Geriatric Update Nov 18, 2024
Galantamine 8 to 12 mg twice daily improved outcomes in a Cochrane review of 10,990 participants, age 74 years:
Alzheimer's Disease Assessment Scale - Cognitive Subscale (ADAS-cog) (MD-2.86, 95% CI -3.29 to -2.43)
Disability Assessment for Dementia (DAD) scale (MD 2.12, 95% CI 0.75 to 3.49)
Behavioral function, as assessed with the Neuropsychiatric Inventory (NPI) (MD -1.63, 95% CI -3.07 to -0.20)
Death rates at six months, but not at 24 months.
Nausea was significantly increased and led to stoppage for many (29.4% versus 10.7%) (OR 3.49, 95% CI 2.75 to 4.44).
The article mentioned minimum clinically important difference (MCID) = 2.6‐ to 4‐point change, but a primary care article found a 10% difference to be clinically important, and I have repeatedly stopped acetylcholinesterase inhibitors without significant worsening.
Three risk factors significantly increase the risk of stroke: Hypertension (OR 3.21; 95% CI 2.97–3.47 for severe stroke, OR 2.87; 95% CI 2.69–3.05 for non-severe stroke), atrial fibrillation (OR 4.70; 95% CI 4.05–5.45 for severe stroke, OR 3.61; 95% CI 3.16–4.13 for non-severe stroke), and smoking (OR 1.87; 95% CI 1.72–2.03 for severe stroke, OR 1.65; 95% CI 1.54–1.77 for non-severe stroke). Diabetes mellitus, lower diet quality, physical inactivity, global stress and waist-to-hip ratio had a weaker association, with ORs <2.
SGLT-2 inhibitor use was associated with reduced total cardiovascular disease (CVD) risk vs. DPP-4 inhibitor therapy (hazard ratio [HR], 0.82 [95% CI, 0.69-0.98]) but not the first CVD event, and the use of SGLT-2 therapy were more effective for patients at high risk of CVD (ie, HR, 0.70 [95% CI, 0.62-0.80] for individuals with estimated glomerular filtration rate lower than 60 mL/min/1.73 m2; HR, 0.70 [95% CI, 0.64-0.78]; for individuals having any diabetes-related complications; and HR, 0.72 [95% CI, 0.65-0.80] for women.
SGLT-2 inhibitors was associated with reduced dementia: incidence rate 0.22 per 100 person years and 0.35 per 100 person years in initiators of DPP-4 inhibitors, with hazard ratios of 0.65 (95% CI 0.58 to 0.73) for dementia, 0.54 (0.46 to 0.63) for dementia requiring drugs, 0.61 (0.53 to 0.69) for Alzheimer’s disease, and 0.48 (0.33 to 0.70) for vascular dementia. It also showed slightly lower risk of osteoarthritis and cataract surgery but higher risk of genital infections 2.67 (2.57 to 2.77). The mechanism may be due to the natriuresis of SGLT-2 inhibitors, which leads to lower BP. Animal studies have shown the neuroprotective effects of SGLT-2 inhibitors, such as inhibition of acetylcholinesterase, prevention of beta-amyloid deposition, restoration of mTOR pathway, etc., but these effects were neither directly proven in humans nor head-to-head compared with DPP-4 inhibitors. In my July 1 update I discussed a study that showed GLP-1 agonists reduced dementia. DPP-4 inhibitors are not as potent as GLP-1 agonists, and I would like to see a randomized trial comparing GLP-1 with SGLT-2 agonists on brain and heart outcomes.
SGLT-2 inhibitors significantly reduced the rate of gout and nephrolithiasis (kidney stones) requiring emergency department visits or hospital admission (RR, 0.67). A reduced rate of nephrolithiasis (RR, 0.67) and gout flares (RR, 0.72) compared to GLP-1 and DPP-4 meds, in a Canadian emulation trial, based on a large database review. The study and emulation trial is described nicely in a commentary by Dr. Rakel. The number needed to treat as 20 for recurring nephrolithiasis and it dropped to 5 for patients with recently active urinary tract stones. The mechanism is likely due to diuresis.
SGLT-2 inhibitors co-prescribed with statins did not increase the risk of rhabdomyolysis.
Gabapentinoid dispensing was associated with increased odds of hip fractures (OR, 1.96; 95% CI, 1.66-2.32). They cause ataxia and are on the Beers list and should not be used by older adults, yet are prescribed for pain by orthopedics and other specialists often, despite the only evidence of efficacy is for herpetic neuralgia. Whenever I taper my patients off these meds, they show no symptoms of worsening pain.
Air purifiers with HEPA-14 filters placed in residents’ rooms reduced the incidence of acute respiratory infections among 104 nursing home residents, age 85.2, who completed the study, but did not reach statistical significance: 35.6% (37 participants) in the control group to 24.0% (25 participants) in the intervention group (OR, 0.53; 95% CI, 0.28-1.00; P = .048. The small number of participants and the smaller percentage of COVID infections, which are aerosol transmitted, compared to flu, RSV and other respiratory viruses that are droplet and contact transmitted.
Steroid treatment has shown to improve survival in ICU patients with COVID-19 and elevated C-reactive protein, but the steroid Dexamethasone did not significantly improve survival or time to clinical improvement in patients with diabetes and COVID-19 infection. Possibly because of worse hyperglycemia from steroids and its adverse effect on the immune system.
An open label placebo (OLP) of a single nondeceptive placebo (saline) injection vs usual care, reduced chronic back pain (CBP) intensity for 1 month posttreatment and provided benefits lasting for at least 1 year posttreatment (relative reduction, 0.61; Hedges g = 0.45; 95% CI, −0.89 to 0.04; P = .02). Brain mechanisms of OLP in a clinical population overlap with those of deceptive placebos in healthy volunteers, including engagement of prefrontal-brainstem pain modulatory pathways.
Fatty liver disease is common in the US, 42% of American adults by 2018 had some form of fatty liver disease, with Hispanic adults 47%.
Despite equal healthcare access, the relative risk of prostate cancer (PC) in Black vs White veterans (n= >6 million) ranged from 2.09 (95% CI, 2.01-2.18; P < .001) for nonmetastatic hormone-sensitive PC (nmHSPC) in 2012 to 4.12 (95% CI, 3.39-5.02; P < .001) for nonmetastatic castration-resistant PC (nmCRPC) in 2017. In nmHSPC, hazard ratios for progression to metastatic CRPC (mCRPC) and nonmetastatic castration-resistant PC (nmCRPC) were 1.36 (95% CI, 1.33-1.40) and 1.60 (95% CI, 1.51-1.70), respectively, for Black patients and 1.38 (95% CI, 1.31-1.45) and 1.55 (95% CI, 1.40-1.72), respectively, for Hispanic patients vs White patients. In contrast, in mCRPC, the hazard ratio for death was lower for Black (0.84; 95% CI, 0.81-0.88) and Hispanic (0.76; 95% CI, 0.69-0.83) patients compared with White patients.
Human papilloma virus (HPV) infection has been associated with infertility in men. The mechanism is thought to be through impaired semen quality, such as motility and morphology, as well as DNA fragmentation connecting HPV infections in men to poor fertility outcomes. Yet, other research challenges these findings possibly due to incomplete infection identification.
Over 10 years, the national per capita supply of Geriatricians decreased by 12.7%, from 13.4 per 100 000 older adults in 2010 to 11.7 per 100 000 older adults in 2020, while Geriatric Nurse Practitioners increased by 125.0%, from 4.4 per 100 000 older adults in 2010 to 9.9 per 100 000 older adults in 2020. The combined geriatric workforce increased by 21.3%, with 63.9% of counties, predominantly small and nonmetropolitan counties, having no geriatric care. We need to empower primary care professionals to become skilled in geriatrics.
For older unmarried couples, caregiving obligations can be murky as many choose not to marry after their spouses have died. And these relationships tend to be happier than those in earlier years.
