Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
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 would be your approach to the consideration of the use of antiamyloid monoclonal antibodies for nonamnestic Alzheimer's disease with a positive biomarker for brain amyloid pathology?
Because treatment appropriateness is based on the stage of cognitive impairment, we base our evaluation on whether the patient meets criteria for mild cognitive impairment or early-stage dementia. We do not use cognitive testing cutoffs, even in amnestic Alzheimer's disease, as staging accounts for ...
How do you approach Vitamin D testing and supplementation in older adults following a fragility fracture?
Current evidence does not consistently support the use of vitamin D supplementation to prevent falls or fractures among community-dwelling older adults (1–3). However, several studies have reported that individuals who experience osteoporotic or fragility fractures are frequently found to be vitamin...
What is your approach to initiation of mirtazapine for appetite stimulation and depression in older adults, both in terms of starting dose and titration?
I consider initiation of mirtazapine for older adults who could benefit from at least two of the three potential effects of mirtazapine - improvement of mood, appetite, and/or sleep. I always start at a low dose of 7.5 mg nightly, potentially uptitrating to 15 mg nightly after a week or two if the m...
How would you recommend approaching screening for elder abuse in the primary care setting for older adults?
Based on a combination of evidence and experience, here are 3 questions to ask every older adult in a primary care setting, after normalizing the process (e.g., "There are a few sensitive questions I ask all of my patients"): Is anybody using your money or taking your stuff without your permission?...
How can we approach tapering or discontinuing biologic DMARDs in patient in their 80s with well controlled rheumatoid arthritis?
Not a simple answer, unfortunately, as we know Rheumatoid arthritis (RA) is a chronic disease and thus requires long-term treatment!If, however, the patient's preference is to taper or discontinue a biologic DMARD, per ACR RA treatment guidelines, it can be considered after the patient has been in r...
How do you approach balancing the treatment of urinary incontinence with anticholinergic medications with the use of cholinesterase inhibitors in dementia?
This is a great question and speaks to the importance of shared decision-making and understanding the context of individual patients. Ultimately, it would be best to avoid anticholinergic medications in our patients living with dementia. Medications with anticholinergic properties increase the risk ...
What suggestions for environmental modifications do you find most helpful to reduce the risk of falls in the geriatric population?
Great question! The following recommendations encompass those that have been deemed cost-effective for fall prevention. The CDC STEADI program is also useful for reviewing these things. First, I would usually order home health PT/OT to do an assessment if the person has Medicare, and they will often...
During treatment of severe osteoporosis with PTH analogs (abaloparatide), would a rise in alkaline phosphatase level >200 (in the setting of normal GGT) warrant discontinuation of medication?
During treatment with PTH analogs, it is not recommended to monitor the alkaline phosphatase but only Vitamin D and calcium every three months. The alkaline phosphatase, of course, increases with PTH analog therapy, but there is no upper limit, and the concerns about osteosarcoma have been removed f...
How do you decide when to initiate medical workup (e.g., thyroid, B12, infection) in a geriatric patient experiencing new onset or worsening low mood?
It is important to distinguish between low mood, which can occur from a host of environmental stressors, and frank depression, and there are 3 ways to look at either in the older patient: Early onset depression in someone now older, and the patient feels the present one is exactly the same as previo...