Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
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...
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 ...
How do you approach requests from facilities requesting a urinalysis (either on demand or PRN) for "behavioral changes"?
First, I would do a happy dance (discreetly, of course) because rather than asking me to prescribe a psychoactive medication, the facility thought about the possibility that a behavior change has an underlying medical cause. And before getting too distracted by the request for a UA, I would get more...
In your clinical practice, do you find that patients with moderate dementia due to Alzheimer's see much benefit from increasing donepezil dosing from 10 mg/day to a higher dose such as 23 mg/day?
Personally, I do not see much benefit in increasing to 23 mg. To be fair, I do not do this very often, as our cognitive neurologists that I trained with during fellowship rarely did this, given their experience that 23 mg did not offer noticeably more benefit and often many more side effects. I have...
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...
How do you counsel patients on the risks and benefits of chemotherapy or radiation offered with palliative intent?
Before I start counseling a patient on these decisions, I want to know a few things first. I would want to know from the oncologists what they think the benefits are (i.e., how much more time might they get? Symptom control?) and what the risks are. The chances that the patient will see a benefit. ...
How would you approach the counseling and management of a 76-year-old man presenting to clinic having purchased a direct to consumer pTau181 Elecsys test (rule out) that is positive for amyloid, with MoCA 29/30?
I so wish this wouldn’t happen, but in reality, it’s happening! I tell people who are cognitively intact to ignore the results of the PTau test if possible. It is not a “crystal ball” that will predict their future. Is it a risk factor for developing AD in the future? Perhaps. But it’s one that is n...
What clinical tools and/or thresholds do you use to determine driving risk among older patients with mild cognitive impairment?
I like to use the Clinical Assessment of Driver-Related Skills (CADReS). It reminds me to assess multiple domains, and reminds me which part of the MOCA is more pertinent to driving-related skills. If I have concerns, depending on the extent of my concern, I will either then file a concern with the ...
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...
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.