Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you approach the management of newly discovered prediabetes in adults over the age of 65?
We know that even at the same given HgA1c, a 90-year-old patient and a 30-year-old patient have different patterns in their day-to-day sugars. The 90-year-old patient will have a wider amplitude of sugars above and below a given average sugar level. Therefore, while a given HgA1c gives us an idea of...
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.
Should we be recommending a specific daily protein intake to prevent sarcopenia in geriatric patients, or do you find it more beneficial to focus on encouraging activity within their mobility limitations to preserve muscle mass?
Muscle mass decreases about 3–8% per decade after the age of 30, with this rate of decline increasing after age 60. (Holloszy, PMID 10959208 and Melton et al., PMID 10855597). Hospitalizations also cause acute muscle loss, disproportionately more in older adults."Among medically stable older adults,...
How have the results of the U.S. POINTER study involving multidomain lifestyle interventions to protect cognitive function influenced your practice?
Let me start my response by acknowledging that I was a site PI for this study at Wake Forrest.I think this study was important because it gives us more data that a healthy lifestyle can delay the onset of cognitive changes. As a dementia specialist, it is great to be able to counsel patients who hav...
What is your approach to counseling older patients and their families regarding expected recovery of aphasia following a large hemispheric stroke?
There is no precise answer for this question. Every patient follows their own course after a stroke. The size of the infarct and the age of the patient will affect the prognosis. Older patients and those with larger infarcts tend not to have as much recovery. The improvement of aphasia can proceed o...
How do you approach the management of older adult patients with dementia who repeatedly aspirate with oral intake but whose family/HCP may be unwilling to accept the aspiration risk associated with comfort eating?
This is a challenging situation where clinicians play a crucial role in providing education to families and caregivers. However, before we provide education, it’s important to assess the knowledge of families and caregivers around dysphagia and aspiration in persons with dementia (e.g., “What have o...
How are you incorporating the newer RCT data suggesting no mortality benefit to indefinite beta-blocker therapy for patients who are several years out from an MI with preserved LVEF and no angina or arrhythmia?
I have been de-prescribing after counseling once the patient is a couple of years out. This reduces symptoms, pill burden, drug interactions, etc., so I see an active benefit even if the patient seems to be tolerating medication. Obviously, they would have no other indication for BB, mainly arrhythm...
Which anticoagulant (DOAC or Warfarin) would you recommend in the case of a 70-year-old male with persistent atrial fibrillation and history of rheumatic mitral stenosis now status post bioprosthetic MVR?
There won't be perfect data on this, per the 2023 guidelines:The distinction between “valvular” and “nonvalvular “AF remains a matter of debate. Their definitions may be confusing. Recent trials comparing vitamin K antagonists with non-vitamin K antagonist oral anticoagulants in AF were performed am...
How do you select between antipsychotics in the treatment of delirium refractory to nonpharmacological management in hospitalized older adults with dementia?
I have learned that antipsychotic selection is very institution-based/variable.Traditionally, at the Brigham, we have preferred Seroquel because it is titratable and avoids issues if the patient has underlying Parkinson's. However, now that Zyprexa is available in IV form, house staff often prefer t...
What are some practical steps physicians can take to optimize mobility and reduce falls in hospitalized patients?
Falls have long been a complex challenge for clinicians, inpatient unit leaders, and hospitals/health systems in the management of hospitalized patients. The solution is nuanced and depends on many patient- and facility-related factors – no single intervention is enough on its own. Evidence from rec...