Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
Has the recent large observational data suggesting that continuing metformin during hospitalization is associated with lower post-discharge mortality and hypoglycemia changed your approach to holding it on admission in stable, non-critically ill patients with T2DM?
I really like this paper, but I don't think it is plausible that a 5-day difference in receipt of metformin (the median length of stay was 5 days) could really affect 90-day mortality.The study question is a good one because the evidence that metformin causes lactic acidosis is extremely limited. In...
What resources or interventions do you provide to older adults who are experiencing financial mistreatment/scams?
The intervention I recommend depends on the type of mistreatment. If there is suspicion of elder financial abuse (e.g., a family member is taking money away from the patient without the patient's permission/knowledge), then you may be obligated to report this suspected abuse to appropriate authoriti...
What is your approach to the management of pressure ulcers in bedbound older adults who are community-dwelling?
Management of pressure ulcers in bedbound community-dwelling older adults centers on three pillars: Pressure off-loading, nutritional optimization, and stage-appropriate wound care, supported by an interdisciplinary approach that includes caregiver education. Pressure Off-Loading This is the single ...
How do you counsel patients on the risks and benefits of chemotherapy or radiation offered with palliative intent?
Before I start counseling a patient on these decisions, I want to know a few things first. I would want to know from the oncologists what they think the benefits are (i.e., how much more time might they get? Symptom control?) and what the risks are. The chances that the patient will see a benefit. ...
How do you weigh the risks of antipsychotic induced metabolic side effects when treating behavioral symptoms of dementia in a patient with diabetes?
This is an excellent question and is a difficult clinical metabolic risk concern in a poorly characterized population. Most of what we know about antipsychotic-induced metabolic syndrome, such as weight gain, dyslipidemia, insulin resistance, and hyperglycemia, comes from younger patients with schiz...
Do you have any tips for best practices or resources for interacting with adult protective services when reporting elder mistreatment?
Interacting with Adult Protective Services can sometimes feel like a one-way valve: we make a report, provide information, and don't hear back. I've come to learn that in many jurisdictions, APS is prohibited from sharing information with the reporter, and they actually want to have more/better inte...
Are there clinical scenarios in which you might use buspirone on an as-needed basis for older adult patients?
I have not generally used buspirone as an as-needed medication for older adults experiencing anxiety. I will use it as an adjunct to other medication management, SSRIs, if needed [1]. However, its effect is generally seen with consistent dosing, and even then, the effect may not be realized for many...
How, if at all, have you changed your approach to the use of escitalopram for agitation in Alzheimer's dementia based on results from the S-CitAD RCT?
The S-CitAD trial results have changed preference from escitalopram over citalopram to citalopram over escitalopram. Citalopram is R-enatiomer and escitalopram is the S-enantiomer. This study was underpowered due to difficulty in recruitment and randomized only 173 patients rather than the intended ...
What is your approach to screening for cognitive impairment in hospitalized older adults?
Upon admission to the hospital, all older adults should undergo a brief cognitive screening. This initial step helps establish a baseline and can identify previously unrecognized cognitive issues. Several tools are well-suited for this purpose; we use minicog as the screening tool at our hospital. ...
Do you see any reason to consider the use of brexpiprazole over older atypical antipsychotics that may be less expensive for the management of agitation refractory to nonpharmacological management in older adults with dementia?
While I will say up front that I am not an expert in Geriatric Psychiatry, I have not yet found a reason to start brexipipraxole out of the gate. For agitation that really requires pharmacologic management, my go-to remains Seroquel. It has one of the lowest rates of side effects, although we exploi...