Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
What is your antipsychotic of choice and general titration regimen in the outpatient setting for a patient with dementia and behavioral disturbances (assuming reversible causes such as urinary retention, constipation, etc. have been addressed)?
While not set in stone and knowing that there is a black box warning, make sure you get informed consent. I start with low doses of quetiapine (12.5 to 25 mg), as it has the shortest half-life, and will use it twice or 3 times a day. This allows for quicker recovery if they are too sedated. Dependin...
How do you approach the management of extremely low LDL levels in older adult patients receiving statin therapy for primary prevention of cardiovascular disease?
In the absence of side effects, I am not concerned about very low LDL levels (e.g., less than 20 mg/dL), as there is a fairly linear association between LDL and CV risk, and there is no convincing evidence that even extremely low LDL levels are associated with cognitive impairment, intracranial hemo...
What is your approach to determining eligibility for hospice in persons with Alzheimer's disease?
We strongly recommend early hospice enrollment for patients with dementia as soon as they meet eligibility criteria. In our approach, we carefully evaluate both functional and cognitive decline. One area that is often overlooked, however, is nutrition. When a patient with Alzheimer’s disease begins ...
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...
What would be your approach for the management of asymptomatic, severe AS with a peak velocity of 5 m/s in an otherwise physically active patient in their mid-90s without significant co-morbidities?
The EARLY TAVR trial (Généreux et al,. PMID 39466903) showed that in patients with asymptomatic severe AS, early TAVR was associated with a 50% reduction in the primary composite endpoint of death, stroke, or unplanned hospitalization for cardiovascular causes compared to clinical surveillance over ...
Do you consider using buspirone for the management of anxiety in older patients?
While buspirone has been FDA-approved for the treatment of generalized anxiety disorder (GAD) and for short-term relief of anxiety symptoms in general since the 1970s, it is not generally considered a first-line treatment, despite its low misuse potential as a non-benzodiazepine. There are no large ...
How do you counsel patients on the risks and benefits of chemotherapy or radiation offered with palliative intent?
Before I start counseling a patient on these decisions, I want to know a few things first. I would want to know from the oncologists what they think the benefits are (i.e., how much more time might they get? Symptom control?) and what the risks are. The chances that the patient will see a benefit. ...