Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
When considering deprescribing antihypertensives in older patients, how do you approach prioritization of which antihypertensives to target first?
When deprescribing antihypertensives in older adults, my approach is individualized, goal-concordant, and iterative with close monitoring after each step. Every patient is a little different, so there isn't one class of antihypertensives I always deprescribe first. My general rule of thumb is that w...
How do you approach the frequency of DEXA scan monitoring for older adults on bisphosphonate therapy during the course of therapy?
Depends who you read. ACP: Recommendation 4: ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women. (Grade: weak recommendation; low-quality evidence) [1] Monitoring wasn't addressed in the 2023 update. ACR: For adults continuing...
What is the next best osteoporosis treatment option for patients who completed 2 years of teriparatide, but has contraindication to bisphosphosnate therapy (e.g. history of atypical femur fracture)?
I have successfully treated several patients with bisphosphonate-induced subtrochanteric femoral fractures with Forteo. However, before initiating another antiresorptive therapy, I first want to be sure that the Forteo at the desired effect on bone remodeling by increasing both bone formation and bo...
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...
How do you approach the management of newly discovered prediabetes in adults over the age of 65?
We know that even at the same given HgA1c, a 90-year-old patient and a 30-year-old patient have different patterns in their day-to-day sugars. The 90-year-old patient will have a wider amplitude of sugars above and below a given average sugar level. Therefore, while a given HgA1c gives us an idea of...
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 ...
In an older man on tamsulosin for BPH who is presenting with recurrent falls, how do you manage the medication, in light of urinary symptom control and fall risk?
Tamsulosin carries the risk of orthostatic hypotension and falls, especially in older adults1. In the situation of an older adult man taking tamsulosin for BPH symptoms who is presenting with recurrent falls, I would first check orthostatic vitals and if positive, I would discuss this finding with t...
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...
What is your clinical approach to deprescribing vs continuing low-dose aspirin used for primary prevention in older adults who are already taking this medication?
I generally continue a low-dose aspirin in patients at higher risk (e.g., diabetes, CKD, strong family history) who would be at risk for a significant reduction in quality of life were s/he to have a cardiac/vascular/cerebrovascular event, provided there is no history of significant anemia (transfus...
In outpatient primary care settings, would you recommend routinely checking Cystatin-C as a marker of renal function in older adults?
I probably would not recommend routine Cystatin-C testing for all older adults, but would consider it in certain scenarios where eGFR may be inaccurate or misleading. In geriatrics, sarcopenia and low muscle mass often make serum creatinine a less reliable marker of true kidney function. Cystatin-C ...