Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How are you incorporating the newer RCT data suggesting no mortality benefit to indefinite beta-blocker therapy for patients who are several years out from an MI with preserved LVEF and no angina or arrhythmia?
I have been de-prescribing after counseling once the patient is a couple of years out. This reduces symptoms, pill burden, drug interactions, etc., so I see an active benefit even if the patient seems to be tolerating medication. Obviously, they would have no other indication for BB, mainly arrhythm...
Which anticoagulant (DOAC or Warfarin) would you recommend in the case of a 70-year-old male with persistent atrial fibrillation and history of rheumatic mitral stenosis now status post bioprosthetic MVR?
There won't be perfect data on this, per the 2023 guidelines:The distinction between “valvular” and “nonvalvular “AF remains a matter of debate. Their definitions may be confusing. Recent trials comparing vitamin K antagonists with non-vitamin K antagonist oral anticoagulants in AF were performed am...
How do you select between antipsychotics in the treatment of delirium refractory to nonpharmacological management in hospitalized older adults with dementia?
I have learned that antipsychotic selection is very institution-based/variable.Traditionally, at the Brigham, we have preferred Seroquel because it is titratable and avoids issues if the patient has underlying Parkinson's. However, now that Zyprexa is available in IV form, house staff often prefer t...
What are some practical steps physicians can take to optimize mobility and reduce falls in hospitalized patients?
Falls have long been a complex challenge for clinicians, inpatient unit leaders, and hospitals/health systems in the management of hospitalized patients. The solution is nuanced and depends on many patient- and facility-related factors – no single intervention is enough on its own. Evidence from rec...
Would you consider transitioning patients older than 75 years of age with coronary disease from statins and/or other lipid-lowering agents to PCSK9 inhibitors given concerns for polypharmacy, provided their LDL levels remain at or below goal?
We do not have any data to suggest PCSK9i are better than statins, and all of the PCSK9i outcomes data are on top of statins. Data show generally that lower is better, and there isn’t a “floor” to benefit. That said, if I have someone on statin + ezetimibe who then gets LDL-C very low on a PCSK9i, I...
When is it useful to test for multiple amyloid-related biomarkers for patients undergoing work-up for cognitive impairment?
If a patient has a presentation consistent with MCI or early dementia due to AD (slow progressive decline, STM loss, no hallucinations, no neuro deficits), I will get an MRI and amyloid blood-based biomarkers. If the goal is just a diagnosis, I stop there. If they are interested in “mab” therapy, I ...
What is your preferred approach to obtaining an objective measure of frailty on physical exam in a primary care practice setting?
Impaired physical performance is a major feature of frailty, but it is not synonymous with frailty. Frailty is a broader clinical syndrome reflecting reduced physiologic reserve and increased vulnerability, often resulting from multisystem dysregulation. The choice of frailty assessment tools should...
What therapies do you recommend for patients with limited life expectancy (<3 months) but whose depression is significantly reducing their quality of life?
I agree with Dr. @Dr. First Last that the first thing we need to do is to make sure that the patient actually meets the criteria for depression rather than demotivation or demoralization. If the patient is depressed, using Ritalin may have an effect in a very short amount of time, although there isn...
Would you recommend a GLP-1 agonist as an option to reduce the risk of dementia in patients with a strong family history?
I'm recommending GLP-1 for many things right now, but I haven't yet independently recommended it just to reduce the risk of dementia. However, if microvascular disease can contribute to vascular dementia, then there may be a benefit to better controlling diabetes with this drug.
What is your approach to deprescribing gabapentinoids so as to prevent withdrawal effects?
Prescriptions for gabapentinoids are increasingly common, particularly for off-label indications such as neuropathic pain (1). There is relatively limited evidence to guide deprescribing strategies for gabapentinoids, as demonstrated in a 2023 scoping review (2). Abrupt discontinuation of gabapentin...