Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...
In your clinical practice, how are you approaching consideration of limbic-predominant age-related TDP-43 encephalopathy (LATE) in the differential diagnosis for older adults previously thought to have Alzheimer's disease?
At the moment, I am not finding that this diagnosis is extremely helpful. In general, LATE looks for all the world like AD at the time of diagnosis in the oldest patients, but it doesn't progress like we expect it to. LATE, by itself, seems to be a much more slowly progressive disease. So I find mys...
When evaluating an older adult patient for cognitive concerns, what is your process for deciding whether or not to refer them for neuropsychological testing?
When I'm deciding whether to pursue neuropsychological testing, this can come down to 2 questions: Will the results change management and/or prognosis? Can the person do the testing? 1) Will the results change management and/or prognosis?Many different aspects can inform this question. F.e., Is this...
What framework or risk assessment tool is most effective in determining surgical or palliative management of acute hip fracture after a fall in an elderly patient with co-morbidities and poor functional status?
I have found the NSQIP calculator to be the most useful in situations of acute hip fractures in elderly patients. In particular, it looks at more than just cardiac risk perioperatively - it examines functional, pulmonary, and ICU risks. They incorporate a number of co-morbidities and functional stat...
How do you choose among SSRIs and dosing strategies for the management of behavioral and psychological symptoms of dementia?
The best supported SSRI for BPSD generally is citalopram. Much of this came out of the CitAD trials [1]. This primarily showed citalopram may be useful for hyperactive behaviors, irritation, but also for depression and anxiety [1, 2]. The effect and response to citalopram, though, may be affected by...
At what point would you consider stopping antidepressant treatment of late life depression after remission?
My first step here would be to answer some clarifying questions: What is the patient's current prognosis? (If the patient has a limited life expectancy- weeks to small order months- then I would certainly consider deprescribing with more ease.) Are there any foreseeable anticipated triggers for depr...
Which patients with mild cognitive impairment do you consider referring for amyloid-targeted therapy?
This is an important question, as clearly, not everyone with MCI is appropriate or interested in Amyloid-Targeted Therapy. In general, I would say that the TRAILBLAZER-ALZ 2 trial did not change my approach to patient selection much, but it did provide more evidence that this class of drugs has a pl...
Do you consider using buspirone for the management of anxiety in older patients?
While buspirone has been FDA-approved for the treatment of generalized anxiety disorder (GAD) and for short-term relief of anxiety symptoms in general since the 1970s, it is not generally considered a first-line treatment, despite its low misuse potential as a non-benzodiazepine. There are no large ...