Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
Have results from recent quasi-experimental trials around herpes zoster vaccination and dementia risk/progression affected your clinical practice?
There have been several studies that have suggested that herpes zoster vaccination may reduce the risk of dementia. One risk of applying these studies to clinical care is that these studies are observational, meaning there has not been a randomized controlled trial comparing people were randomly ass...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
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 ...
How do you evaluate and manage incidental urinary retention in hospitalized patients?
Another great question. First, we need to confirm the presence of urinary retention (>300 ml on postvoid residual [PVR] bladder scan is considered clinically significant to continue evaluating for common reversible causes, such as medications, structural abnormalities, presence of constipation, feca...
In adults ≥80 years with TSH 6–10 mIU/L and minimal symptoms, do you initiate levothyroxine, monitor, or avoid treatment entirely?
I tend to check free T4 in this situation. Aging is associated with some elevation in TSH value up to 10 mIU/L with normal free T4, and in those patients, levothyroxine is not needed. In some patients, I have seen it rise above 10 with normal free T4. Supplementing levothyroxine to lower serum TSH w...
Does global brain atrophy increase risk for intracranial bleed after fall in older adults?
It depends on the location of the hemorrhage. Subdural bleeding/hematoma is much more likely in elderly people with brain atrophy and a fall. Epidural hemorrhage is much more common in young patients. Intracerebral hemorrhage is more related to risk factors such as hypertension in middle age and amy...
What is your approach to picking a dose/formulation of Vitamin D for a community-dwelling older adult found to have Vitamin D deficiency?
Supplementation with cholecalciferol (vitamin D3) 1000–2000 IU daily would be my choice for community-dwelling older adults with documented deficiency, and is preferred over ergocalciferol (vitamin D2). I would also co-administer calcium (1000–1200 mg/day) to support fracture prevention. Routine lab...
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 will assess how long I am treating the person/infection, and go from there in terms of how likely I am to induce the AmpC based on the duration of treatment. For example, if it's a 7-day course for UTI or GN bacteremia, I may risk the penicillin/cephalosporin (based on susceptibilities, of course)...
In an older adults with dementia-related behavioral symptoms refractory to nonpharmacological management in whom you are starting SSRI, do you ever consider a short course of antipsychotic medication to overlap with the initiation of SSRI while waiting for therapeutic effect?
The American Geriatric Society recommends that antipsychotics may be considered when behaviors do not respond to non-pharmacological management and the patient is at risk of harming themselves or others. Thereby, it may be reasonable to overlap short-term antipsychotic with SSRI initiation in older ...
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?
I have changed my approach to the use of escitalopram for agitation in AD only slightly based on this article. For treatment of agitation in AD, the first line is always going to be non-pharmacologic, based on the acknowledge, reassure, and redirect strategy. Caregivers need to be taught to respond,...