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 do you decide when to recommend conservative kidney management over dialysis initiation in a frail older adult with stage 5 CKD?
This is definitely not a one-size-fits-all answer. Functional status and cognitive status, rather than age, are the most important considerations. The frailty syndrome itself is associated with poor outcomes for patients on dialysis. There is a clear association between kidney disease and frailty, w...
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...
How do you approach balancing the treatment of urinary incontinence with anticholinergic medications with the use of cholinesterase inhibitors in dementia?
This is a great question and speaks to the importance of shared decision-making and understanding the context of individual patients. Ultimately, it would be best to avoid anticholinergic medications in our patients living with dementia. Medications with anticholinergic properties increase the risk ...
What would be your approach for the management of asymptomatic, severe AS with a peak velocity of 5 m/s in an otherwise physically active patient in their mid-90s without significant co-morbidities?
The EARLY TAVR trial (Généreux et al,. PMID 39466903) showed that in patients with asymptomatic severe AS, early TAVR was associated with a 50% reduction in the primary composite endpoint of death, stroke, or unplanned hospitalization for cardiovascular causes compared to clinical surveillance over ...
How do you approach initiating a deprescribing conversation about a long-standing benzodiazepine in an older adult who has been on a stable dose for years and reports no side effects?
First, I try to understand what symptoms led to the initiation of the benzodiazepine, which can help me identify whether there is a safer alternative treatment. Then I make sure people understand why we want them to come off the benzodiazepine in the first place, since this is not common knowledge (...
Do you routinely prescribe vitamin D to reduce the risk of fall-related fractures in elderly patients regardless of their serum levels?
Right now, the evidence would NOT support daily vitamin D in older adults who are not deficient just for the purposes of fall prevention. Kahwati et al., PMID 33847712However, lots get missed on fall prevention - so be sure to review all risk factors and make a personalized plan (STEADI resources ar...
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 requests from facilities requesting a urinalysis (either on demand or PRN) for "behavioral changes"?
First, I would do a happy dance (discreetly, of course) because rather than asking me to prescribe a psychoactive medication, the facility thought about the possibility that a behavior change has an underlying medical cause. And before getting too distracted by the request for a UA, I would get more...
What is your clinical approach to deprescribing vs continuing low-dose aspirin used for primary prevention in older adults who are already taking this medication?
I generally continue a low-dose aspirin in patients at higher risk (e.g., diabetes, CKD, strong family history) who would be at risk for a significant reduction in quality of life were s/he to have a cardiac/vascular/cerebrovascular event, provided there is no history of significant anemia (transfus...