Dear Dr. Roach: My husband is 77, and I am 68. Our health deteriorated during the pandemic. When should we switch to a gerontologist for our general care?
A.M.P.
Nearly all adult primary care doctors, including family medicine doctors and internists, have expertise in taking care of older adults, as older people tend to see doctors more than younger people. However, geriatricians focus their practice exclusively on older people and have additional training in the special health-care needs of older adults.
There is no one right answer to your question. If your regular primary care doctor is handling all your medical needs, there might be no reason to switch. A geriatrician is most valuable in older patients who have multiple medical problems, patients who take a lot of medications or patients whose functioning has recently deteriorated. Some geriatricians assume primary care for their patients, while others work collaboratively as consultants.
There are some so-called “geriatric syndromes” (dementia, incontinence, delirium, falls, pressure ulcers and others) that occur commonly, in which all geriatricians are experts. Some general physicians are less comfortable with managing these conditions. There are several new treatments in dementia requiring special expertise that only a few generalists have acquired. These treatments are often managed by geriatricians or neurologists with a subspecialty training in memory disorders.
Again, though, if your regular doctor is treating your issues well, a person satisfied with their care doesn’t need to leave. But if they aren’t, a geriatrician is an excellent resource.
Dear Dr. Roach: I was recently diagnosed with complex regional pain syndrome (CRPS), and I’m undergoing continuous testing. It was recommended by one of the many doctors that I might want to try ketamine infusion therapy. But I’m getting mixed reviews. Do you have any thoughts on this approach?
R.S.
CRPS is a poorly understood pain disorder that usually begins after trauma, such as a fracture, surgery or another injury.
Initial treatment with physical and occupational therapy helps retain function of the affected area, which is usually a limb. When drug therapy is considered, there are many drugs that are shown to be useful in some people with CRPS, although there is no single treatment that is effective for everyone. Pain management specialists will often try an injection called a sympathetic block, along with one or more standard medications for nerve-induced pain. Topical treatments may also be used in combination.
I don’t prescribe ketamine, but some of the consultants I refer to have used it. Ketamine is not a first-line treatment. The evidence supporting its use is limited to small studies and suggests that the benefit lasts around one to three months. As you say, most experts use ketamine as an infusion under observation instead of oral ketamine, which has a significant potential for harm. In the few patients I have known who received benefit from ketamine, the infusions are repeated every three months. Unfortunately, not everyone responds to it.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
