Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you discuss the benefits and potential risks of anticoagulation for a strong indication (e.g., atrial fibrillation with high CHA2DS2-Vasc score) with older adult patients with frequent falls?
Current guidelines from AHA/ACC emphasize that oral anticoagulants should not be withheld simply because a patient is at risk of falling.Instead, I try to manage involving shared decision-making with the patient or DPOA that weighs stroke risk against modifiable bleeding and fall risk factors( with ...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
How do you weigh the risks of antipsychotic induced metabolic side effects when treating behavioral symptoms of dementia in a patient with diabetes?
This is an excellent question and is a difficult clinical metabolic risk concern in a poorly characterized population. Most of what we know about antipsychotic-induced metabolic syndrome, such as weight gain, dyslipidemia, insulin resistance, and hyperglycemia, comes from younger patients with schiz...
Would you use a parathyroid hormone analog for treatment of osteoporosis in a patient with mildly elevated AlkPhos of unclear etiology?
I would be hesitant to administer an anabolic in this setting without first delineating the reason for an elevated AlkPase. I would suggest starting with sorting out the source of the AlkPase (i.e., bone, liver, or gut with measuring bone-specific AlkPase, G-GGT levels, and possibly a liver ultrasou...
What are the best practices for optimizing transitions from hospital to skilled nursing facilities for older adult patients, with specific regard to adapting hospital medication regimens to the skilled nursing facility setting?
Medication errors and discrepancies are well known to lead to adverse drug events during transitions of care, as well as rehospitalization. The standard of care that has emerged over the last twenty years or so is rigorous medication reconciliation. Medication reconciliation is defined as comparing ...
What is your antipsychotic of choice and general titration regimen in the outpatient setting for a patient with dementia and behavioral disturbances (assuming reversible causes such as urinary retention, constipation, etc. have been addressed)?
While not set in stone and knowing that there is a black box warning, make sure you get informed consent. I start with low doses of quetiapine (12.5 to 25 mg), as it has the shortest half-life, and will use it twice or 3 times a day. This allows for quicker recovery if they are too sedated. Dependin...
Do you recommend vitamin K2 supplements in patients with osteoporosis?
The answer, as with most vitamin supplementations, cannot be answered with high-level evidence to support a "yes or no". A bit of background and then a brief review of available evidence.Vitamin K is thought to be important for bone health because it activates several proteins involved in bone forma...
In an older man on tamsulosin for BPH who is presenting with recurrent falls, how do you manage the medication, in light of urinary symptom control and fall risk?
Tamsulosin carries the risk of orthostatic hypotension and falls, especially in older adults1. In the situation of an older adult man taking tamsulosin for BPH symptoms who is presenting with recurrent falls, I would first check orthostatic vitals and if positive, I would discuss this finding with t...
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 ...
How do you decide when to recommend conservative kidney management over dialysis initiation in a frail older adult with stage 5 CKD?
This is definitely not a one-size-fits-all answer. Functional status and cognitive status, rather than age, are the most important considerations. The frailty syndrome itself is associated with poor outcomes for patients on dialysis. There is a clear association between kidney disease and frailty, w...