Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
Would you recommend PFO closure in patients >60 years old with presumed paradoxical embolism as their mechanism of stroke?
Technically, based on the available clinical trial evidence, PFO closure is not indicated for patients over age 60 or for patients whose stroke was > 6 months ago. However, we frequently need to extrapolate from clinical trial populations to manage the patients we see in practice. Also, presumably, ...
For patients over 90 years old, is there any foreseeable benefit to undergoing left atrial appendage occlusion over permanent cessation of anticoagulation, particularly for those at high risk for major bleeding?
I would have no qualms about referring a 90+ year-old patient with a-fib and high bleeding risk for an LAA occlusion device. However, this requires a shared decision-making process whereby the risks and benefits of the various treatment options are discussed with the patient and, when appropriate, t...
Do you typically screen every patient with headaches after the age of 60 with ESR?
I would not. Many patients will have elevated ESR because of other conditions (for example, chronic kidney disease). The history is going to be key in determining which cases to send for lab testing.
What criteria are used to choose a specific dose of aspirin in ischemic stroke?
In my training and current practice, most stroke specialists have adjusted from the standard 81 mg aspirin dose (one-size-fits-all) to weight-based dosing. A meta-analysis of RCTs (Rothwell et al., PMID 30017552) suggests that low-dose aspirin may not suffice for stroke prophylaxis for patients who ...
How do you manage myasthenia gravis in patients over the age of 90?
Steroids always carry the risk for side-effects and these need to be explained to each patient and weighed against co-morbidities to determine if they are in fact reasonably indicated in a particular instance. Nevertheless, steroids should be first-line agents for elderly MG patients as a significan...
Does aspirin dose (81 mg vs 325 mg) matter for secondary stroke prevention?
This topic has been debated extensively. There are two camps in this debate: Aspirin with a dose of 81 mg is adequate for platelet inhibition in the general population. Aspirin with a dose of 325 mg may be needed for individuals who weigh more (>70 kg) to achieve appropriate platelet inhibition. T...
Is there any role for 25-OH Vitamin D testing in patients older than 75 years old in the general population?
The recent Endocrine Society Guideline on Vitamin D no longer recommends testing for vitamin D status unless there are unusual circumstances. The Guideline however recognized that approximately 20% of adults greater than 75 years of age are vitamin D deficient i.e. 25-hydroxyvitamin D <20 ng/mL. The...
How do you approach a mildly positive finding on an autoimmune encephalitis panel when there is no other evidence of encephalitis (such as elevated CSF protein, abnormal imaging, or EEG findings)?
In general, low positive Abs by ELISA or radioimmunoprecipitation assays have low predictive value for neurological disease and cancer outside of specific clinical contexts (e.g. a PQ of 0.03 nmol/L in a patient with myasthenic syndrome).For encephalitis, GAD65 < 20 nmol/L, and PQ type calcium chann...
What duration of dual antiplatelet therapy do you use for secondary prevention of ischemic stroke due to intracranial atherosclerotic disease?
It is a fair question that we don't have a solid evidence-based answer for. I agree that the SAMMPRIS trial was driven by events within the first 30 days, although this was primarily driven by procedure-related events in the stented group. We do know that intracranial athero (ICAS) risk of stroke re...
Would you recommend AV fistula placement in a CKD Stage 5 patient who is over the age of 80?
Depends. If this is an active 80-year-old, then creating a distal fistula (radial-cephalic, when vessels are available) would be ideal compared to a catheter. For someone with limited life expectancy, an alternative (graft or catheter) may be acceptable.