Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
What is your approach to managing hallucinations in dementia?
One thing to remember is that hallucinations are not always disturbing to the patient, but to the caregiver! If the patient is fine with seeing a little girl or dog (often in LBD), the family just needs to be educated to let it go. They don’t need to AGREE that the hallucinations are present; they j...
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 prioritize and sequence GDMT classes when polypharmacy or frailty limits up-titration in an older patient with symptomatic HFrEF?
I am also concerned about pushing too much and too high levels of GDMT in elderly patients with a chance for hypotension, falls, and fractures. I usually try to get my elderly CHF patients on carvedilol at a modest dose and an ACEI/ARB at a moderate dose. I have the patients keep a first AM BP log t...
Do you recommend starting a statin in patients above 75 years old with diabetes but no known ASCVD?
The time to benefit (TTB) for statins in primary prevention of cardiovascular events is generally about 1.5 to 3 years. This means that adults aged 50 to 75 years typically need to take statins for at least 2.5 years to achieve a meaningful reduction in major adverse cardiovascular events (MACE), su...
What is your threshold for pursuing a lumbar puncture in an older hospitalized patient with acute altered mental status when the initial workup — including labs, imaging, and urinalysis — is unrevealing?
My threshold for lumbar puncture in an older hospitalized patient with acute altered mental status is high. In my practice, I will not pursue an LP in a patient over 65 solely because an otherwise routine evaluation for delirium is unrevealing. A negative workup alone does not sufficiently increase ...
How does premorbid dementia affect your decision to offer acute stroke intervention?
I would try to engage the family, along with the patient, about goals of care, quality of life before the stroke, whether APOE status is known (E4E4 is a contraindication for tenecteplase), etc. This would lead to a decision about aggressive therapy, tenecteplase and/or endovascular therapy. Previou...
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...
What is your approach to counseling older patients and their families regarding expected recovery of aphasia following a large hemispheric stroke?
There is no precise answer for this question. Every patient follows their own course after a stroke. The size of the infarct and the age of the patient will affect the prognosis. Older patients and those with larger infarcts tend not to have as much recovery. The improvement of aphasia can proceed o...
How have you refined your approach to disclosing a new diagnosis of dementia to a patient and their family?
I tend to think about this disclosure as layers of an onion. My general layers are: Explain what dementia is (and is not) and how we got to that diagnosis. Something like "You and your family have noticed memory problems, and the testing we just did confirms that. The memory problem appears signifi...
Have you used POCUS with color power Doppler to assess blood pressure in a patient whose cuff readings are in doubt?
Thank you for bringing up this question, as it focuses on a POCUS topic I often think about. I will split my assessment into two categories: clinical utility and physiologic limitations, with a brief EBM note at the end. Clinical Utility While the referenced study suggests this technique is feasible...