Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
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...
How do you weigh the potential value or need for formal neuropsychological testing in patients with Alzheimer’s Disease prior to starting antiamyloid monoclonal antibody treatment?
It depends on what you mean by neuropsychological testing. Everyone who is to be considered for anti-amyloid treatment needs to have a diagnosis of MCI or Mild AD. So, to arrive at this diagnosis, some testing must be done that documents a decline from baseline. This can often be accomplished with m...
When evaluating an older adult patient for cognitive concerns, what is your process for deciding whether or not to refer them for neuropsychological testing?
When I'm deciding whether to pursue neuropsychological testing, this can come down to 2 questions: Will the results change management and/or prognosis? Can the person do the testing? 1) Will the results change management and/or prognosis?Many different aspects can inform this question. F.e., Is this...
How do you counsel non-diabetic patients who wish to start metformin to reduce the risk of developing dementia?
There have been some interesting observational studies evaluating the reduction of cognitive decline in patients with type 2 DM. First, they are all in patients WITH diabetes, so not yet generalizable to patients without DM. Second, they are observational trials, which means that they cannot adjust ...
How do you decide when an older patient's weight loss warrants an extensive workup versus a more focused or watchful approach?
I always start with the standard cut off of 5% of normal body weight in 6-12 months. If this cut-off is met, then I probe about intentional or unintentional. Many older adults are not eating enough protein (they need more than the RDA recommendation) -- I encourage 1-1.3 (sometimes 1.5) g/kg protein...
What are the clinical prompts that lead you to consider deprescribing bisphosphonate therapy in older adults with osteoporosis?
As a Geriatrician, the essence of my practice is to determine, on regular review (reconciliation), whether an older adult’s medication is appropriate to continue or continue at the same dosing on the basis of physiology, pathology, and/or risk modification. We know well today that medications for os...
What is your approach to patients requesting prescription sleep aids, such as trazodone, quetiapine, or olanzapine, at discharge after they have found them beneficial during a prolonged hospitalization?
I don't see the harm in continuing a patient on trazodone or melatonin on discharge until they see their PCP, if they were benefiting from it in the hospital. For example, if you see a dementia patient with sundowning and have helped them sleep peacefully with trazodone, melatonin, or low-dose Remer...
Is it necessary to prescribe a steroid taper after two weeks of high-dose prednisone (60 mg daily)?
Interesting question. Not being an endocrinologist, I don't have the expertise to advise but the reference below makes the statement that even short-term steroids can be an issue. I suspect that if you have to stop abruptly from 60 mg daily for 2 weeks, it would probably be fine in most instances bu...