CCFP priority topic 36 of 105
Elderly on the CCFP exam
5 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 5 key features for Elderly. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 5
Medicine review
For an older adult on many drugs, recheck each drug's purpose, dose, harms and clashes.
CFPC skill Clinical reasoningPhase Treatment, follow-upSources Choosing Wisely Canada, Health Canada
On the exam
A 79-year-old man on a diuretic and a prostate drug is newly depressed. Expect one best answer on the safest antidepressant.
Pick the safest drug and dose.
Common mistakes
Citalopram 40 mg, or amitriptyline because it helps sleep. Citalopram tops out at 20 mg from 65. A tricyclic brings urinary retention, confusion and falls.
Approach
- At every review, ask of each drug: is it still needed, and is the dose right for this patient now?
- Reconcile the full list each time the patient moves between home, hospital and long-term care. Look for drugs to stop.
- Think of a drug first when an older adult has new confusion, falls or a slide in what they can do.
- Citalopram at 65 or older: 20 mg a day is the usual dose and the maximum. You can start at 10 mg. Its heart rhythm risk (QT prolongation) rises with dose.
- Watch sodium on a selective serotonin reuptake inhibitor (SSRI). Low sodium is seen mostly in older adults, above all older women. Some cases are in people on a diuretic.
- Recheck cholinesterase inhibitors and memantine regularly. Think about stopping when harms outweigh benefits or dementia is advanced.
- In diabetes, do not chase a low glycated hemoglobin (A1c) with drugs that cause low blood sugar. Targets loosen as health and life expectancy fall.
| Older adult | Suggested A1c |
|---|---|
| Healthy, long life expectancy | 7.0 to 7.5% |
| Some other illness, life expectancy under 10 years | 7.5 to 8.0% |
| Many illnesses, shorter life expectancy | 8.0 to 8.5% |
Key feature 2 of 5
Store-bought drugs
Ask an older adult directly about every product taken without a prescription.
CFPC skill Clinical reasoningPhase HistorySources Choosing Wisely Canada
On the exam
A 78-year-old woman with two falls takes dimenhydrinate to sleep. Expect one best answer on what to do with it.
Pick what to do with the sleep aid.
Common mistakes
Halving her dose, or swapping to a diphenhydramine sleep aid. Diphenhydramine is the active part of dimenhydrinate: same confusion, same falls. A prescription sleeping pill is no safer.
Approach
- Ask by name: sleep aids, cold and allergy pills, nausea pills, pain relievers, herbal products, vitamins and lozenges.
- Ask the patient to bring every bottle, box and jar to the visit.
- Stop diphenhydramine sleep aids, including night-time pain relievers and dimenhydrinate. Older adults get next-day drowsiness, confusion and poor balance.
- Do not swap in a prescription sleeping pill. In older adults these more than double the risk of falls and hip fractures, and raise crash risk.
- Treat poor sleep without drugs first: a fixed schedule, no caffeine after 3 p.m., less alcohol, and get up if awake.
- Look for what keeps the patient awake: depression, anxiety, pain or restless legs.
- Unused or expired medicines and natural health products go to a take-back site. Not the sink, toilet or trash.
Key feature 3 of 5
Eyes, ears and falls
Look for problems such as poor sight or hearing that can be fixed to keep them safe.
CFPC skill Clinical reasoningPhase History, hypothesis generationSources Canadian Task Force on Preventive Health Care
On the exam
A 78-year-old woman with two falls has acuity of 6/30 and a dull red reflex. Expect one best answer for the cause, then for driving.
Pick the cause, then the driving advice.
Common mistakes
Calling it macular degeneration or a glasses problem. A dull red reflex and a pinhole that barely helps point to cataract. Letting her drive until surgery is wrong too.
Approach
- Ask every older patient about sight, hearing, falls and driving. Each can often be fixed or made safer.
- Check acuity with a pinhole and look at the red reflex. A pinhole corrects a glasses problem, not a cataract.
- Refer a cataract that limits daily life, reading or driving.
- Check acuity against your province's driving standard. Below it, advise the patient not to drive now and follow your province's reporting rules.
- Ask about hearing. Offer a hearing test and aids when it limits talk or safety.
- The Canadian Task Force advises against routine vision screening in well adults 65 and over living at home. It is a weak recommendation.
- That advice does not cover glaucoma, diabetes, dementia, eye specialist care or residential care. A complaint is not screening: examine the eyes.
Key feature 4 of 5
Function and help
Learn what the patient can still do, and who helps, to plan for a future move.
CFPC skill Clinical reasoning, patient-centred approachPhase Treatment, historySources Choosing Wisely Canada
On the exam
An 82-year-old man is ready to leave hospital, and the planner suggests long-term care. Expect a short menu (pick several from a list) on what to ask.
Pick what to ask before placement.
Common mistakes
Choosing care homes before you know what he can do. Smoking, family and prostate history fill the page but do not decide where he lives.
Approach
- Ask about self-care: bathing, dressing, eating, toileting, getting out of bed and bladder control.
- Then ask about running a home: cooking, shopping, money, medicines, phone and transport.
- Ask who helps now, who else could, and how close they live. Ask how the main caregiver is coping.
- Match the plan to the need. Someone who still runs a home and cooks after two falls needs supports, not long-term care.
- Raise future moves early, while the patient can take part. Ask what matters most to them.
- Before tests or procedures, weigh the likely course of illness and the patient's goals of care.
| Self-care | Running a home | |
|---|---|---|
| Examples | Bathing, dressing, eating, toileting, moving from bed to chair | Cooking, shopping, money, medicines, transport |
| Usually lost | Later | Earlier |
| Loss usually needs | Hands-on help, often daily | Help with tasks: meals, rides, blister packs |
Key feature 5 of 5
Illness in disguise
In an older adult, rule out serious illness that shows up without its usual signs.
CFPC skill Selectivity, clinical reasoningPhase Hypothesis generation, diagnosisSources Canadian Task Force on Preventive Health Care, Choosing Wisely Canada
On the exam
A widower of 80 has weight loss and forgetfulness, feels a burden and enjoys nothing. His computed tomography (CT) is normal. Expect one best answer for the diagnosis.
Pick the diagnosis that fits.
Common mistakes
Grief, dementia, or a positron emission tomography (PET) scan after a normal CT. Feeling a burden and enjoying nothing point to major depression, not grief.
Approach
- New confusion, falls, weakness or not eating can be the only sign of infection. Fever and cough may be missing.
- Examine the chest and belly even when the story is vague. Pneumonia or appendicitis may bring little pain or fever.
- A positive urine test does not explain confusion on its own. Bacteria in the urine without urinary symptoms need no antibiotic, so keep looking.
- Ask about mood when weight loss, tiredness or memory complaints have no clear cause. Advice against depression screening does not apply once you suspect it.
- A memory concern from the patient or family needs an assessment. Advice against memory screening covers only people with no symptoms.
- Grief comes in waves and self-worth survives. Feeling worthless or a burden, with no interest in anything, points to depression.
Flashcards
Answer it first, then check.
KF 1A 70-year-old takes citalopram 40 mg a day. What is the most you should give?
20 mg a day. From 65, the Canadian monograph sets 20 mg as the maximum. Source: Health Canada
KF 1A healthy 76-year-old with type 2 diabetes is expected to live long. What A1c target?
7.0 to 7.5%. Do not push lower with drugs that can cause low blood sugar. Source: Choosing Wisely Canada
KF 2She takes dimenhydrinate every night to sleep. Halve it, or stop it?
Stop it. It works through diphenhydramine, which brings confusion and poor balance in older adults. Source: Choosing Wisely Canada
KF 2Name four products bought without a prescription to ask an older adult about.
Any four of: sleep aids, cold and allergy pills, pain relievers, herbal products, vitamins, lozenges.
KF 3A well 72-year-old at home has no eye complaints. Screen her vision routinely?
No. The Canadian Task Force advises against it, a weak recommendation on low-quality evidence. Source: Canadian Task Force on Preventive Health Care
KF 4The hospital wants him moved to long-term care. What comes first?
Find out what he can do for himself and who helps him. Placement follows from that.
KF 5A confused 85-year-old has a positive urine dipstick and no urinary symptoms. Done?
No. Bacteria in the urine alone need no antibiotic. Look for another cause, such as pneumonia. Source: Choosing Wisely Canada
KF 5His family says he is forgetful. Does the advice against memory screening apply?
No. It covers only people without symptoms. A family concern means you assess him. Source: Canadian Task Force on Preventive Health Care
FAQ
Do I need to memorize a list of drugs to avoid in older adults?
No. Marks go to the method: is each drug needed, at the right dose, and safe with the others? Know the main culprits: sleeping pills, drugs that confuse, and drugs that drop blood sugar.
Should I screen older adults for memory, mood or vision problems?
Not routinely. The Canadian Task Force advises against routine screening for all three. Each covers only people without symptoms. A complaint, a fall or a family concern means you assess.
What do I say about driving when vision falls below the standard?
Tell the patient to stop driving now, not after surgery. Each province sets its own vision standard and reporting rules. Check yours and report as it requires.
Is 6/30 the same as 20/100?
Yes. Both mean the patient sees at the first distance what a normal eye sees at the second. Canada often writes it in metres; the 20 system uses feet.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada
- Drug Product DatabaseHealth Canada
- Published prevention guidelinesCanadian Task Force on Preventive Health Care