Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you approach osteoporosis screening in men?
While osteoporosis is more prevalent in postmenopausal women, it is often under-recognized in men. The risk of mortality after hip fracture is higher in men, and that risk may extend over 10 years after injury. Men who sustain a wrist fracture are more likely to have severe osteoporosis and a higher...
Have you used lithium for agitation in dementia?
Non-pharmacologic approaches are first indicated. If they fail, then a psychotropic treatment algorithm is indicated, which generally starts with a serotonin reuptake inhibitor. Lithium would not be considered standard or first-line treatment for agitation in Alzheimer's disease, and in most other m...
For patients over 90 years old, is there any foreseeable benefit to undergoing left atrial appendage occlusion over permanent cessation of anticoagulation, particularly for those at high risk for major bleeding?
I would have no qualms about referring a 90+ year-old patient with a-fib and high bleeding risk for an LAA occlusion device. However, this requires a shared decision-making process whereby the risks and benefits of the various treatment options are discussed with the patient and, when appropriate, t...
For elderly patients (i.e. older than 80) with only one documented episode of paroxysmal atrial fibrillation following a stress event (such as acute illness/steroid administration) and a CHADsVASc score greater than 1, how would you counsel them on the risks/benefits of anticoagulation and subsequent monitoring for afib recurrence?
If it were an isolated event, I would advocate continued monitoring for recurrence before starting an anticoagulant with the understanding that the risk of AF recurrence is relatively high.
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...
How do you approach the management of older adult patients with coronary artery disease on aspirin who have developed intermittent diverticular bleeds?
This is a tough clinical scenario that comes up often in older adults. You will often have subspecialists involved and will need to adapt your approach to their management and communication styles. Generalists can add value here by looking at the whole picture and figuring out what matters most to t...
In a frail older adult with moderate-to-severe lower urinary tract symptoms, when do you start a beta-3 agonist like vibegron over an anticholinergic?
In a frail older adult with OAB-predominant moderate-to-severe LUTS, I generally start a β3 agonist (vibegron or mirabegron) as the first-line pharmacologic option once behavioral interventions are insufficient. Behavioral therapies may include fluid management, bladder retraining, pelvic floor exer...
How do you counsel older adults regarding the use of melatonin (dose and timing) for sleep-related problems?
Although many patients take up to 10 mg of melatonin, in older adults, the data support doses in the 2-4 mg range (dose response peaks at 4 mg for sleep). I find 30 minutes is not long enough prior to desired sleep time, and I try to give it to hospitalized older patients at about 7 pm so they can f...
Do you have go-to resources for how to advise older patients with a history of falling about ideal footwear?
For advising older adults on footwear for fall prevention, there are several evidence-based resources designed specifically for clinicians. Because fall prevention requires a multifactorial approach, the best resources come from major geriatric and public health guidelines.Here are the "go-to" clini...
What non-pharmacological management strategies have you found particularly helpful for older adults with restless leg syndrome?
Ensure appropriate sleep opportunity (around 7 hours in older adults). Avoid certain medications when possible, including SSRIs/TCAs, dopamine antagonists, and antihistamines. Avoid alcohol, caffeine, nicotine, and large amounts of carbohydrates. Ensure regular exercise. Ensure adequate iron stores...