Geriatric Update April 22, 2024

RSV disease was less common but similar in severity compared with COVID-19 or influenza disease among unvaccinated patients and more severe than COVID-19 or influenza disease among vaccinated patients for the most serious outcomes of mechanical ventilation or death.

In 6248 adults hospitalized for RSV infection before vaccine became available, age, 72.7 years, 56.4% with underlying cardiovascular (CV) disease, 22.4% experienced a CV event, 33.0% in those with CV disease vs 8.5% in those without. I look forward to seeing the data after RSV vaccine rollout.

As of 11th of April, 121 measles cases were reported in 2024, this is twice the 58 cases in all of 2023. With immunization rates <95%, outbreaks will increase and worsen. Measles infection is scary because it leads to immunosuppression by depleting memory and naïve B cells and reducing diversity of pre-existing antibodies, leading to susceptibility to other infections that continues for years after apparent recovery.

Current use (90 days after a prescription) of antipsychotics in patients with dementia was associated with elevated risks of pneumonia (hazard ratio 2.19, 95% confidence interval (CI) 2.10 to 2.28), and cumulative incidence of pneumonia of 4.48% (4.26% to 4.71%) versus 1.49% (1.45% to 1.53%) in the matched cohort of non-users (difference 2.99%, 95% CI 2.77% to 3.22%), acute kidney injury (1.72, 1.61 to 1.84), venous thromboembolism (1.62, 1.46 to 1.80), stroke (1.61, 1.52 to 1.71), fracture (1.43, 1.35 to 1.52), myocardial infarction (1.28, 1.15 to 1.42), and heart failure (1.27, 1.18 to 1.37).

A liquid biopsy assay that combines a microRNA signature identified in the exomes shed from pancreatic cancers and a well-known biomarker from cell-free DNA found in the blood of patients with pancreatic cancer, has demonstrated an accuracy of 97% for detecting stage I/II pancreatic ductal adenocarcinoma, the most common type of pancreatic cancer.

In 379,699 participants without diabetes at baseline from the UK Biobank over 14.1 years, Vitamin D sufficient blood levels 25(OH)D >30 ng/ml  vs. deficiency 25(OH)D <10 ng/ml, diabetes incidence was:

• 0.64 (0.58, 0.70) for those with prediabetes (n=9085)

• 0.62 (0.56, 0.70) for normoglycemic patients at baseline (n= 6315)

• The optimal serum level is 50 ng/ml, while levels >90 ng/ml also increase the risk, and that level also has been shown to increase CVD.

Previous studies have shown a possible link between Glucagon-like peptide 1 receptor agonist (GLP1) use and thyroid cancer, but subsequent studies did not reach statistical significance. Now a postmarketing study of GLP1, dipeptidyl peptidase 4 (DPP4) inhibitor or sodium-glucose cotransporter 2 (SGLT2) inhibitor use did not increase the risk of thyroid cancer in a Scandinavian cohort study of 145,410 patients over about 4 years. Considering the impressive beneficial effect on diabetes and cardiovascular outcomes with these meds, and the overall low rate of thyroid cancer, we should inform our patients and put it into context.

Exercise reduces new CVD events  and that effect was greater among those with (vs without) preexisting depression (HR: 0.860; 95% CI: 0.810-0.915; vs HR: 0.929; 95% CI: 0.910-0.949; P interaction = 0.011). The mechanism is through stress-related neural activity as measured in the ratio of resting amygdalar-to-cortical activity on 18F-fluorodeoxyglucose positron emission tomography/computed tomographic (PET) imaging. The largest effect is for those exercising >150 min / week.

Using wearable device data to categorize 29,836 obese (BMI ≥30 kg/m2) participant’s physical activity by morning, afternoon or evening, the researchers uncovered that aerobic moderate to vigorous physical activity– the kind that raises our heart rate and gets us out of breath– between 6 pm and midnight had the lowest risk of premature death and death from cardiovascular disease over 7.9 years. The frequency and vigor physical activity in short bouts >3 minutes, also appeared to be more important than their total amount of physical activity daily.

Following exercise, appetite decreased rather than increased in patients with prediabetes or T2DM. These results were accompanied by inconsistent changes in appetite-regulating hormone levels. The overall risk of bias was low.

In 573 participants, age 69 years, randomized to the semaglutide group and 572 in the placebo group, over 1 year, semaglutide was superior in improving heart failure-related symptoms and physical limitations (17 m longer 6 min walk test), and reducing bodyweight (10%) in participants with obesity (>30% BMI) related heart failure with preserved ejection fraction. Semaglutide was well tolerated and results were consistent across patient demographic and clinical characteristics.

A meta-analysis of 17 studies on heart failure with 23,523 patients (age, 69) found, patients taking SGLT2 inhibitors have significant increases in peak oxygen consumption and 6-minute walk distance (increased by 13.09 meters) as well as an improved quality of life, regardless of their sex, ejection fraction, or diabetes status.

In 240 patients randomized within 24 hours of hospital presentation for hypervolemic acute heart failure, the SGLT-2 inhibitor dapagliflozin added to routine care improved median 24-hour natriuresis (P = 0.03) and urine output (P = 0.005), expediting hospital discharge. Patients in the SGLT-2 group required less diuretics and less uptitration, without adverse effects.

In 7185 APOEε4 homozygous carriers a variant in fibronectin (FN1) was protective of Alzheimer's disease AD (OR = 0.29; 95% CI [0.11, 0.78], P = 0.014) and delayed age at onset by 3.37 years. Vascular deposition of FN1 is related to the pathogenicity of APOEε4, and the loss of function variant in FN1 may reduce APOEε4-related AD risk.

A review of 30 studies found that pain increased the development of delirium: Pain at rest (OR 2.14; 95% confidence interval [CI] 1.39–3.30), with movement (OR 1.30; 95% CI 0.66–2.56) and pain categorized as ‘severe’ (OR 3.42; 95% CI 2.09–5.59).

In 204,155 US Medicare beneficiaries, age 77, diltiazem compared with metoprolol For every 1000 person-years of treatment with diltiazem doses >120 mg/d, there were an additional 15 cases (or 1.5%) of the primary composite outcome of serious bleeding, which increased to 22 for patients with HAS-BLED scores of >4 and 21 for patients who received rivaroxaban. The authors did not show the risk with apixaban, but I expect it was not statistically significant. Because of the bleeding risk, rivaroxaban is on the Beers criteria, a list of meds not to be used by older adults, and apixaban is the preferred drug. 

XpressO is a self-administered digital cognitive prescreening tool of 3 tasks repeated in 3 variations, to a total of 9 tasks, evaluates memory recall, executive functions, and processing times, was validated with the Montreal Cognitive Assessment (MoCA) and showed strong correlation with area under the operator curve (AUC) of 0.845. To classify individuals with normal and abnormal MoCA scores, two threshold values were introduced for the total XpressO scores: sensitivity of 91% at a cutoff of 72, specificity of 90% at a cutoff of 42, and an undetermined range in between.

I recently mentioned that vision diseases such as cataract, age-related macular degeneration, or glaucoma have about a third higher risk of falls and fractures, and cataract surgery increased falls.  This study of 2951 patients, age >70, showed that the mechanism is poor contrast sensitivity (20.8% vs. 14.7%; PR = 1.30, 95% CI 1.01–1.67) rather than visual acuity leading to higher fall risk.

Quaternary compounds, ubiquitous in disinfecting agents and personal care products, were potently and selectively cytotoxic to developing oligodendrocytes, whereas organophosphate flame retardants, common in furniture and electronics, prematurely arrested oligodendrocyte maturation, which continues well into adulthood.

Hyperbaric oxygen therapy after breast irradiation, reduced pain by 32% and fibrosis by 86% in a small Dutch study.  

This excellent 5 min video by Dr. Gaur explains the reason well why older adults should get COVID booster shots.

This is an excellent GeriPal podcast on artificial intelligence (AI). 

Thursday’s OMDA congregate care call is on: Weight loss and new diabetic meds, Dr. Shar Jwayyed.

The road to medical knowledge is through the pathological museum and not through an apothecary's shop.

Dr. William W. Gull

Happy Passover! In Hebrew: Chag Sameach!