Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
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...
What is your approach to a newly diagnosed LBBB in individuals >70 years old who are free of any signs or symptoms of heart disease and without other significant ASCVD risk factors besides age?
The presence of BBB; whether IVCD or RBBB or LBBB, signifies infranodal conduction delay from a myopathy. That myopathy may be hypertensive (LVH) or ischemic (LAD disease) or something less common (inflammatory etc). The ideal test would evaluate anterior septal LV thickness and vascular flow; it’s ...
Is a target TSH closer to the mid normal range justified in older individuals (age 70 or above) without any known cardiac ischemia or dysrhythmia or osteoporosis?
There are observational data showing decreased mortality rates and improved measures of well-being in elderly persons with TSH levels that are above the traditional reference range for the general population. Therefore, having a target TSH range of about 7 is more appropriate for elderly persons. Th...
Do you recommend life long aspirin 81 mg daily for non-specific T2 white matter hyper-intensities on MRI brain?
"Non-specific" means non-specific, indeed, and ASA risks of bleeding increase with age.
Is there any benefit in maintaining statin or aspirin therapy in patients >75 years old with stable, multivessel ischemic heart disease in light of challenges encountered with polypharmacy?
This is a great geriatric cardiology question because it acknowledges that guidelines may not apply in an older patient with multiple medical problems and a complex medication regimen. The question further implies that treatment should be individualized and patient-centered. I agree with the questio...