Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
What goes into your decision making when choosing between oral and intravenous bisphosphonate therapies for osteoporosis?
From my perspective if you are going to give a bisphosphonate IV is preferred since it is convenient and there is no risks of GI side effects and issues of compliance. I do not think there is any significant difference in causing ONJ and subtrochanteric femoral fractures. However my preference is De...
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...
In older adults with chronic mild hyponatremia (Na 128–132) attributed to SSRIs but good psychiatric response, do you tolerate persistent hyponatremia, reduce the dose, or switch agents?
In my practice, I generally tolerate mild hyponatremia, Na>130, if asymptomatic and mood symptoms have good control. If there’s moderate hyponatremia, Na 125-130, I generally consider either changing the dose or the agent. If severe, Na<125, I would change the agent and likely avoid the entire class...
Do you recommend vitamin K2 supplements in patients with osteoporosis?
The answer, as with most vitamin supplementations, cannot be answered with high-level evidence to support a "yes or no". A bit of background and then a brief review of available evidence.Vitamin K is thought to be important for bone health because it activates several proteins involved in bone forma...
Do you separate RSV and recombinant zoster vaccines to reduce reactogenicity in an older adult eligible for both at the same visit?
Yes. I never give the zoster vaccine with any other vaccine.
What is your approach to screening for cognitive impairment in hospitalized older adults?
Upon admission to the hospital, all older adults should undergo a brief cognitive screening. This initial step helps establish a baseline and can identify previously unrecognized cognitive issues. Several tools are well-suited for this purpose; we use minicog as the screening tool at our hospital. ...
When stopping denosumab and transitioning to PO bisphosphonate, do you wait for 6 months after the last denosumab injection to start PO bisphosphonate?
Some background: In patients discontinuing denosumab without subsequent antiresorptive therapy, BMD rapidly reverts back to baseline with an elevation in vertebral fracture risk (with an enhanced risk of multiple vertebral fractures). Thus, sequential treatment regimens following denosumab have been...
If an older adult is being worked up for concerns around progressive cognitive impairment, what is your process for determining the need for repeated head imaging (i.e., how far back will you allow a prior brain MRI to stand in as part of the workup)?
Older adults are a heterogeneous group: someone <65 years old with progressive cognitive impairment may need repeat head imaging to help assess interval development even if the last one was only 1 year ago. The other end of the spectrum, 80+ year-olds or those with poor functional status, may not ne...
How do you select between antipsychotics in the treatment of delirium refractory to nonpharmacological management in hospitalized older adults with dementia?
Five rules for choosing an antipsychotic in delirium for internal medicine residents called overnight for agitation/delirium in an older adult: Treat the cause first. The first-line treatment of delirium is to identify and address precipitating factors such as infection, hypoxia, urinary retention,...