Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
Do you consider using buspirone for the management of anxiety in older patients?
While buspirone has been FDA-approved for the treatment of generalized anxiety disorder (GAD) and for short-term relief of anxiety symptoms in general since the 1970s, it is not generally considered a first-line treatment, despite its low misuse potential as a non-benzodiazepine. There are no large ...
How do you approach the management of older adult patients with coronary artery disease on aspirin who have developed intermittent diverticular bleeds?
This is a tough clinical scenario that comes up often in older adults. You will often have subspecialists involved and will need to adapt your approach to their management and communication styles. Generalists can add value here by looking at the whole picture and figuring out what matters most to t...
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
Have you used lithium for agitation in dementia?
Non-pharmacologic approaches are first indicated. If they fail, then a psychotropic treatment algorithm is indicated, which generally starts with a serotonin reuptake inhibitor. Lithium would not be considered standard or first-line treatment for agitation in Alzheimer's disease, and in most other m...
Do you have any tips for best practices or resources for interacting with adult protective services when reporting elder mistreatment?
Interacting with Adult Protective Services can sometimes feel like a one-way valve: we make a report, provide information, and don't hear back. I've come to learn that in many jurisdictions, APS is prohibited from sharing information with the reporter, and they actually want to have more/better inte...
Do you see any reason to consider the use of brexpiprazole over older atypical antipsychotics that may be less expensive for the management of agitation refractory to nonpharmacological management in older adults with dementia?
While I will say up front that I am not an expert in Geriatric Psychiatry, I have not yet found a reason to start brexipipraxole out of the gate. For agitation that really requires pharmacologic management, my go-to remains Seroquel. It has one of the lowest rates of side effects, although we exploi...
How do you discuss the benefits and potential risks of anticoagulation for a strong indication (e.g., atrial fibrillation with high CHA2DS2-Vasc score) with older adult patients with frequent falls?
Current guidelines from AHA/ACC emphasize that oral anticoagulants should not be withheld simply because a patient is at risk of falling.Instead, I try to manage involving shared decision-making with the patient or DPOA that weighs stroke risk against modifiable bleeding and fall risk factors( with ...
Has the recent large observational data suggesting that continuing metformin during hospitalization is associated with lower post-discharge mortality and hypoglycemia changed your approach to holding it on admission in stable, non-critically ill patients with T2DM?
I really like this paper, but I don't think it is plausible that a 5-day difference in receipt of metformin (the median length of stay was 5 days) could really affect 90-day mortality.The study question is a good one because the evidence that metformin causes lactic acidosis is extremely limited. In...
How do you choose between various nonpharmacological strategies for prevention of behavioral and psychological symptoms of dementia such as bright light therapy, pet therapy, robot therapy, exercise, massage?
Non pharmacological strategies are most effective strategies with no potential side effects, but they are resource heavy. So it is crucial to assess specific symptoms, access to resources and the enviornment.A 3-Step Approach to ChoosingIdentify the Target Symptom: Are you treating agitation, apathy...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...