Geriatric Medicine

Dr. Corrie Vincent

Sunday December 11, 2022

www.internalmedicinereview.ca © Internal Medicine Review 2023

 Outline
I. Delirium MIND
II. Dementia and MCI
a. Diagnosis
b. Management
III. Depression
IV. Falls MOBILITY
V. Disease Management in Older Persons MEDS
MULTICOMPLEXITY
VI. COVID-19 & Geriatrics
VII. BONUS SLIDES: CGA, more disease management, normal
aging, polypharmacy, weight loss, incontinence,
constipation, bonus MCQs
 BONUS
Read on own
Short forms used in this talk
Short Full text Short Full text

CAM Confusion Assessment Method PPA Primary Progressive Aphasia

MMSE Mini Mental Status Exam (Folstein) PCA Posterior Cortical Atrophy

MoCA Montreal Cognitive Assessment BPSD Behavioural and Psychological Symptoms of

RUDAS Rowland Universal Dementia Assessment Scale Dementia

ADLs / Activities of Daily Living / Instrumental Activities ChEI Acetylcholinesterase Inhibitor

IADLs of Daily Living (e.g. Donepezil, Galantamine, Rivastigmine)

SCI Subjective Cognitive Impairment NMDA- N-methyl-D-aspartate Receptor Antagonist (e.g.

MCI Mild Cognitive Impairment RA Memantine)

AD Alzheimer’s Dementia SSRI Selective Serotonin Reuptake Inhibitor

VaD Vascular Dementia Others DDx = Differential Diagnosis, Hx = History, P/E =

Physical Exam, Rx = Treatment
DLB Dementia with Lewy Bodies

FTD Frontotemporal Dementia

 I. Delirium

“Acute brain failure”

Key Guidelines:

1. Canadian Coalition for Seniors Mental

Health (CCSMH) Assessment and
Treatment of Delirium. 2014 update.
2. American Geriatrics Society Clinical
Practice Guideline for Postoperative
Delirium in Older Adults. 2014.
3. NICE Clinical Practice Guideline
Delirium: prevention, diagnosis and
management. 2010, 2019 update.
 Delirium: Diagnosis
Core features (DSM-V):
A. Disturbance in attention (reduced ability to direct, focus, sustain, and shift
attention) and awareness (reduced orientation to the environment).
B. Develops over a short period of time (usually hours to a few days),
represents a change from baseline, and tends to fluctuate in severity during
the course of a day.
C. Additional disturbance in cognition (memory deficit, disorientation,
language, visuospatial ability, or perception).
D. Disturbances in Criteria A and C are not better explained by another
preexisting, established, or evolving neurocognitive disorder and do not
occur in the context of a severely reduced level of arousal, such as coma.
E. Hx, P/E, or labs suggest disturbance is a direct physiological consequence of
another medical condition, substance intoxication or withdrawal, or
exposure to a toxin.
American Psychiatric Association (APA)’s
Diagnostic and Statistical Manual, 5th edition (DSM-V).
 Confusion Assessment Method (CAM)

• Screen for delirium at bedside w/ CAM1

– Sn 94%, Sp 89%2
Memorize!
• Four core features: mnemonic “IADL”
1) Inattention (serial 7s, months backwards)
2) Acute onset and fluctuating course (from observation-> ask bedside RN)
3) Disorganized thinking (Is the patient making sense? e.g. “can a stone float on water?”)
4) LOC altered (hypervigilant? somnolent?)

• Need 1 and 2 + either 3 or 4

1. Inouye. Ann Int Med. 1990.

2. Wei. JAGS. 2008.
 Delirium: Risk Factors
• Risk Factors:
– Predisposing: Age (RR 4.0), Known cognitive impairment (RR 2.8),
Functional impairment (RR 4.0), sensory impairment
– Precipitating: Drugs (polypharmacy, sedatives) (RR 4.5), Physical restraints
(RR 4.4), Bladder catheter (RR 2.4), Infection (RR 3.1)
Phenotypes:
Hyperactive
agitated, increased vocalizations, hallucinations,
delusions, inappropriate behaviour
Hypoactive
drowsy, decreased mental status, lethargic
Mixed
components of both

Inouye et al. Lancet. 2014.

 Delirium: Prevention/ Non-Pharm Review prior to
oral exam

Bridging the Targeted Risk Factor Strategies

CHASSM:
Cognitive impairment Orientation protocols, provision of clocks and calendars, family visits
Cognition
Hydration/ Sensory impairment Provide glasses, hearing aids
malnutrition
Malnutrition Dentures, assistance with feeding, positioning
Agitation
Sensory Fluid/Electrolyte Volume assessment; normal glucose, Na, K, Ca
Sleep imbalances
Mobility
Provide redirection, correct over/understimulation (move to quiet room, provide tasks
Agitation*
such as folding towels), family visits
*For patients Inpatient Unit strategies to reduce noise; Schedule medications and procedures to
Sleep deprivation
with known allow for proper sleep; Non-pharmacologic measures to prevent sleep deprivation
BPSD or as
Functional impairment Mobilize early! PT, OT
part of non-
pharm Pain Scheduled pain control; judicious use of opioids
management
Remove urinary catheters, screen for retention/incontinence; Skin care regimen;
of delirium Iatrogenic complications
Bowel regimen; Chest physiotherapy; Treat nosocomial infections
High-risk medications Avoid/ Minimize benzodiazepines, anticholinergics, antihistamines
Holroyd et al. CMAJ. 2010. CCSMH Guideline 2006/2014 update. AGS Post Operative delirium 2014 Guidelines;
 Indications for neuroimaging:
1. Focal neurological sign
Delirium: Work-up 2. Head trauma
3. Fever + acute change (if encephalitis is suspected)
4. No other cause identified
1. Assess for cause(s) and contributors 5. Cannot do a neuro exam (hypoactive/somnolent)
Etiology History/Environment Observation/Physical Exam/investigations
Drugs Too much: opioids, benzodiazepines, sedatives, anticholinergics, intoxications/recreational,
Too Little: Pain undertreated, withdrawal (EtOH, benzo, opioid, nicotine)
+/- ASA/Tylenol/EtOH levels, tox screen
Infection/ Vitals, focal signs/sources of infection, cultures as appropriate (blood, urine, Chest XR, +/- LP)
Inflammation
Metabolic CBC, lytes, Cr, LEs/LFT, Calcium, VBG, glucose, TSH, B12
Environment Sensory deprivation (windowless room, hearing/vision aids), sensory overload, isolation from
familiar surroundings, absence of orientation (clock/calendar), restraints, disruption to rest/sleep
Retention Abdominal XR, bladder scan
Structural Neuro: ex. sz, stroke, hemorrhage (exam, +/- neuroimaging, EEG), Cardiac: MI/CHF (Troponin, CK,
abnormality ECG +/-BNP); Resp ex. asthma/COPDe, PE (+/-CTPA), Abdo exam, Derm (rashes), MSK
examination for source of pain, etc.
 Delirium: Management
1. Treat the underlying cause
2. Supportive care (Non-Pharmacological)
– Multi-component intervention (see Prevention: relieve sensory deprivation, re-
orient, mobilize, ensure hydration/nutrition, sleep, cognitive stimulation)
– Pharmacological intervention not effective as treatment1,2,3
3. Safety (Non-Pharmacological +/- Pharmacological)
– Address safety/behavioural disturbances to prevent complication
– Antipsychotics only if i) danger to self/others, ii) distressing psychosis, or iii)
preventing medically necessary care
• When needed: Low dose, short duration. Haldol or atypical antipsychotic 1st line
1. Burry et al. Cochrane. 2018. 2. Agar et al. JAMA Int Med. 2017. 3. Nikooie
et al. Ann. Med. 2019. 4. CCSMH 2014 Guideline5. Inouye et al. NEJM. 2006.
 Delirium: Pharmacologic Strategies
Medication Dose Route Side effects

Haloperidol 0.25-0.5 mg q4h PO, IM, IV High risk of extrapyramidal symptoms (EPS), QTc prolongation,
lowers seizure threshold. Versatility in routes of administration.
Risperidone 0.25-0.5 mg daily PO, PO melt Moderate EPS risk, QTc prolongation, lowers seizure threshold
to BID
Olanzapine 2.5-5 mg daily to PO, PO melt, Moderate EPS risk, QTc prolongation. Sedating. lowers seizure
BID IM, IV threshold.
Quetiapine 6.25-25 mg daily PO Least EPS, QTc prolongation. Sedating. lowers seizure threshold.
to q8h Preferred agent if parkinsonism present.
Lorazepam 0.5-1 mg q4h PO, SL, IM, IV Paradoxical worsening. Preferred for withdrawal delirium,
neuroleptic malignant syndrome, 2nd line if parkinsonism.
Trazodone 25-150 mg qHS PO Second line, atypical serotonin reuptake inhibitor – caution if
other SSRI on board
Adapted from Inouye et al. NEJM. 2006.
 MCQ #1
78F with admitted to hospital after fall and hip fracture.
PMHx: MCI, HTN, insomnia
Home Meds: Amlodipine 2.5mg daily, lorazepam 1 mg po qhs for sleep, vitamin D3 1000u daily
Current Meds: Acetaminophen 1 g TID, amlodipine 2.5mg daily, lorazepam 1 mg po qhs,
hydromorphone 0.5 mg PO q4h PRN, Senna 2 tabs BID, enoxaparin 40 mg SC daily, and vitamin
D3 1000 IU daily.
On POD2 she becomes disoriented. On exam she is calm but not able to follow a conversation
and her responses are disorganized. Physical exam otherwise unremarkable. HR 90, regular, BP
125/58, afebrile, RR 16, SpO2 94% RA. Routine labs and ECG are repeated and unchanged
from previous. What is the next best step in management:
A. Discontinue Hydromorphone
B. Start Quetiapine 12.5mg po qhs
C. Insert Foley catheter for presumed urinary retention
D. Decrease lorazepam to 0.75mg po qhs
taper with close monitoring is indicated.
withdrawal and worsen delirium. It is likely contributing to current presentation and
The correct answer is D. While sudden discontinuation of lorazepam could result in
12
IIa. Dementia and Mild Cognitive
Impairment (MCI) - Diagnosis
“Chronic brain failure”
Key Guidelines:

1. Lancet Commission report on

Dementia prevention, intervention,
and care (2020)
2. Recommendations of the 5th Canadian
Consensus Conference on the diagnosis
and treatment of dementia (2020)
3. WHO Guidelines on Risk reduction of
cognitive decline and dementia (2019)
4. CMA Driver’s Guide edition 9.1, Section
8 (Revised 2019)
Lightspring/Shutterstock
 Normal aging
§ Decline: Normal aging is
– Performance speed like a computer
– Short term memory (e.g. recalling a list) with a full hard
– Episodic memory (e.g. details about a previous event) drive – everything
– Divided attention/Task switching is there, but it’s
– Abstract reasoning hard to put in
– “Tip of the tongue” phenomenon new data and
§ Preserved: slower to retrieve
– Semantic memory (e.g. what is the capital of Turkey?)
– Cued recall
– Sustained attention
– Vocabulary, syntax, grammar
 Approach to cognitive impairment

1. Is it dementia (or Mild Cognitive Impairment (MCI) or Subjective

Cognitive impairment (SCI)), or something else?
– e.g. delirium, depression, medication side effect
2. Rule out reversible causes of MCI or dementia
3. What dementia syndrome is it?
– e.g. which domains affected, what is chronology of symptoms
– Presenting symptoms are most useful (all domains affected in severe
disease)
4. How bad is it?
– e.g. cognitive testing, ADL/IADL function
 Risk Factors for
Dementia
• Risk factor (percent of dementia
cases attributable):
– Hearing loss (8%)
– Less education (7%)
– Smoking (5%)
– Depression (4%)
– Social Isolation (4%)
• 40% of risk factors for
dementia are modifiable!
Livingston et al. Lancet. 2020.
Risk Unknown 60%
 Dementia and MCI

Mild Moderate Severe End Stage

SCI MCI Dementia Dementia Dementia Dementia
 Subjective Cognitive Impairment (SCI)

§ Subjective cognitive decline

§ No objective impairment on cognitive testing
§ Preserved function

– ? age-related decline in short term/working memory

– ? precursor to MCI or AD
– Not used clinically yet, area of ongoing research

*Do NOT screen asymptomatic older adults for cognitive impairment*

Canadian Task Force on Preventive Health

Care. CMAJ. 2016.
 Mild Cognitive Impairment (MCI)
a.k.a. Minor Neurocognitive Disorder (DSM-V)

§ Cognitive decline in 1 or more domains

§ Objective impairment on cognitive screen or testing
§ Preserved function (normal IADLs/ADLs)
§ can have coping strategies like lists, calendars, etc.
§ Not attributed to delirium, depression, psychosis, other medical
etiology
Cognitive impairment with
normal function
 Dementia
a.k.a. Major Neurocognitive Disorder (DSM-V)

§ Cognitive decline in 1 or more domains

§ Objective impairment on cognitive screen or testing
§ Functional impairment (at least 1 IADL)
– Earliest to go: driving, finances, medications, meal
preparation1
§ Not attributed to delirium, depression, psychosis, other medical/
mental health disorder
Cognitive impairment with
impaired function 1. Morris et al. 2013
 Dementia and MCI
Objective findings Functional Impairment

Mild Moderate Severe End Stage

SCI MCI Dementia Dementia Dementia Dementia

1 IADL impaired 2 IADL impaired 2 ADL impaired

OR
1 ADL impaired

Per Livingston et al. Lancet 2017 and the

Clinical Dementia Rating Scale
 Cognitive Domains
Executive function
Any problems with paying
for something at the store? Personality
Has he lost interest in previous
activities?
Language
Does he mix up words?
Memory
Any problems with remembering
appointments or losing things?
Visuospatial
Has he ever put his clothing
on incorrectly or gotten lost
recently?

McKhann et al. Alz and Dem. 2011.

*DSM-V criteria have an additional domain
for attention
 Cognitive Testing
Cognitive Domain MMSE (≤23 for dementia) MoCA (≤26 MCI/dementia) RUDAS (≤22 for MCI/dementia)

Executive Function No Trails, Clock draw, Abstraction, Praxis sequence (complex),

Letter fluency Crossing road

Language Naming, Phrase repetition Naming, Sentence repetition Animal fluency

Attention Serial 7s or WORLD Digit span, Vigilance A, Serial 7s No

Visuospatial Intersecting pentagons Trails, Cube, Clock draw Body orientation, Cube

Immediate recall Yes Yes Yes

Delayed recall Yes Yes Yes

When to use English-speaking, English-speaking, highly Non-Western cultural

limited education educated upbringing, limited education

Briefly review these tests

 A note on executive function:

• What is better to test for executive function? MoCA, MMSE,

Clock draw test (CDT)?
– As always, read the wording of the prompt carefully.
• The more specific test for executive function is the clock draw:
– you can score quite poorly on the MoCA due to impairments in other domains (e.g.
memory, language, etc.) while your executive function remains preserved.
• The more sensitive test for executive function is the MoCA, given it has
multiple tasks that assess for it (e.g. sample Trails B, CDT, abstraction, letter
fluency).
• Thus, the “better” test overall depends on whether you want to prioritize
specificity or sensitivity.

24
 Workup for dementia
• History: REVERSIBLE CAUSES: sleep, meds, alcohol use
– Ask about domains, get collateral, obtain functional history, screen for safety
• Physical examination:
– Cognitive testing, mental status examination
– Neurologic examination, with emphasis on UMN findings and parkinsonism
• Bloodwork:
– CBC, lytes, Cr, calcium, LEs/LFTs, blood glucose, TSH, vitamin B12
– +/- HIV, VDRL
– Limited role for biomarkers or genetic testing (not covered)
• Imaging:
– Imaging not required for all persons with cognitive impairment see next slide
– MRI preferred to CT given higher sensitivity to vascular lesions, some subtypes of dementia
and other more rare conditions
– Order “Dementia protocol” for more detailed reformats of specific brain regions
1. Feldman et al. CMAJ. 2008
2. Ismail et al. Alzheimers Dement 2020.
 When to image: “BrAIN”
Bleeding Risk
• Head trauma
• Anticoagulant use (or bleeding disorder)
Practically, almost all get
Abnormal Presentation imaging unless classic picture
• Age <60 years of AD. MRI recommend over
• Rapid, unexplained decline (1-2 months) CT for evaluation of
• Shorter duration of dementia (<2 years) microangiopathic changes.
• Unusual or atypical cognitive presentation
Intracranial Lesion
• History of cancer
• Unexplained focal neuro signs or symptoms (headache, seizure)
Normal Pressure Hydrocephalus (NPH)
• Gait disturbance, incontinence
PLUS if the presence of cerebrovascular disease would change clinical
management Gauthier et al. CGJ. 2012
Moore et al. 2014
 Dementia Syndromes

27
iStock
 Dementia syndrome vs. disease

Dementia (as syndrome) Dementia (as disease)

Used in clinical practice
Based on clinical presentation and
location of deposits
Confirmed via clinical examination
Used for research (and interventions)
Based on pathology (eg, amyloid, tau, alpha-
synuclein, etc.)
Confirmed via biological markers (amyloid-PET
scan or CSF amyloid)

Syndromes tend to correlate with disease, but not always

(which leads to all sorts of confusion)
 Alzheimer’s Dementia
• Diagnosis:
– Dementia AND
– Insidious onset, gradual progression (months-years)
– Atrophy on imaging
– Initial and most prominent deficits in:
• Memory (aka amnestic AD, most common)
• Non-amnestic (Do not memorize, but some examples below)
– Ex language (e.g. Logopenic Primary progressive aphasia – trouble
with naming and sentence repetition)
– Visuospatial (e.g. posterior cortical atrophy / Benson’s syndrome)

McKhann et al. Alz and Dem. 2011.

Jack et al. Alz and Dem. 2018.
 Vascular Dementia
• Diagnosis:
1. Cognitive impairment (any domain, but often frontal/executive)
AND
2. Imaging evidence of cerebrovascular disease
+/- temporal relationship

Note, two main syndromes:

– post-stroke vascular dementia – “step-wise decline”
– subcortical ischemic syndrome – more common, insidious onset
• Imaging: periventricular white matter changes, lacunar infarcts
• Clinically: frontal/executive syndrome
• Supportive findings: insidious onset, gait disturbance, “slow”
Skrobot et al. 2018
 Dementia with Lewy Bodies (DLB)
• Diagnosis:
– Dementia and 2 of:
• Fluctuating cognition
• Recurrent visual hallucinations
• Parkinsonism (bradykinesia, rest tremor,
rigidity)
• REM sleep behaviour disorder
“1 year rule” to distinguish DLB and Parkinson’s
disease dementia (PDD)
– if dementia precedes or begins within 1 year of
onset of parkinsonism, then DLB
McKeith et al. Neurology. 2017.
May also have 1 clinical feature
and 1 biomarker, including:
-Low dopamine uptake in basal ganglia
-Abnormal iodine-MIBG myocardial
scintigraphy
-Polysomnographic confirmation of REM
sleep without atonia
Supportive but non-diagnostic
features:
Sensitivity to antipsychotics, postural
instability, repeated falls, severe
autonomic dysfunction (constipation,
urinary incontinence, orthostasis,
syncope), hyposmia, hallucinations or
delusions, apathy/anxiety/depression
 Frontotemporal Dementia (FTD)
• Diagnosis:
– Dementia and 3 of
• Disinhibition Perseverative behaviours – may be
• Apathy unable to switch appropriately
between tasks.
• Loss of empathy
• Perseveration
• Hyperorality Putting things into mouth, or eating
• Executive dysfunction indiscriminately

Rascovsky. Brain. 2011.

 Mixed Dementia
• Diagnosis:
– Dementia
– Any combination of above syndromes
– Most common:
• Alzheimer’s clinical syndrome AND
• Imaging findings consistent with vascular dementia
 Rapidly Progressive Dementia
• Evolving “more rapidly than expected for dementia syndrome” i.e. less than 1-2 years from
first symptom to dementia
• Causes:
– Degenerative (MOST COMMON): Prion disease (CJD) relatively common cause of RPD (up to 59% of
cases), other neurodegenerative (up to 22%)*
– Inflammatory, Vascular, Toxic, Metabolic, Neoplastic, Infectious
• Work-up:
– History and Physical Exam
– Investigations (consider the following):
• Labs lytes, ext lytes, liver panel, Cr, B12, TSH, ESR, CRP, ANA, ANCA, SPEP, anti-TPO, anti Tg, syphilis, lyme,
HIV
• LP: CSF for cell count, protein, glucose, c+s, serologies, paraneoplastic panel (consult neuro)
• Neuroimaging: MRI indicated, consider MRV/ vessel wall imaging
• Other imaging as indicated (ex. paraneoplastic syndrome)
• Brain Biopsy: Indicated if there dx unclear and indentifiable focus on imaging
• Management: consider thiamine if poor nutritional status or alcohol, manage according to
etiology
* Not truly rapidly progressive but may present as such due to poor history.
Day & Tang-Wai342014
 MCQ #2
75M presents with cognitive decline. He has a history of T2DM, PVD, DLP,
peripheral neuropathy, and GERD. Medications include ASA, metformin,
empagliflozin, rosuvastatin, ramipril, bisoprolol. He feels that he is becoming
more forgetful. His wife comments that he is slower to respond in
conversation. He previously prepared all family meals but recently finds that
he will forget a dish or that items are ready at different times. He gave up
driving this past year due to a near miss. His wife has taken over managing
finances as he had started to make mistakes. MoCA 22/30. What is the most
likely diagnosis?
A. Dementia with Lewy Bodies
B. Alzheimer’s Disease
C. Vascular Dementia evaluate for microangiopathic changes and infarcts
D. Frontotemporal dementia planning) and slow processing speed. MRI brain indicated to
and deficits are predominantly in executive function (poor
The correct answer is C. He has significant vascular risk factors
35
IIb. Dementia and MCI - management
Key Guidelines:

- Lancet Commission report on Dementia

prevention, intervention, and care (2020)

- Recommendations of the 5th Canadian

Consensus Conference on the diagnosis and
treatment of dementia (2020)

- WHO Guidelines on Risk reduction of

cognitive decline and dementia (2019)

- CMA Driver’s Guide edition 9.1, Section 8

(Revised 2019)
 Review prior to oral exam

Principles of Dementia Management

1. Track progression/response to therapy
• Repeat subjective and objective assessments of cognition and function

2. Screen for complications, looking for:

• Geriatric review of systems: dysphagia, malnutrition, weight loss,
incontinence, falls
• Behavioral and psychological symptoms of dementia
• Dementia safety concerns (related to ADLs and IADLs) essentially a CGA (eg
functional history +
• Caregiver burnout
Geriatric ROS) with a
focus on cognition
and function
 Review prior to oral exam

Principles of Dementia Management

3. Address complications
• Behavioral and psychological symptoms of dementia: non-pharmacological
and pharmacological management [see next slides]
• Safety concerns:
• Environmental modifications (stove, faucets, falls; via OT home safety referral)
• Wandering (Medic-Alert bracelets, geo-locating devices, wander registry)
• Weapons and power tools
• Finances (scams, POA for finances, tax credits; via SW referral)
• Medications (blister packs, assisted/supervised administration; via RN/PharmD)
• Driving (duty to report provincially mandated in Ontario)
• Caregiver burnout: support services (referral to other local services)
 Review prior to oral exam

Principles of Dementia Management

4. Reduce dementia risk factors / treat dementia
• Non-pharmacologic management [see next slides]
• Pharmacologic treatment [see next slides]
5. Future planning
• Discuss natural history of disease
• Goals of care and advanced directives (eg, code status, POA for personal care)
• Other advance care planning (eg, completing a will, feeding tubes,
institutionalization, MAID)
Medical Assistance in Dying (MAID) – as of March, 2021 technically persons with dementia can
request this procedure and submit a waiver of final consent should they become incapacitated for
consent in later state of disease IF they are assessed and approved for MAID and:
- The person’s natural death is reasonably foreseeable,
- The person has been deemed eligible for MAiD after being assessed by a qualified healthcare
provider, and
- The person has set a date for when MAiD would be administered.
 Non-pharmacologic treatment
All Recommended3 for general health benefit, esp. given minimal harms and significant 1. WHO Guidelines. 2019
2. Livingston et al. Lancet.2020
heterogeneity in how they were studied. 3. Ismail et al. Alzheimers
Healthy adult MCI Dementia Dement. 2020.
4. Naqvi et al. CMAJ. 2013.
Exercise Overall body of May reduce risk of No difference6,7 Some improvement in ADLs 5. Peterson et al. Neurology.
evidence supports cognitive decline, May reduce in dementia possible6 in 2018.
6. Lamb et al. BMJ. 2018.
protective low quality of cognitive addition to numerous well- 7. Forbes et al. Cochrane. 2015.
effects1,2,3 evidence1,2,3,4,5 decline13, 14 recognized health benefits 8. Butler et al. Ann Int Med. 2018.
9. Belleville et al. JAGS. 2018.
Cognitive Improves, domain- Cognitive training Inconsistent, Generally improves scores
10. Bahar-Fuchs et al. Cochrane.
training (+/- specific.1,2,3,8 Some improves1,2,3,8 evidence in trained domain, but 2013.
social evidence of suggest benefit clinical relevance is 11. Woods et al. Cochrane. 2012.
engagement) benefit for social in mild- questioned 12. Martinez-Lapiscina et al. JNNP.
intervention2 moderate 2013.
13. Jia et al. BMC Geriatr. 2019
dementia2,10,11 14. Sanders et al. PLoS One . 2019
Diet Recommended Mediterranean diet No evidence Observational studies with
diets: recommended by long follow up. Colour coding is for
Mediterranean, WHO1,2, more effect on cognition
unsaturated FAs, limited evidence only
fruit/veggies1,2,3,12 Evidence for Indeterminate Evidence against
NB: effect sizes are of questionable clinical significance (usually a 1% increase on objective testing)
 Non-pharmacologic treatment
All Recommended4 given minimal harms and other clinical benefits
1. Amieva and Ouvrard 2020.
Healthy adult MCI Dementia 2. Rockwood et al. 2000.
3. Richards et al. 2019.
Hearing aids Based on No evidence No evidence 4. Ismail et al. Alzheimers
observational studies, Dement. 2020.
but RCT evidence
lacking1
CPAP in the setting Supported by Based on pilot trial data No evidence
of OSA observational studies2 underpowered to
demonstrate effect3
 Pharmacologic treatment
Healthy adult MCI Dementia
Over the counter No1,2,3 No1,2 No1 Negative studies for: vitamin
supplements B, folate, vitamin E, gingko,
flavonoids, omega-3
Cardiovascular Emerging evidence for BP No evidence for No SPRINT-MIND showed
medications control4 and lipid control statins, ASA, or evidence. decreased MCI and combined
(mid-life)1,2. No evidence for glycemic control. 2 MCI/probable dementia, but
statins started in later life, no significant decrease in
intensive glucose control or Exception: Vascular cognitive dementia.
impairment with prior stroke (not
ASA1
just microvascular changes)6
Cognitive No3 No4 Yes* See next slides
Enhancers
*for specific dementia syndromes 1. Livingston et al. Lancet. 2020.
2. WHO Guidelines. 2019.
3. Naqvi et al. CMAJ. 2013.
4. Williamson et al. JAMA. 2019.
5. Peterson et al. Neurology. 2018
6. Ismail et al. Alzheimers Dement. 2020..
 Pharmacotherapy: WHEN?
Objective findings Functional Impairment

Mild Moderate Severe End Stage

SCI MCI Dementia Dementia Dementia Dementia

Risk factor Consider memantine

management Report to MoT

Consider ChEIs

Modify risk factor management to emphasize QoL, increase safety

 Pharmacotherapy for Alzheimer’s
Dementia
• ChEIs (Donepezil, Galantamine, Rivastigmine)
– Trial is recommended for most patients with AD.
– Modest improvements in cognition, function, global assessment &
behaviour
– Side Effects: GI intolerance (anorexia), urinary incontinence, wild or
vivid dreams, bradycardia
– Avoid if pts have conduction defects (except RBBB), bradycardia, or
unexplained syncope. Use with caution in asthma, COPD, seizures, GI
bleeds, urinary incontinence
– When to discontinue: Intolerable side effects, lack of benefit, end-
stage dementia (as no ongoing benefit), consider if significant cognitive
decline not explained by other precipitant
 Pharmacotherapy for Alzheimer’s
Dementia
• NMDA RA (Memantine)
– DOMINO-AD trial: memantine had benefit vs. placebo in moderate-
severe dementia (defined as MMSE 5-13), but no additional benefit
when combined with cholinesterase inhibitors
– Canadian guidelines say combination is rational, but not enough
evidence to recommend

Practically, Memantine not covered in Ontario. If no private drug coverage, often

encourage family to use money on other services instead (e.g. day programs,
transportation, PSW).

Gauthier et al. CGJ. 2012.

Howard et al. NEJM. 2012.
Pharmacotherapy for Alzheimer’s Dementia
What if?
“Mild dementia on donepezil then progresses to moderate dementia -
what would be recommended for pharmacologic management? Add
memantine, d/c donepezil and add memantine, or not change
anything?”
= Don’t change anything based upon DOMINO-AD trial.

“a patient has moderate dementia – would you start Memantine

without first trying ChEI?”
= Unless there's a clear contra-indication to ChEI usually not used first line
due to cost.

46
 BONUS A note about aducanumab à Not the right
Read on own
choice on your MCQ for AD treatment options!

• FDA approved, but clinical trials not yet published

• Not yet approved or available in Canada
• Skipped Phase 2 trials; started with 2 Phase 3 trials (EMERGE and ENGAGE)
for biomarker-proven Alzheimer’s disease
• Overall effect of trials showed decrease in amyloid, but no clinical benefit in
cognitive measures or function
• Subgroup analysis of high-dose group showed mild benefit (eg, MMSE decline
of 2.7 vs 3.3 over 1.5y), $56K USD / year
• Main side effect: brain edema (requiring MRI q6mo, 35% had brain edema,
6% discontinued treatment)
• Note: other anti-amyloid treatments (solanezumab, verebucestat,
donanemab) all target amyloid protein in early or pre-Alzheimer’s; none have
significant clinical benefit à is the amyloid hypothesis wrong?
 Pharmacotherapy for Vascular
Dementia
• Optimization of vascular risk factors (nonpharm & pharm)
• ChEIs
– 2020 Canadian Consensus Recommendations suggest that ChEIs
and memantine “may be considered” given diagnostic
uncertainty and lack of other options
– Indicated in mixed AD & vascular dementia
• ASA is not indicated with white matter changes only,
considered if micro-infarcts detected

Livingston et al. Lancet. 2017.

Ismail et al. Alzheimers Dement. 2020.
Pharmacotherapy for Dementia with Lewy Bodies
(DLB) & Parkinson’s Disease Dementia (PDD)
• ChEIs
– Good evidence cognition, global assessment, and
behavioural disturbance, hallucinations
– 1st trials used rivastigmine, but donepezil is better
tolerated

• May have some benefit for parkinsonism

Rolinski et al. Cochrane. 2012.

Matsunaga et al. Int J Neuropsychopharmacol. 2016.
 Pharmacotherapy for Frontotemporal
Dementia (FTD)
• No role for ChEIs
• NO medication has been shown to help the cognitive decline
in FTD
• Trazodone or SSRIs for behaviours (cautiously), often
paradoxical worsening to antipsychotics
• Androgen Deprivation Therapy for sexual disinhibition

Lebert et al. Dem & Ger Cog Dis. 2004.

Bang et al. Lancet. 2015.
 Summary of Pharmacologic Treatment
Dementia
Alzheimer’s dementia
Vascular dementia
Dementia with Lewy bodies
Parkinson’s disease dementia
Frontotemporal dementia
Pharmacotherapy
ChEI indicated1
Optimize vascular risk factors1,2
Consider ChEI, indicated in mixed AD + VaD2
ChEI indicated for cognition, hallucinations & behaviours3
ChEI indicated, similar evidence as DLB3
Trazodone4, SSRIs (for behaviours only)
No role for ChEI
1. Livingston et al. Lancet. 2017.
2. Ismail et al. Alzheimers Dement. 2020.
3. Rolinski et al. Cochrane. 2012.
4. Lebert et al. Dem & Ger Cog Dis. 2004.
 MCQ # 3
80M referred for cognitive assessment. He has a history of T2DM,
describes a 2-3 year history of worsening forgetfulness. His partner
reports he frequently repeats stories and forgets things he has been
told. More recently he has developed word finding difficulty. This year
his partner took over managing finances due to missed bill payments.
MoCA 22/30. BP 124/68, HR 48, RR 18, SpO2 99%. Neuro exam is
normal. What is the next best step in management?
A. Exercise
B. Donepezil 2.5mg daily
C. Ginko Bilboa
D. Donepezil 10mg daily
Exercise is recommended per CCCDTD. No evidence for ginko bilboa
which requires work-up, donepezil should not be initiated in this context.
The correct answer is A. STEM describes mild AD. Patient has bradycardia
52
 Behavioural & Psychological
Symptoms of Dementia (BPSD)
• Clusters of symptoms:
– Psychosis: delusions, hallucinations, suspiciousness
– Aggression: verbal, physical, defensive, resistance to care
– Agitation: restlessness, anxiety, vocalization, repetitive actions,
pacing, wandering, hoarding
– Depression: sadness, guilt, hopelessness, irritability, suicidality
– Mania: irritability, euphoria, pressured speech, sexual
disinhibition
– Apathy: amotivation, withdrawn
 Behavioural & Psychological
Symptoms of Dementia (BPSD)
• Non-pharmacologic:
– CATIE-AD trial1: identify and modify triggers or “unmet needs”

– PIECES approach2: identify contributing physical, intellectual, emotional,

capabilities, environmental, and social factors

– Recent network meta-analysis3 demonstrated non-medication

treatments (e.g. outdoor therapy, music and massage, massage and
touch) were as or more efficacious than medications

1. Schneider et al. NEJM. 2006.

2. Centre for Effective Practice. 2016.
3. Watt et al. Ann Intern Med. 2019.
 Behavioural & Psychological
Symptoms of Dementia (BPSD)
• Pharmacologic:
– Some symptoms (e.g. delusions, hallucinations, anxiety) respond more
to Rx than others (e.g. vocalizations, exit seeking, wandering)

– Empiric pain control, Tylenol 1 g PO TID often suffices1

– Risperidone2 approved by Health Canada (max 1 mg/d) only if all three

conditions met: pure AD, non-pharm Rx ineffective, and risk to
self/others or distressing psychotic symptoms
• Re-evaluate and taper q3months
ANTI-PSYCHOTIC BLACK BOX WARNING:
Increased stroke risk 2x, Increased risk of death 1.6x, NNH (stroke, death) = 100
1. Husebo et al. BMJ. 2011.
2. Kales. BMJ. 2015.
 Adjuncts for BPSD - FYI

• Methylphenidate for apathy in AD (2nd positive RCT)

– ADMET2 trial, showing treated patients had greater reduction in apathy
of 1.25 points on a 12 point NPI apathy scale
– Dose: 10mg PO BID
– Side effects: weight loss
• Pimavanserin (serotonin modulator) for psychosis in any dementia
– HARMONY trial, a discontinuation trial showed sustained pimavanserin
showed less relapse in psychotic symptoms (13 vs. 28%, HR 0.35)
– Dose: 34mg or 20mg PO daily
– Side effects: headache, UTI, constipation

Mintzer et al. JAMA Neurology. 2021.

Tariot et al. NEJM. 2021.
 MCQ # 4
64 year old man with no past medical history. Brought in by wife as she has
noticed a change in personality. He repeatedly checks that doors are locked
and has made inappropriate sexual comments to a family friend. He has been
missing appointments and his wife has taken over managing these. He has
episodes of irritability and verbal aggression directed at his wife, and a few
weeks ago he threw a phone at her. MoCA 22/30, no abnormality on physical
exam. What is the most appropriate with respect to management?
A. Start Donepezil
B. Start Memantine
C. Start Trazodone
D. Start Risperidone
anti-psychotics, SSRI or Trazodone generally first line. No role for CI or memantine in FTD
wife.Risperidone is another possible option; however there can be paradoxical worsening with
The correct answer is C. There is escalating aggression which poses a safety concern for patient’s
57
III: Depression
Key Guidelines:

1. Canadian Coalition for Seniors Mental

Health (CCSMH) Canadian Guidelines
on Prevention, Assessment and
Treatment of Depression Among Older
Adults. 2021.
2. Canadian Network for Mood and Anxiety
Treatments (CANMAT) 2016 Clinical
Guidelines for the Management of Adults
with Major Depressive Disorder: Section 6.
Special Populations: Youth, Women, and
the Elderly.
 Depression: diagnosis
• Diagnostic criteria same for older and younger adults
(need anhedonia or low mood)
• Differences:
– Chief complaint may be somatic or cognitive, but need to
ask about mood symptoms
– More complexity (eg, other chronic conditions like
dementia or comorbidities causing poor concentration,
low energy, low appetite, or even depression itself)
– “Pseudodementia” is the cognitive symptoms of
depression (decreased frontal activity)
– Attempt suicide less, but higher completion rate
Kok and Reynolds. JAMA. 2017.
 Depression: screening tools
Screening tools:
• Patient Health Questionnaire 9 (PHQ-9) (excerpted below
are the 2 questions that comprise the PHQ-2)
1. During the past two weeks, have you often been bothered by
feeling down, depressed or hopeless?
2. During the past two weeks, have you often been bothered by
little interest or pleasure in doing things?

• Geriatric Depression Scale (GDS), 15 item

– Sensitivity 74-100%, specificity 53-98%1
1. Watson et al. J Fam Pract 2003;52(12):956 64.
 Depression
Non-pharmacologic treatment:
• Group-based intervention vs. loneliness and social isolation
• Physical activity
• Cognitive behavioral therapy, problem-solving therapy
Advanced therapies:
• ECT has excellent RCT evidence for refractory depression1
• rTMS can be considered for patients with unipolar
depression who have failed 1 antidepressant (but not for
those who have failed ECT). 2

1. Kellner et al. Am J Psy. 2016.

2. CCSMH 2021
 Depression
Pharmacologic treatment:
– First line: sertraline, duloxetine
– Second line: citalopram, escitalopram (watch for QT prolongation)
– Other appropriate therapies: venlafaxine, mirtazapine, buproprion
vortioxetine
– Longer trial of therapy for effect (10-12 weeks)
– Third (or fourth) line: Tricyclic antidepressants (generally try to avoid)
– Avoid: paroxetine, fluoxetine (anticholinergic), MOA-i
• Monitor for hyponatremia in first 2 weeks
• Augment if partial response (eg add another antidepressant,
lithium, or aripiprazole)
CCSMH 2021
IV: Falls

Key Guidelines:
1. Montero-Odasso et al. 2022. World
guidelines for falls prevention and
management for older adults: a global
initiative.
2. Sarmiento & Lee 2017 CDC STEADI Initiative.
3. AGS/BGS/AAOS Clinical Practice Guidelines.
Falls Prevention. 2011 update.
4. Ganz et al 2007. JAMA Rational Clinical
Exam: Will my patient fall?

Canadian Task Force for Preventive Health Care

to release a Falls Plan in 2022 (?)
 Falls
Fall: An unexpected event in which an
individual comes to rest on the ground, floor, 1. SCREEN Annually
or lower level
3 Key Questions for falls in person >65:
Recurrent falls: 2 or more falls in prior 12 1) Have you fallen in the past year?
months 2) Do you feel unsteady when
standing/walking?
• Falls are COMMON: 33% of older adults per 3) Do you worry about falling?
year, ~10% have a major injury such as
fracture1
2. Risk Stratify
• Multiple systems (cognition, motor,
sensory, perfusion) must be intact to stay 3. Management/ Risk Reduction
upright
Montero-Odasso et al. 2022
Ganz et al 2020 NEJM
 Falls Overview : New Guidelines
1. SCREEN Annually

2. Risk Stratify

Screen
Negative 3. Management/ Risk Reduction

Some guidelines
recommend check for
vitamin D deficiency and
replace as needed

Montero-Odasso et al. 2022

Sarmiento & Lee 2017
 Approach to Falls
Ask yourself:
1. Why? (risk factors, intrinsic and extrinsic/env’ t)
“Fell”
2. Why now? (acute illness, delirium, seizure,
syncope, neurodegenerative - PD, PSP, MSA, NPH)
3. How do we prevent the next fall? (assessment
and management)
[4. How do we prevent injury? (bone health,
indication for blood thinner etc.)]

“Multifactorial”
Syncope Seizure
fall

This approach assumes history confirms a fall, not syncope or seizure.

Most geriatricians have moved away from the term “mechanical” fall,
recognizing the multifactorial etiology of falls.
 History
BONUS Falls Assessment should be
Read on own multifactorial & multi-professional

1. HPI:
– What happened before? (what were they doing? where? Prodromes?)
Circumstances
– What happened during? (length of lie, how did they get up) regarding the fall
– What happened after? (trauma, fracture, anxiety)
2. PMHx: cognitive decline, movement disorders, MSK/pain, cardiac
conditions, cataracts, hearing impairment
3. Medications: psychotropics, benzos, BP/HR reducing meds, >4 meds
4. Social History: EtOH, home/ social supports
5. Functional: ADL/iADL impairment (assess for frailty), prior falls, lifeline,
footwear, assistive devices Risk factors, target
6. Other Risk factors: incontinence, vision, hearing, nutrition, pain, cog, mood modifiable ones
7. Patient perceptions of falls, risk, prevention, goals. Screen for fear of
falling.
– Many have erroneous beliefs about fall causes, their own risk and how best to
avoid future falls
– Screening for fear of falling with validated tool is recommended Ganz et al. JAMA. 2010.
Montero-Odasso et al. 2022
Hopewell et al. Cochrane Database Syst Rev 2018
 BONUS
Read on own
Physical Examination/
Investigations
1. Vitals: Orthostatic
2. CVS: AS, arrhythmia, carotid bruit, ECG
3. [Routine Resp/Abdo – in acute setting to rule out illness as
precipitant]
4. Neuro exam: motor (tone, strength, reflexes), sensory (primary and
secondary), cerebellar (finger-nose, heel shin), Parkinsonism
5. MSK exam: foot exam, knee and hip exam, osteoporosis
6. Gait and balance assessment: At minimum, Gait Speed or Timed
Up and Go and balance screen (tandem gait, 1 leg stand)
– Assess appropriate use of gait aid if applicable
6. Cognitive Testing: MMSE (cognitive impairment [LR 13])
7. Vision and hearing screen (at least in the past 1-2 years)
Montero-Odasso et al. 2022
Additional investigations should be tailored to findings on Hx & P/E Jepsen et al 2022 BMC Geriatr.
 BONUS
Read on own
Falls: Modifiable Risk Factors
Recommendations
Medications Medication review using standardized tool (STOPP/START, STOPPFall, FORTA, Beers
Criteria) and appropriate deprescribing. (RR 0.34 for withdrawal of psychotropic; benzo
LR +27 for falls in one study)
Cardiovascular/ Assess for and treat underlying cardiac conditions and orthostatic hypotension.
Orthostatic Unexplained falls syncope equivalent when considering additional cardiac Ix
Hypotension
Exercise Individualized exercise program with balance and functional exercises 3 times per week
for at least 12 weeks. Include Tai Chi and/or additional individualised progressive
resistance strength training. (RR 0.68-0.85 with focus on balance & strength training.)
Environmental Assessment and modification of home environment considering capacities and
hazards behaviours by trained clinician (RR 0.69 for OT home safety assessment; footwear RR
0.64, non-slip boots for ice RR 0.42)

Montero-Odasso et al. 2022, Kwan and Straus. CMAJ.

2014. Tricco et al. JAMA. 2017. Ganz et al JAMA 2007
Guirguis-Blake et al. JAMA. 2018.
 BONUS
Read on own
Falls: Modifiable Risk Factors
Recommendation
Nutritional Assess nutritional status including vitamin D and supplement as appropriate (Expert opinion -
Status conflicting evidence of vitamin D supplementation on falls but indicated for bone health)
Vision Inquire and assess vision, refer to specialist as appropriate (RR 0.66 for 1st cataract repair)
Hearing Inquire and assess hearing, refer to specialist as appropriate (expert opinion)
Vestibular Inquire about, investigate, & manage dizziness, refer as appropriate (expert opinion)
Fear of falling Screen with validated tool: Falls Efficacy Scale International (FES-I) or Short FES-I. Manage:
CBT/ exercise / OT to reduce fear of falling (meta-analyses evidence of benefit )
Mood Inquire about, assess, manage/refer as appropriate. (Expert opinion)
Pain Assess and treat pain (expert opinion)
Urinary Inquire about and manage/refer for urinary symptoms as appropriate (expert opinion)
Symptoms
Kruisbrink et al Gerontologist 2021, Chua et al. J Adv Nurs 2019, Coninck et al
JAGS 2017, Montero-Odasso et al. 2022 Kwan and Straus. CMAJ. 2014., Tricco
et al. JAMA. 2017. Ganz et al JAMA 2007, Guirguis-Blake et al. JAMA. 2018.
 Falls Management
• Education on falls & fracture prevention including physical activity, lifestyle habits
and nutrition & vitamin D intake: All risk groups
• Exercise:
– Low Risk: Advise physical activity
– Intermediate Risk: Tailored intervention balance and gait and strength training.
Physiotherapist preferred.
– High Risk: Tailored intervention targeting balance gait and strength training. Progressive
intensity 3 times / week for at least 12 weeks. Including Tai Chi or individualized resistance
training if possible.
• Multifactorial Multidisciplinary Assessment & Individualized Fall Prevention Plan:
High risk group
– Take into account patient’s priorities, beliefs and resources.
– Target modifiable RFs (prior slides)
• Bone Health: Osteoporosis work-up and management as indicated (covered in
endocrinology lecture)
Montero-Odasso et al. 2022
71
 Falls Management in LTC
• All LTC residents should be considered high risk for falls
• Similar management: multifactorial assessment, address modifiable risk factors,
nutritional optimization (Ca, protein, Vit D), Exercise training where feasible and safe
Do NOT use physical restraints (Geri chairs, lap-belts) as a measure for falls prevention
(actually shown to increase falls) (Castle et al 2009, Capezuti JAGS 1996, Capezuti JAGS 2004).

Hip Fracture (HF) Prevention for Older Adults in LTC

Intervention HF reduction
Multifactorial intervention: exercise, medication review, assess 10 per 1000 treated
environmental hazards, assistive devices, manage incontinence
Hip protectors 4 per 1000 treated
Dietary calcium 1200 mg/d, vitamin D supplementation 7 per 1000 treated
Consider bisphosphonate/denosumab (if prognosis >1 year) 25 per 1000 treated
Montero-Odasso et al. 2022, Papaioannou
et al. CMAJ. 2015.
 A note on NPH
• Classic Triad: Gait apraxia (magnetic gait), executive dysfunction
(dementia), and urinary incontinence
– However this is a late presentation
Typical Course: Cognitive Symptoms Urinary Symptoms
(dysexecutive MCI à Dementia)
Gait Change
nonspecific gait imbalance à falls à gait
apraxia Urinary Symptoms Cognitive Symptoms
frequency à urgency à incontinence)

• Imaging: Ventriculomegaly (must be differentiated from ex vacuo).

• Diagnosed with objectively measured gait speed before and after
lumbar puncture, leading to VP shunt for permanent management

Fasano et al. Movement Disorders 2020

V. Disease Management in Older Persons
 Normal Aging – An internist’s summary
System Change
Cognition Preserved long-term functions (learned skills, vocabulary), decreased short-term functions
(attention, processing speed, short term recall)
CVS Hypertension, widening pulse pressure, subclinical HFpEF (thick stiff LV), decreased number
pacemaker cells, subclinical bradycardia, max cardiac output lower
Respiratory Subclinical emphysema (increased RV, dead space, mismatch; decreased VC, FVC, DLCO, FEV1)
Renal Decreasing eGFR (1ml/min/yr after age 40), Cr production also declines, decreased functional
reserve (higher risk of AKI), decreased vitamin D production
GU Increased volume at first desire to void, decreased bladder capacity, detrusor activity, sphincter
tone Men: increase prostate size, Women: decreased urethral length and mucosal atrophy
GI Constipation, decreased phase 1 liver metabolism
MSK Decreased muscle and bone mass But function should not be impaired with
normal aging alone
Neuro Slowed reflexes, reduced sensation
 Hypertension in Older Adults
Hypertension Canada 2020 guidelines1:
• Age ≥75 is a criterion for intensive management (targeting SBP ≤
120 mmHg)
• Exclusion criteria for SPRINT trial:
– T2DM, previous stroke, eGFR < 20, protein >1g/day
– Orthostatic hypotension with SBP < 110mmHg
– Dementia, prognosis <3 year, institutionalized
• Frailty not part of management algorithm, but meta-analysis finds
no benefit of even SBP < 140mmHg in frail persons2
– Diabetes Canada suggests “individualized target” for those who are
functionally dependent, frail, or experience orthostasis 1. Rabi et al. CJC. 2020.
2. Todd et al. Age and Ageing. 2019.
 Diabetes in Older Adults*
Diabetes Canada guidelines:
• Avoid sulfonylureas (eg, glyburide) due to hypoglycemia risk
• Generally: metformin, then DPP-4 inhibitors or GLP-1 (however known s.e.
of weight loss), then SGLT2 (may be at higher risk of dehydration) then
long-acting insulin
• A1c targets should scale based on functional status
– Functionally independent, A1c ≤ 7.0%
– Functionally dependent, A1c 7.1 - 8.0%
– Frail and/or dementia, A1c 7.1 - 8.5%
– End of life: avoid symptomatic hyperglycemia and hypoglycemia, BG checks
not indicated
https://guidelines.diabetes.ca/cpg/chapter37
– If below target, de-intensify therapy
* Older adult defined as >70 but with greater focus on functional status as many older adults age
70+ are independent with > 10 year life expectancy and would benefit from usual management
 During hospitalization
Avoid intensification of antihypertensives and diabetes regimens
among patients over age 65 during hospitalization
• Intensification of antihypertensives not associated with reduced
cardiac events or improved BP control, but increased 30 day
readmission and adverse events1
• Intensification of diabetes medications not associated with reduced
A1c or reduced hyperglycemia, but increased risk of hypoglycemia
within 30 days2

1. Anderson et al. JAMA Int Med. 2019

2. Anderson et al. JAMA Network Open. 2021
 Primary prevention of CV events
Hypertension Canada 2020 guidelines:
• Aspirin: no longer recommended for primary prevention of
cardiovascular disease, based on the ASPREE trial1
– Slightly increased mortality due to cancer deaths in intervention arm
– Still indicated for secondary prevention
• Statin: still recommended if 3 or more CV risk factors (one for age
≥ 55, male sex, LVH, ECG findings, family Hx, PAD, prior stroke,
smoking, microalbuminuria, T2DM)
– Observational evidence suggests not effective for primary prevention2
– RCT evidence still pending
1. McNeil et al. NEJM. 2018.
2. Han et al. JAMA Int Med. 2017.
 Choosing Wisely Geriatrics Recommendations
1. Don’t use antimicrobials to treat bacteruria in older adults unless specific
urinary tract symptoms are present.

2. Don’t use benzodiazepines or other sedative-hypnotics in older adults as first

choice for insomnia, agitation or delirium.

3. Don’t recommend percutaneous feeding tubes in patients with advanced

dementia; instead offer oral feeding.

4. Don't use antipsychotics as first choice to treat behavioural and

psychological symptoms of dementia.

5. Avoid using medications known to cause hypoglycemia to achieve

hemoglobin A1c <7.5% in many adults age 65 and older; moderate control is
generally better.
http://www.choosingwiselycanada.org/recommendations/geriatrics/
 Polypharmacy
More medication than is clinically indicated or warranted.
– Multiple cut-offs >5 medications >9 medications, etc.
• Why does it matter: more meds + frail older adult = more
ADVERSE EVENTS
– 50% of elderly (>65) w/ 5+ meds experience ADE
• Avoid prescribing cascade:
– HTN à rx HCTZ à gout à rx allopurinol
• Resources to help identify medications for deprescribing:
– Beers’ Criteria (list by pharmacologic effect), STOPP/START criteria,
Deprescribing.org, Medication Appropriateness index
 Approach to Deprescribing
1. Determine all drugs (prescribed, OTC, supplements, substances) currently taking (or not
taking) and reasons for each
– Requires BPMH (multiple information sources) consider pharmacy consult
2. Consider overall risk of drug-induced harm
– Number of drugs, high risk drugs (ex. benzo), prior/current toxicity,
– Patient characteristics: age >80, cog impairment, non-adherence, substance use
3. Assess each drug’s eligibility to be discontinued
– No valid indication, no longer indicated, non-adherence with no negative consequence, part of
prescribing cascade, inappropriate dose, lack of clinical benefit, harms (actual or potential) outweigh
benefit (current or future), preventative and unlikely to benefit given remaining lifespan, patient
preference
4. Prioritize drugs for discontinuation
– Greatest harm, least benefit
– Least risk of withdrawal or disease rebound
– Patient buy-in
5. Implement a discontinuation regimen and monitor patients
– 1 drug at a time, wean to prevent withdrawal, document reasons and inform other healthcare providers

Scott et al. JAMA Intern Med 2015

82
 Potentially inappropriate medications
• Several groups issue different criteria for PIMs
• AGS offers the Beers’ Criteria, last updated 2019:
Category Examples
PIMs to avoid Sliding scale insulin, anticholinergics, benzodiazepines,
sedatives, etc.
PIMs to be used with caution Dabigatran for AF, TMP-SMX with ACEI
PIMs due to drug-disease interaction Syncope and AChEIs, Parkinson’s disease and
metoclopramide, falls and antiepileptics
PIMs due to drug-drug interactions Opioids and sedatives, opioids and gabapentinoids
PIMs to avoid based on renal clearance Spironolactone, ciprofloxacin, enoxaparin, gabapentin, etc.
Anticholinergics Amitriptyline, dimenhydrinate, hydroxyzine, tolterodine,
AGS Beers Criteria 2019.
paroxetine
 VI. COVID-19 & Geriatrics
• COVID-19 impacts older adults disproportionately—from severe
illness and hospitalization to increased risk for death.
– People aged 80 or over have a more than 20 fold increased risk
compared with 50-59 year olds
• COVID-19 mRNA vaccinations strongly recommended for all
older adults; additionally:
– NACI STRONGLY recommends fall booster dose of mRNA vaccine
regardless of number of boosters previously received
• Adults over 65 and those at increased risk of severe illness
– NACI STRONGLY recommends bivalent omicron containing mRNA
vaccine is preferred booster for adults
Williamson et al. Nature 2020
https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-
part-4-active-vaccines/page-26-covid-19-vaccine.html
Questions?
 BONUS SLIDES
• Comprehensive Geriatrics Assessment Primer
• Disease management in older adults (cancer screening,
vaccination)
• Normal physiology of aging
• Medications and polypharmacy
• Nutrition and weight loss
• Incontinence and Constipation
• Extra MCQs
 Comprehensive Geriatric Assessment
• Geriatric specialization
• Assessment of: medical, functional,
mental, social and environmental
problems Internal Geriatric
• Co-ordinated multidisciplinary meeting Medicine Medicine
• Formulation of plan around patient-
centered goals
• Delivery of care plan, including
rehabilitation Head:
HEENT,
Limbs:
Skin, muscle,
Holistically:
Function
• Iterative review of progress and care plan cognition, nerves, bone, Prognosis
mood, sleep pain

Ellis 2017 Cochrane Review

 Functional assessment
Basic (BADLs) Instrumental (IADLs)
Dressing Medication management*
ADLs = Grooming Finances *
Activities of Toileting Driving *
Daily Living Ambulation/transfers Cooking
Eating Cleaning
Bathing Shopping
Laundry
* Highest level / often first to go
 Rockwood Clinical Frailty Scale
Used to quickly
convey
vulnerability
 Physical Examination Maneuvers
Examination How to do it

Orthostatic Lie down for 5 minutes, measure BP and HR supine, stand the patient, repeat BP and HR
hypotension at 1 and 3 minutes. Positive if: SBP drops by 20mmHg, DBP drops by 10mmHg or patient is
symptomatic
Vision Snellen chart (wall, or handheld)

Hearing During the examination; can offer a pocket talker

Gait assessment General description: symmetric or asymmetric, wide or narrow based, high or low step
height
Types of gait: antalgic, hemiplegic, ataxic, parkinsonian, steppage, spastic
Difficulty standing without pushing off chair [LR 4.3 in men]
Timed Up and Go Stand up, walk 3 metres, turn around, sit down. Normal <12s, normal for frail adults <20s

Neuro/MSK Motor (check tone, strength, reflexes), sensation (light touch, vibration, proprioception),
cranial nerves, cerebellar examination (coordination), Parkinsonism
 A note on elder abuse
• Comes in many types: physical, verbal, emotional, sexual,
financial, and neglect
– Most common fracture is humerus but can be accidental1;
zygomatic fractures less likely to be accidental2
• Mandatory reporting per provincial requirements
– Required if abuse occurs in long-term care

1. Murphy et al. CARJ. 2013.

2. Lachs and Pillemer. NEJM. 2015.
 Cancer Screening in Older Adults
Cancer Type (Guideline) Recommendation for Older Adults Notes
Colorectal Cancer Do NOT screen adults >=75 Weak recommend’n
(CPSTF 2016) Low quality evidence

Lung Cancer Do NOT screen adults >=75 with low dose CT Strong recommend’n
(CPSTF 2016) Do not use CXR (in anyone) for screening Low quality evidence

Prostate Cancer Recommend AGAINST screening men >=70 with PSA Strong recommend’n
(CPSTF 2014) Low quality evidence

Breast Cancer 50-74F mammogram q2-3 years Conditional recommend’n

(CPSTF 2018) Do not recommend routine mammo >=75 Very low quality evidence

Cervical Cancer Continue screening in women >70 who have not been Weak recommend’n
(CPSTF 2013) adequately screened in the past until 3 neg successive Low quality evidence
pap tests

Cease screening in women >70 who have had adequate

screening to date (3 successive neg pap in last 10 y)

Community Preventative Services Task Force

 Vaccinations in Older Adults
– Tdap: one booster per lifetime
– Td (tetanus, diphtheria): every 10 years
– Influenza: annually for age >65 years (high dose approved and
covered for those >65 in Ontario)
– Pneumococcal: Prevnar + Pneumovax (8 wks later) 65 years
– Zoster: recombinant subunit adjuvant vaccine (Shingrix), as of
October 2020; 2 doses 2-6mo apart
– COVID 19 mRNA vaccination – fall booster recommended Influenza each fall
http://healthycanadians.gc.ca/
https://www.canada.ca/en/services/health/publications/healthy-living.html#a3
 Shingles vaccination
Zostavax Shingrix

Vaccine Live attenuated vaccine Adjuvant non-live vaccine, two doses

given 2-6 months apart
Coverage Covered (adults aged 65-70) Covered as of Oct 2020 in Ontario for
adults age 65-70
Efficacy vs. shingles 51% reduction, reduced in 91% reduction
older patients
Efficacy vs. post- 67% reduction 89% reduction
herpetic neuralgia

Side effects Pain at site: 35% Pain at site: 69%

Fever: 1% Fever: 12%
Subjective fever: 7% Fatigue/myalgia/headache: 53%

Oxman et al. NEJM. 2005.

Cunningham et al. NEJM. 2016.
 Normal Aging: Neuro
• Cognition:
– Age-related changes occur typically after age >70 and should not affect function
– Executive Function:
• Processing and Performance Speed: êrxn time, finger tapping, timed tests
• Attention span: difficulty with multi-tasking
– Memory:
• ê in short term memory (recall) and free recall of events (“tip of the tongue” experience)
• ê in episodic long-term memory
– Semantic memory/fund of knowledge, procedural memory preserved
– Registration preserved

Clinical Neurology of the older adult, 2nd Edition, 2008

 Normal Aging: Neuro Exam
• Cranial nerves:
– Vision: ê accommodation, reduced contrast sensitivity, dark adaptation and depth perception
– Hearing: Presbycusis – bilateral symmetric sensorineural hearing loss êhigh frequency, cerumen
impaction
– Diminished olfaction
• Peripheral nervous system:
– ê or absent ankle reflexes
– ê vibration sense to ankle, proprioception
• Autonomic nervous system:
– ê baroreceptor response, increase vascular tone/decreased elasticity (SBP>>DBP)
– ê innervation of detrusor muscle
• Gait:
– 10-20% reduction in gait velocity and stride length. Increased stance width, increased time in
double support phase.
 Normal Aging
• Cardiovascular system:
– HTN: isolated systolic; pulse pressure widens
– valves thicken, LV stiffens… less tolerance to increased workload. Systolic function preserved
– LA enlargement by 50%; No significant changes to RV or RA
– Maximum HR decreased by 5-6 beats per decade
• Respiratory system:
– Functional changes:
• éRV, ERV, FRC due to gas trapping
• ê VC, FVC, FEV, compliance, FEV1/FVC
– Anatomical changes: increased dead space (30% of surface area per lung volume lost over
lifespan)
– Increased V-Q mismatch
– Changes in surfactant + decreased ciliary function and elasticity
– Decline in diffusion capacity (5% per decade)
 Normal Aging
• Renal:
– 30% decline in mass
– functional decline with CrCl decrease of 7.5 – 10 mL/min/decade
– 30% of glomeruli sclerosed by age 75
– ability to maximally dilute urine decreased
– hydroxylation of vitamin D decreased
– erythropoietin production preserved
• GI:
– reflux d/t reduced tone at LES
– preserved nutrient absorption in small intestine
– colonic changes in motility with decreased myenteric neurons; diverticuli formation, greater
water absorption and subsequently harder stool
– Liver: decreased mass and blood flow
– Phase 1 reactions: decreased oxidation
– Phase 2: no change to glucuronidation
 Normal Aging
• MSK: êmuscle & bone mass
– sarcopenia - appendicular muscle mass
• loss in legs greater than arms
• Immune:
– immunosenescence, êefficiency, infections more severe w/ slower recovery
• Endo:
– menopause in women, êestrogen à vulvovaginal atrophy
– ê GH and testosterone, ê DHEA secretion
– Mean 24h cortisol concentrations higher – 30 to 50% àê bone density, fractures, memory loss
– Vasopressin response to volume increases, less to osmolality à less renal response, less thirst
• Sleep:
– longer to initiate, êstage 3, 4, no Δ in REM
 Pharmacodynamics & Aging
“What drug does to body”
• Additive: A+B = AB
– ex: ASA & SSRI (for platelet inhibition)

• Antagonistic: A+B < AB

– ex: oxybutynin & ChEI (for cholinergic effect)

Minimal change w/ age, ñsensitivity

 Pharmacokinetics & Aging
“What body does to drug”
• Absorption: relatively unaffected
• Distribution: Less muscle & water, more fat
– Water soluble drugs – increased serum concentrations
– Fat soluble drugs – increased half life
• Metabolism: Reduced hepatic metabolism
– Enzymatic transformations:
• Demethylation
• Phase 1 (CYP450) oxidation (decreased)
• Phase 2 glucuronidation (less affected)
• Elimination: Reduced GFR – less clearance

Significant changes w/ age

 Considerations in Med Review
Reason to stop or D/C Selected examples
Anti-HTN
Non compliance w/o negative health effect
Oral diabetic medication
Takes incorrectly w/o negative effect or
Puffers
benefit
Statin, ASA for primary prevention
Not indicated or relative contraindication Docusate
CCB in pt with systolic heart failure
Bisphosphonate after 5 yrs*
No longer indicated Benzos, NSAIDs, PPIs
ChEI (consider if fully dependent)
Digoxin
Inappropriate dose for geriatric patient
Amitryptiline
Statins (<5 yr life expected)
Not aligning with goals of care, life
Bisphosphonate (<1 yr life expected)
expectancy
Warfarin

Adapted from Frank et al. Deprescribing for older patients. CMAJ 2014
 A note on Peri-Op & ICU delirium
• Peri-operative delirium:
– Risperidone after cardiac surgery (but not other surgeries) is effective
– Dexmedetomidine intra-operatively for all surgeries may be effective
– Bispectral index monitoring intra-operatively is not effective
• ICU-related delirium:
– Eye masks and ear plugs is effective
– Dexmedetomidine

Xin et al. Int J Geri Psych. 2021.

Subramaniam et al. JAMA. 2019.
Litton et al. Critical Care. 2016.
Wildes et al. JAMA. 2019.
 Weight Loss Oral Scenario
80M presents with 25lb weight loss in past 6
months, low energy, eating 3+ meals a day, no
fever/night sweats
• PMHx: osteoporosis, prior left hip #, OA,
hypothyroidism, hypercholesterolemia
• Rx: levothyroxine, rosuvastatin, alendronate, vitamin
D, calcium, ibuprofen, hydromorphone PRN
• SocHx: recently widowed, ex-smoker, no EtOH
• P/E: poor fitting dentures, weight 55kg, BMI 21, OA
changes in knees
• Investigations: CXR, CBC, Cr, TSH, albumin within
normal limits
History:
• Weight loss in past 6 months
• Dietary intake change
• GI symptoms: anorexia, nausea, vomiting, diarrhea
• Functional capacity
Physical:
• Vitals, height, weight, BMI
• Examine for loss of subcutaneous fat: deltoids,
triceps, interossei, palmar hands
• Examine for muscle wasting: temporal muscles,
deltoid squaring, quadriceps
• Examine for edema: ascites, anasarca, leg edema
• Examine for nutritional deficiencies
*each of the above assessments can be graded 1+
to 3+
Detsky et al, JAMA 1994
104
 The “Subjective Global Assessment”
Uses a standard history/physical but then
a “subjective global assessment” (SGA),
a.k.a. a gestalt, to classify patients as:
• Well nourished (LR 0.66 for post-op
complication)
– increasing/normal appetite even with <5%
weight loss
• Moderately malnourished (LR 0.96)
– 5-10% weight loss, reduced dietary intake,
loss of subcutaneous tissue (1+)
• Severely malnourished (LR 4.44)
– obvious physical signs of malnutrition (3+
muscle wasting, edema) AND weight loss
>10%
*Assessment is specific but not sensitive (may miss mild malnourishment)

Detsky et al. JAMA. 1994.

Used to summarize H & P into 3 categories

 Bonus H & P findings: nutritional
deficiencies, by system
• H&N: fragile hair (zinc, copper deficiency), poor night vision (vitamin A), anosmia
(zinc), caries (fluoride), angular cheilitis (iron, vitamin B2), goiter (iodine)
• CV: CHF (vitamin B1)
• Dermatologic: follicular hemorrhage (vitamin C), sun-exposed dermatitis
(vitamin B3), bleeding (vitamin K), impaired wound healing (zinc, iron)
• Nails: koilonychia (iron)
• MSK: osteoporosis/osteomalacia (vitamin D)
• Neuro: paresthesia (vitamin B12), cognitive impairment (vitamin B3, B9, B12)

Look at the teeth, skin, nails, sensory impairment, cognition

Collated from UpToDate.

 What is the cause?
Common causes of unintentional weight loss in elderly patients:

• Malignant disease (16%–36%)

• Psychiatric disorder (especially depression) (9%–42%) APPROACH: Causes include any step
• Gastrointestinal disease (6%–19%) from acquisition of food, absorption of
food, and metabolically active processes:
• Endocrine disorder (especially hyperthyroidism) (4%–11%)
• Cardiovascular disease (2%–9%) Money/finances, functional ability to get
• Nutritional disorders or alcoholism (4%–8%) groceries
• Respiratory disease (~6%) Cognition/depression and other
• Neurologic disorder (2%–7%) psychiatric issues affecting eating
• Chronic infection (2%–5%) Dentures/dentition, dysphagia
• Renal disease (~4%) Review of systems for disease
Medication side effects
• Connective tissue disease (2%–4%)
• Drug-induced weight loss (medication side effects) (~2%)
• Unknown (10%–36%)
Alibhai. CMAJ. 2005.
Weight Loss: Non Pharmacologic Management
• Minimize dietary restrictions
• Optimize energy by:
– Maximizing intake with high-energy foods at best meal of day
– Smaller meals more often
– Offer favourite foods and snacks
– Provide finger foods
• Optimize dietary texture
• Ensure adequate oral health
• High energy supplements, or add fats and oils to usual foods
• Time supplements between meals
• Eat in company of others or with assistance
• Trial flavour enhancers
• Regular exercise
• Use community nutritional support (Meals on Wheels, etc)
Alibhai. CMAJ. 2005.
 Weight Loss: Pharmacologic Management
• Daily multivitamin supplement
• Dietary calcium intake target 1200 mg po daily from all sources
• Vitamin D 1000 IU po daily
• If indicated, additional supplementation (thiamine, iron, B12)
• No evidence for megestrol acetate in the elderly,1 risk of clots
and death
• No evidence for dronabinol in the elderly, concerns about CNS
side effects
1. Stajkovic. CMAJ. 2011.
2. Alibhai. CMAJ. 2005.
 Types of Urinary Incontinence
Most common in older women:
• Stress Urge or Mixed (~70%)
– Involuntary leakage on stress/exertion/cough/sneezing
• Urge
– Sudden, strong need to void and involuntary leakage
– History of urine loss associated with urinary urgency +LR 4.2
• Mixed
– Combination of stress and urge
• Overflow
– Overdistension of bladder (obstruction, neurologic)
• Functional (Can’t get there in time)
– Cognitive, functional, mobility difficulty
Holroyd-Leduc. JAMA RCE. 2008
 Simplified Bladder Physiology

• Sympathetic Nervous System (STORES!)

– alpha adrenergic è constricts internal sphincter
– beta adrenergic è relaxes detrusor

• Parasympathetic Nervous System (PEES!)

– cholinergic è contracts detrusor
 Incontinence Management
• Non-Pharmacological - First line treatment for all types:
– LIFESTYLE modifications: limit fluids, caffeine and EtOH; weight loss; treat constipation; bladder
training (cog intact), prompted/timed voiding (cog impaired), kegel exercises or pessary (stress)
• Stress:
• No pharmacotherapy, surgical options only (intra-abdominal pressure overcomes sphincter)
• Effective, but trials do not represent older adult population. Health Canada warning re: mid urethral
sling due to complications.
• Urge:
• Antimuscarinic: s.e. anticholinergic sedation, confusion, dizziness, urinary retention, constipation,
• On Beer’s List.Fesoterodine most studied, more favorable cognitive profile, oxybutynin worst
• Beta-agonist (Mirabegron): s.e. headache, tachycardia afib, HTN, nasopharyngitis effectiveness low
(<1/3), ++ side effects (on BEERs List to avoid)
• Botox into detrusor

Holroyd-Leduc. JAMA RCE. 2008

 Constipation
Underlying causes for constipation:
• medications: anticholinergics, opiates, iron,
calcium, calcium channel blockers, NSAIDs
CONSTIPATION RED FLAGS:
• immobility
• neurologic: Parkinson’s disease, diabetes, Family history of colon cancer
stroke, spinal cord injury Hematochezia
Anemia
• volume depletion Weight loss ≥ 5 kg in previous 6 months
• metabolic: hypothyroidism, hypercalcemia, Positive result of fecal occult blood test
hypokalemia Persistent constipation unresponsive to
treatment
• mechanical obstruction Acute onset of constipation
• dementia or depression
• low dietary fibre

Gandell. CMAJ. 2013

 Approach and Management for Constipation Scenarios
Step Interventions
1. Determine predominant Frequency, straining, incomplete evacuation
symptoms
2. Identify possible • Meds (e.g., opioids, nondihydropyridine calcium-channel
secondary causes of blockers, iron supplements and antidiarrheal agents)
constipation • Disease states (e.g., colon cancer, stroke, Parkinson’s)
• Secondary causes are treated in same
manner as primary constipation
• If alarm S&S are present, follow guidelines for colon cancer
screening
3. Consider fecal impaction • Consider abdominal radiograph or a digital rectal examination can
be used to diagnose impaction (especially if bedbound, advanced
dementia)
• Manual disimpaction if fecal impaction present
Gandell. CMAJ. 2013
4. Optimize behavioural factors • Seated position, knees at/above the level of hips
• If moderate to severe cognitive impairment, allow time to toilet after am meal,
to take advantage of gastrocolic reflex
5. Trial of dietary modifications • Gradually increase fibre intake to 20–30 g/d from dietary (fruits, vegetables,
(2-4 wks) legumes) or supplemental sources (psyllium, methylcellulose, calcium
polycarbophil)
• Not advised in a person who is immobile or bedbound, to avoid impaction or
obstruction
6. Trial of previously preferred • The patient may prefer one agent over another from past
laxative agent (2-4 wks) experience
7. Trial of laxative agents from • Polyethylene glycol 17–34 g/d
RCTs involving older people (2-4 • Lactulose 15–30 mL daily to twice daily
wks)
8. Trial of another laxative • Magnesium hydroxide 15–30 mg daily to twice daily
agent or combination of agents • Docusate calcium 240 mg twice daily
from different classes (2-4 wks) • Bisacodyl 5–10 mg/d orally or rectally
• Sennosides, up to 68.8 g/d in divided doses
• Enema or suppository
9. Consider referral Geriatrician or gastroenterologist
 Bonus MCQ 2023
82 woman with mild Alzheimer’s dementia. MMSE 21/30. What
medication is indicated to diminish declining cognitive
impairment?

A. memantine
B. memantine + donepezil
C. donepezil
D. atorvastatin
first line agent.
The correct answer is C. Memantine is indicated in moderate-severe dementia. Donepezil is the
 BONUS MCQ 2023
An 87 year old female resident in a nursing home with a diagnosis of severe
dementia has been reported to yell and curse at staff around bathing. She
is argumentative with other residents throughout the day. She has gone
without bathing weeks at a time because staff are unwilling to approach
her. When asked months of the year backwards, she consistently
completes December to April then gives up. What is the best next step in
her management?
a. Quetapine 12.5mg PO PRN prior to bathing
b. Tylenol 1g PO TID
c. Risperidone 0.125mg PO BID
d. Routine bloodwork including CBC, lytes, creatinine, LFT, TSH, B12 and head
imaging
which is more suggestive of BPSD than delirium.
The correct answer is B. Adequate pain control reduces BPSD. This patient’s aggression is stable,
 BONUS MCQ 2023
87M presents with fall and rib fracture. He has a history of BPH, HTN, DLP,
T2DM. Medications include metformin, glyburide, amlodipine, ramipril,
rosuvastatin, and tamsulosin. He is functionally independent. He reports 2
other falls this year. The current fall occurred while using a step ladder to
change a light fixture he described feeling “unsteady” before the fall. BP
122/72, HR 72, RR 18, SpO2 98%. A1c 6.5%. Which of the following would
NOT be part of your initial management plan?
A. Discontinue amlodipine
B. Discontinue glyburide
C. Obtain orthostatic vitals
D. Refer to exercise program
are at increase risk of asymptomatic hypoglycemia which is not captured by A1c.
vitals first. Scale back HTN therapy if evidence of drop. Glyburide is on beers list. Older adults
The correct answer is A. Functionally independent and BP within target, obtain orthostatic
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