Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
How would you approach the consideration of a levodopa trial in an older adult with a history of schizophrenia, stable on antipsychotic medication, who has changes consistent with drug-induced Parkinsonism vs Parkinson's disease?
The first step is to establish if it is degenerative Parkinsonism, such as Parkinson's disease (presynaptic dopaminergic loss) or drug-induced Parkinsonism DIP (due to postsynaptic dopaminergic blockade). I will order a DaT scan to differentiate between the two. If the DaT scan is abnormal, I will s...
How soon after a fracture would it be safe to start anti-resorptive therapy?
This is an important question. There is no definitive answer, and there have been no clinical or preclinical studies that demonstrate delayed healing in the presence of bisphosphonates. Personally, I favor waiting a few weeks before we start. That also gives us time to do a proper metabolic workup. ...
Under what circumstances would you consider treating obstructive sleep apnea in an older adult who has few or no daytime symptoms?
I always treat OSA if severe with respect to the level of hypoxemia or of fragmentation of sleep (which can be approximated by the AHI). Even if there are no symptoms of daytime sleepiness, I would treat it if there are nighttime symptoms (e.g., middle-of-the-night insomnia, nocturia, or waking too ...
What criteria do you use to determine fitness to resume driving following recovery from delirium in an older adult patient?
There are no validated delirium-specific criteria for determining fitness to resume driving. In general, driving should be deferred until the delirium has resolved and the patient has substantially recovered toward their cognitive and functional baseline. Assessment should include attention and cogn...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
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.
How do you weigh the risks and benefits of ongoing hospitalization in elderly patients with protracted delirium but without clear acutely reversible cause?
Even when no clearly reversible cause of delirium has been identified, clinicians should maintain a high index of suspicion for a missed diagnostic or therapeutic opportunity, recognizing that an initially "negative" evaluation may have overlooked factors such as polypharmacy, occult infection, unco...
After major non-cardiac surgery in high-risk older adults, do you routinely check post-operative troponins to screen for myocardial injury?
I do not routinely check postoperative troponins on every older adult after major non-cardiac surgery, but I do use them selectively in patients who are at high risk for perioperative cardiovascular complications. My practice has evolved as our understanding of myocardial injury after non-cardiac su...
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...