Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you choose between various nonpharmacological strategies for prevention of behavioral and psychological symptoms of dementia such as bright light therapy, pet therapy, robot therapy, exercise, massage?
Non pharmacological strategies are most effective strategies with no potential side effects, but they are resource heavy. So it is crucial to assess specific symptoms, access to resources and the enviornment.A 3-Step Approach to ChoosingIdentify the Target Symptom: Are you treating agitation, apathy...
How do you choose among SSRIs and dosing strategies for the management of behavioral and psychological symptoms of dementia?
The best supported SSRI for BPSD generally is citalopram. Much of this came out of the CitAD trials [1]. This primarily showed citalopram may be useful for hyperactive behaviors, irritation, but also for depression and anxiety [1, 2]. The effect and response to citalopram, though, may be affected by...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
How do you counsel patients about the potential benefits of laxatives when they are experiencing overflow diarrhea and are concerned about it getting worse with these medications?
I'll preface this by saying I rarely see this, and I will approach this answer as if this patient were in palliative care. But I think I would start with education on the mechanism of this type of diarrhea and the rationale for using laxatives to improve the situation. I would also discuss that, aft...
Are there any specific scenarios in which you calculate estimated creatinine clearance over eGFR in an older adult patient?
This would be something to consider for patients in whom there is a discrepancy between clinical manifestations and creatinine estimated eGFR, for patients at the borderline of CKD stages, and for patients with extremes of muscle mass (which would lead you to think that the eGFR is less accurate). T...
Have you changed your approach to delaying hip surgery in the context of decompensated CHF given the findings of the HIP-ATTACK study?
That is an interesting question. Patients with a hip fracture have a high mortality, and delaying surgery could contribute to this mortality. On the other side of the pendulum is acute heart failure. Patients with acute heart failure have increased mortality in the perioperative period. Some of this...
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?...
Would you use a parathyroid hormone analog for treatment of osteoporosis in a patient with mildly elevated AlkPhos of unclear etiology?
I would be hesitant to administer an anabolic in this setting without first delineating the reason for an elevated AlkPase. I would suggest starting with sorting out the source of the AlkPase (i.e., bone, liver, or gut with measuring bone-specific AlkPase, G-GGT levels, and possibly a liver ultrasou...
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 ...
How do you differentiate cognitive impairment from normal age-related cognitive decline?
Dr. @Dr. First Last's answer is right on target. I have a couple of additional tips when taking a history. First: normal cognitive decline would include certain features and not others. Normal aging typically leads to slower processing, more effort with multitasking and learning something new, and m...