Geriatric Update Jan 15, 2024

This is an excellent and detailed review of cardiovascular autonomic dysfunction in post-COVID-19 syndrome.

In Geriatric and Other News,

6100 patients with mild ischemic stroke or high-risk transient ischemic attack (TIA) who had not undergone thrombolysis or thrombectomy were randomized to receive clopidogrel 75 mg daily for 90 days plus aspirin 100 mg daily for 21 days or matching clopidogrel placebo plus aspirin 100 mg daily for 90 days. A new stroke occurred in 222 patients (7.3%) in the clopidogrel-aspirin group and in 279 (9.2%) in the aspirin only group (hazard ratio, 0.79; 95% confidence interval [CI], 0.66 to 0.94; P = 0.008).

A review of 29 studies with 183,291 participants and 10,561 total strokes, showed an 18% reduction of strokes with higher blood levels of omega-3. My criticism of this and similar studies is that is not clear what part of fish consumption may be contributing to the benefit, iodine, protein, etc. or omega-3. I would like to see a long-term randomized trial with omega-3 supplements but so far they have not shown a benefit. 

In this article the author describes his success of treating restless legs by avoiding sugar in the diet. May be hard but worth a try. And in a study, for every 1% increase in price of sugar sweetened beverages, there was a 1% reduction in purchases of the products, and the effects were seen quickly after the taxes went into effect.

Oct 2nd I mentioned that GLP-1 meds for diabetes and weight loss were associated with suicidal thoughts. Now an FDA review updated the evaluation of reports of suicidal thoughts or actions and found no association between glucagon-like peptide 1 receptor agonist (GLP-1 RA) medications and suicidal thoughts or actions. This may be because of the higher background risk in patients with diabetes or obesity, but we should still have it on our radar.

This Practice Update summarized the 2023 ACC/AHA/ACCP/HRS atrial fibrillation (AF) guideline nicely: It is only 5 pages long, including references. There are 10 key take-away messages, listed concisely, and those that are really important or new are actually bolded so that if one does not have time, one can just read those key recommendations, 3 takeaways:

• Four stages of AF

• Rhythm control should be tried in low AF

• Uncomplicated paroxysmal AF, catheter ablation is a first-line option for rhythm control.

A propensity-matched retrospective cohort study of 27,878 Canadians undergoing elective surgery, showed a lower risk of developing dementia (HR 0.88; 95% CI 0.80–0.97; p = 0.01) over 5 years. The study excluded half of patients, and we all have seen worsening of function and development of delirium in our older adults after surgery that makes me question the study’s validity.

This review of chronic pain associated with temporomandibular disorders recommends: Cognitive behavioral therapy (CBT), postural and stretching exercises, manipulation and acupuncture among others.

Cognitive behavioral therapy (CBT) is also effective in treating sequellae of tinnitus. 30 patients were randomized to receive iCBT delivered through a chatbot mobile app (Tinnibot) or Tinnibot combined with telepsychology (i.e., hybrid-intervention group). After 8 week intervention and 2-month follow up, the Tinnitus Functional Index (TFI) improved in both groups, 64%. The secondary outcome measures, PHQ-9 and GAD-7 improved significantly over time, but the Hyperacusis Questionnaire did not.

Empagliflozin caused a 6% reduction in eGFR in the first 2 months and thereafter halved the chronic slope of kidney function decline over time. The effect was stronger earlier in chronic kidney disease progression. Monitor for side effects in our older adults: dehydration, ketoacidosis and fungal infections in the groin.

A prospective cohort study of 15-year physical activity, 150 min a week, with time-in-target range of 75% or more among young adults was associated with a 40% lower risk of cardiovascular events after a median follow-up of 18.9 years.

A single dose of the two-dose recombinant zoster virus vaccine prevents shingles with an efficacy of 64%, and the full vaccine series with an efficacy of 76% over a four-year period. 

A cancer vaccine enhances lymph node delivery for T-cell immune response to colon and pancreatic cancer peptides. Immune response correlates with cancer suppression as high as 86-100% in this phase 2 study.

Epinephrine nasal spray had outcomes comparable with autoinjectors and manual injection, and longer duration, requiring less repeat dosing.

Tianeptine, also called gas-station heroin, sold as dietary supplement alarms health officials due to difficult to treat overdoses.  Tianeptine is a tricyclic antidepressant with a μ-Opioid receptor agonist effect that can induce euphoria at high doses. It is more hepatotoxic but less anticholinergic and cardiotoxic than tricyclics. Sometimes naloxone can help in overdoses. The director of the New Jersey Poison Control Center said “Some people apparently think it can help with chronic pain instead of having to use an opioid, which might explain the older demographic.” In 2022, Ohio Governor Mike DeWine made all products containing tianeptine a Schedule I controlled substance.

Thank you, Felicia for sharing these 60-Minute segments on a study of ultrasound reducing Alzheimer's and addiction, exciting, and looking for longer term data.

Thank you Eileen Higgins, who sent this new review of 6 articles since 2018 showed with moderate certainty of evidence that massage therapy benefits chronic low back pain, fibromyalgia, and myofascial pain.

If you feel that patients have become more complex over time, you are right: Over a 15 year interval, 3.3 million inpatients at the end of the study were more likely to have been admitted via the emergency department (odds ratio [OR], 2.74), to have multimorbidity (OR, 1.50) and polypharmacy (OR, 1.82) at presentation, to receive treatment for 5 or more acute medical issues (OR, 2.06), to experience an in-hospital adverse event (OR, 1.20) and unplanned readmission and death in the 30 days after discharge (OR, 1.14; 95% CI, 1.12-1.16, and OR, 1.28; 95% CI, 1.25-1.31, respectively).But the likelihood of an intensive care unit stay and of in-hospital death declined over the study interval (OR, 0.96; 95% CI, 0.95-0.97, and OR, 0.81; 95% CI, 0.80-0.83, respectively).

10 minutes of physical activity 5 x a week in older adults >50, keeps anxiety at bay with higher intensity physical activity showing greater effect. As little as 1 to < 200 MET/min/week led to 47% lower odds of GAD vs. those performing no activity.

The AMA offers 10 hours of CME on Firearm Safety, Injury Treatment and Risk Factors, most of them free.

A liter of bottled water contains about a quarter million nanoparticles of plastic. A glass of tap water looks really good….

Science gathers knowledge faster than society gathers wisdom. 

Isaac Asimov