Geriatrics is the section of the FNP boards that candidates love to skip. Why? Because the content feels endless. Polypharmacy. Falls. Cognitive decline. Incontinence. Frailty. Pressure injuries. End-of-life care. It can feel like an entire specialty squeezed into a section.
But here's what experienced test-takers know: the questions are predictable. There are about 8 to 12 geriatric-specific concepts the exam reaches for again and again. Master those and you'll outperform 80% of candidates on this section.
Geriatrics on the boards is pattern recognition. The patterns are limited. Learn them.
The Beers Criteria
If you don't know what the Beers Criteria is, learn it now. Updated by the American Geriatrics Society, it lists medications that are potentially inappropriate in older adults. Key drugs to avoid (or use cautiously):
- Benzodiazepines (especially long-acting)
- Antihistamines, first-generation (diphenhydramine)
- Tricyclic antidepressants (amitriptyline)
- NSAIDs (chronic use)
- Muscle relaxants (cyclobenzaprine, carisoprodol)
- Sliding-scale insulin alone
- Glyburide and chlorpropamide
- Anticholinergics broadly
Anticholinergic burden is a recurring exam concept. Drugs with anticholinergic effects → confusion, urinary retention, constipation, falls. The exam loves to ask which drug should be discontinued in a confused elderly patient. It's almost always the anticholinergic.
Polypharmacy
Defined as five or more medications. Each new med adds drug-drug interaction risk and adverse event risk. The exam will ask what your first step is when a polypharmacy patient presents with confusion or falls — answer is almost always medication reconciliation and discontinuation of non-essential drugs.
Falls
Every adult 65+ should be assessed annually for fall risk. If they've had ≥2 falls in the past year, or one fall with injury, or report a gait disturbance — full workup.
The CDC's STEADI algorithm is the most-tested framework. Components:
- Stay Independent screening
- Timed Up and Go test (>12 seconds = increased risk)
- 30-second chair stand
- 4-stage balance test
- Orthostatic vitals
- Medication review (especially psychotropics)
- Vision check
- Vitamin D assessment
- Home safety
Clinical Pearl: The single most modifiable risk factor for falls is medication. Always review the med list first.
Cognitive Screening
Mini-Mental State Exam (MMSE), Mini-Cog, MoCA, and SLUMS are the screening tools you should know. The Mini-Cog is the fastest (3-item recall plus clock draw). MoCA is more sensitive for mild cognitive impairment.
Differentiate the three big diagnoses:
- Dementia — slowly progressive, multiple cognitive domains, persistent, no clouding of consciousness.
- Delirium — acute onset, fluctuating, attention disturbance, often reversible cause (infection, medication, dehydration, hypoxia).
- Depression — affects memory and concentration, can mimic dementia ("pseudodementia"). Reversible with treatment.
The exam will give you a vignette and ask which is which. Acute onset = delirium. Slow + progressive = dementia. Affective symptoms + complaints about memory = depression.
Urinary Incontinence
Categorize:
- Stress — leak with cough, laugh, exercise. First-line: pelvic floor exercises.
- Urge — sudden, intense urgency. First-line: bladder training. Second: anticholinergics or beta-3 agonist (mirabegron).
- Overflow — constant dribbling, incomplete emptying. Check post-void residual.
- Functional — physical or cognitive barrier to reaching the toilet.
Pressure Injuries
- Stage 1: Intact skin, non-blanchable redness.
- Stage 2: Partial-thickness, blister or shallow open ulcer.
- Stage 3: Full-thickness, subcutaneous tissue visible.
- Stage 4: Muscle, bone, or tendon visible.
- Unstageable: Wound base obscured by slough or eschar.
- Deep tissue injury: Intact or non-intact skin with localized purple discoloration.
End-of-Life and Advance Care Planning
- Advance directives, living wills, healthcare power of attorney — know what each does.
- POLST/MOLST — actionable medical orders for seriously ill patients.
- Hospice eligibility: prognosis of 6 months or less if disease runs its expected course.
- Palliative care can occur at any disease stage; hospice is end-of-life.
The Frail Patient
Frailty is a syndrome: weakness, weight loss, exhaustion, slow gait, low activity. Three or more = frail. Frail patients need gentler workups, gentler goals, more attention to function over numbers.
How to Study This Section
Don't try to learn everything. Learn the 8 to 12 concepts above. Drill them until they're instinct. The rest of the section becomes easier when these are solid.