Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
What is your approach to monitoring of inflammatory markers during treatment of native vertebral osteomyelitis?
As long as the patient is clinically stable and CRP is coming down, there is generally no need for follow up imaging. Key reference: Kowalski et al., PMID 16779743.Also, good to remember that ESR is a very expensive test which basically measures fibrinogen (may cost $500 or more since it has to be r...
What suggestions for environmental modifications do you find most helpful to reduce the risk of falls in the geriatric population?
Great question! The following recommendations encompass those that have been deemed cost-effective for fall prevention. The CDC STEADI program is also useful for reviewing these things. First, I would usually order home health PT/OT to do an assessment if the person has Medicare, and they will often...
How do you approach treatment of hypersomnolence in dementia?
To state the obvious first that you will have had to exclude a hypoactive delirium. And then, considerations: 1. What stage of dementia is the person in? If severe or later stages, this could be normal and physiologic given the level of cerebral atrophy and damage. 2. What type of dementia? If you t...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...
How do you approach deprescribing or continuing statin therapy in older adults with end-stage kidney disease who are initiating dialysis?
My practice in older adults starting dialysis is no different from that of younger patients starting dialysis. If the patient is on a statin, I do not discontinue it. If the patient is not on a statin, I do not start it when they begin dialysis, as there is no strong evidence that it reduces cardiac...
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
How do you approach the choice of basal-bolus insulin vs correctional insulin alone to manage hyperglycemia in a hospitalized older adult with type 2 diabetes and significant frailty?
Frail older adults with type 2 diabetes, compared to their less-frail counterparts, may have less predictable oral intake, and you may have more difficulty obtaining an accurate medication reconciliation. You may need to review facility records or speak to multiple collateral historians to find out ...
Which patients with mild cognitive impairment do you consider referring for amyloid-targeted therapy?
This is an important question, as clearly, not everyone with MCI is appropriate or interested in Amyloid-Targeted Therapy. In general, I would say that the TRAILBLAZER-ALZ 2 trial did not change my approach to patient selection much, but it did provide more evidence that this class of drugs has a pl...
In adults ≥80 years with TSH 6–10 mIU/L and minimal symptoms, do you initiate levothyroxine, monitor, or avoid treatment entirely?
I tend to check free T4 in this situation. Aging is associated with some elevation in TSH value up to 10 mIU/L with normal free T4, and in those patients, levothyroxine is not needed. In some patients, I have seen it rise above 10 with normal free T4. Supplementing levothyroxine to lower serum TSH w...
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...