Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you advise older adult patients with cognitive impairment and/or caregivers who inquire about commercial cognitive apps/games for the prevention of cognitive decline?
There is no data that suggests that participating in cognitive apps/games can help patients who already have cognitive impairment. That said, my bias is that doing something is better than doing nothing, so any cognitive challenge is better than just watching TV.There is some data that cognitive sti...
When diuretics or lactulose are newly started or uptitrated at discharge, what clinical factors make you schedule follow-up within 72–96 hours rather than the usual 7–14 days?
In reality, follow-up in 72-96 hours is quite difficult to achieve, so we do rely a bit on nursing check-ins as opposed to clinic follow-up. But clinical factors such as severity of VOL or HE, suspected compliance, out-of-hospital discharge setting (home vs shelter), support structure for patient, a...
For patients with acute renal failure and possible urinary retention, do you obtain a bedside bladder POCUS exam before ordering renal imaging or placing a Foley catheter?
Bedside Bladder Ultrasound has a strong role in the evaluation of acute urinary retention (AUR) as a possible cause for acute renal failure. Practice varies, as does the evidence base, but most POCUS experts recommend ultrasounding both the bladder (to assess for post-void residual volume) and both ...
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...
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
What is your approach to determining eligibility for hospice in persons with Alzheimer's disease?
We strongly recommend early hospice enrollment for patients with dementia as soon as they meet eligibility criteria. In our approach, we carefully evaluate both functional and cognitive decline. One area that is often overlooked, however, is nutrition. When a patient with Alzheimer’s disease begins ...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
What is your approach to antibiotic selection for bacterial species that demonstrate susceptibility to penicillins or cephalosporins on testing, but are known to harbor inducible AmpC resistance?
I follow the recommendations from the IDSA guidelines (Tamma et al., PMID 39108079). Duration of treatment does not influence my decision about whether to use a beta-lactam for organisms with inducible AmpC. For Enterobacter cloacae complex, Klebsiella aerogenes, and Citrobacter freundii, I do not u...
How can we approach tapering or discontinuing biologic DMARDs in patient in their 80s with well controlled rheumatoid arthritis?
Not a simple answer, unfortunately, as we know Rheumatoid arthritis (RA) is a chronic disease and thus requires long-term treatment!If, however, the patient's preference is to taper or discontinue a biologic DMARD, per ACR RA treatment guidelines, it can be considered after the patient has been in r...
What is your approach to the management of wandering behaviors and risk in community dwelling older adults with dementia?
Non-pharmacologic, behavioral strategies are the first-line approaches to wandering in people with dementia. One of the best approaches is to try to understand why the person is wandering and whether that need (e.g., the need to move, confusion about where something is located) can be met more safel...