Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you differentiate cognitive impairment from normal age-related cognitive decline?
Dr. @Dr. First Last's answer is right on target. I have a couple of additional tips when taking a history. First: normal cognitive decline would include certain features and not others. Normal aging typically leads to slower processing, more effort with multitasking and learning something new, and m...
How do you counsel patients who are concerned that discontinuation of certain chronic medications may actually perpetuate suffering at the end of life?
Great question, and it’s very nuanced. I’ll share how I typically approach this based on my experience. In the end-of-life care setting, when I review a medication list, I go through every single one and ask: “What is the purpose of this medication in this particular case?” For example, anticoagul...
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...
Are there any situations in which you consider initiation of dronabinol for sleep-related problems in older adult patients?
No, I do not use this in my practice. I'm not aware of any data supporting its use for sleep disturbances.
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. ...
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...
How do you approach initiating a deprescribing conversation about a long-standing benzodiazepine in an older adult who has been on a stable dose for years and reports no side effects?
First, I try to understand what symptoms led to the initiation of the benzodiazepine, which can help me identify whether there is a safer alternative treatment. Then I make sure people understand why we want them to come off the benzodiazepine in the first place, since this is not common knowledge (...
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. ...
Would you start romosozumab in an active smoker?
This is not simple! But we are good at assessment of risk vs benefit (or benefit vs risk!)First I would reassess fracture risk, prior treatments, reason to consider romo. Then I would do a deep dive into risk assessment for cardiovascular disease: how much do they smoke, prior cardiovascular disease...
How soon after a fracture would it be safe to start anti-resorptive therapy?
This is an important question. There is no definitive answer, and there have been no clinical or preclinical studies that demonstrate delayed healing in the presence of bisphosphonates. Personally, I favor waiting a few weeks before we start. That also gives us time to do a proper metabolic workup. ...