Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How would you approach the counseling and management of a 76-year-old man presenting to clinic having purchased a direct to consumer pTau181 Elecsys test (rule out) that is positive for amyloid, with MoCA 29/30?
I so wish this wouldn’t happen, but in reality, it’s happening! I tell people who are cognitively intact to ignore the results of the PTau test if possible. It is not a “crystal ball” that will predict their future. Is it a risk factor for developing AD in the future? Perhaps. But it’s one that is n...
In a hospitalized older adult with significant pain and delirium, in which delirium may be due either to underlying pain or use of pain medications such as narcotics, how do you approach clinical management of delirium?
This is such a common and challenging scenario! Older adults experiencing delirium often cannot identify/vocalize the need for PRN medications. If there is high clinical suspicion for sub-optimally controlled pain being a contributor to the delirium, a strategy could be scheduling low-dose pain medi...
How do you decide when to give antibiotics for an older adult receiving comfort-focused care who develops signs of a symptomatic infection?
In an older adult receiving comfort-focused care, the decision to use antibiotics should be guided by goals of care and likelihood of symptom relief, rather than by the presence of infection alone. The main question is whether antibiotics are likely to meaningfully improve distressing symptoms such ...
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
At what point would you consider stopping antidepressant treatment of late life depression after remission?
My first step here would be to answer some clarifying questions: What is the patient's current prognosis? (If the patient has a limited life expectancy- weeks to small order months- then I would certainly consider deprescribing with more ease.) Are there any foreseeable anticipated triggers for depr...
In your clinical practice, how are you approaching consideration of limbic-predominant age-related TDP-43 encephalopathy (LATE) in the differential diagnosis for older adults previously thought to have Alzheimer's disease?
At the moment, I am not finding that this diagnosis is extremely helpful. In general, LATE looks for all the world like AD at the time of diagnosis in the oldest patients, but it doesn't progress like we expect it to. LATE, by itself, seems to be a much more slowly progressive disease. So I find mys...
Which patients with mild cognitive impairment do you consider referring for amyloid-targeted therapy?
This is an important question, as clearly, not everyone with MCI is appropriate or interested in Amyloid-Targeted Therapy. In general, I would say that the TRAILBLAZER-ALZ 2 trial did not change my approach to patient selection much, but it did provide more evidence that this class of drugs has a pl...
Have results from recent quasi-experimental trials around herpes zoster vaccination and dementia risk/progression affected your clinical practice?
There have been several studies that have suggested that herpes zoster vaccination may reduce the risk of dementia. One risk of applying these studies to clinical care is that these studies are observational, meaning there has not been a randomized controlled trial comparing people were randomly ass...
Would you ever consider sending any labs to help determine if a certain level of systemic inflammation could interfere with novel amyloid blood-based biomarkers for the detection of brain amyloid?
Not at this time. If I have concerns about using blood-based biomarkers in a specific patient (due to CKD, other chronic conditions, etc) but have reason to rule Alzheimer's disease in or out, I go straight to amyloid PET CT instead.
How do you evaluate and manage incidental urinary retention in hospitalized patients?
Another great question. First, we need to confirm the presence of urinary retention (>300 ml on postvoid residual [PVR] bladder scan is considered clinically significant to continue evaluating for common reversible causes, such as medications, structural abnormalities, presence of constipation, feca...