Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
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 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...
What suggestions for environmental modifications do you find most helpful to reduce the risk of falls in the geriatric population?
Great question! The following recommendations encompass those that have been deemed cost-effective for fall prevention. The CDC STEADI program is also useful for reviewing these things. First, I would usually order home health PT/OT to do an assessment if the person has Medicare, and they will often...
During treatment of severe osteoporosis with PTH analogs (abaloparatide), would a rise in alkaline phosphatase level >200 (in the setting of normal GGT) warrant discontinuation of medication?
During treatment with PTH analogs, it is not recommended to monitor the alkaline phosphatase but only Vitamin D and calcium every three months. The alkaline phosphatase, of course, increases with PTH analog therapy, but there is no upper limit, and the concerns about osteosarcoma have been removed f...
How do you decide when to initiate medical workup (e.g., thyroid, B12, infection) in a geriatric patient experiencing new onset or worsening low mood?
It is important to distinguish between low mood, which can occur from a host of environmental stressors, and frank depression, and there are 3 ways to look at either in the older patient: Early onset depression in someone now older, and the patient feels the present one is exactly the same as previo...
Is a target TSH closer to the mid normal range justified in older individuals (age 70 or above) without any known cardiac ischemia or dysrhythmia or osteoporosis?
There are observational data showing decreased mortality rates and improved measures of well-being in elderly persons with TSH levels that are above the traditional reference range for the general population. Therefore, having a target TSH range of about 7 is more appropriate for elderly persons. Th...
Do you recommend life long aspirin 81 mg daily for non-specific T2 white matter hyper-intensities on MRI brain?
"Non-specific" means non-specific, indeed, and ASA risks of bleeding increase with age.
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...