
At least 30 minutes of moderate physical activity on most days, plus balance and strength training (e.g., Otago Exercise Programme), reduces falls risk by 20–30%.
Aboriginal and Torres Strait Islander peoples experience dementia at 3–5 times the rate of non-Indigenous Australians and have higher rates of falls, chronic disease, and medication-related harm.
Advance care planning should be initiated early in the disease trajectory, with documentation of substitute decision-maker preferences and resuscitation wishes.

Introduction & Australian Epidemiology

Australia's population is ageing rapidly. In 2023, approximately 17% of Australians were aged ≥65 years, and this proportion is projected to reach 22% by 2050 (Australian Bureau of Statistics). Older adults account for a disproportionate share of GP consultations, hospital admissions, prescription medicines use, and residential aged care facility (RACF) placements.

Geriatric medicine recognises that ageing involves a decline in physiological reserve across all organ systems. This decline, combined with multimorbidity and polypharmacy, makes older patients more vulnerable to acute illness, decompensation, falls, cognitive decline, and adverse drug reactions. Effective care requires a holistic, patient-centred approach that prioritises function, independence, and quality of life alongside disease management.

This guideline addresses four core geriatric domains encountered in Australian primary care: the biology of ageing and health deterioration, dementia assessment and management, falls risk assessment and prevention, and prescribing safety in older adults.

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Key principle: In the elderly, new symptoms should always prompt consideration of acute illness, medication adverse effects, or functional decline before being attributed to "normal ageing." A low threshold for clinical review is essential.

Key Australian Statistics

Metric	Data	Source
Population ≥65 years (2023)	~4.4 million (17%)	ABS 2023
Dementia prevalence	~411,100 (2023)	Dementia Australia 2024
Falls per year (≥65 years)	~1 in 3 people fall annually	AIHW 2023
Falls-related hospitalisations (2021–22)	~236,000	AIHW Injury in Australia
Polypharmacy prevalence (≥75 years)	~40%	PBS data / AIHW
RACF residents	~190,000 permanent residents	GEN Aged Care Data 2023

Ageing & Disease / Deterioration in Health

Physiological Changes of Ageing

Ageing involves predictable declines in organ function that reduce homeostatic reserve. These changes are distinct from disease but lower the threshold at which clinical decompensation occurs. Key changes include:

System	Age-Related Change	Clinical Consequence
Cardiovascular	Increased arterial stiffness, diastolic dysfunction, reduced max HR	Isolated systolic hypertension, reduced exercise capacity, susceptibility to heart failure
Renal	Decline in GFR (~1 mL/min/year after 40), reduced tubular function	Impaired drug clearance, electrolyte disturbance, dehydration
Hepatic	Reduced hepatic mass and blood flow (20–30% decrease)	Slower Phase I metabolism; altered drug half-lives
Musculoskeletal	Sarcopenia (1–2% loss/year after 50), reduced bone mineral density	Frailty, falls, osteoporotic fractures
Neurological	Reduced cerebral blood flow, white matter changes, neurotransmitter decline	Slower processing speed, reduced balance, cognitive decline
Immune	Immunosenescence — reduced T-cell repertoire, blunted vaccine response	Increased infection susceptibility, impaired wound healing, atypical presentations
Gastrointestinal	Reduced gastric acid, delayed gastric emptying, decreased gut motility	Malabsorption (B12, iron, calcium), constipation

The Geriatric Giants

The classic "geriatric giants" describe syndromes that are not inevitable consequences of ageing but result from the interaction of physiological decline, multimorbidity, and environmental factors:

Immobility — loss of independent mobility from any cause; leads to pressure injuries, contractures, DVT, deconditioning
Instability — impaired balance and gait; precursor to falls
Intellectual impairment — delirium, dementia, depression (the "3 Ds")
Incontinence — urinary incontinence affects ~30% of community-dwelling older adults and ~50% of RACF residents
Iatrogenesis — harm caused by medical treatment, most commonly medication-related

Atypical Presentations of Acute Illness

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Critical concept: Older adults frequently present atypically with acute illness. Myocardial infarction may present as confusion or dyspnoea without chest pain. Urinary tract infection may present as falls or behavioural change rather than dysuria. Pneumonia may present without fever or cough. A high index of suspicion is essential.

Delirium is the most common atypical presentation of acute illness in the elderly — always search for underlying cause (infection, medication, metabolic, pain, constipation, urinary retention)
Falls may be the presenting feature of acute infection, cardiac event, stroke, or medication toxicity
Functional decline (new inability to perform ADLs) is a red flag requiring urgent assessment
Reduced appetite / weight loss may signal malignancy, depression, medication side effects, or infection

Comprehensive Geriatric Assessment (CGA)

The CGA is a multidimensional, interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of an older person. It is the gold-standard approach for evaluating geriatric syndromes. Core domains include:

Medical — comorbidities, disease burden, medication review
Functional — activities of daily living (ADLs: Katz Index), instrumental ADLs (Lawton scale)
Cognitive — MMSE, MoCA, or GPCOG screening
Mood — Geriatric Depression Scale (GDS-15)
Social — living situation, carer support, financial stress, social isolation
Environmental — home safety, access to services, transport
Nutritional — Mini Nutritional Assessment (MNA), BMI, weight trend
Advance care planning — goals of care, resuscitation preferences, substitute decision-maker

Dementia (Alzheimer, Vascular, Lewy Body) & Management

Epidemiology

Dementia is the second leading cause of death in Australia and the leading cause of burden of disease among Australians aged ≥65 years. An estimated 411,100 Australians lived with dementia in 2023, projected to reach 849,300 by 2058 (Dementia Australia). Prevalence doubles every 5 years after age 65, reaching ~30% in those aged ≥85 years.

Types of Dementia

Type	Proportion	Key Features	Neuropathology
Alzheimer Disease (AD)	65–70%	Insidious episodic memory loss → visuospatial, language, executive dysfunction. Most common form.	Amyloid-β plaques, neurofibrillary tangles (tau)
Vascular Dementia (VaD)	15–20%	Stepwise decline, executive dysfunction > memory, focal neurological signs, associated with stroke/CVD risk factors	Cerebrovascular disease, lacunar infarcts, white matter lesions
Lewy Body Dementia (DLB)	5–10%	Fluctuating cognition, visual hallucinations, parkinsonism, REM sleep behaviour disorder, neuroleptic sensitivity	Cortical Lewy bodies (α-synuclein)
Frontotemporal Dementia (FTD)	~5%	Behavioural variant (disinhibition, apathy) or primary progressive aphasia. Often younger onset (<65 years).	Tau or TDP-43 aggregates
Mixed Dementia	~10–15%	Combination (most commonly AD + VaD); common in the very elderly	Multiple pathologies

Diagnostic Approach

Diagnosis of dementia in Australian primary care follows a structured process. The GP is the usual first point of contact and plays a central role in early detection, referral, and ongoing management.

Identify Concern

Patient, family, or GP notices memory loss, functional decline, behavioural change, or difficulty with complex tasks. Use the GPCOG (General Practitioner Assessment of Cognition) — a validated, quick (<5 min) screening tool designed for Australian primary care.

Exclude Reversible Causes

Check for delirium, depression (GDS-15), medication effects (anticholinergics, benzodiazepines, opioids), B12/folate deficiency, thyroid dysfunction (TSH), syphilis (if risk factors), and normal pressure hydrocephalus (CT brain if suspected).

Formal Cognitive Testing

MMSE (sensitivity ~85%, specificity ~80% for scores <24) or MoCA (more sensitive for mild cognitive impairment / MCI; score <26/30 abnormal). Adjust for education level and cultural/linguistic background.

Referral for Specialist Assessment

Refer to a geriatrician, neurologist, psychiatrist, or memory clinic for confirmation. This typically includes neuropsychological testing and brain MRI (to assess vascular disease, atrophy patterns, exclude space-occupying lesions).

Ongoing GP-Led Management

Pharmacotherapy, behavioural management, carer support, advance care planning, driving assessment (Austroads guidelines), coordination with My Aged Care and Dementia Support Australia.

Pharmacotherapy for Dementia

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Donepezil

Aricept® · Acetylcholinesterase inhibitor

Indication Mild-to-moderate Alzheimer disease

Adult dose 5 mg PO once daily (night-time); increase to 10 mg after 4–6 weeks if tolerated

Duration Ongoing; review at 3 months, then every 6 months. Discontinue if no perceived benefit or intolerable side effects.

Renal / Hepatic No renal adjustment; use with caution in hepatic impairment

Key ADRs Nausea, diarrhoea, bradycardia, vivid dreams, muscle cramps

PBS status PBS Authority Required

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Galantamine

Reminyl® · Acetylcholinesterase inhibitor

Indication Mild-to-moderate Alzheimer disease

Adult dose 4 mg PO BD (with food); titrate to 8 mg BD after 4 weeks, then 12 mg BD if needed

Renal Max 16 mg/day if eGFR 9–59 mL/min; contraindicated if eGFR <9

Key ADRs Nausea, vomiting, anorexia, weight loss

PBS status PBS Authority Required

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Rivastigmine

Exelon® · Cholinesterase inhibitor

Indication Mild-to-moderate Alzheimer disease and Parkinson disease dementia

Adult dose PO: 1.5 mg BD with food → titrate to 3 mg BD after 2 weeks → 4.5 mg BD → 6 mg BD (max). Transdermal patch: 4.6 mg/24 h → 9.5 mg/24 h → 13.3 mg/24 h

Renal / Hepatic No adjustment; caution in hepatic impairment

Key ADRs GI effects (less with patch), dizziness, headache

PBS status PBS Authority Required

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Memantine

Ebixa® · NMDA receptor antagonist

Indication Moderate-to-severe Alzheimer disease (when cholinesterase inhibitors not tolerated or contraindicated)

Adult dose 5 mg PO once daily → increase by 5 mg weekly to target 10 mg BD (20 mg/day)

Renal Reduce to 10 mg/day if eGFR 5–29 mL/min

Key ADRs Dizziness, headache, constipation, confusion

PBS status PBS Authority Required

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Lewy body dementia — neuroleptic sensitivity: Patients with DLB are exquisitely sensitive to antipsychotics (especially haloperidol). Even low doses can cause severe parkinsonism, neuroleptic malignant syndrome, and increased mortality. Avoid typical antipsychotics; if an antipsychotic is essential, use quetiapine at the lowest effective dose under specialist guidance.

Non-Pharmacological Management

Cognitive stimulation therapy (CST) — group-based programme; evidence for mild-to-moderate dementia
Physical exercise — maintains function, may slow cognitive decline, improves mood
Carer education and support — Dementia Australia (1800 100 500), Dementia Support Australia (1800 699 799), Carer Gateway (1800 422 737)
Environmental modification — reduce clutter, improve signage, maintain routine, safe kitchen and bathroom
Behavioural management strategies — identify triggers for agitation; avoid physical restraint
Advance care planning — initiate early while capacity is preserved; nominate substitute decision-maker under relevant state/territory legislation

Managing Behavioural and Psychological Symptoms of Dementia (BPSD)

BPSD (agitation, aggression, wandering, psychosis, depression, apathy) affect up to 90% of people with dementia at some point. Management follows a stepped approach:

Identify and treat precipitants — pain, constipation, urinary retention, infection, medication effects, environmental triggers
Non-pharmacological strategies first — de-escalation, distraction, music therapy, sensory interventions, consistent routine
Pharmacological options (specialist-recommended):
- Agitation/aggression: citalopram 10–20 mg PO daily (first-line SSRI), risperidone 0.25–0.5 mg PO nocte (PBS authority required for psychosis in dementia)
- Depression: sertraline 50–100 mg or escitalopram 5–10 mg daily
- Avoid: benzodiazepines (increased falls, paradoxical agitation), anticholinergics, typical antipsychotics in DLB

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Driving and dementia: Under Austroads guidelines, patients diagnosed with dementia must be reported to the relevant state/territory licensing authority. Mild dementia may allow conditional licensing (e.g., short local trips) with regular specialist review; moderate-to-severe dementia requires cessation of driving. The GP should document the discussion and notification.

Falls in the Elderly (Diagnostic Model, Prevention)

Australian Burden

Falls are the leading cause of injury-related hospitalisation and death in Australians aged ≥65 years. In 2021–22, there were approximately 236,000 fall-related hospitalisations in this age group. Hip fractures carry a 12-month mortality of 20–30%, and ~50% of survivors never regain pre-fracture functional level. The estimated annual cost of falls in older Australians exceeds .3 billion.

Risk Factor Assessment — Multifactorial Model

The Australian Commission on Safety and Quality in Health Care (ACSQHC) recommends a multifactorial falls risk assessment for all older adults who present after a fall or report recurrent falls. Key domains include:

Domain	Assessment Tool / Approach	Modifiable?
Gait & Balance	Timed Up and Go (TUG); ≥12 seconds = increased risk. Berg Balance Scale. 4-Stage Balance Test.	Yes — physiotherapy, exercise
Muscle Strength	Chair stand test (>14 seconds for 5 stands = weakness). Handgrip dynamometry.	Yes — resistance exercise, nutrition, vitamin D
Vision	Visual acuity, cataracts, macular degeneration, depth perception	Yes — optometry referral, cataract surgery
Medications	Review for falls-risk drugs (see below); polypharmacy review	Yes — deprescribing
Cognitive / Delirium	MMSE/MoCA, assess for delirium (CAM tool), depression (GDS-15)	Partially
Postural Hypotension	Lying-standing BP (≥20/10 mmHg drop = orthostatic)	Yes — hydration, medication review, compression stockings
Feet & Footwear	Podiatry assessment; check for ill-fitting shoes, neuropathy	Yes
Home Hazards	Home safety assessment (OT-led) — rugs, lighting, stairs, grab rails, bathroom safety	Yes
Continence	Nocturia, urgency, urge incontinence → rushing to toilet	Yes — bladder training, medication

Medications That Increase Falls Risk

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High-risk medications for falls: Any sedative or psychoactive medication increases falls risk. Benzodiazepines (OR ~1.5–2.0), antipsychotics (OR ~1.5–2.0), opioids (OR ~1.7), and antidepressants — particularly SSRIs/SNRIs (OR ~1.4–1.7) — are the most commonly implicated. Antihypertensives, especially when causing orthostatic hypotension, also contribute significantly. Gradual dose reduction should be attempted where safe.

Falls Prevention Strategies — Evidence Base

Strong Evidence

Exercise Programmes

Supervised exercise incorporating balance and strength training reduces falls by 23–30%. The Otago Exercise Programme (home-based, physiotherapist-supervised) is the gold standard.

Setting: Community / Home

Strong Evidence

Multifactorial Intervention

Individualised assessment + targeted interventions (exercise, medication review, home modification, vision correction, vitamin D) reduces falls by 15–25%.

Setting: Primary care led

Strong Evidence

Vitamin D Supplementation

Recommended for all older adults at risk of falls or vitamin D deficiency. Cholecalciferol 1000 IU daily (PBS-listed as General Benefit). Reduces falls in institutionalised elderly; evidence for community-dwelling mixed.

Setting: Community / RACF

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Cholecalciferol (Vitamin D3)

Various · Vitamin D supplement

Adult dose 1,000 IU PO once daily (maintenance); 3,000–5,000 IU daily for 6–12 weeks if deficient, then recheck

Renal Use calcitriol (0.25 mcg daily) if eGFR <30 mL/min (specialist guidance)

PBS status PBS General Benefit (1000 IU)

Post-Fall Assessment Algorithm

Acute Assessment

Exclude injury (fracture, head injury, soft tissue), assess for underlying acute illness (infection, cardiac event, stroke), check lying-standing BP, ECG, bloods (FBC, EUC, glucose, TFTs, B12)

Falls Risk Review

Multifactorial risk assessment (see table above). Identify intrinsic and extrinsic factors. Use TUG and chair stand test.

Intervention

Refer to physiotherapy (exercise programme), OT (home assessment), optometry, podiatry. Review and reduce falls-risk medications. Prescribe vitamin D. Consider hip protectors for RACF residents.

Follow-Up

Reassess at 4–6 weeks and 3 months. Monitor for recurrent falls. Update GP Management Plan (MBS item 721) and Team Care Arrangement (MBS item 723) to coordinate multidisciplinary care.

Osteoporosis and Fracture Prevention

All older adults who fall should have fracture risk assessed. Use the FRAX tool (incorporated into Australian clinical practice) or the Garvan calculator (developed in Australia). A DEXA scan should be arranged if not performed within the past 2 years and fracture risk is elevated. Consider bisphosphonate therapy (alendronate 70 mg PO weekly, PBS-listed) or denosumab (60 mg SC every 6 months) if indicated.

Prescribing & Adverse Drug Reactions in the Elderly

The Scale of the Problem

Australians aged ≥65 years account for ~15% of the population but consume ~40% of all prescription medicines. Approximately 40% of Australians aged ≥75 years take ≥5 regular medicines (polypharmacy). ADRs cause 2–3% of all hospital admissions in older adults, and up to 30% of these are considered preventable. Medication-related problems cost the Australian health system an estimated

.4 billion annually.

Principles of Prescribing in the Elderly

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START low, GO slow, but GO! — Start with lower doses and titrate gradually, but do not withhold necessary treatment due to age alone. The goal is to use the minimum effective dose of appropriate medications while avoiding potentially inappropriate medicines (PIMs).

Indication for every medicine — ensure each drug has a clear, ongoing indication; question continuation of long-term medications regularly
Consider pharmacokinetic changes — reduced renal clearance (use Cockcroft-Gault or measured eGFR), reduced hepatic metabolism (Phase I), altered volume of distribution (increased body fat:water ratio), decreased serum albumin
Start low, titrate slowly — begin at the lower end of the dose range; allow adequate time between dose changes
Prefer short-acting agents — avoid long-acting benzodiazepines, long-acting sulfonylureas, digoxin (narrow therapeutic index, renal dependence)
Avoid therapeutic cascades — recognise when a new symptom is an ADR of an existing medicine and avoid adding another drug to treat it
Use once-daily dosing where possible — improves adherence
Regular medication review — at least annually, or with any change in health status, hospital discharge, or transition to RACF

STOPP/START Criteria

The STOPP/START criteria (v2, 2015) are evidence-based screening tools for potentially inappropriate prescribing in older adults, validated in European and Australian settings.

STOPP (Screening Tool of Older Persons' Prescriptions)

Identifies potentially inappropriate medicines. Key examples relevant to Australian practice:

Long-term benzodiazepines (>4 weeks)
Anticholinergics in dementia or cognitive impairment
NSAIDs with heart failure, CKD, or hypertension
Proton pump inhibitors >8 weeks without clear indication
Sulfonylureas with long duration of action (glibenclamide) — hypoglycaemia risk
Opioids for >2 weeks without pain review
Antipsychotics in dementia without BPSD or behavioural specialist input

START (Screening Tool to Alert to Right Treatment)

Identifies potentially omitted beneficial medicines. Key examples:

Vitamin D in recurrent falls or institutionalised elderly
ACE inhibitor/ARB in heart failure with reduced EF
Statin therapy if established cardiovascular disease and no contraindication
Antiplatelet therapy in established atherosclerotic disease
Bone protection (bisphosphonate) in osteoporosis with fracture history
Influenza and pneumococcal vaccination
Laxatives with regular opioid use

Common Adverse Drug Reactions in the Elderly

ADR / Syndrome	Commonly Implicated Medicines	Clinical Features
Falls	Benzodiazepines, opioids, antipsychotics, antidepressants, antihypertensives	Unsteadiness, syncope, injury
Delirium	Anticholinergics, benzodiazepines, opioids, corticosteroids, antipsychotics	Acute confusion, fluctuating consciousness, inattention
GI Bleeding	NSAIDs, aspirin, anticoagulants (especially combinations)	Haematemesis, melaena, anaemia
Acute Kidney Injury	NSAIDs, ACE inhibitors/ARBs, diuretics, aminoglycosides, contrast agents ("triple whammy")	Rising creatinine, oliguria, hyperkalaemia
Hyponatraemia	SSRIs, carbamazepine, thiazide diuretics, ACE inhibitors	Confusion, nausea, seizures (if severe)
Hypoglycaemia	Sulfonylureas (especially glibenclamide), insulin	Sweating, tremor, confusion, falls, seizures
Constipation	Opioids, anticholinergics, calcium channel blockers (verapamil), iron, calcium supplements	Infrequent stools, abdominal pain, overflow incontinence

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The "prescribing cascade" — a common pitfall: Patient prescribed amlodipine → develops ankle oedema → prescribed furosemide → develops gout → prescribed allopurinol → develops rash. Always ask: "Could this new symptom be caused by an existing medication?" before prescribing.

Home Medicines Review (HMR) — MBS Item 900

The HMR programme enables GPs to refer eligible patients to a pharmacist for a comprehensive medication review conducted in the patient's home. Eligibility includes patients:

Taking ≥5 regular prescription medicines
Taking ≥12 doses of medicines per day
Recently discharged from hospital (within 2 weeks) with medication changes
With a significantADR or compliance concern
With dementia, cognitive impairment, or dexterity problems affecting self-administration

The pharmacist provides a written report to the GP, who discusses the recommendations with the patient and implements agreed changes. The service is fully funded under Medicare (no out-of-pocket cost to the patient).

Residential Medication Management Review (RMMR) — MBS Item 903

Available for permanent residents of residential aged care facilities. Conducted by an accredited pharmacist on referral from the resident's GP. Required on admission, with significant clinical changes, and at least annually (in line with Aged Care Quality Standards). The RMMR report includes a medication management plan agreed between the pharmacist and GP.

Deprescribing — A Structured Approach

Deprescribing is the planned and supervised process of dose reduction or stopping of medication that might be causing harm or is no longer of benefit. Key principles:

Comprehensive Medication Review

Ascertain all medicines (including OTC, supplements, complementary). Identify PIMs using STOPP/START or Beers criteria. Prioritise based on risk-benefit.

Patient Engagement

Discuss rationale for stopping/reducing. Address patient fears ("My specialist started this"). Use shared decision-making. Provide written plan.

Gradual Withdrawal

Taper one medicine at a time. Example: benzodiazepines reduce by 10–25% every 1–2 weeks. PPIs step down to alternate day → PRN. Opioids taper 10% weekly.

Monitor

Review at 2–4 weeks after each change. Watch for withdrawal effects or disease recurrence. Continue with next medicine only after stability confirmed.

Vaccinations in the Elderly — Australian Recommendations

Vaccine	Schedule	Funding
Influenza (annual)	Every autumn; high-dose (Fluzone® High-Dose) or adjuvanted (Fluad®) preferred for ≥65 years	Free under NIP for ≥65 years
Pneumococcal (23vPPV)	Single dose at ≥65 years; consider PCV13 first if immunocompromised (specialist advice)	Free under NIP for ≥65 years
Shingles (Shingrix®)	2 doses (0, 2–6 months) for adults ≥65 years	Free under NIP for 65 years (catch-up to 2025)
COVID-19	Recommended every 12 months for ≥65 years (or per current ATAGI advice)	Free under NIP
Pertussis (dTpa)	One dose if not received in adulthood; boost every 10 years if at risk	Free under NIP (as dTpa booster)

Investigations in the Elderly

Investigations in older adults should be guided by clinical context, not by age alone. Avoid routine screening batteries in asymptomatic elderly; instead, target investigations to clinical questions. Conversely, do not withhold necessary investigations based on age.

Baseline / Screening Investigations

Essential Full Blood Count (FBC) Anaemia of ageing, occult blood loss, haematological malignancy. Available at all pathology providers.

Essential Electrolytes, Urea, Creatinine (EUC) + eGFR Renal function assessment; essential for drug dosing. Use Cockcroft-Gault for medication dosing.

Essential Liver Function Tests (LFTs) Baseline hepatic function; medication monitoring.

Essential Thyroid Function (TSH ± fT4) Hypo- and hyperthyroidism common in elderly; reversible cause of cognitive decline.

Essential Vitamin B12 and Folate Deficiency common in elderly (reduced absorption, PPI use); reversible cause of cognitive/neuropsychiatric symptoms.

Available Vitamin D (25-OH) Deficiency common (≥50% of elderly Australians); essential if falls, osteoporosis, or institutionalised. MBS rebate available.

Available Calcium, Phosphate, ALP Bone metabolism; osteoporosis workup. PTH if calcium abnormal.

Available HbA1c Diabetes screening/monitoring. Consider relaxed targets (7–8.5%) in frail elderly with limited life expectancy.

Available Urinalysis / Urine MCS Only if symptomatic (dysuria, frequency, confusion). Asymptomatic bacteriuria is common in elderly — do NOT treat.

Available ECG (12-lead) Baseline; atrial fibrillation screening; QTc assessment if starting QT-prolonging drugs; falls assessment.

Referral CT / MRI Brain For cognitive decline assessment (exclude NPH, stroke, tumour) or post-fall head injury. MRI preferred for dementia workup.

Referral DEXA (Bone Densitometry) Fracture risk assessment. MBS item 12310 (eligible if FRAX/Garvan high risk, or ≥70 years with risk factors).

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Avoid asymptomatic bacteriuria treatment: The prevalence of asymptomatic bacteriuria rises to 20–50% in elderly women and 15–40% in elderly RACF residents. It does NOT require treatment in the absence of symptoms (urinary urgency, dysuria, suprapubic pain, fever, rigors). Treating asymptomatic bacteriuria drives antibiotic resistance and Clostridioides difficile infection.

Special Populations Within the Elderly

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The Frail Elderly (≥80 years)

Frailty is a distinct clinical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. The Clinical Frailty Scale (CFS, 1–9) is widely used; scores ≥5 indicate moderate-severe frailty.

Avoid aggressive targets for blood pressure (target <150/90 if ≥80; avoid SBP <120), HbA1c (7.5–8.5% acceptable), and cholesterol in the frail.

Medication review frequency: every 3 months for CFS ≥5

Consider goals of care discussions; comfort-focused care may be appropriate.

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Elderly with Chronic Kidney Disease

CKD affects ~40% of Australians ≥65 years. Many drugs require renal dose adjustment: metformin (avoid if eGFR <15, reduce if <30), lithium, digoxin, DOACs, gabapentin, allopurinol, colchicine.

Use Cockcroft-Gault for drug dosing (not CKD-EPI eGFR). Avoid NSAIDs. Review all renally cleared medicines at every visit.

Refer to nephrology if eGFR <30 with rapid decline, proteinuria, or unexplained anaemia.

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RACF Residents

RACF residents are the fralest elderly population. They have high rates of dementia (~52%), polypharmacy (~60% take ≥9 regular medicines), falls, incontinence, and depression.

RMMR (MBS item 903) is required on admission and annually. Psychotropic medication use (antipsychotics, benzodiazepines) must be minimised in line with Aged Care Quality Standards.

Antipsychotic use in RACF has been the subject of Aged Care Royal Commission recommendations. Must have documented indication, specialist input, regular review, and behaviour management plan.

Advance care plan and resuscitation status should be documented on admission.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples experience dementia, falls, and medication-related harm at significantly higher rates than non-Indigenous Australians. Culturally safe, trauma-informed care is essential. Engage Aboriginal and Torres Strait Islander health workers and liaison officers wherever available.

Dementia burden

Aboriginal and Torres Strait Islander peoples experience dementia at 3–5 times the rate of non-Indigenous Australians, with earlier onset (often ≥50 years compared to ≥65 years). The Kimberley Indigenous Cognitive Assessment (KICA) tool is validated for use with Aboriginal and Torres Strait Islander peoples and should be used instead of the MMSE in these populations.

Falls and injury

Falls-related hospitalisation rates are 1.5–2 times higher for Aboriginal and Torres Strait Islander peoples, particularly in remote communities. Risk factors include overcrowded housing, uneven ground surfaces, reduced access to allied health services, and higher rates of chronic disease. Hip fracture outcomes are poorer due to delayed access to surgical care.

Medication safety

Polypharmacy rates are high in Aboriginal and Torres Strait Islander peoples with multimorbidity. Barriers include limited access to HMR services in remote areas, health literacy challenges, blister pack availability, and distance from pharmacies. Medication Continuity of Care (MBS item 900) should be offered where available.

Access to services

Specialist geriatric services, memory clinics, and aged care assessments are limited in regional and remote areas. Telehealth (Medicare-subsidised since 2020) can bridge the gap. Aboriginal Community Controlled Health Organisations (ACCHOs) provide holistic care and should be the primary point of contact where available.

Cultural considerations

Dementia may be understood differently in Aboriginal and Torres Strait Islander communities — associated with spiritual causes, ageing, or normalised. Family and community decision-making may differ from Western models. Use culturally validated resources (Dementia Australia's Aboriginal and Torres Strait Islander resources, Yarning about Dementia toolkit). Ensure gender-concordant health workers for sensitive discussions.

Life expectancy gap

The life expectancy gap is ~8 years for both males and females. Geriatric syndromes present 10–20 years earlier in Aboriginal and Torres Strait Islander peoples. Chronic disease management plans (MBS item 721) and Team Care Arrangements (MBS item 723) should be initiated proactively for all Aboriginal and Torres Strait Islander patients aged ≥50 years with multimorbidity.

Advance Care Planning

Advance care planning (ACP) is a communication process that enables individuals to define their goals and preferences for future medical care. It should be initiated early in the disease trajectory — ideally while the person retains decision-making capacity — and revisited regularly.

Key Components

Goals of care discussion — explore the patient's values, what matters most to them, and what treatments they would or would not want (e.g., ICU admission, CPR, artificial nutrition)
Substitute decision-maker — formally nominate under relevant state/territory legislation (e.g., Enduring Power of Attorney / Enduring Guardian)
Advance care directive (ACD) — a written, legally recognised document that records the person's treatment preferences. Each state/territory has specific requirements.
Resuscitation plan — document using the national Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form where available
Integration with My Health Record — upload ACD and substitute decision-maker details where the patient consents

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ACP conversations attract MBS funding under chronic disease management items (MBS items 721, 723) and health assessments (MBS item 707 for ≥75 years). End-of-life items (MBS items 961–965) provide additional funding for terminal care planning.

📚 References

1. Dementia Australia. Dementia Prevalence Data 2023–2058. Canberra: Dementia Australia; 2024. Available from: dementia.org.au
2. Australian Institute of Health and Welfare (AIHW). Injury in Australia: Falls. AIHW; 2023. Cat. no. INJ 4.
3. Australian Commission on Safety and Quality in Health Care (ACSQHC). Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Residential Aged Care Facilities. 3rd ed. Sydney: ACSQHC; 2021.
4. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–218.
5. American Geriatrics Society (AGS). Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: 2023 update. J Am Geriatr Soc. 2023;71(7):2052–2081.
6. Hilmer SN, Gnjidic D. The effects of polypharmacy in older adults. Clin Pharmacol Ther. 2009;85(1):86–88.
7. Sherrington C, Fairhall N, Wallbank G, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019;1:CD012424.
8. Thomas S, Mackintosh S, Halbert J. Does the 'Otago exercise programme' reduce mortality and falls in older adults?: a systematic review and meta-analysis. Age Ageing. 2010;39(6):681–687.
9. Flicker L, Holdsworth K. Aboriginal and Torres Strait Islander people and dementia: a review of the research. Alzheimers Dement. 2021;17(7):1144–1155.
10. Smith K, Flicker L, Lautenschlager NT, et al. High prevalence of dementia and cognitive impairment in Indigenous Australians. Neurology. 2008;71(19):1470–1473.
11. Austroads. Assessing Fitness to Drive. 4th ed. Sydney: Austroads; 2022.
12. Royal Australian College of General Practitioners (RACGP). Medical Care of Older Persons in Residential Aged Care Facilities. 4th ed. Melbourne: RACGP; 2006 (updated 2019).
13. Australian Government Department of Health and Aged Care. National Immunisation Program Schedule. Canberra: Commonwealth of Australia; 2024.
14. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392–397.
15. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827–834.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).