Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
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...
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...
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...
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...
Would you ever consider sending any labs to help determine if a certain level of systemic inflammation could interfere with novel amyloid blood-based biomarkers for the detection of brain amyloid?
Not at this time. If I have concerns about using blood-based biomarkers in a specific patient (due to CKD, other chronic conditions, etc) but have reason to rule Alzheimer's disease in or out, I go straight to amyloid PET CT instead.
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...
How do you weigh the potential value or need for formal neuropsychological testing in patients with Alzheimer’s Disease prior to starting antiamyloid monoclonal antibody treatment?
It depends on what you mean by neuropsychological testing. Everyone who is to be considered for anti-amyloid treatment needs to have a diagnosis of MCI or Mild AD. So, to arrive at this diagnosis, some testing must be done that documents a decline from baseline. This can often be accomplished with m...
Do you recommend initiating treatment with an SGLT2 inhibitor or semaglutide first for a patient with obesity and heart failure with preserved ejection fraction?
Irrespective of body weight status, my first line of treatment for patients with HFpEF is with SGLT2 inhibitors if there are no contraindications (DELIVER trial and EMPEROR preserved trial). For patients with obesity (cardiometabolic) phenotype HFpEF, who qualify for GLP1 receptor agonists, I add on...