Geriatric Update April 29, 2024

IgA is the mucosal immunoglobulin that is produced in response to respiratory infection and fights virus in the nose, mouth and throat. It usually is produced for about 40 days as most respiratory infections are seasonally limited. In 427 individuals, avg. age 68, COVID mRNA vaccines produced SARS-CoV-2–specific salivary IgA levels that peaked later, day 57, than with infection, day 29, and not as high, but very close. This answered one of my long standing questions: if an IM vaccine can raise IgA at all.  This is very encouraging, considering that recent nasal vaccines were only slightly better than placebo and IgA is required to decrease spread. 

Thank you, Joe for sending this article on intranasal neomycin, a generic aminoglycoside antibiotic.  By inducing the expression of interferon-stimulated genes (ISGs) in the nasal mucosa, it protected from COVID and influenza in several rodent studies. In healthy humans, it was well tolerated and induced ISG expression in the nose in a subset of participants.

The new heart failure guidelines stress four medications for HFrEF <40%. Once congestion is controlled with a loop diuretic, angiotensin receptor/neprilysin inhibitor (ARNI), beta blocker, mineralocorticoid antagonist, and an SGLT2 inhibitor should be titrated up. This combination of medications increases years of survival and reduces cardiac-related mortality and rehospitalization. Dr. Rakel wrote a great summary of the guidelines with a nice table.

Heart failure mortality decreased from 1995 to 2012 and since then has increased, see graph. As we live longer, survive cancer and accidents, this is not surprising.

Sodium-glucose cotransporter type 2 inhibitors (SGLT2i) reduced the incidence of gout in a propensity matched study of 34,604 Canadians, compared to sulfonylureas, −2.64 per 1000 person-years. I would like to see a comparison with GLP-1 inhibitors, which contribute to weight loss, to see if it is the diuretic or weight loss effect.  

A Hungarian dataset of >3 million showed that diabetes increases the risk of cancer, especially in younger cohorts (40–54 years: for patients with diabetes 5.4 % vs. controls 4.4 %; 70–89 years: for patients with diabetes 12.7 % vs. controls 12.4 %). The highest risk was for pancreatic cancer (HR = 2.294, 99 % CI: 2.099; 2.507) and for liver cancer (HR = 1.830, 99 % CI: 1.631; 2.054); it adds the lowest – but still significant – risk for breast cancer (HR = 1.137, 99 % CI: 1.055; 1.227) and prostate cancer (HR = 1.171, 99 % CI: 1.071; 1.280).

Primary care clinicians, in states that require reporting of a dementia diagnosis to the Department of Motor Vehicles, had an adjusted 12.4% probability of underdiagnosing dementia. In states with requirements that drivers self-report dementia diagnoses, the probability of underdiagnosing was 7.8%, similar to states without mandates, 7.7%. Patients in early dementia have been found to cause no more accidents, but later in the disease this increases. Could it be that physicians in mandatory reporting states, may wait to document until they feel the patient may be unsafe to drive.

A pooled analysis of several studies with cumulative > 1 million participants, stair climbing was associated with a 39% reduced risk for CV mortality, and a 24% reduced risk for all-cause mortality.

This is my PracticeUpdate Commentary on: Association between vision impairment and increased prevalence of falls in older US adults.

This Thursday’s OMDA presentation is on: ID/DD Population with Cognitive Changes, by Jennifer Pettis, MS, RN, CNE