Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
When do you consider using aspirin 81 mg PO BID for VTE prophylaxis over other agents in patients with a fracture, considering recent trial data?
Aspirin for VTE prophylaxis may be reasonable in selected low-risk patients, but many patients undergoing surgery for a fracture are at high risk for VTE. In addition to the METRC trial you cited, another relevant study informing my opinion on this is the CRISTAL trial.In METRC, the mean patient age...
Do you routinely prescribe vitamin D to reduce the risk of fall-related fractures in elderly patients regardless of their serum levels?
Right now, the evidence would NOT support daily vitamin D in older adults who are not deficient just for the purposes of fall prevention. Kahwati et al., PMID 33847712However, lots get missed on fall prevention - so be sure to review all risk factors and make a personalized plan (STEADI resources ar...
Do you routinely adjust your interpretation of SLUMS and/or MOCA tests in patients depending on their level of education?
I have routinely adjusted the MOCA score based on their educational level. If their educational level is less than 8th grade, I use MOCA Basic for assessment. Personally, I have not used SLUMS for assessment, so I cannot comment on that.
How do you approach treating depressive symptoms in an older adult already taking an SSRI?
I would uptitrate first; then consider adding another agent, or switching if appropriate.
What would be your approach to the consideration of the use of antiamyloid monoclonal antibodies for nonamnestic Alzheimer's disease with a positive biomarker for brain amyloid pathology?
Because treatment appropriateness is based on the stage of cognitive impairment, we base our evaluation on whether the patient meets criteria for mild cognitive impairment or early-stage dementia. We do not use cognitive testing cutoffs, even in amnestic Alzheimer's disease, as staging accounts for ...
How do you approach Vitamin D testing and supplementation in older adults following a fragility fracture?
Current evidence does not consistently support the use of vitamin D supplementation to prevent falls or fractures among community-dwelling older adults (1–3). However, several studies have reported that individuals who experience osteoporotic or fragility fractures are frequently found to be vitamin...
What is your approach to initiation of mirtazapine for appetite stimulation and depression in older adults, both in terms of starting dose and titration?
I consider initiation of mirtazapine for older adults who could benefit from at least two of the three potential effects of mirtazapine - improvement of mood, appetite, and/or sleep. I always start at a low dose of 7.5 mg nightly, potentially uptitrating to 15 mg nightly after a week or two if the m...
How would you recommend approaching screening for elder abuse in the primary care setting for older adults?
Based on a combination of evidence and experience, here are 3 questions to ask every older adult in a primary care setting, after normalizing the process (e.g., "There are a few sensitive questions I ask all of my patients"): Is anybody using your money or taking your stuff without your permission?...
How can we approach tapering or discontinuing biologic DMARDs in patient in their 80s with well controlled rheumatoid arthritis?
Not a simple answer, unfortunately, as we know Rheumatoid arthritis (RA) is a chronic disease and thus requires long-term treatment!If, however, the patient's preference is to taper or discontinue a biologic DMARD, per ACR RA treatment guidelines, it can be considered after the patient has been in r...
How do you approach balancing the treatment of urinary incontinence with anticholinergic medications with the use of cholinesterase inhibitors in dementia?
This is a great question and speaks to the importance of shared decision-making and understanding the context of individual patients. Ultimately, it would be best to avoid anticholinergic medications in our patients living with dementia. Medications with anticholinergic properties increase the risk ...