Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
How do you counsel your patients with diabetes that tighter glycemic control could be harmful as they age when they've been committed to a goal A1c% <7.0-7.5 for many years?
I counsel my elderly patients and their families that at a certain age, the risk of developing long-term sequela of diabetes (eye disease, kidney disease) becomes lower because those things take many years to develop. However, elderly people are more vulnerable to medication side effects, so we adju...
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...
How do you recommend counseling patients on the prognosis of advanced cancer as a generalist who is not highly specialized in cancer literature or cancer-directed therapies?
Generalists can accurately prognosticate on the order of days to short months without specialized knowledge when caring for people with advanced cancer because the prognosis is often clinically obvious, and because most cancer-directed therapies take weeks to months to work (a patient may not live l...
How do you select an SSRI and dosing strategy for older adults newly being treated for depression?
SSRIs are preferred based on tolerability, drug interaction potential, and comorbidities. Start at low doses (e.g., sertraline 25 mg daily) and titrate gradually to therapeutic levels over 1–2 weeks, monitoring closely for adverse effects. Among SSRIs, sertraline and escitalopram are particularly r...
For patients with acute renal failure and possible urinary retention, do you obtain a bedside bladder POCUS exam before ordering renal imaging or placing a Foley catheter?
Bedside Bladder Ultrasound has a strong role in the evaluation of acute urinary retention (AUR) as a possible cause for acute renal failure. Practice varies, as does the evidence base, but most POCUS experts recommend ultrasounding both the bladder (to assess for post-void residual volume) and both ...
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...
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
How would you approach counseling an older patient with significant hearing loss and nonadherence to use of hearing aids?
Using my own grandmother as an example, hearing aides were an affront to her vanity, and she perceived them as a sign of weakness in aging…and she probably felt as if they were thrust upon her by the family—so, in the end, she was stuck in silence within her own world—which was a sad and lonely and ...