Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you manage sleep disturbances in patients with Alzheimer’s disease without relying heavily on deliriogenic medications?
Sleep disturbances are common in older people and in those with Alzheimer’s disease (AD) in particular, and there are often multiple etiologies. Whether sleep disturbances increase the risk for AD, or are a result, metanalyses have suggested that the magnitude of sleep impairment correlates with the...
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 differentiate cognitive impairment from normal age-related cognitive decline?
It can be tricky to differentiate normal aging from true cognitive impairment. I think the key ingredients are objective cognitive testing and bringing in a trusted informant. When a patient or a carepartner expresses a memory concern, or you wonder about memory during a routine evaluation, the firs...
In outpatient primary care settings, would you recommend routinely checking Cystatin-C as a marker of renal function in older adults?
I probably would not recommend routine Cystatin-C testing for all older adults, but would consider it in certain scenarios where eGFR may be inaccurate or misleading. In geriatrics, sarcopenia and low muscle mass often make serum creatinine a less reliable marker of true kidney function. Cystatin-C ...
Would you use a parathyroid hormone analog for treatment of osteoporosis in a patient with mildly elevated AlkPhos of unclear etiology?
I would be hesitant to administer an anabolic in this setting without first delineating the reason for an elevated AlkPase. I would suggest starting with sorting out the source of the AlkPase (i.e., bone, liver, or gut with measuring bone-specific AlkPase, G-GGT levels, and possibly a liver ultrasou...
What treatment options are there for uremic pruritus in an elderly patient with risk of sundowning?
Uremic pruritus is increasingly recognized as a multifactorial condition involving peripheral neuropathy and immune dysregulation, particularly upregulation of type 2 cytokine pathways. Dysregulated opioid signaling further contributes to itch amplification. Accordingly, κ-opioid receptor agonists, ...
How do you approach decision-making around initiation of osteoporosis therapy in patients with advanced dementia?
Great question, there are many things that I consider. First, I limit consideration of osteoporosis therapy to patients who have a life expectancy of 1 year or more. This is because the time to benefit from a bisphosphonate is estimated to be about 12 months (Deardorff et al., PMID 34807231). Assumi...
What practical next steps would you recommend once identifying loneliness in an older adult patient?
First, normalize and validate the experience, emphasizing that it is common and appreciating that the patient is willing to discuss this with you. Explaining that they can and deserve to feel better may help set the stage for the conversation. Listen with genuine attention. Clarify the type of lonel...
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 do you counsel non-diabetic patients who wish to start metformin to reduce the risk of developing dementia?
There have been some interesting observational studies evaluating the reduction of cognitive decline in patients with type 2 DM. First, they are all in patients WITH diabetes, so not yet generalizable to patients without DM. Second, they are observational trials, which means that they cannot adjust ...