Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
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. ...
How do you counsel older adults regarding the use of melatonin (dose and timing) for sleep-related problems?
Although many patients take up to 10 mg of melatonin, in older adults, the data support doses in the 2-4 mg range (dose response peaks at 4 mg for sleep). I find 30 minutes is not long enough prior to desired sleep time, and I try to give it to hospitalized older patients at about 7 pm so they can f...
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 ...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
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 trial did not change my approach to patient selection much, but it did provide more evidence that this class of drugs have a place i...
For patients over 70 with elevated ASCVD risk but no prior cardiovascular events, do you ever recommend continuing or initiating low-dose aspirin?
Yes, I might still recommend low-dose ASA for primary prevention for someone over 70 if the patient is very functional.
How soon after a fracture would it be safe to start anti-resorptive therapy?
This is an important question. There is no definitive answer, and there have been no clinical or preclinical studies that demonstrate delayed healing in the presence of bisphosphonates. Personally, I favor waiting a few weeks before we start. That also gives us time to do a proper metabolic workup. ...
What are the clinical prompts that lead you to consider deprescribing bisphosphonate therapy in older adults with osteoporosis?
As a Geriatrician, the essence of my practice is to determine, on regular review (reconciliation), whether an older adult’s medication is appropriate to continue or continue at the same dosing on the basis of physiology, pathology, and/or risk modification. We know well today that medications for os...
When considering deprescribing antihypertensives in older patients, how do you approach prioritization of which antihypertensives to target first?
When deprescribing antihypertensives in older adults, my approach is individualized, goal-concordant, and iterative with close monitoring after each step. Every patient is a little different, so there isn't one class of antihypertensives I always deprescribe first. My general rule of thumb is that w...