Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you approach the use and interpretation of the FDA-approved plasma pTau181 blood test for Alzheimer's disease in a community-dwelling older adult with subjective cognitive complaints and a normal cognitive screen?
I follow current guidelines, which recommend against testing in those without objective cognitive impairment, given the high rate of false positives. Unless the pre-test probability is high, I would not test. That having been said, future developments (such as subQ modes of anti-amyloid Rx, greater ...
What go-to resources or apps do you recommend for CBT-I for older adults with insomnia?
A great place to start is at the American Academy of Sleep Medicine's "Insomnia Toolkit for Clinicians". The toolkit provides links for free digital CBTI platforms, as well as other resources for treatment.
In what patient population(s) do you recommend RSV vaccination in adults 50-74 years old who would not meet the general age recommendation (>75 years old)?
For adults 50–74 years old who do not meet the routine age-based recommendation (>75 years), I would consider RSV vaccination for those at increased risk for severe RSV disease, consistent with guidance from the Advisory Committee on Immunization Practices (ACIP) of the CDC. In practice, this includ...
Do you recommend any specific tools or processes/references to help with the determination of capacity for decision-making for hospitalized older adults with cognitive impairment?
It is important to recognize that decision-making capacity in hospitalized older adults with cognitive impairment is both decision-specific and time-specific. Assessment should focus on the patient’s ability to demonstrate the four elements described by Appelbaum and Grisso: understanding, appreciat...
Does global brain atrophy increase risk for intracranial bleed after fall in older adults?
It depends on the location of the hemorrhage. Subdural bleeding/hematoma is much more likely in elderly people with brain atrophy and a fall. Epidural hemorrhage is much more common in young patients. Intracerebral hemorrhage is more related to risk factors such as hypertension in middle age and amy...
What is your approach to picking a dose/formulation of Vitamin D for a community-dwelling older adult found to have Vitamin D deficiency?
Supplementation with cholecalciferol (vitamin D3) 1000–2000 IU daily would be my choice for community-dwelling older adults with documented deficiency, and is preferred over ergocalciferol (vitamin D2). I would also co-administer calcium (1000–1200 mg/day) to support fracture prevention. Routine lab...
In an older adults with dementia-related behavioral symptoms refractory to nonpharmacological management in whom you are starting SSRI, do you ever consider a short course of antipsychotic medication to overlap with the initiation of SSRI while waiting for therapeutic effect?
The American Geriatric Society recommends that antipsychotics may be considered when behaviors do not respond to non-pharmacological management and the patient is at risk of harming themselves or others. Thereby, it may be reasonable to overlap short-term antipsychotic with SSRI initiation in older ...
What are your thoughts about lion's mane supplementation to slow the decline or improve cognitive capacity for those at risk of dementia?
Lion's mane is the latest in the ever-evolving list of supplements that have a whiff of animal data, very small human trials, or frankly, anecdotal evidence. A decade ago, it was coconut oil; last week, it was lithium. There will always be suggestions of the benefit of this or that. Currently, there...
How do you approach the choice of pharmacological therapy when treating insomnia in older adults in the outpatient setting with a high falling risk?
My approach is to first see if there are non-pharmacologic options to help with sleep - are there behavioral factors to target (e.g., caffeine or alcohol use; inappropriate sleep scheduling or daytime napping), medications that could disrupt sleep-wake schedules, or untreated sleep or mood disorders...
Do you have any pearls for how to manage OSA with CPAP in older adults with cognitive impairment?
I try to involve a partner or other family member in the process, including getting a sleep study in the first place. If the study shows moderate or severe sleep apnea, especially with substantial oxygen desaturation, I remind the patient and partner that use of CPAP will help the patient's memory. ...