1High-yield associations
| Finding or trigger | Classic association | The exam point |
|---|---|---|
| Drowsy and inattentive after hip fracture repair | Hypoactive delirium | Treat causes; antipsychotics not recommended (ACSQHC 2021). |
| Fluctuating cognition, visual hallucinations, REM sleep behaviour disorder | Dementia with Lewy bodies | Severe antipsychotic sensitivity; try a cholinesterase inhibitor first. |
| Magnetic gait, urinary urgency, slowed thinking | Normal pressure hydrocephalus | Gait gain after a large-volume tap predicts shunt response. |
| Early backward falls, impaired vertical gaze | Progressive supranuclear palsy | Poor levodopa response. |
| Disinhibition, apathy, hyperorality at 60 | Behavioural variant frontotemporal dementia | Cholinesterase inhibitors don't help and may worsen behaviour. |
| Aggression in Alzheimer dementia despite non-drug care | Behavioural and psychological symptoms of dementia | TGA: risperidone up to 12 weeks. PBS continuing phase: trial of dose reduction or cessation. |
| Vertebral fractures months after a missed denosumab dose | Rebound after stopping denosumab | Bridge with a bisphosphonate for at least 12 months (RACGP 2024). |
| Thigh or groin ache on long-term antiresorptive | Atypical femoral fracture | Examine the other femur too (Prolia PI, TGA 2026). |
| Injurious fall, recurrent falls, frailty, long lie, possible syncope | High falls risk (World Falls Guidelines 2022) | Multifactorial assessment; RACGP 2024 adopts this algorithm. |
| Sodium 124 mmol/L weeks after starting an SSRI | SIADH | Older age and diuretics add risk; check sodium early. |
| New confusion and urinary retention on oxybutynin | Anticholinergic burden | Deprescribe with a plan and follow-up (MJA 2026). |
2Australia-only high-yield (won't be in UK or US banks)
Aged care (Aged Care Act 2024, in force 1 November 2025). Access starts with My Aged Care and a needs assessment: from 65, or 50 for Aboriginal and Torres Strait Islander people. Support at Home replaced Home Care Packages (OPAN).
Dementia drugs (PBS, October 2026). Donepezil, galantamine and rivastigmine: Authority Required for mild to moderately severe Alzheimer disease; memantine for moderately severe; initial and continuing phases. Deprescribe when there is no benefit or dementia is severe (MJA 2019).
Amyloid antibodies (TGA 2025). Donanemab and lecanemab are registered for mild cognitive impairment or mild dementia due to Alzheimer disease, amyloid confirmed, in APOE4 non-carriers or heterozygotes, not homozygotes; MRI monitoring for ARIA. Neither was found in the PBS medicine index in October 2026.
Delirium (ACSQHC Delirium Clinical Care Standard, 2021). Screen at presentation from 65, or 45 for Aboriginal and Torres Strait Islander people. Non-drug care first; antipsychotics are not recommended.
Deprescribing (Australian guideline, MJA 2026). Review need at every repeat, by shared decision. Taper where withdrawal or relapse is likely.
Bone (RACGP and Healthy Bones Australia 2024; PBS). Romosozumab is first line at very high fracture risk. PBS lists denosumab for osteoporosis, and romosozumab (first-line and second-line phases) and teriparatide for severe established osteoporosis.
Vaccines (NIP, NSW schedule October 2026). From 65: pneumococcal (Capvaxive), two doses of Shingrix, yearly influenza; RSV (Arexvy) from 75. Aboriginal and Torres Strait Islander people: zoster from 50, RSV from 60.
Decisions and safety. Advance care directives and substitute decision-makers are state and territory law; the terms differ. Elder abuse: 1800 ELDERHelp (Compass). See Physify's Delirium, Dementia and Polypharmacy courses.
3Sample questions (Physify format)
1. A 78 year old woman has had denosumab 60 mg every 6 months for 6 years for postmenopausal osteoporosis. Her femoral neck T-score is now -2.1, with no fractures on treatment, and she wants to stop the injections. What does the 2024 Australian osteoporosis guideline advise?
- A. Stop now and repeat bone density in 2 years
- B. Stretch the dosing interval to every 12 months
- C. Stop, then a bisphosphonate for at least 12 months
- D. Stop, then raloxifene for 5 years as a bridging agent
- E. Refuse: denosumab must continue for life
Answer: C
C. Correct. RACGP and Healthy Bones Australia 2024: don't interrupt denosumab; if it is ceased, transition to a bisphosphonate for at least 12 months.
A. An unbridged stop risks rebound bone loss and multiple vertebral fractures.
B. A longer interval is an interruption, with the same rebound risk.
D. The guideline names a bisphosphonate, not a SERM, as the follow-on.
E. Ceasing is allowed with a planned bisphosphonate transition.
2. An 86 year old man, independent and cognitively normal before admission, is drowsy, inattentive and muddled on day 2 after hip fracture repair. He has had no bowel action and is on regular oxycodone. Under the 2021 Australian Delirium Clinical Care Standard, what is the most appropriate next step?
- A. Regular low-dose haloperidol until he is settled
- B. Look for and treat causes, such as constipation
- C. Lorazepam at night to restore his sleep pattern
- D. Urgent CT brain before any bedside assessment
- E. Start donepezil for presumed new-onset dementia
Answer: B
B. Correct. This is hypoactive delirium. Look for causes (retention, constipation, opioids, infection, pain) and use non-drug care first (ACSQHC 2021).
A. Antipsychotics are not recommended and don't treat the cause.
C. Benzodiazepines worsen delirium outside alcohol or benzodiazepine withdrawal.
D. Imaging is for focal signs or head injury, not before bedside assessment.
E. Dementia can't be diagnosed during delirium, and donepezil doesn't treat it.
3. A 71 year old woman has mild cognitive impairment with an amyloid-positive PET scan. Genotyping shows she is APOE4 homozygous, and her MRI shows no microhaemorrhages. She asks about lecanemab. What is the most accurate advice in Australia in October 2026?
- A. Eligible, as any amyloid-positive early disease qualifies
- B. Eligible, because her MRI has no microhaemorrhages
- C. Outside its TGA indication because of her genotype
- D. Outside its TGA indication because she has no dementia
- E. Eligible only once her dementia becomes moderate
Answer: C
C. Correct. The TGA indication (2025) excludes APOE4 homozygotes, who have the highest ARIA risk.
A. The indication covers only APOE4 non-carriers and heterozygotes.
B. A clear baseline MRI is needed but does not override her genotype.
D. Mild cognitive impairment due to Alzheimer disease is within the indication.
E. The indication is early disease only; moderate dementia is outside it.