Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
What is your approach to counseling severely frail older adults regarding their planning for invasive life-sustaining therapy?
My approach is pragmatic, evidence-based, and bi-directional. Patients/family make the decision, but I ensure they are fully informed about the pros and cons and provide them time to think through.
How do you weigh the risks and benefits of ongoing hospitalization in elderly patients with protracted delirium but without clear acutely reversible cause?
Even when no clearly reversible cause of delirium has been identified, clinicians should maintain a high index of suspicion for a missed diagnostic or therapeutic opportunity, recognizing that an initially "negative" evaluation may have overlooked factors such as polypharmacy, occult infection, unco...
After major non-cardiac surgery in high-risk older adults, do you routinely check post-operative troponins to screen for myocardial injury?
I do not routinely check postoperative troponins on every older adult after major non-cardiac surgery, but I do use them selectively in patients who are at high risk for perioperative cardiovascular complications. My practice has evolved as our understanding of myocardial injury after non-cardiac su...
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,...
How do you approach the management of extremely low LDL levels in older adult patients receiving statin therapy for primary prevention of cardiovascular disease?
In the absence of side effects, I am not concerned about very low LDL levels (e.g., less than 20 mg/dL), as there is a fairly linear association between LDL and CV risk, and there is no convincing evidence that even extremely low LDL levels are associated with cognitive impairment, intracranial hemo...
How has your approach to de-escalating a conversation with a distressed or angry family member evolved over your career?
My approach to de-escalating conversations with distressed or angry family members has shifted from trying to solve the problem immediately to first understanding the emotion driving the conflict. Early in my career, I often responded by providing more medical information, assuming that greater clar...
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...
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 decide in older adults with newly diagnosed stage 2 hypertension when to start with two antihypertensive agents versus taking a more cautious approach due to concerns about potential orthostasis, frailty, or polypharmacy?
Starting Dual Therapy vs. a Staged Approach in Older Adults with Newly Diagnosed Stage 2 HypertensionThe core question isn't just how high blood pressure is; it's how much treatment this patient can safely absorb.In geriatric cardiology, cardiovascular risk reduction and treatment-related harm are t...