GRS Table of Contents

AGS Staff
Linda Hiddemen Barondess, Executive Vice President
Nancy Lundebjerg, MPA, Associate Vice President, Education, Communications, and Publications
Elvy Ickowicz, MPH, Senior Director, Education, Communications, and Special Projects
Linda Saunders, MSW, Senior Director, Professional Education and Special Projects
Dennise McAlpin, Manager, Professional Education and Special Projects

Fry Communications, Inc.
Melissa Durborow, Information Services Manager
Terry Plyler, Content Management Architect
Jason Hughes, Technical Services Manager
Robyn Diven, Compositor
Julie Stevens, Customer Service

ACKNOWLEDGMENTS

As the editors, it is our pleasure and privilege to acknowledge the many people who have made the Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th Edition (GRS6) possible.

We express our gratitude to the Syllabus Editors: Colleen Christmas, MD; Steven R. Counsell, MD; G. Paul Eleazer, MD; Anne R. Fabiny, MD; Susan K. Schultz, MD; and to the Question Editors: William J. Burke, MD; Alison A. Moore, MD, MPH; and Gail M. Sullivan, MD, MPH; all of them devoted countless hours to the development of this program. We are thankful for the assistance from our Special Advisors: James T. Pacala, MD, MS; and Stephanie Studenski, MD, MPH; as well as our Consulting Editors: Carmel Bitondo Dyer, MD; and Todd P. Semla, PharmD, MS. Special thanks also to our Consulting Question Reviewers: Itamar B. Abrass, MD; and Jane F. Potter, MD. We also appreciate the outside chapter review by David H. Stern, MD. On behalf of all these editors, we thank the contributing authors for lending us their expertise in the various fields of medicine covered in this publication.

We thank Andrea Sherman, MS, GRS Managing Editor, for her guidance, organization, and coordination overseeing the administrative, editorial, and distribution aspects of the program. Her tireless dedication to ensuring that the GRS is of the highest quality and to making sure the train runs on time is instrumental to our success. So too, Barbara B. Reitt, PhD, ELS(D), is an extraordinary medical editor whose fine hand is evident throughout the GRS and whose wise guidance on production is always on target. Thanks also go to Dalia Ritter for editing the first round of questions and critiques, helping us to ensure that these are consistent with the questions that you will face on secure Board exams, and to L. Pilar Wyman for her comprehensive index of the GRS, which contributes greatly to its ease of use.

We wish to express our appreciation for their ongoing support to the AGS Board of Directors and to Linda Hiddemen Barondess, AGS Executive Vice President; Nancy Lundebjerg, MPA, Associate Vice President, Education, Communications and Special Projects; Elvy Ickowicz, MPH, Senior Director, Education, Communications, and Special Projects; Linda Saunders, MSW, Senior Director, Professional Education and Special Projects; and Dennise McAlpin, Manager, Professional Education and Special Projects.

We also give special thanks to the administrative assistants and secretaries of the editors and contributing authors for their contributions and assistance in preparing the initial drafts of the chapters, questions and critiques. We want to express thanks to our patients, who keep us honest and teach us so much. Finally, and most importantly, we thank our families.

Peter Pompei, MD
John B. Murphy, MD
Chief Editors

EDITORS

Editorial Board

Chief Editors

Peter Pompei, MD
Chief Editor, Syllabus
Associate Professor of Medicine
Stanford University School of Medicine
Stanford, CA

John B. Murphy, MD
Chief Editor, Questions
Director of Graduate Medical Education, Lifespan
Associate Director, Division of Geriatrics, Department of Medicine
Professor of Medicine and Family Medicine
Brown Medical School
Office of Graduate Medical Education
Providence, RI

Syllabus Editors

Colleen Christmas, MD
Assistant Professor of Medicine
Johns Hopkins University School of Medicine
Division of Geriatric Medicine and Gerontology
Baltimore, MD

Steven R. Counsell, MD
Mary Elizabeth Mitchell Professor of Geriatrics
Director, Indiana University Geriatrics Program
Indiana University School of Medicine
Indianapolis, IN

G. Paul Eleazer, MD
Director, Division of Geriatrics
University of South Carolina, School of Medicine
Columbia, SC

Anne R. Fabiny, MD
Assistant Professor of Medicine
Harvard Medical School
Boston, MA

Susan K. Schultz, MD
Associate Professor, Department of Psychiatry
University of Iowa College of Medicine
Iowa City, IA

Question Editors

William J. Burke, MD
Professor and Vice Chair, Psychiatry
University of Nebraska Medical Center
Omaha, NE

Alison A. Moore, MD, MPH
Associate Professor of Medicine
David Geffen School of Medicine at UCLA
Division of Geriatrics
Los Angeles, CA

Gail M. Sullivan, MD, MPH
Associate Professor of Medicine
Associate Director for Education
UConn Center on Aging
University of Connecticut School of Medicine
Farmington, CT

Consulting Editor for Pharmacotherapy

Todd P. Semla, MS, PharmD
Clinical Pharmacy Specialist
Department of Veterans Affairs
Pharmacy Benefits Management & Strategic Health Group
Hines, IL
Associate Professor
Department of Psychiatry and Behavioral Sciences
The Feinberg School of Medicine
Northwestern University
Chicago, IL

Consulting Editor for Ethnogeriatrics

Carmel Bitondo Dyer, MD
Associate Professor of Medicine
Baylor College of Medicine
Director, Geriatrics Program
Harris County Hospital District
Houston, TX

Special Advisors

James T. Pacala, MD, MS
Associate Professor
Distinguished University Teaching Professor
Department of Family Medicine and Community Health
University of Minnesota Medical School
Minneapolis, MN

Stephanie Studenski, MD, MPH
Professor, Department of Medicine (geriatrics)
Staff Physician, VA Pittsburgh GRECC
Pittsburgh, PA

Consulting Question Reviewers

Itamar B. Abrass, MD
Professor and Division Head,
Gerontology and Geriatric Medicine
University of Washington
Harborview Medical Center
Seattle, WA

Jane F. Potter, MD
Harris Professor of Geriatric Medicine
Chief, Section on Geriatrics and Gerontology
Department of Internal Medicine
University of Nebraska Medical Center
Omaha, NE

CONTRIBUTING CHAPTER AUTHORS

Sumaira Z. Aasi, MD
Assistant Professor
Department of Dermatology
Yale University School of Medicine
New Haven, CT

Harold P. Adams, Jr., MD
Professor and Director
Division of Cerebrovascular Diseases, Department of Neurology
University of Iowa Hospitals and Clinics
Iowa City, IA

Reva N. Adler, MD, MPH
Medical Director, STAT Centre and At-home Supports
Vancouver Hospital & Vancouver Community Health Services
Clinical Associate Professor, Division of Geriatric Medicine
University of British Columbia
Vancouver, BC

Marc E. Agronin, MD
Director of Mental Health Services
Miami Jewish Home and Hospital for the Aged
Assistant Professor of Psychiatry
Miller School of Medicine at the University of Miami
Miami, FL

Cathy A. Alessi, MD
Associate Director
Clinical Programs: Geriatric Research, Education and Clinical Center, Sepulveda Division
Veterans Administration Greater Los Angeles Healthcare System
Professor, University of California, Los Angeles
Multicampus Program in Geriatric Medicine and Gerontology
Sepulveda, CA

Neil B. Alexander, MD
Professor, Division of Geriatric Medicine
Department of Internal Medicine
Research Professor, Institute of Gerontology
University of Michigan
Director, VA Ann Arbor Health Care System Geriatric Research, Education and Clinical Center
Ann Arbor, MI

Wilbert S. Aronow, MD
Clinical Professor of Medicine
Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care
Westchester Medical Center and New York Medical College
Valhalla, NY
Adjunct Professor of Geriatrics and Adult Development
Mount Sinai School of Medicine
New York, NY

Priscilla Faith Bade, MD, MS
Associate Professor of Internal Medicine
University of South Dakota School of Medicine
Rapid City, SD

Cynthia Barton, RN, MSN
Gerontological Nurse Practitioner
Memory and Aging Center
Assistant Clinical Professor, School of Nursing
University of California, San Francisco
San Francisco, CA

Marc R. Blackman, MD
Chief, Endocrine Section
Laboratory of Clinical Investigation
National Center for Complementary and Alternative Medicine
National Institutes of Health
Bethesda, MD

Caroline S. Blaum, MD, MS
Associate Professor of Internal Medicine
Division of Geriatric Medicine
University of Michigan
Research Scientist, Ann Arbor DVAMC Geriatric Research, Education and Clinical Center
Ann Arbor, MI

Harrison G. Bloom, MD
Senior Associate
International Longevity Center, USA
Associate Clinical Professor
Brookdale Department of Geriatrics and Adult Development
Mount Sinai School of Medicine
New York, NY

Chad Boult, MD, MPH, MBA
Professor of Public Health
Director, Lipitz Center for Integrated Health Care
Johns Hopkins Bloomberg School of Public Health
The Johns Hopkins University
Baltimore, MD

Cynthia J. Brown, MD
GRECC Investigator
Medical Director
Falls Prevention and Mobility Clinic
Birmingham/Atlanta VA Geriatric Research, Education and Clinical Center
Assistant Professor
University of Alabama at Birmingham
Birmingham, AL

David M. Buchner, MD, MPH
Chief, Physical Activity and Health Branch, Division of Nutrition and Physical Activity
Centers for Disease Control and Prevention
Atlanta, GA

Lynda C. Burton, ScD
Associate Professor
Department of Health Policy and Management
The Johns Hopkins Bloomberg School of Public Health
Baltimore, MD

David Bush, MD
Director, Cardiac Catheterization Laboratory
Johns Hopkins Bayview Medical Center
Associate Professor of Medicine
Division of Cardiology
The Johns Hopkins University School of Medicine
Baltimore, MD

Erin L. Cassidy, PhD
Research Associate
Department of Psychiatry and Behavioral Sciences
Stanford University School of Medicine
Palo Alto, CA

Gurkamal S. Chatta, MD
Associate Professor of Medicine
Division of Hematology-Oncology
University of Pittsburgh
Pittsburgh, PA

Colleen Christmas, MD
Assistant Professor of Medicine
Division of Geriatric Medicine and Gerontology
The Johns Hopkins University School of Medicine
Baltimore, MD

Anne L. Coleman, MD, PhD
Professor of Ophthalmology and Epidemiology
Frances and Ray Stark Chair of Ophthalmology
Jules Stein Eye Institute
University of California, Los Angeles
Los Angeles, CA

Leo M. Cooney, Jr., MD
Humana Foundation Professor of Geriatric Medicine
Chief, Section of Geriatric Medicine
Yale University School of Medicine
New Haven, CT

G. Willy Davila, MD
Chairman, Department of Gynecology
Head, Section of Urogynecology and Reconstructive Pelvic Surgery
Cleveland Clinic Florida
Ft. Lauderdale, FL

Margaret A. Drickamer, MD
Associate Professor of Medicine (Geriatrics)
Yale University School of Medicine
New Haven, CT

Catherine E. DuBeau, MD
Associate Professor of Medicine
Section of Geriatrics
University of Chicago
Chicago, IL

Pamela W. Duncan, PhD
Professor, College of Medicine
Career Health Scientist-Department of Veteran Affairs
Director of Department of Veterans Affairs Center of Excellence in Rehabilitation Outcomes
Department of Aging and Geriatrics Research
Co-Director, Institute of Aging
Department of Aging and Geriatric Research
University of Florida
Gainseville, FL

G. Paul Eleazer, MD
Director, Division of Geriatrics
University of South Carolina School of Medicine
Columbia, SC

E. Wesley Ely, MD, MPH
Associate Professor of Medicine
Associate Director of Aging Research
Tennessee Valley Geriatric Research, Education and Clinical Center
Allergy, Pulmonary and Critical Care
Vanderbilt University School of Medicine
Nashville, TN

William B. Ershler, MD
Director
Institute for Advanced Studies in Aging and Geriatric Medicine
Washington, DC

Terry T. Fulmer, PhD, RN
The Erline Perkins McGriff Professor and Dean
College of Nursing
New York University
New York, NY

Angela Gentili, MD
Associate Professor of Internal Medicine
Director, Geriatrics Fellowship Training Program
VA Medical Center/Virginia Commonwealth University
Richmond, VA

Thomas M. Gill, MD
Associate Professor of Medicine
Yale University School of Medicine
New Haven, CT

Lisa J. Granville, MD
Professor and Associate Chair
Department of Geriatrics
Florida State University College of Medicine
Tallahassee, FL

David A. Gruenewald, MD
Associate Professor of Medicine
Division of Gerontology and Geriatric Medicine
Department of Medicine
University of Washington School of Medicine
Staff Physician, Geriatrics Research, Education and Clinical Center
VA Puget Sound Health Care System
Seattle, WA

Arthur E. Helfand, DPM
Professor Emeritus
Temple University School of Podiatric Medicine
Retired Chair, Department of Community Health, Aging & Health Policy
Adjunct Professor, Department of Medicine
Temple University School of Medicine
Philadelphia, PA

Kenneth W. Hepburn, PhD
Professor and Associate Dean for Research
School of Nursing
University of Minnesota
Minneapolis, MN

Kevin Paul High, MD, MSc
Associate Professor of Medicine
Sections of Infectious Diseases and Hematology/Oncology
Wake Forest University School of Medicine
Winston Salem, NC

Gordon L. Jensen, MD, PhD
Director, Vanderbilt Center for Human Nutrition
Professor of Medicine
Vanderbilt University Medical Center
Nashville, TN

Donald A. Jurivich, DO
Chief, Section of Geriatric Medicine
Vitoux Associate Professor of Medicine
University of Illinois at Chicago Medical School
Chicago, IL

Jennifer M. Kapo, MD
Assistant Professor of Clinical Medicine
Division of Geriatrics
University of Pennsylvania
Philadelphia, PA

Judith D. Kasper, PhD
Professor, Department of Health Policy and Management
The Johns Hopkins University Bloomberg School of Public Health
Baltimore, MD

Jurgis Karuza, PhD
Visiting Professor of Rochester Medical Center
Rochester, NY
Professor and Chair, Psychology Department
State University College at Buffalo
Buffalo, NY

Paul R. Katz, MD
Professor of Medicine
Chief, Division of Geriatrics
University of Rochester School of Medicine and Dentistry
Rochester, NY

Catherine Lee Kelleher, MD
Nephrology Division
Denver Health Medical Center
University of Colorado Medical Center
Denver, CO

Gary J. Kennedy, MD
Professor of Psychiatry and Behavioral Science
Albert Einstein College of Medicine
Director, Division of Geriatric Psychiatry
Montefiore Medical Center
Bronx, NY

Anne M. Kenny, MD
Associate Professor of Medicine
UConn Center on Aging
University of Connecticut Health Center
Farmington, CT

Douglas P. Kiel, MD, MPH
Associate Professor of Medicine
Harvard Medical School Division on Aging
Director, Medical Research
HRCA Research and Training Institute
Boston, MA

Kurt Kroenke, MD
Professor of Medicine
Indiana University School of Medicine
Senior Scientist
Regenstrief Institute for Health Care
Indianapolis, IN

C. Seth Landefeld, MD
Professor of Medicine
Chief, Division of Geriatrics
Director, UCSF/Mount Zion Center on Aging
University of California, San Francisco
Associate Chief of Staff, Geriatrics and Extended Care
San Francisco VA Medical Center
San Francisco, CA

Melinda S. Lantz, MD
Director of Psychiatry
Jewish Home and Hospital
Assistant Professor, Department of Geriatrics and Adult Development
Mount Sinai School of Medicine
New York, NY

Robert Dean Lindeman, MD
Professor Emeritus of Medicine
University of New Mexico School of Medicine
Albuquerque, NM

David A. Lipschitz, MD, PhD
Professor of Geriatrics
Chair, Donald W. Reynolds Department of Geriatrics
University of Arkansas for Medical Sciences
Little Rock, AR

Dan L. Longo, MD
Scientific Director
National Institute on Aging
Baltimore, MD

Courtney H. Lyder, ND, GNP
University of Virginia Medical Center Professor
Chairman, Department of Acute and Specialty Care
University of Virginia School of Nursing
Charlottesville, VA

Constantine G. Lyketsos, MD, MHS
Professor of Psychiatry and Behavioral Sciences
Co-Director, Division of Geriatric Psychiatry and Neuropsychiatry
The Johns Hopkins University and Hospital
Baltimore, MD

William L. Lyons, MD
Assistant Professor
Section of Geriatrics and Gerontology
Department of Internal Medicine
University of Nebraska Medical Center
Omaha, NE

Edward R. Marcantonio, MD, SM
Associate Professor of Medicine
Harvard Medical School
Director of Research
Division of General Medicine and Primary Care
Beth Israel Deaconess Medical Center
Boston, MA

Coleman O. Martin, MD
Clinical Associate
Department of Neurology
University of Iowa Hospitals and Clinics
Iowa City, IA

Alvin M. Matsumoto, MD
Professor, Department of Medicine
University of Washington School of Medicine
Division of Gerontology and Geriatric Medicine
Director, Clinical Research Unit
Associate Director, Geriatric Research, Education, and Clinical Center
VA Puget Sound Health Care System
Seattle, Washington

Robert McCann, MD
Professor of Medicine
University of Rochester School of Medicine and Dentistry
Highland Hospital Department of Medicine
Rochester, NY

Barbara E. Moquin, PhD(c), MSN, APRN
Senior Nurse Specialist (Research)
National Center for Complementary and Alternative Medicine
National Institutes of Health
Division of Intramural Research
Bethesda, MD

R. Sean Morrison, MD
Hermann Merkin Professor of Palliative Care
Professor of Geriatrics and Medicine
Vice-Chair for Research
Brookdale Department of Geriatrics and Adult Development
Mount Sinai School of Medicine
New York, NY

Thomas Mulligan, MD
Ruth S. Jewett Professor of Medicine
Chief, University of Florida Division of Geriatrics
Director, Geriatrics Research, Education and Clinical Center
North Florida/South Georgia Veterans Health System
Gainesville, FL

David W. Oslin, MD
Associate Professor
Geriatric and Addiction Psychiatry
University of Pennsylvania
Philadelphia, PA

Stacie T. Pinderhughes, MD
Assistant Professor
Albert Einstein College of Medicine
Medical Director
Harlem Community Hospice of Continuum Healthcare
New York, NY

Peter Pompei, MD
Associate Professor of Medicine
Stanford University School of Medicine
Stanford, CA

James S. Powers, MD
Associate Professor of Medicine
Vanderbilt University Medical Center
Nashville, TN

Karen M. Prestwood, MD
Associate Professor of Medicine
UConn Center on Aging
University of Connecticut Health Center
Farmington, CT

Peter V. Rabins, MD
Professor of Psychiatry, Medicine, Mental Health and Health Policy and Management
Johns Hopkins Medical Institution
Baltimore, MD

John W. Rachow, PhD, MD
Assistant Clinical Professor
Department of Medicine
University of Iowa College of Medicine
Iowa City, IA

Paula A. Rochon, MD, MPH
Associate Professor
Department of Medicine and Health Policy Management and Evaluation
University of Toronto
Senior Scientist and Assistant Director
Kunin-Lunenfeld Applied Research Unit
Baycrest Centre for Geriatric Care
Scientist, Institute for Clinical Evaluative Sciences
Toronto, ON

David Sarraf, MD
Assistant Clinical Professor of Ophthalmology
Jules Stein Eye Institute, UCLA School of Medicine and the Greater Los Angeles VA Healthcare Center
Assistant Professor of Ophthalmology
Martin L. King Medical Center/Charles R. Drew University of Medicine
Los Angeles, CA

Todd P. Semla, PharmD, MS
Clinical Pharmacy Specialist
Department of Veterans Affairs
Pharmacy Benefits Management & Strategic Health Group
Hines, IL
Associate Professor
Department of Psychiatry and Behavioral Sciences
The Feinberg School of Medicine
Northwestern University
Chicago, IL

Kenneth Shay, DDS, MS
Director of Geriatric Programs
Office of Geriatrics and Extended Care
VA Central Office, Washington, DC
Adjunct Professor of Dentistry
University of Michigan School of Dentistry
Ann Arbor, MI

Javaid I. Sheikh, MD
Professor
Department of Psychiatry and Behavioral Sciences
Stanford University School of Medicine
Stanford, CA
Chief of Staff
VA Palo Alto Health Care System
Palo Alto, CA

Gary W. Small, MD
Parlow-Solomon Professor of Psychiatry and Biobehavioral Sciences
Director, UCLA Center on Aging
University of California, Los Angeles
Los Angeles, CA

Stephanie A. Studenski, MD, MPH
Professor, Department of Medicine (Geriatrics)
Staff Physician
Veterans Affairs Pittsburgh Geriatric Research, Education and Clinical Center
Pittsburgh, PA

Mark A. Supiano, MD
Professor and Chief, Division of Geriatric Medicine
University of Utah Health Science Center
Director, Veterans Affairs Salt Lake City
Geriatric Research, Education and Clinical Center
Executive Director, University of Utah Center on Aging
Salt Lake City, UT

George Triadafilopoulos, MD
Clinical Professor of Medicine
Division of Gastroenterology and Hepatology
Stanford University School of Medicine
Stanford, CA

Bruce R. Troen, MD
Associate Professor of Medicine
Miller School of Medicine
University of Miami
Geriatric Research, Education and Clinical Center
Miami Veterans Affairs Medical Center
Miami, FL

Andrew C. Warren, MB, BS, DPhil
Attending Physician, Sheppard Pratt Hospital
Associate Professor of Psychiatry
The Johns Hopkins University School of Medicine
Baltimore, MD

Debra K. Weiner, MD
Associate Professor of Medicine, Psychiatry and Anesthesiology
University of Pittsburgh School of Medicine
Pittsburgh, PA

Kristine Yaffe, MD
Associate Professor
Departments of Psychiatry, Neurology, Biostatistics and Epidemiology
University of California, San Francisco
Chief, Geriatric Psychiatry
San Francisco Veterans Administration Medical Center
San Francisco, CA

CONTRIBUTING QUESTION AND CRITIQUE AUTHORS

Reva N. Adler, MD, MPH
Medical Director, STAT Centre and At-home Supports
Vancouver Hospital and Vancouver Community Health Services
Clinical Associate Professor
Division of Geriatric Medicine
University of British Columbia
Vancouver, BC

Kathryn A. Atchison, DDS, MPH
Professor and Associate Dean for Research
School of Dentistry
University of California, Los Angeles
Los Angeles, CA

Sidney T. Bogardus, Jr., MD
Associate Professor of Medicine
Yale University School of Medicine
New Haven, CT

Kenneth Brummel-Smith, MD
Charlotte Edwards Maguire Professor of Geriatrics
Chair, Department of Geriatrics
Florida State University College of Medicine
Tallahassee, FL

Susan Charette, MD
Assistant Clinical Professor
Division of Geriatrics
Department of Medicine
University of California, Los Angeles
Los Angeles, CA

Pejman Cohan, MD
Assistant Professor of Medicine
Co-Director, Pituitary Program
School of Medicine
University of California, Los Angeles
Los Angeles, CA

Leo M. Cooney, Jr., MD
Humana Foundation Professor of Geriatric Medicine
Chief, Section of Geriatric Medicine
Yale University School of Medicine
New Haven, CT

Robert S. Crausman, MD, MMS
Chief Administrative Officer
Rhode Island Board of Medical Licensure and Discipline
Providence, RI

James Cummins, MD
Staff Psychiatrist
OhioHealth Behavioral Health
Columbus, OH

Margaret A. Drickamer, MD
Associate Professor
Yale University School of Medicine
New Haven, CT

Edmund H. Duthie, Jr, MD
Professor of Medicine (Geriatrics/Gerontology)
Chief, Division of Geriatrics and Gerontology
Medical College of Wisconsin
Lead Physician, Geriatrics Section, Consultant Care Division
VA Medical Center, Milwaukee
Milwaukee, WI

Carmel Bitondo Dyer, MD
Associate Professor of Medicine
Baylor College of Medicine
Director, Geriatrics Program
Harris County Hospital District
Houston, TX

Michelle S. Eslami, MD
Associate Professor of Medicine
Division of Geriatrics
David Geffen School of Medicine
University of California, Los Angeles
Los Angeles, CA

Mark H. Fleisher, MD
Associate Professor of Psychiatry
Medical Director, Adult Community Psychiatry Clinics
Director, Neurodevelopmental Psychiatry
University of Nebraska College of Medicine
Omaha, NE

Alastair J. Flint, MB
Professor of Psychiatry
University of Toronto
Head, Geriatric Psychiatry Program
University Health Network
Toronto, ON

David G. Folks, MD
Professor of Psychiatry
University of Nebraska College of Medicine
Omaha, NE

Christine Himes Fordyce, MD
Medicare Medical Director
Group Health Cooperative
Seattle, WA

Andrea R. Fox, MD, MPH
Associate Director
Clinical Care GRECC
VA Pittsburgh Healthcare System
Associate Professor of Medicine
University of Pittsburgh
Pittsburgh, PA

Angela Gentili, MD
Associate Professor of Internal Medicine
Director, Geriatrics Fellowship Program
VA Medical Center/Virginia Commonwealth University
Richmond, VA

Mary Kane Goldstein, MD, MS
Associate Director for Clinical Services
Geriatrics Research Education and Clinical Center
VA Palo Alto Health Care Systems
Professor of Medicine
Center for Primary Care and Outcomes Research
Stanford University
Palo Alto, CA

Shelly L. Gray, PharmD, MS, BCPS
Director, Geriatric Pharmacy Program
Associate Professor, School of Pharmacy
Seattle, WA

Nathan Herrmann, MD
Professor, Department of Psychiatry
University of Toronto
Head, Division of Geriatric Psychiatry
Sunnybrook & Women's College Health Science Centre
Toronto, ON

Kevin Paul High, MD, MSc
Associate Professor of Medicine
Sections on Infectious Diseases and Hematology/Oncology
Wake Forest University School of Medicine
Winston Salem, NC

Michele Iannuzzi-Sucich, MD
Family Practice and Geriatrics
Modena Family Practice
Modena, NY

Gail Ishiyama, MD
Assistant Professor
Department of Neurology
Division of Neurotology
University of California, Los Angeles
Los Angeles, CA

Thomas Vincent Jones, MD, MPH
Associate Editor
The Merck Manuals
Merck & Co, Inc.
Blue Bell, PA

Fran E. Kaiser, MD
Chief Executive Officer
Kaiser and Associates Consulting
Clinical Professor of Medicine
University of Texas Southwestern Medical School
Dallas, TX
Adjunct Professor of Medicine
St. Louis University School of Medicine
St. Louis, MO

Anne Kenny, MD
Associate Professor of Medicine
UConn Center on Aging
University of Connecticut Health Center
Farmington, CT

Mary B. King, MD
Assistant Professor of Medicine
University of Connecticut School of Medicine
Geriatrician, Hartford Hospital
Division of Geriatric Medicine and Gerontology
Hartford, CT

George A. Kuchel, MD
Director, University Connecticut Center on Aging
Chief, Division of Geriatric Medicine
University of Connecticut Health Center
Farmington, CT

Robert K. Lee, DPM
Assistant Clinical Professor
David Geffen School of Medicine
University of California, Los Angeles
Los Angeles, CA

Michael C. Lindberg, MD
Director of Clinical Inpatient Services
Department of Medicine
Hartford Hospital
Clinical Associate Professor
University of Connecticut School of Medicine
Hartford, CT

Shari M. Ling, MD
Clinical Research Branch
National Institute on Aging
Intramural Research Program
Baltimore, MD

Mathew S. Maurer, MD
The Advanced Cardiac Care Center
Columbia University
Irving Assistant Professor of Medicine
Director, Clinical Cardiovascular Research Laboratory for the Elderly
Columbia University College of Physicians and Surgeons
New York, NY

Ellen McMahon, MD
Assistant Professor
University of Massachusetts Medical School
Oak Bluffs, MA

Lynn McNicoll, MD
Assistant Professor of Medicine
Geriatrician
Division of Geriatrics
Rhode Island Hospital
Providence, RI

Daniel Ari Mendelson, MS, MD
Assistant Professor of Medicine
Division of Geriatrics
University of Rochester School of Medicine and Dentistry
Medical Director
Acute Care for Elders Unit, Highland Hospital
Medical Director
Visiting Nurse Service of Rochester and Monroe County
Rochester, NY

Laura Mosqueda, MD
Director of Geriatrics
Professor of Family Medicine
Ronald W. Reagan Endowed Chair in Geriatric Medicine
University of California, Irvine School of Medicine
Orange, CA

Benoit H. Mulsant, MD
Professor of Psychiatry
Center for Addiction and Mental Health
University of Toronto
Toronto, ON

Arash Naeim, MD, PhD
Assistant Professor of Medicine
University of California, Los Angeles
Los Angeles, CA

Joseph G. Ouslander, MD
Professor of Medicine and Nursing
Director, Division of Geriatric Medicine and Gerontology
Chief Medical Officer
Wesley Woods Center of Emory University
Director, Emory Center for Health in Aging
Research Scientist
Birmingham/Atlanta VA Geriatric Research, Education and Clinical Center
Atlanta, GA

Ronald Frederick Pfeiffer, MD
Professor and Vice Chair
Department of Neurology
University of Tennessee Health Science Center
Memphis, TN

James T. Pacala, MD, MS
Associate Professor
Distinguished University Teaching Professor
Department of Family Medicine and Community Health
University of Minnesota Medical School
Minneapolis, MN

Joe W. Ramsdell, MD
Professor and Head
Division of General Internal Medicine/Geriatrics
University of California, San Diego
UCSD Medical Center
San Diego, CA

Anthony E. Ranno, PharmD
Clinical Education Consultant
Pfizer Inc.
Sherwood, OR

Michael W. Rich, MD
Associate Professor of Medicine
Washington University School of Medicine
Director, Cardiac Rapid Evaluation Unit
Barnes-Jewish Hospital
St. Louis, MO

Debra Saliba, MD, MPH
Research Associate
VA Health Services Research and Development
Center for the Study of Healthcare Provider Behavior
Sepulveda, CA

Gary Schiller, MD
Department of Medicine
Division of Hematology/Oncology
School of Medicine
University of California, Los Angeles
Los Angeles, CA

Nancy Shafer Clark, MD
Assistant Professor, Medicine and Geriatrics
University of Rochester
Rochester, NY

Alan M. Singer, DPM
Department of Medicine
Division of Podiatry
University of California, Los Angeles
Los Angeles, CA

Upinder Singh, MD
Clinical Associate Professor
School of Medicine, UNR
Chief of Geriatrics
Southwest Medical Associates
Sierra Health Services
Las Vegas, NV

Monica Stallworth Kolimas, MD
Faculty, Harvard Division on Aging
Shattuck House, Harvard University
Boston, MA

David H. Stern, MD
Specialized Ambulatory Geriatric Evaluation Clinic (S+AGE)
Sherman Oaks, CA

Gwen K. Sterns, MD
Chief, Department of Ophthalmology
Rochester General Hospital
Clinical Professor of Ophthalmology
University of Rochester Eye Institute
Rochester, NY

Dennis H. Sullivan, MD
Director, Geriatric Research Education and Clinical Center
Central Arkansas Veteran's Healthcare System
Vice Chairman and Professor
Donald W. Reynolds Department of Geriatrics
University of Arkansas for Medical Sciences
Little Rock, AR

Mark Supiano, MD
Professor and Chief, Division of Geriatric Medicine
University of Utah Health Science Center
Director, VA Salt Lake City Geriatric Research, Education and Clinical Center
Executive Director, University of Utah Center on Aging
Salt Lake City, UT

Robert A. Sweet, MD
Associate Professor of Psychiatry
Vice-Chair, Institutional Review Board
University of Pittsburgh
Pittsburgh, PA

David C. Thomas, MD, MS
Associate Professor of Medicine and Rehabilitation
Department of Medicine, Division of General Internal Medicine
Medical Director, Ambulatory Care/Outpatient Services
Mount Sinai School of Medicine
New York, NY

Corina M. Velehorschi, MD
Adjunct Professor of Psychiatry
University of Western Ontario
Windsor Regional Hospital
Windsor, ON

Katherine Ward, MD
Assistant Clinical Professor
Division of Geriatric Medicine
University of California, Los Angeles
Los Angeles, CA

Michael R. Wasserman, MD
Senior Care of Colorado
Assistant Clinical Professor
University of Colorado Health Science Center
Denver, CO

Barbara E. Weinstein, PhD
Executive Officer, Clinical Doctoral Programs
The Graduate Center, CUNY
Professor, Lehman College, CUNY
Bronx, NY

Steven P. Wengel, MD
Chair, Department of Psychiatry
University of Nebraska Medical Center
Omaha, NE

INTRODUCTION

The core mission of the American Geriatrics Society (AGS) is to promote the optimal health, function, and well-being of older persons. Through the Syllabus, we advance this goal by providing health care providers with a current fund of knowledge that is evidence based and incorporates the most recent advances in health care. In 1989 the AGS published its first Geriatrics Review Syllabus (GRS). This publication was enormously successful and has become the standard resource in the field of medicine to assist clinicians in staying current and providing the best possible care to their older patients. We update the GRS to keep pace with advances in medical knowledge. It is with a great sense of accomplishment that the AGS publishes this sixth edition (GRS6) authored largely by AGS members who are leaders in the field of geriatric medicine.

In addition to this website version, the GRS6 is available as a 3-volume set of books or in CD-ROM format. Book 1 contains the Syllabus of 59 chapters, annotated references that allow the interested reader to pursue topics in greater depth, and an appendix with assessment instruments and practical resources. Book 2 contains 263 case-oriented, multiple-choice questions and is accompanied by an answer sheet for those participating in the continuing education program. Book 3 repeats the questions and contains answers, supporting critiques, and references, providing an effective self-assessment tool. The CD-ROM format comprises the entire program.

The Syllabus is divided into five sections-Current Issues in Aging, Approach to the Patient, Syndromes, Psychiatry, and Diseases and Disorders-that encompass 59 chapters. Each chapter provides a synopsis of the current thinking about a particular topic or field. The goal of the GRS editorial board is to provide a comprehensive resource that covers the scope of geriatric medicine. Accordingly, discussions of certain subjects that are well-covered in other resources are kept brief, and participants are referred to more in-depth discussions in an annotated bibliography. In compiling the bibliography, the Editorial Board has made every attempt to restrict the references to journals listed in Index Medicus. By intention, GRS6 focuses on recent developments since the publication of the fifth edition rather than on basic principles of caring for older persons. Finally, little attention is devoted to topics that are core components of medicine and are not unique to the care of older persons; this information can be found in standard medical texts.

The Question Editors, using questions drafted by a team of question writers, have developed an entirely new set of 263 case-oriented, multiple-choice self-study questions. These questions are designed to complement material in the Syllabus chapters, and they draw on the entire knowledge base of geriatric medicine, rather than limiting themselves to the text of the GRS Syllabus. We recommend that participants prepare for answering these questions by first carefully reading through the Syllabus chapters. Any material addressed in the questions that is not discussed in the chapters is amply discussed in the critiques. The questions have been developed independently of any specialty board and will not be a part of any secure board certification examination.

GRS6 is the result of a major collaborative effort by AGS members and staff. The Editorial Board selected over 100 authors to develop the 59 chapters and 263 questions with answers, explanations, and references.

All GRS authors were encouraged to include information on health disparities among racial and ethnic minorities in those areas where accurate data exist. Although there has been an increase in the understanding of the health outcomes and diseases among older minorities, these populations remain insufficiently studied. Clinicians must recognize the differences between various ethnic groups and are encouraged to be sensitive to cultural issues in the care of older persons. Doorway Thoughts: Cross-Cultural Health Care for Older Adults (a series of volumes also published by the AGS) is a useful companion to the GRS for readers who are interested in exploring cultural issues in more depth.

Topics for inclusion were carefully selected by the editorial team. Authors were chosen on the basis of their in-depth knowledge of a particular area and their ability to condense large amounts of information into clinically applicable, succinct essays. Editors and authors are experienced in caring for geriatric patients and emphasize the geriatrics perspective in the preparation of manuscripts, bibliographies, and questions.

With each new edition, the Syllabus has included increasing amounts of information about drugs commonly used in treating older adults, though no effort is made to provide comprehensive coverage of available drugs for each disease or disorder. (See the AGS Geriatrics At Your Fingertips, published annually, for details about individual agents.) When Syllabus authors have chosen to discuss specific drugs, we have made certain that the information provided was up to date at the time of publication and that any mentions of uses not specifically approved by the U.S. Food and Drug Administration (so called "off-label" uses) are so tagged.

Another product supplementing the GRS is the AGS GRS Teaching Slides, available as a subscription through the AGS Web site. The slide presentations in Microsoft� Power Point� are based on GRS chapters and suitable for faculty, fellows, residents, and students. Each presentation is designed for approximately a 1-hour seminar and may be used as a stand-alone lecture or to complement the lecturer's personal teaching materials.

Chapters new to GRS6 include those on perioperative care, cultural aspects of care, persistent pain, and diabetes mellitus. Also new to the GRS are key points provided at the beginning of each chapter. The Appendix offers material that clinicians find useful in clinical practice.

The GRS self-assessment program in book and CD-ROM formats provides participants with the option of applying for 75 Continuing Medical Education (CME) credits through the American Medical Association, American Academy of Family Physicians, and American Osteopathic Association. For information on self-scoring or submitting answer sheets for CME credit, please see the Program Guidelines. In addition to the CME credit offered by successfully completing the GRS6, the American Board of Internal Medicine (ABIM) has approved the CD-ROM version of the GRS6 self-assessment program for 100 lifelong learning points for ABIM diplomates who are enrolled in the Maintenance of Certification program.

We hope the GRS will meet our goal of improving participants' knowledge base in geriatrics and thus enhancing the practice patterns of clinicians who care for older persons by providing a self-study tool that is current, concise, scholarly, and clinically relevant. We encourage your comments and suggestions, as the AGS continually strives to better serve its members, other health professionals, and the older persons they treat.

LEARNING OBJECTIVES

At the conclusion of this program, participants will be better able to:

Describe the general principles of aging and the biomedical and psychosocial issues of aging;
Discuss legal and ethical issues related to geriatric medicine
Evaluate the financing of health care for older persons;
Identify the basic principles of geriatric medicine, including assessment, pharmacology, prevention, exercise, palliative care, rehabilitation, and sensory deficits;
Diagnosis and manage geriatric syndromes, including dementia, delirium, urinary incontinence, malnutrition, osteoporosis, falls, pressure ulcers, sleep disorders, pain, dysphagia, and dizziness;
Use state-of-the-art approaches to geriatric care while providing care in hospital, office-practice, nursing-home, and home-care settings;
Apply relevant information from the fields of internal medicine, neurology, psychiatry, dermatology, and gynecology to the care of older patients;
Adjust patient care in the light of evidence-based data regarding the particular risks and needs of ethnic, racial, and sexual patient groups; and
Employ evidence-based data to increase the effectiveness of teaching geriatrics to all health professionals.

DISCLOSURE OF FINANCIAL INTERESTS

As an accredited provider of Continuing Medical Education, the American Geriatrics Society continuously strives to ensure that the education activities planned and conducted by our faculty meet generally accepted ethical standards as codified by the ACCME, the Food and Drug Administration, and the American Medical Association's Guide for Gifts to Physicians. To this end, we have implemented a process wherein everyone who is in a position to control the content of an education activity has disclosed to us all relevant financial relationships with any commercial interests as related to the content of their presentations and under which we work to resolve any real or apparent conflicts of interest. Faculty conflicts of interest in this particular CME activity have been resolved by having the content independently peer reviewed before publication by the Editorial Board and Question Review Committee.

The following faculty (and/or their spouses/partners) have reported real or apparent conflicts of interest that have been resolved through a peer review content validation process.

Harold Adams, MD
Dr. Adams has received speaking honorarium from Bayer (aspirin) and has received research grants from Bristol-Meyers-Squibb (clopidogrel).

Marc E. Agronin, MD
Dr. Agronin is a member of the Speaker's Bureau for Janssen (risperidone) and for Forest Laboratories (escitalopram oxalate).

William J. Burke, MD
Dr. Burke serves as a paid consultant and is a member of the Speakers Bureau for Forest Pharmaceuticals (psychopharmacology) and for Cyberonics (depression). He receives grants from Cyberonics (depression) and Merck (Alzheimer disease).

Anne L. Coleman, MD, PhD
Dr. Coleman receives grant support from Pfizer.

Catherine E. DuBeau, MD
Dr. DuBeau serves as a paid consultant and is a symposium speaker for Astellas (solifenacin), Indevus (trospium chloride), Novartis (darifenacin), and is a symposium speaker for Watson (oxybutynin).

William B. Ershler, MD
Dr. Ershler receives grant support and is a member of the Speaker's Bureau for Amgen.

Anne R. Fabiny, MD
Dr. Fabiny discloses that her spouse/partner serves as a paid consultant to Abgenix (bone and mineral metabolism).

Lisa J. Granville, MD
Dr. Granville serves as a paid consultant for Novartis and Pfizer in the area of incontinence.

Nathan Herrmann, MD
Dr. Herrmann serves as a paid consultant and is a member of the Speaker's Bureau for Janssen (risperidone).

Fran E. Kaiser, MD
Dr. Kaiser was CEO of Kaiser and Associates Consulting when she began work on the GRS-6 and is currently an employee of Merck & Co., Inc.

Gary J. Kennedy, MD
Dr. Kennedy discloses that he receives grant support and is a member of the Speaker's Bureau for Forest Laboratories (escitalopram), and is a member of the Speaker's Bureau for Pfizer (sertraline).

Melinda S. Lantz, MD
Dr. Lantz receives grant support from Bristol-Myers Squibb (aripiprazole) and from Forest Laboratories (memantine).

Courtney H. Lyder, ND, GNP
Mr. Lyder is a member of the Speaker's Bureau for ConvaTec (wound dressings), and for Hil-Rom (mattress replacements).

Constantine G. Lyketsos, MD, MHS
Dr. Lyketsos receives grant support and speaking honorarium from Forest, serves as a paid consultant and is a member of the Speaker's Bureau for Novartis, receives grant support and speaking honorarium from Pfizer, and receives speaking honorarium from GlaxoSmithKline.

Alison A. Moore, MD, MPH
Dr. Moore owns shares of Merck stock.

Thomas Mulligan, MD
Dr. Mulligan owns significant shares of Pfizer stock, and receives grant support from Ascend (dihydrotestosterone) and Solvay (testosterone).

Benoit H. Mulsant, MD
Dr. Mulsant is a member of the Speaker's Bureau for Pfizer (sertraline), and is a paid consultant and a member of the Speaker's Bureau for Forest Labortatories (citalopram, escitalopram).

Joseph G. Ouslander, MD
Dr. Ouslander serves as a paid consultant, receives grant support and is a member of the Speaker's Bureau for Pfizer (tolterodine).

Peter V. Rabins, MD
Dr. Rabins is a member of the Speaker's Bureau for Pfizer, AstraZeneca, Janssen, Eli Lilly, and Forest Laboratories.

Anthony E. Ranno, PharmD
Dr. Ranno is an employee of Pfizer (sertraline).

Michael W. Rich, MD
Dr. Rich is a member of the Speaker's Bureau for Merck & Co. (simvastatin, losartan) and receives grant support from Bristol-Myers Squibb (irbesartan).

Todd P. Semla, PharmD, MS
Dr. Semla serves as a paid consultant for Omnicare and Ovations (a part of United Healthcare) Pharmacy and Therapeutics Committees, and his spouse is employed by and holds shares of Abbott Laboratories.

Javaid I. Sheikh, MD
Dr. Sheikh is a member of the Speaker's Bureau for Pfizer, Forest, and Janssen Pharmaceutica.

Gary W. Small, MD
Dr. Small is a member of the Speaker's Bureau for Pfizer (donepezil) and Novartis (rivastigmine). He is a significant shareholder in MFI (educational information), and holds a license with Siemens for FDDNP-PET.

Stephanie Studenski, MD, MPH
Dr. Studenski serves as a paid consultant for Wyeth and receives grants from Eli Lilly and Co. and Ortho-Biotech for studies of measurement of physical function.

Dennis H. Sullivan, MD
Dr. Sullivan receives grant support from Bristol-Myers Squibb (megase).

George Triadafilopoulos, MD
Dr. Triadafilopoulos serves as a paid consultant, receives grant support, and is a member of the Speakers Bureau for Astra-Zeneca (omeprazole), Pfizer (celecoxib), TAP (lansoprazole). He is also a paid consultant and member of the Speaker's Bureau for Santarus (omeprazole).

Kristine Yaffe, MD
Dr. Yaffe serves as a paid consultant for Novartis.

The following faculty have returned disclosure forms indicating that they (and/or their spouses/partners) have no affiliation with, or financial interest in, any commercial interest that may have direct interest in the subject matter of their presentation(s):

Sumaira Aasi, MD

Itamar B. Abrass, MD

Reva N. Adler, MD, MPH

Cathy A. Alessi, MD

Neil B. Alexander, MD

Wilbert S. Aronow, MD

Kathryn A. Atchison, DDS, MPH

Priscilla F. Bade, MD, MS

Cynthia Barton, RN, MSN

Marc R. Blackman, MD

Caroline Blaum, MD

Harrison G. Bloom, MD

Sidney T. Bogardus, Jr., MD

Chad Boult, MD, MPH, MBA

Cynthia J. Brown, MD

Kenneth Brummel-Smith, MD

David M. Buchner, MD, MPH

Lynda C. Burton, ScD

David Bush, MD

Erin L. Cassidy, PhD

Susan Charette, MD

Gurkamal S. Chatta, MD

Colleen Christmas, MD

Pejman Cohan, MD

Leo M. Cooney, Jr., MD

Steven R. Counsell, MD

Robert S. Crausman, MD, MMS

James Cummins, MD

G. Willy Davila, MD

Margaret A. Drickamer, MD

Pamela W. Duncan, PhD

Edmund H. Duthie, Jr., MD

Carmel Bitondo Dyer, MD

G. Paul Eleazer, MD

E. Wesley Ely, MD, MPH

Michelle S. Eslami, MD

Mark H. Fleisher, MD

Alastair J. Flint, MB

David G. Folks, MD

Christine Himes Fordyce, MD

Andrea R. Fox, MD, MPH

Terry T. Fulmer, RN, PhD

Angela Gentili, MD

Thomas M. Gill, MD

Mary K. Goldstein, MD, MS

Shelly L. Gray, PharmD, MS

David A. Gruenewald, MD

Arthur E. Helfand, DPM

Kenneth W. Hepburn, PhD

Kevin P. High, MD, MSc

Chris Himes, MD

Michelle Iannuzzi-Sucich, MD

Gail Ishiyama, MD

Gordon L. Jensen, MD, PhD

Thomas V. Jones, MD, MPH

Donald A. Jurivich, DO

Jennifer M. Kapo, MD

Jurgis Karuza, PhD

Judith Kasper, PhD

Paul R. Katz, MD

Catherine Lee Kelleher, MD

Anne Kenny, MD

Douglas P. Kiel, MD, MPH

Mary B. King, MD

Kurt Kroenke, MD

George A. Kuchel, MD

C. Seth Landefeld, MD

Robert K. Lee, MD

Michael C. Lindberg, MD

Robert D. Lindeman, MD

Shari M. Ling, MD

David A. Lipschitz, MD, PhD

Dan L. Longo, MD

William L. Lyons, MD

Edward R. Marcantonio, MD, SM

Coleman O. Martin, MD

Alvin M. Matsumoto, MD

Matthew S. Maurer, MD

Robert M. McCann, MD

Ellen McMahon, MD

Lynn McNicholl, MD

Daniel A. Mendelson, MD

Barbara E. Moquin, PhD, MSN, APRN, BC-P

R. Sean Morrison, MD

Laura Mosqueda, MD

John B. Murphy, MD

Arash Naeim, MD, PhD

David W. Oslin, MD

James T. Pacala, MD, MS

Ronald F. Pfeiffer, MD

Stacie T. Pinderhughes, MD

Peter Pompei, MD

Jane F. Potter, MD

James S. Powers, MD

Karen M. Prestwood, MD

John W. Rachow, MD, PhD

Joe W. Ramsdell, MD

Paula A. Rochon, MD, MPH

Debra Saliba, MD, MPH

David Sarraf, MD

Gary Schiller, MD

Susan K. Schultz, MD

Nancy Shafer-Clark, MD

Kenneth Shay, DDS, MS

Alan M. Singer, DPM

Upinder Singh, MD

Monica Stallworth-Kolimas, MD

David H. Stern, MD

Gwen K. Sterns, MD

Gail M. Sullivan, MD, MPH

Mark A. Supiano, MD

Robert A. Sweet, MD

David C. Thomas, MD

Bruce R. Troen, MD

Corina M. Velehorschi, MD

Katherine Ward, MD

Andrew C. Warren, MB, BS, DPhil

Michael R. Wasserman, MD

Debra K. Weiner, MD

Barbara E. Weinstein, PhD

Steven P. Wengel, MD