Geriatric Update Nov 4, 2024

The World Health Organization reported that tuberculosis replaced COVID-19 as the top cause for infectious disease-related deaths in 2023. Last year about 8.2 million people were newly diagnosed, the highest number recorded since WHO began global TB monitoring in 1995, up from 7.5 million the previous year.

About 10 years ago we advocated probiotics after antibiotics, recent, more robust research suggests that probiotic supplements have no significant benefit for the gut microbiome after antibiotic use and may even slow gut recovery. Fermented foods or drinks like kimchi or kefir, which contain diverse communities of bacteria, can help replace the good bacteria, but the key is fiber, at least 21 to 38 grams a day, depending on your age and sex, provide the substrate for good bacteria, especially onions, garlic, leeks, bananas, asparagus, artichokes, oats and legumes are great sources. Ginger can help with nausea, bloating and gas. 

Although 97% of Medicare Advantage (MA) plans cover hearing aids to some degree, the use of them is similar as in traditional Medicare, which does not cover hearing aids or audiology services.  Of 19,818 Medicare Current Beneficiary Survey  (MCBS) participants (mean [SD] age, 77.0 [7.3] years, 48.7% reported hearing loss or hearing aid use: routine hearing tests (TM, 4.2% MA, 5.3%) hearing aid fittings (TM, 3.2%, MA, 3.6%), and hearing aid purchases (TM, 2.1%, MA, 2.4%). Limited to beneficiaries with self-reported hearing loss or hearing aid use, they had greater use of routine hearing examinations in MA (TM, 7.1%, MA, 9.9%).

A eucaloric carbohydrate-restricted (CR) diet (∼9% energy from carbohydrate, 65% energy from fat), compared to a eucaloric usual diet (∼55% energy from carbohydrate, 20% energy from fat) improved β-cell response to glucose by 22% in patients with type 2 diabetes over 12 weeks in 57 African American and European American adults not using insulin. European Americans had a greater effect, 48% and the oral glucose tolerance test results were 32% greater with the CR diet. No diabetes medicine has been shown to improve β-cell function, but sticking to a low carbohydrate diet would be hard for me.

Higher levels of physical activity correlated with lower levels of fatigue among patients with inflammatory rheumatic diseases such as rheumatoid arthritis.  Yet, >2/3 of patients with inflammatory rheumatic diseases fall short of physical activity targets for moderate-to-vigorous exercise.

For people with severe symptomatic hip osteoarthritis (OA), total hip replacement (THR) alleviates hip pain and improves function much more effectively than a resistance training: Oxford Hip Scores from baseline to 6 months were 15.9 points for THR and 4.5 points for resistance training. The 11.4-point difference in scores was both statistically and clinically significant, regardless of the type of exercise. This is in contrast to knee OA, which can be managed with exercise.

Among 407 participants with obesity, BMI 40.3, and knee osteoarthritis (OA) with moderate-to-severe pain, treatment with once-weekly injectable semaglutide resulted in significant weight loss (−13.7% with semaglutide and −3.2% with placebo) and reduced pain related to knee OA than placebo (WOMAC pain score at week 68 was −41.7 points with semaglutide and −27.5 points with placebo).

In 2020,the percentage of medications dispensed to Medicare patients >65 years, to be avoided without exception by Beers criteria, were 4.7%: benzodiazepines, “Z-drugs”, long-acting sulfonylureas, 1st-generation antihistamines, and tricyclic antidepressants. Additionally, 11.3% of all prescriptions were in the category to use with caution: diuretics, selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tramadol, and mirtazapine, for a total of 16% of dispensed medications.

A randomized clinical trial of 81 patients, age 73, with amyloid-confirmed mild cognitive impairment or early Alzheimer disease randomly assigned 2:1 to receive the chelating agent deferiprone 15 mg/kg twice a day or placebo for 12 months, deferiprone decreased brain iron accumulation but accelerated cognitive deterioration. Increased brain volume loss was observed in frontal brain areas, consistent with the cognitive findings. This is similar to the hype over aluminum findings in brain in the 1980s, or calcium deposits in blood vessels, inflammation causes the deposits, and the inflammation contributes to cognitive decline or blood vessel damage.

In ischemic stroke, early (≤ 4 days) or delayed (7-14 days) direct oral anticoagulant (DOAC) initiation groups, showed an equal 3.3%, of the main composite outcome of recurrent ischemic stroke, symptomatic intracranial hemorrhage, unclassifiable stroke, or systemic embolism by 90 days, non-inferior using the pre-specified margin of 2 percentage-points (P = .0003) and not superior (P = .96). The incidence of symptomatic intracranial hemorrhage did not differ between the groups (0.6% vs 0.7%; P = .78), regardless of subgroups.

Diabetic wounds are difficult to heal, so, even small improvements can be significant, as with intact cod fish skin grafts: More wounds healed at 16 weeks than with standard-of-care (44.0% vs 26.4% adjusted odds ratio [aOR], 2.58; 95% CI, 1.48-4.56) and continued at weeks 20 (aOR, 2.15; 95% CI, 1.27–3.70) and 24 (aOR, 2.19; 95% CI, 1.31–3.70). The mean time to healing was 17.31 weeks for the intact fish skin graft group and 19.37 weeks for the standard-of-care group (hazard ratio, 1.59; 95% CI, 1.07-2.36). Target wound infections, the most common adverse events, occurred in similar numbers.

Chronic low back pain improved in participants in the virtual yoga group:

•             Mean pain intensity at 12 weeks (mean change, -1.5 points; P < .001) and 24 weeks (mean change, -2.3 points; P < .001) compared to the wait-list control group.

•             Back-related function improved significantly in the virtual yoga group at 12 weeks (mean change, -2.8 points; P < .001) and 24 weeks (mean change, -4.6 points; P < .001) compared to the control group.

•             Any analgesic medication use during the past week was 21.2% less at 24 weeks compared to the control group.

•             Sleep quality improved more in the virtual yoga group at 12 weeks (mean change, 0.4 points; P = .008) and 24 weeks (mean change, 0.4 points; P = .005) compared to the control group.

In a survey of 763 patients (mean age, 59 years; 84.1% women), who reported current use of cannabis, 62.5% reported substituting, mostly delta-9-tetrahydrocannabinol by inhalation or vaping, for certain medications, including NSAIDs (54.7%), opioids (48.6%), sleep aids (29.6%), muscle relaxants (25.2%), benzodiazepines (15.5%), and gabapentinoids (10.5%), and reported fewer side effects (39%), better symptom control (27%), and fewer adverse effects (12%).

Low healthcare quality was associated with increased dementia risk over 12 years (unadjusted HR: 1.68, 95% CI: 1.27–2.21; fully adjusted HR: 1.50, 95% CI: 1.12–2.01, p-value: 0.006). To date, we have focused on individual-level behaviors to reduce dementia but structural changes to improve healthcare quality for older persons could reduce dementia prevalence.

CMS reported that the accountable care organizations saved Medicare $2.1 billion, the largest yearly savings in program history, in 2023, mostly from the Medicare Shared Savings Program (MSSP), which saved a net $1.8 billion in 2022, at the time the second-highest annual savings. It is the seventh consecutive year the program generated savings.

Project 2025’s health reform proposals include prioritizing corporations over patients through deregulation and privatization,  defunding federal health care programs, and making Medicare Advantage plans the default enrollment option, while simultaneously being deregulated. Medicare fee-for-service would be replaced with a version of value-based payments. Despite bipartisan support for reducing drug costs, the Inflation Reduction Act’s Medicare Part D prescription drug price negotiation program would be repealed.