Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
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.
How do you approach selecting biologic therapy vs non-biologic DMARD (such as methotrexate) as initial therapy in patients with new RA diagnosis with significant erosive disease?
In my clinical experience, not everyone is the best candidate for methotrexate. Businessmen who feel alcohol consumption is part of their ability to finish business deals are uncomfortable taking methotrexate and I am uncomfortable prescribing for them. Men and women who are hoping to bear children ...
How would you approach the work up of SLE in a patient over 80 years old?
Elderly onset lupus is uncommon and in the past twenty-five years has been reported to occur in as few as 6% of patients to as many as 19% of patients with the diagnosis of lupus. Typical clinical presentations tend to include arthritis/arthralgias, fever, weight loss, lymphadenopathy, serositis, si...
What is your approach to checking serum vWF antigen levels in adult patients with CNS vasculitis for monitoring disease activity?
I never have checked them but I am aware of interest in this by the Hamburg group. (Ref) Following disease activity in CNS-V is challenging but reduction/clearing of pleocytosis is important to us. Also now being able to look at serial direct vascular wall imaging is of interest and appears to corre...
In patients with thrombocytosis with negative MPN workup from peripheral blood and bone marrow, is there a role for daily 81mg aspirin or other treatment?
In the absence of an MPN, there is no data to support the use of low-dose ASA. Unless there was extreme thrombosis and acquired von Willebrand syndrome, there would also be little reason to bring the platelet count down as well. In the absence of MPN, thrombocytosis itself is not a risk factor for t...
Given the "LDL Paradox", in which RA patients with the highest levels of inflammation can have ultra-low levels of LDL (<70), how do you approach initiation of statin therapy in these patients?
Evaluate lipids at the time of remission/low disease activity and if elevated and the patient is a good candidate for statin therapy, initiate a statin using criteria for the general population.