Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
What treatment options are there for uremic pruritus in an elderly patient with risk of sundowning?
Uremic pruritus is increasingly recognized as a multifactorial condition involving peripheral neuropathy and immune dysregulation, particularly upregulation of type 2 cytokine pathways. Dysregulated opioid signaling further contributes to itch amplification. Accordingly, κ-opioid receptor agonists, ...
When considering deprescribing antihypertensives in older patients, how do you approach prioritization of which antihypertensives to target first?
When deprescribing antihypertensives in older adults, my approach is individualized, goal-concordant, and iterative with close monitoring after each step. Every patient is a little different, so there isn't one class of antihypertensives I always deprescribe first. My general rule of thumb is that w...
What is the next best osteoporosis treatment option for patients who completed 2 years of teriparatide, but has contraindication to bisphosphosnate therapy (e.g. history of atypical femur fracture)?
I have successfully treated several patients with bisphosphonate-induced subtrochanteric femoral fractures with Forteo. However, before initiating another antiresorptive therapy, I first want to be sure that the Forteo at the desired effect on bone remodeling by increasing both bone formation and bo...
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...
In outpatient primary care settings, would you recommend routinely checking Cystatin-C as a marker of renal function in older adults?
I probably would not recommend routine Cystatin-C testing for all older adults, but would consider it in certain scenarios where eGFR may be inaccurate or misleading. In geriatrics, sarcopenia and low muscle mass often make serum creatinine a less reliable marker of true kidney function. Cystatin-C ...
When an older adult with multiple comorbidities develops a new, significant functional decline after a hospitalization, how do you decide whether to pursue further diagnostic workup versus accept it as post-hospitalization deconditioning and focus on rehabilitation?
I try to characterize the nature of the functional decline in a descriptive sense - what has become difficult and why, what are the patient and caregivers experiencing? I think through a differential diagnosis for that, and then I look at the totality of diagnosed problems from the hospitalization a...
What is your approach to deprescribing cholinesterase inhibitors and/or memantine in advancing stages of dementia?
This is an important question, as pill burden does have a negative effect on the quality of life for the patient as well as the care provider. This becomes even more important with patients having dysphagia and or loss of appetite, common symptoms in patients with advanced dementia. It is important ...
What framework or risk assessment tool is most effective in determining surgical or palliative management of acute hip fracture after a fall in an elderly patient with co-morbidities and poor functional status?
I have found the NSQIP calculator to be the most useful in situations of acute hip fractures in elderly patients. In particular, it looks at more than just cardiac risk perioperatively - it examines functional, pulmonary, and ICU risks. They incorporate a number of co-morbidities and functional stat...
For elderly patients (i.e. older than 80) with only one documented episode of paroxysmal atrial fibrillation following a stress event (such as acute illness/steroid administration) and a CHADsVASc score greater than 1, how would you counsel them on the risks/benefits of anticoagulation and subsequent monitoring for afib recurrence?
If it were an isolated event, I would advocate continued monitoring for recurrence before starting an anticoagulant with the understanding that the risk of AF recurrence is relatively high.
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...