Geriatric Medicine
Physician insights on aging-related care, polypharmacy management, cognitive decline, and geriatric syndromes.
Recent Discussions
How do you counsel older adults regarding the use of melatonin (dose and timing) for sleep-related problems?
Melatonin has a weak hypnotic (i.e., sleep-inducing) effect. It helps people to fall asleep but not to stay asleep. It is not effective in people with chronic insomnia, but it is perfectly safe in low doses (i.e., below 10 mg) and can be helpful for occasional problems with falling asleep. For sleep...
For patients over 70 with elevated ASCVD risk but no prior cardiovascular events, do you ever recommend continuing or initiating low-dose aspirin?
Yes, I might still recommend low-dose ASA for primary prevention for someone over 70 if the patient is very functional.
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...
How do you counsel your patients with diabetes that tighter glycemic control could be harmful as they age when they've been committed to a goal A1c% <7.0-7.5 for many years?
I counsel my elderly patients and their families that at a certain age, the risk of developing long-term sequela of diabetes (eye disease, kidney disease) becomes lower because those things take many years to develop. However, elderly people are more vulnerable to medication side effects, so we adju...
How do you recommend counseling patients on the prognosis of advanced cancer as a generalist who is not highly specialized in cancer literature or cancer-directed therapies?
Generalists can accurately prognosticate on the order of days to short months without specialized knowledge when caring for people with advanced cancer because the prognosis is often clinically obvious, and because most cancer-directed therapies take weeks to months to work (a patient may not live l...
How do you select an SSRI and dosing strategy for older adults newly being treated for depression?
SSRIs are preferred based on tolerability, drug interaction potential, and comorbidities. Start at low doses (e.g., sertraline 25 mg daily) and titrate gradually to therapeutic levels over 1–2 weeks, monitoring closely for adverse effects. Among SSRIs, sertraline and escitalopram are particularly r...
For patients with acute renal failure and possible urinary retention, do you obtain a bedside bladder POCUS exam before ordering renal imaging or placing a Foley catheter?
Bedside Bladder Ultrasound has a strong role in the evaluation of acute urinary retention (AUR) as a possible cause for acute renal failure. Practice varies, as does the evidence base, but most POCUS experts recommend ultrasounding both the bladder (to assess for post-void residual volume) and both ...
Have you changed your approach to delaying hip surgery in the context of decompensated CHF given the findings of the HIP-ATTACK study?
That is an interesting question. Patients with a hip fracture have a high mortality, and delaying surgery could contribute to this mortality. On the other side of the pendulum is acute heart failure. Patients with acute heart failure have increased mortality in the perioperative period. Some of this...
How would you approach counseling an older patient with significant hearing loss and nonadherence to use of hearing aids?
Using my own grandmother as an example, hearing aides were an affront to her vanity, and she perceived them as a sign of weakness in aging…and she probably felt as if they were thrust upon her by the family—so, in the end, she was stuck in silence within her own world—which was a sad and lonely and ...
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...