Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to screening a cancer survivor for iron overload, and what is your treatment of choice?
We check the ferritin level after completion of chemotherapy. If ferritin is >1,000 ng/ml, we recheck the level as it can be falsely elevated with inflammation/infection. If ferritin is >1,000, we obtain a liver MRI with iron quantification. If liver iron concentration (LIC) is > 5 mg/g dry weight, ...
In a hospitalized older adult with significant pain and delirium, in which delirium may be due either to underlying pain or use of pain medications such as narcotics, how do you approach clinical management of delirium?
This is such a common and challenging scenario! Older adults experiencing delirium often cannot identify/vocalize the need for PRN medications. If there is high clinical suspicion for sub-optimally controlled pain being a contributor to the delirium, a strategy could be scheduling low-dose pain medi...
How do you decide when to give antibiotics for an older adult receiving comfort-focused care who develops signs of a symptomatic infection?
In an older adult receiving comfort-focused care, the decision to use antibiotics should be guided by goals of care and likelihood of symptom relief, rather than by the presence of infection alone. The main question is whether antibiotics are likely to meaningfully improve distressing symptoms such ...
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
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.
At what point would you consider stopping antidepressant treatment of late life depression after remission?
My first step here would be to answer some clarifying questions: What is the patient's current prognosis? (If the patient has a limited life expectancy- weeks to small order months- then I would certainly consider deprescribing with more ease.) Are there any foreseeable anticipated triggers for depr...
What is your view on the potential role of immune-targeted therapies in Parkinson’s disease?
In my opinion, the role of immune-targeted therapies in Parkinson’s disease remains uncertain at this time. While both activated microglial cells and various cytokines associated with immune activation have been detected in Parkinson’s patients, it remains unclear whether these are pathologically si...
In your clinical practice, how are you approaching consideration of limbic-predominant age-related TDP-43 encephalopathy (LATE) in the differential diagnosis for older adults previously thought to have Alzheimer's disease?
At the moment, I am not finding that this diagnosis is extremely helpful. In general, LATE looks for all the world like AD at the time of diagnosis in the oldest patients, but it doesn't progress like we expect it to. LATE, by itself, seems to be a much more slowly progressive disease. So I find mys...
Which patients with mild cognitive impairment do you consider referring for amyloid-targeted therapy?
This is an important question, as clearly, not everyone with MCI is appropriate or interested in Amyloid-Targeted Therapy. In general, I would say that the TRAILBLAZER-ALZ 2 trial did not change my approach to patient selection much, but it did provide more evidence that this class of drugs has a pl...
How do you approach the decision to initiate or continue bisphosphonate therapy in an older patient with significant esophageal disease or swallowing dysfunction?
Unless there are indications to turn first to non-bisphosphonate therapies, I would first consider whether the patient would be a candidate for IV bisphosphonate therapy. Many patients, even those without esophageal disease or dysphagia, find the convenience of an annual outpatient infusion appealin...