Geriatric Update May 6, 2024

The CDC tested 22,020 individuals at high risk for developing tuberculosis with a tuberculin skin test (TST), QuantiFERON-TB Gold (QFT), and T-SPOT simultaneously so that they can be compared directly in their ability to predict the development of active tuberculosis over up to 8 years. The TSPOT and QFT-GIT assays performed significantly better than the TST (positive predictive value ratio, 1.65 [95% CI, 1.35-2.02] and 1.47 [95% CI, 1.22-1.77], respectively).

Paxlovid (nirmatrelvir–ritonavir) within 5 days after symptom onset, reduced the risk of outcomes after hospitalization with COVID-19, followed for >1yr: Inpatient death (hazard ratio 0.62 [95% CI 0.57–0.68]), congestive heart failure (0.70 [0.58–0.85]), atrial fibrillation (0.63 [0.52–0.76]), coronary artery disease (0.71 [0.59–0.85]), chronic pulmonary disease (0.68 [0.54–0.86];), acute respiratory distress syndrome (0.71 [0.58–0.86]), interstitial lung disease (0.17 [0.04–0.75]), and end-stage renal disease (0.37 [0.18–0.74]).

Bird flu has caused conjunctivitis in 2 farmers. The FDA reports virus found in milk, but inactivated by pasteurization.  Moreover, I have not read of cases in those drinking unpasteurized milk, which the FDA strongly advises against.

Legislation for support and training of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use in China, improved clinical outcomes for: return of spontaneous circulation (72 patients [0.92%] vs 425 patients [7.21%]), survival to arrival at the hospital (68 patients [0.87%] vs 321 patients [5.45%]), and survival at discharge (44 patients [0.56%] vs 165 patients [2.80%]) In 7858 out of hospital cardiac arrests in 2010-2018 before and 5893 in 2018-2022 after legislation took effect.

The FDA approved Pivya (pivmecillinam) tablets for the treatment of adult women with uncomplicated urinary tract infections (UTIs) caused by susceptible isolates of Escherichia coli, Proteus mirabilis and Staphylococcus saprophyticus. It has been used in Europe for >40 years for UTIs. While the most common side effects of Pivya included nausea and diarrhea, others are: clostridium difficile, rash and carnitine depletion (relevant for patients with mitochondrial diseases).

In 326 Asian overweight participants (body mass index, 25.0-39.9) with type 2 diabetes  (diagnosed within prior 2 years, not on insulin) an energy-restricted diet of 790 kcal/d on 2 days each week was better than aerobic and strength exercise 2 times a week in: diabetes remission, and weight, BMI, HDL cholesterol and HbA1c reductions, but had similar effects on reduced adiposity, liver fat content, and diastolic blood pressure.

A review of 22 articles showed 50 mg oral semaglutide weekly led to higher incidence of skin dysesthesia (1.8% vs 0%), hyperesthesia (1.2% vs 0%), skin pain (2.4% vs 0%), paresthesia (2.7% vs 0%), and sensitive skin (2.7% vs 0%), than those receiving placebo or comparator. Reports of alopecia (6.9% vs 0.3%) were higher in patients who received 50 mg oral semaglutide weekly than in those on placebo, but only 0.2% of patients on 2.4 mg of subcutaneous semaglutide reported alopecia vs 0.5% of those on placebo. It is not clear if these patients also were on metformin that is known to block vitamin B-12 absorption, and deficiency leads to neuropathy.

A retrospective database review of 29,648 older VA long-term care nursing home residents, age 78, showed an incidence rate of fractures per 100 person-years in those initiating antihypertensive medication was 5.4 compared with 2.2 in the control group. For more info and mgmt. see my short commentary: increasing fluid intake when starting or increasing antihypertensives compensates for the relative hypovolemia from the vasodilation.

The prevalence of resident-to-resident aggression among the 930 Assisted Living  Facility residents (mean age, 88, 80% women) was: verbal 11.2%, physical 4.4%, sexual 0.8% in one month.

The NHANES study showed that the optimal systolic blood pressure (SBP) level associated with the highest probability of surviving to 90 years among women aged 65 years or older is 110-130. And by adequately hydrating our patients, allows us to optimally control BP without falls or other adverse effects.

Consuming at least 7 g/d of olive oil was associated with a 28% lower risk of dementia-related death (adjusted pooled HR, 0.72 [95% CI, 0.64-0.81]) compared with never or rarely consuming olive oil, in a dietary recall study over 28 years. There was benefit over margarine and mayonnaise but not over other oils, so oils in general may be beneficial. Now that margarines do not contain dehydrogenated oils anymore, this difference may also disappear.

Based on Medicare data from 1995-1998, late-midlife (avg age 54) oxygen desaturation to less than 80% during sleep was associated with subsequent development of late-life (avg age 76) onset epilepsy (LOE), aHR 3.28 (1.18–9.08), but the apnea–hypopnea index was not related. Participant report of diagnosis of sleep apnea in 2011–2013 was also associated with subsequent LOE, aHR 2.59 (1.24–5.39).

Medicare patients have lower mortality and readmission rates when treated by female physicians, and the benefit is larger for female (8.15% vs. 8.38%) than male patients (10.15% vs. 10.23%). This difference may appear small but it results in 420 deaths a year in the US. The female physicians were slightly younger and more likely to have a DO than MD degree. 

After adjustment for confounders, there was no association between antidepressant use and dementia risk (hazard ratio [HR], 1.14; 95% CI, 0.92-1.41), accelerated cognitive decline, or atrophy of white and gray matter over 10 years. However, the highly anticholinergic class of tricyclic antidepressant was associated with increased dementia risk (HR, 1.36; 95% CI, 1.01-1.83) compared with the use of selective serotonin reuptake inhibitors (HR, 1.12; 95% CI, 0.81-1.54).

Disrupted Delta wave sleep was associated with higher risk of CV disease (HR: 1.46; 95% CI: 1.02-2.06) and death (HR: 1.94; 95% CI: 1.18-3.18) over 11 years. Here is a free example of a delta wave enhancing audio file.

The USPSTF has come out with new breast cancer screening guidelines that recommend screening all women age 40-74 every other year with mammogram.  Although yearly screening picked up slightly more breast cancer, this was far outweighed by the harm of a 50% higher false positive rate and it’s downstream consequences. 14 min Audio.  

The strongest association of attempted suicide was with trigeminal and autonomic cephalalgias (TAC), (adjusted hazard ratio [aHR], 4.25; 95% CI, 2.85-6.33). For completed suicide, the strongest association was with posttraumatic headache (aHR, 2.19; 95% CI, 0.78-6.16), in a Danish population based cohort study that controlled for sex, age, education, income, comorbidities, and baseline medical and psychiatric diagnoses.

In 1414 older patients (avg age 74) of low surgical risk with severe aortic stenosis (SAS), transcatheter aortic valve implantation (TAVI) was better than surgical aortic valve replacement (SAVR) for death from any cause or stroke at 1 year, 5.4% vs. 10.0% and death from any cause was 2.6% vs. 6.2%. This heavily drug company sponsored study (most authors were employed or received royalties from the manufacturer) did not carry out the study for longer time, as possibly the results may not have been as good, funding would not have been a rate limiting factor. Previous long-term (5-year) results in older patients at high surgical risk showed no difference.

Physician empathy showed clinically relevant difference in chronic pain intensity, back-related disability, fatigue, and pain interference in a cohort study of 1470 patients, the mean (SD) age was 53.1. Physician empathy was associated with more favorable outcomes than non-pharmacological treatments, opioid therapy, and lumbar spine surgery.

This TED talk explains “What happens as we die.”

Beethoven’s 5th symphony, “Freude Schöner Götterfunken” or “Ode to Joy” is celebrating 200 years and has become the European anthem. 

Happy nurses week.