AGPCNP Study Guide: High-Yield Topics on Chronic Disease Management in the Aging Population

Adult–Gerontology Primary Care NPs manage chronic disease where aging physiology, multimorbidity, and polypharmacy collide. This guide focuses on the highest-yield topics you will see on exams and in clinic. For each condition, you’ll get what to diagnose, how to risk-stratify, what to prescribe first, what to avoid in older adults, and what to monitor—plus the “why” behind each choice.

Hypertension in Older Adults

High blood pressure drives stroke, heart failure, and kidney disease. Older adults gain the most absolute risk reduction from control, but are more prone to orthostasis and electrolyte changes.

Targets: Aim for <130/80 in most independent adults if tolerated. In frail adults or those with orthostatic symptoms or limited life expectancy, a more relaxed goal like <140/90 is reasonable. The benefit is fewer strokes; the risk is falls from overtreatment.
First-line meds: Thiazide-type diuretics (chlorthalidone), ACE inhibitors/ARBs, and dihydropyridine CCBs (amlodipine). Black older adults often respond best to thiazide or CCB. If albuminuric CKD or diabetes with albuminuria, prioritize an ACEi/ARB to slow nephropathy.
Monitoring: Check basic metabolic panel and electrolytes 1–2 weeks after starting or titrating ACEi/ARB or thiazide. Reassess orthostatic vitals at each visit. Educate on home BP technique and bring logs.
What to avoid: Alpha-blockers as first-line due to orthostasis. Clonidine patches can cause rebound HTN if missed. NSAIDs raise BP and worsen kidney function.

Type 2 Diabetes in the Aging Population

Hypoglycemia causes falls, arrhythmias, and cognitive decline; it is more dangerous than mild hyperglycemia in older adults. Set A1c targets by health status.

A1c goals: Healthy: 7–7.5%. Multiple comorbidities or mild cognitive/functional limits: 7.5–8%. Very complex health or limited life expectancy: 8–8.5%. The “why”: tight control lowers microvascular risk, but hypoglycemia harms outweigh benefits in frailty.
First-line: Metformin if eGFR ≥45. Reduce dose for eGFR 30–44; stop if <30. It is weight neutral and low risk for hypoglycemia.
Cardiorenal protection: SGLT2 inhibitors (dapagliflozin, empagliflozin) lower HF hospitalization and slow CKD. GLP-1 RAs (semaglutide) reduce ASCVD events and weight. Choose based on comorbidity: HF/CKD → SGLT2; ASCVD/obesity → GLP-1 RA.
Avoid/high risk: Glyburide (Beers) and sliding-scale insulin alone. Long-acting insulin is safer than short-acting in older adults if insulin is needed; start low and titrate slowly.
Monitoring: A1c every 3–6 months; SMBG or CGM if on insulin/sulfonylurea. Annual microalbumin, foot exam, retinal exam, and B12 if on metformin long-term.

Chronic Kidney Disease (CKD)

CKD modifies drug dosing, cardiovascular risk, and anemia/bone health. Recognize stage and albuminuria; they predict progression and guide ACEi/ARB use.

Staging: Use eGFR and albumin-to-creatinine ratio (ACR). Albuminuria is more predictive of progression than eGFR alone.
Slow progression: ACEi/ARB for ACR ≥300 mg/g (or ≥30 mg/g in diabetes). Add SGLT2 inhibitor when eGFR allows. Control BP and avoid NSAIDs.
Statins: Adults ≥50 with CKD generally benefit for ASCVD prevention unless on dialysis with limited life expectancy. Rationale: CKD is a risk equivalent.
Complications: Check Hgb for anemia; address iron deficiency first. Monitor calcium, phosphorus, PTH, vitamin D for mineral-bone disorder.
Drug dosing: Dose renally using Cockcroft–Gault for narrow-therapeutic-index drugs and DOACs. Review meds at every visit; prune nephrotoxins.

Heart Failure: HFrEF vs HFpEF

Symptoms overlap, but treatment differs by ejection fraction. Daily weights and self-management education prevent readmissions.

HFrEF core therapy: The “quadruple” regimen improves survival: ARNI (or ACEi/ARB), evidence beta-blocker (carvedilol, metoprolol succinate, bisoprolol), MRA (spironolactone), and SGLT2 inhibitor. Start low, go slow. Diuretics relieve congestion but do not improve survival.
HFpEF: Control BP, diuretics for volume, SGLT2 inhibitors reduce CV death/HF hospitalization. Manage comorbidities (AF, obesity, OSA).
Education: Sodium moderation, daily weight logs, when to call for 2–3 lb gain in 24–48 hours, and med adherence. Schedule follow-up within 7 days after hospitalization—reduces early decompensation.
Monitoring: BMP and potassium within 1–2 weeks after starting/titrating RAAS agents or MRAs. Assess orthostasis and renal function routinely.

Atrial Fibrillation and Anticoagulation

Stroke prevention is the priority. Falls are not an absolute contraindication; in most older adults, stroke risk exceeds bleed risk.

Risk scores: Use CHA₂DS₂-VASc to decide on anticoagulation; use HAS-BLED to reduce modifiable bleeding risks (BP, NSAIDs, alcohol, labile INRs).
Anticoagulants: DOACs preferred over warfarin for efficacy and lower intracranial bleeding. Dose by renal function and body weight. Example: Apixaban reduce to 2.5 mg BID if ≥2 of: age ≥80, weight ≤60 kg, serum Cr ≥1.5 mg/dL.
Rate control: Beta-blocker is first-line. Non-DHP CCBs (diltiazem) OK if no HFrEF. Use digoxin cautiously in low activity or HFrEF; adjust for kidney function.
Follow-up: Baseline and at least annual renal function; more often in CKD or frailty.

COPD in Older Adults

Dyspnea and exacerbations drive disability. Bronchodilators improve symptoms and reduce exacerbations; inhaler technique determines real-world effectiveness.

Baseline: Spirometry confirms airflow limitation. Assess symptom burden (mMRC/CAT) and exacerbation history to guide therapy.
Initial therapy: Start with a LAMA or LAMA/LABA for symptomatic patients. Add ICS if frequent exacerbations and higher eosinophils, but weigh pneumonia risk.
Exacerbations: SABA/SAMA, systemic steroids (e.g., prednisone 40 mg daily × 5 days). Add antibiotics only if increased sputum purulence plus dyspnea/volume or if severe.
Oxygen: Long-term oxygen therapy if resting SpO₂ ≤88% or PaO₂ ≤55 mmHg. Recheck need after stabilization.
Education: Teach inhaler technique at every visit; simplify to one device type if possible. Pulmonary rehab improves function and is underused.

Osteoporosis and Fracture Prevention

Fracture risk defines treatment, not just T-score. Hip fractures increase mortality; prevention is high-impact.

Screening: DEXA in women ≥65 and younger postmenopausal with risk; consider in men ≥70 or younger men with risk factors.
Treat if: T-score ≤ −2.5, or osteopenia with FRAX 10-year risk hip ≥3% or major osteoporotic ≥20%, or prior fragility fracture.
Therapy: Oral bisphosphonates (alendronate) first-line. Take upright with water, empty stomach. Reassess after 3–5 years for drug holiday in low-to-moderate risk. Consider denosumab if GI intolerance; plan transition to prevent rebound bone loss.
Basics: Calcium ~1200 mg/day (diet first), vitamin D3 800–1000 IU/day, weight-bearing and resistance exercise, fall prevention.
Workup: Check vitamin D, calcium, TSH, CBC, CMP for secondary causes.

Falls and Geriatric Syndromes

Falls are multifactorial; a small improvement in several risks prevents more falls than a single intervention.

Screen: Ask about falls and fear of falling. Perform Timed Up and Go. Check orthostatic BP, vision, footwear, and home hazards.
Medications: Deprescribe or reduce doses of benzodiazepines, Z-drugs, anticholinergics, antipsychotics, and high-dose antihypertensives.
Interventions: Strength and balance training (PT/OT), home safety modifications, vitamin D only if deficient, treat neuropathy and foot pain, provide proper assistive devices.

Delirium vs. Dementia

Distinguish acute delirium from chronic cognitive decline. Delirium is a medical emergency; missed cases lead to long-term decline.

Delirium: Acute, fluctuating attention and cognition. Common triggers: infection, meds (anticholinergics, opioids), dehydration, pain, hypoxia. Use CAM or 4AT. Treat the cause; mobilize, reorient, optimize sleep and vision/hearing. Reserve low-dose antipsychotics for severe distress or danger; avoid benzodiazepines except for withdrawal.
Dementia: Gradual decline; screen with Mini-Cog. Cholinesterase inhibitors or memantine offer modest benefit; consider patient and caregiver goals. Avoid anticholinergics. Discuss driving safety and advance care planning early.

Pain Management and Opioid Stewardship

Untreated pain worsens function and mood, but older adults have more adverse drug effects. Start with safer modalities.

First-line: Acetaminophen (if no severe liver disease). Topical NSAIDs for osteoarthritis reduce systemic risk. Nonpharm: exercise, PT, CBT, heat/cold.
Oral NSAIDs: Use sparingly; add PPI if high GI risk; avoid in CKD and HF due to renal and fluid risks.
Neuropathic pain: Duloxetine or gabapentin/pregabalin (renal-dose adjust; watch for sedation and falls).
Opioids: For severe pain unresponsive to other therapies. Set functional goals. Use lowest effective dose, avoid co-prescribing benzos, provide bowel regimen and consider naloxone. Reassess benefits and harms regularly.

Infections and Antibiotic Stewardship

Older adults have atypical presentations; treat the patient, not the urine culture.

UTI: Diagnose by urinary symptoms (dysuria, frequency, suprapubic pain) plus UA findings. Do not treat asymptomatic bacteriuria except in pregnancy or before urologic procedures. Delirium alone with bacteriuria is not an indication—look for other causes and hydrate.
Pneumonia: Consider aspiration risk and atypical signs (confusion, falls). Ensure timely antibiotics when indicated, then de-escalate based on clinical course.
Skin infections: Watch for diabetic foot ulcers and cellulitis; optimize offloading and glycemic control.

Immunizations for Older Adults

Vaccines prevent hospitalizations that trigger functional decline.

Influenza: Annually; for ≥65 use high-dose, adjuvanted, or recombinant when available.
Pneumococcal: At ≥65, give PCV20 once or PCV15 then PPSV23 after 1 year (8 weeks if immunocompromised). Choose one path and document.
Shingles (RZV): Two doses 2–6 months apart for ≥50, even if prior shingles or Zostavax.
Tdap/Td: One lifetime Tdap, then Td or Tdap every 10 years.
RSV: A single RSV vaccine dose is recommended for many older adults; prioritize those ≥75 or aged 60–74 with risk factors. Shared clinical decision-making for others ≥60.

Polypharmacy and Deprescribing

Every added medication increases adverse events and confusion. Deprescribing is proactive care, not neglect.

Identify targets: Use Beers Criteria as a guide: benzodiazepines, strong anticholinergics (diphenhydramine), Z-drugs, skeletal muscle relaxants, megestrol, chronic PPIs without indication, glyburide, chronic NSAIDs in CKD/HF.
Process: Clarify goals of care; list all meds; stop non-beneficial or duplicative drugs; taper where needed (benzodiazepines, PPIs, clonidine). Replace with safer alternatives.
Why it matters: Fewer meds reduce falls, delirium, syncope, and hospitalizations. A smaller regimen improves adherence.

Preventive Screening You’re Expected to Know

Colorectal cancer: Routine screening to 75. Ages 76–85: individualize based on health, prior screening, and preferences.
Lung cancer: Annual low-dose CT for ages 50–80 with ≥20 pack-years who currently smoke or quit within 15 years; stop if they surpass 15 years since quitting or health precludes treatment.
AAA ultrasound: Men 65–75 who have ever smoked—screen once.
Osteoporosis: Women ≥65; younger with risk. Consider men ≥70 with risk factors.
Depression: Screen with PHQ-2/9 when systems are in place for follow-up.
Vision/hearing: Functional screening improves safety and adherence to instructions.

Lipid Management in Older Adults

Primary prevention benefits narrow with age; focus on life expectancy and patient goals.

Secondary prevention (ASCVD): Continue statins unless intolerance; moderate-to-high intensity as tolerated.
Primary prevention ≥75: Consider moderate-intensity statin in high-risk adults after discussing risks (myopathy, interactions) and time to benefit.
Why: Statins reduce events, but polypharmacy and competing mortality limit net benefit in some. Reassess regularly.

End-of-Life and Goals of Care Integration

Align treatments to what matters most. This prevents burdensome care that does not extend quality life.

Advance care planning: Discuss code status, hospitalization preferences, and surrogate decision-makers before crises.
De-intensify: Consider stopping tight glycemic control, statins for primary prevention, and frequent lab monitoring in late-stage illness.
Symptom-first approach: Prioritize dyspnea control, pain relief, anxiety management, and caregiver support.

High-Yield Medication Dosing and Safety Pearls

Renal dosing: Estimate creatinine clearance for DOACs, gabapentinoids, metformin, and antibiotics. Recheck with any acute illness.
Apixaban rule: Dose-reduce if any two of age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL.
Metformin: Reduce dose at eGFR 30–44; stop <30.
Spironolactone: Check potassium and creatinine 3–7 days after starting and with each increase; stop if K+ persistently >5.5.
Bisphosphonates: Avoid if eGFR <35 or esophageal disorders; ensure adequate calcium/vitamin D.

Social Determinants, Health Literacy, and Adherence

Even a perfect plan fails if the patient cannot follow it. Simplify and support.

Simplify regimens: Once-daily dosing, combination pills, synchronized refills, pill organizers, and clear written plans.
Teach-back: Ask patients to repeat key instructions to confirm understanding. Use large fonts and plain language.
Access: Screen for food insecurity, transportation, and caregiver support. Write to the lowest copay tier when possible.

AGPCNP Exam Pointers and Clinical Shortcuts

Default safely: When uncertain, favor options that reduce harm in older adults: avoid anticholinergics/sedatives, choose nonpharmacologic first, monitor closely.
“Start low, go slow, but go”: Titrate to effect with monitoring; under-treating HTN/HF/diabetes also harms.
Look for reversible factors: In delirium, falls, or decompensation, scan meds and hydration before adding new drugs.
Document goals and trade-offs: Note why you relaxed an A1c goal or stopped a statin in advanced illness—this is good medicine and good testing practice.

Case-Based Quick Hits

Case 1: 82-year-old with new AF, HTN, CKD stage 3. CHA₂DS₂-VASc = 4. Start apixaban with renal- and age-appropriate dosing; choose beta-blocker for rate control; avoid diltiazem if HFrEF suspected. Rationale: stroke risk high; DOAC safer than warfarin intracranially.
Case 2: 76-year-old with T2D, HFpEF, BMI 33, A1c 8.1%. Add SGLT2 for HF benefit; consider GLP-1 RA if weight loss desired and cost allows. Avoid glyburide. Rationale: cardiorenal protection plus weight reduction.
Case 3: 79-year-old with dysuria and positive nitrites. Treat UTI. Different patient with confusion only and positive urine—do not treat; search for dehydration, medications, or pneumonia. Rationale: ASB treatment increases harms without benefit.
Case 4: 70-year-old on amitriptyline for sleep, clonazepam for anxiety, and oxycodone PRN; two recent falls. Deprescribe benzo and TCA slowly; switch to CBT-I and SSRI/SNRI if needed; add fall-prevention PT. Rationale: high fall and delirium risk from sedatives and anticholinergics.

Putting It All Together

For older adults, the best plan balances risk reduction with real-world function. Choose treatments that pull double duty (ACEi/ARB for BP and kidney protection, SGLT2 for HF and diabetes). Check in early after medication changes. Keep the regimen tight and the education simple. And always align the care plan with what the patient values most. That approach earns points on exams and, more importantly, keeps your patients safer and stronger at home.

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com