Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
When is it useful to test for multiple amyloid-related biomarkers for patients undergoing work-up for cognitive impairment?
If a patient has a presentation consistent with MCI or early dementia due to AD (slow progressive decline, STM loss, no hallucinations, no neuro deficits), I will get an MRI and amyloid blood-based biomarkers. If the goal is just a diagnosis, I stop there. If they are interested in “mab” therapy, I ...
What is your preferred approach to obtaining an objective measure of frailty on physical exam in a primary care practice setting?
Impaired physical performance is a major feature of frailty, but it is not synonymous with frailty. Frailty is a broader clinical syndrome reflecting reduced physiologic reserve and increased vulnerability, often resulting from multisystem dysregulation. The choice of frailty assessment tools should...
What therapies do you recommend for patients with limited life expectancy (<3 months) but whose depression is significantly reducing their quality of life?
I agree with Dr. @Dr. First Last that the first thing we need to do is to make sure that the patient actually meets the criteria for depression rather than demotivation or demoralization. If the patient is depressed, using Ritalin may have an effect in a very short amount of time, although there isn...
Would you recommend a GLP-1 agonist as an option to reduce the risk of dementia in patients with a strong family history?
I'm recommending GLP-1 for many things right now, but I haven't yet independently recommended it just to reduce the risk of dementia. However, if microvascular disease can contribute to vascular dementia, then there may be a benefit to better controlling diabetes with this drug.
What is your approach to deprescribing gabapentinoids so as to prevent withdrawal effects?
Prescriptions for gabapentinoids are increasingly common, particularly for off-label indications such as neuropathic pain (1). There is relatively limited evidence to guide deprescribing strategies for gabapentinoids, as demonstrated in a 2023 scoping review (2). Abrupt discontinuation of gabapentin...
How do you approach revascularization in patients over 75 years with NSTEMI, given recent evidence from the SENIOR-RITA trial that an invasive strategy does not significantly reduce cardiovascular events compared to a conservative strategy?
The Senior-Rita trial was a randomized trial of nstemi patients over the age of 75 randomized to conservative therapy versus an invasive strategy plus optimal medical therapy. Non-fatal MI was more common in the conservative strategy group but overall a primary outcome event occurred in 25-26% in bo...
When do you consider using aspirin 81 mg PO BID for VTE prophylaxis over other agents in patients with a fracture, considering recent trial data?
Aspirin for VTE prophylaxis may be reasonable in selected low-risk patients, but many patients undergoing surgery for a fracture are at high risk for VTE. In addition to the METRC trial you cited, another relevant study informing my opinion on this is the CRISTAL trial.In METRC, the mean patient age...
Do you routinely prescribe vitamin D to reduce the risk of fall-related fractures in elderly patients regardless of their serum levels?
Right now, the evidence would NOT support daily vitamin D in older adults who are not deficient just for the purposes of fall prevention. Kahwati et al., PMID 33847712However, lots get missed on fall prevention - so be sure to review all risk factors and make a personalized plan (STEADI resources ar...
Do you routinely adjust your interpretation of SLUMS and/or MOCA tests in patients depending on their level of education?
I have routinely adjusted the MOCA score based on their educational level. If their educational level is less than 8th grade, I use MOCA Basic for assessment. Personally, I have not used SLUMS for assessment, so I cannot comment on that.
How do you approach treating depressive symptoms in an older adult already taking an SSRI?
I would uptitrate first; then consider adding another agent, or switching if appropriate.