Geriatric Update Oct 28, 2024

GLP-1 agonists have a strong history of protecting from cardiovascular events. Semaglutide was also associated with significantly reduced risk for first-time Alzheimer’s diagnosis, most strongly compared with insulin (hazard ratio [HR], 0.33 [95% CI: 0.21 to 0.51]) and most weakly compared with other GLP-1RAs (HR, 0.59 [95% CI: 0.37 to 0.95]). Similar results were seen across obesity status, gender, and age groups.

During 3 years of the COVID-19 pandemic fewer deaths related to COVID-19 were occurring in the semaglutide arm than in the placebo arm (43 vs 65; HR, 0.66; 95% CI, 0.44–0.96). SGLT-2 have not shown to lower COVID-19 mortality.

New autoimmune diseases were not more likely among vaccinated patients infected with omicron or delta variants of COVID-19, compared with those not infected, according to a cohort study of 1,766,036. This is different from prior studies that have reported increased long-term incidence of a wide range of autoimmune sequelae after SARS-CoV-2 infection.

SARS-CoV-2 mutations (10 of 11 [90.9%]) were detected at low frequencies (<20% of viral population) and reverted to the wild type at subsequent time points. Emerging remdesivir resistance mutations were only detected in immunosuppressed individuals (2 of 14 [14.3%]) but were similarly low frequency and transient. Global Initiative on Sharing All Influenza Data analysis showed no evidence of increased nirmatrelvir (Paxlovid) resistance in the United States after the authorization of nirmatrelvir. Resistance mutations were detected in 9 individuals who received nirmatrelvir (11.4%) compared with 2 of those who did not (3.2%) (P = .09). Among the individuals treated with nirmatrelvir, those who were immunosuppressed had the highest emergence of resistance (5 of 22 [22.7%]), without difference in those who experienced rebound. Another study showed low SARS-CoV-2 resistance during persistent infections in immunocompromised patients (n = 15). All patients received remdesivir and some also received nirmatrelvir-ritonavir (n = 3).

Higher binding and neutralizing antibodies against SARS-CoV-2 were observed following boosting with mRNA vaccines (BNT162b2 and mRNA-1273) compared to Novavax NVX-CoV2372, but more rapid waning after mRNA vaccines. Novavax booster caused less side effects and more sustained levels of anti-spike IgG antibodies than mRNA shots. No clinical results were collected, but I expect protection from severe disease to be similar, therefore, we should get any booster available and select Novavax if prior vaccine side effects were severe.

The CDC Advisory Committee on Immunization Practices Recommends PREVNAR 20® (20-Valent) or CAPVAXIVEl (21-Valent) Pneumococcal Conjugate Vaccine for all adults aged >50, down from >65 or those younger with risk factors, because age is the biggest risk factor. CDC estimates that PCV20 targets serotypes that cause between 54% and 65% of invasive pneumococcal disease (IPD) in adults, and PCV21 targets serotypes that cause between 77% and 85% of IPD in adults.

Quadrivalent adjuvanted inactivated influenza vaccine (aIIV4) or high-dose HD-IIV4, and adjuvanted recombinant zoster vaccine (RZV) co-administered in separate arms showed no significant differences in the number of serious adverse events between the groups in 267 adults (median age, 71 years [range, 65-92 years].

US cases of influenza A (H5N1) continue to increase. No person-to-person spread of bird flu has been detected, and pasteurized milk and dairy products are safe to consume. Pasteurization inactivates the bird flu virus.

Deprescribing antihypertensive medication was associated with less cognitive decline on the Cognitive Function Scale (odds ratio, 0.88; 95% CI, 0.78-0.99), particularly among those with dementia of 12,644 VA long-term nursing home residents. Deprescribing was defined as a reduction in the total number of antihypertensive medications or a decrease in medication dosage by 30%. This may have improved brain perfusion in this population that is at very high risk of dehydration. 

The new CHEST guidelines for atrial fibrillation (A-fib) from the American College of Cardiology and American Heart Association (ACC/AHA) stress the role of primary care clinicians in prevention and management. The new recommendations address A-fib and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, risk factor modification and list as first line recommendations: early cardioversion and catheter or surgical ablation.

The National Institute for Health and Care Excellence (NICE) and the European drug agency reject Alzheimer’s drugs donanemab and lecanemab owing to cost and “significant health risks.”

A new ovarian cancer vaccine is being designed to train the immune system to recognize and destroy ovarian cancer cells at their earliest stages, in the fallopian tubes, where most ovarian cancer occurs. This BBC global news episode interviewed the researcher, start at 18 min 18 sec. to 21 min.

In addition to seasonal affective disorder, bright light therapy also treats nonseasonal depressive disorders, with greater remission (40.7% vs 23.5%; odds ratio [OR], 2.42; 95% CI, 1.50-3.91) and improved response time to initial treatment (<4 weeks: 55.6% vs 27.4%; OR, 3.65; 95% CI, 1.81-7.33), in a systematic review and meta-analysis of 11 unique trials with data from 858 patients, age mostly 40s, using mostly 10,000 lux 30 to 60 minutes daily. Conversely, in adolescents, 20 sessions of either morning bright light therapy with an intensity of 10 000 lux showed no benefit over placebo red light (100 lux) in addition to multimodal inpatient treatment as usual over 4 weeks.

Intermittent theta burst stimulation for schizophrenia (iTBS) over the left-dorsolateral prefrontal cortex (L-DLPFC) was associated with reduced positive and negative symptom scores, overall, depression, and anxiety symptom scores and improved overall cognitive impairment scores compared with a sham, with similar discontinuation, in 30 randomized sham-controlled trials with 1424 participants.

Acupuncture resulted in less back pain and better function compared with sham acupuncture at week 4, and these benefits persisted through week 52 in 206 randomized patients with sciatica from a herniated disk, age 51.

Vegetarian, including vegan diets were associated with reduced risk for CVD incidence [Relative Risk: 0.85 (0.79, 0.92)] and CVD mortality [Hazard Ratio: 0.92 (0.85, 0.99)] compared to non-vegetarian diets. With vegan diets showing lower BP, LDL, weight and c-reactive protein concentrations.

A single 30-minute bout of aerobic exercise improved beta cell secretory capacity, insulin secretion pattern, improved insulin action in insulin dependent tissues due to increased insulin sensitivity, and reduced 1-hour glucose levels following an oral glucose tolerance test for at least 24 hours in 35 year old patients.

Energy intake and glycemic load (GL) in late morning, 8am- noon, were inversely associated with cardiovascular (CVD) mortality risk (per 100-kcal energy intake increment, HR 0.90 [95% CI 0.83–0.98]; per 10-unit GL increment, HR 0.86 [95% CI 0.77–0.95]). In contrast, energy intake and GL after midnight were positively associated with CVD mortality risk (per 100-kcal energy intake increment, HR 1.22 [95% CI 1.07–1.40]; per 10-unit GL increment, HR 1.44 [95% CI 1.17–1.77]). While it could be correlated to activity, most of us are sedentary. I believe it has more to do when our body produces insulin to optimally manage the GL. 

Ghrelin, a hormone that increases appetite and is often called the "hunger hormone”, significantly decreased more during high-intensity exercise than during moderate-intensity and no exercise (P < .0001 for both). Hunger scores were higher in the moderate-intensity exercise group than in the no exercise group (P < .01), with no differences found between high-intensity exercise and moderate-intensity or no exercise. I have read years ago, before I collected relevant articles, that women’s appetite increases after exercise, but men’s showed no difference. 

Among current drinkers, more frequent alcohol consumption was associated with a higher risk for gout among both sexes, with the association being stronger in men (HR, 2.05; 95% CI, 1.84-2.30) than in women (HR, 1.34; 95% CI, 1.12-1.61) and more with beer and cider.

Long-term exposure to inorganic arsenic in drinking water (wAs) from U.S. community water supplies (CWS), even at levels below the federal maximum contaminant level of 10 µg/L or parts per billion (ppb), is associated with an increased risk for cardiovascular and ischemic heart disease. The hazard ratios (95% CI) at concentration thresholds were 1.06 (1.00 to 1.12), 1.05 (0.94 to 1.17), 1.20 (1.02 to 1.41), and 1.42 (1.10 to 1.84) for 1.00 to 2.99, 3.00 to 4.99, 5.00 to 9.99, and ≥10 µg/L wAs. Cincinnati’s level is 0.117 ppb.

In Norway’s primary care, 11.7% of visits involved a mental-health condition: depression (23.8%) or anxiety (14.1%), followed by sleep disturbances (12.1%), substance abuse (8.3%), acute stress reactions (7.1%), psychosis (6.9%), dementia/memory problems (5.4%), ADHD (3.8%), phobias/compulsive disorders (1.7%), developmental delay/learning problems (1.5%), PTSD (1.3%) and personality disorder (1.1%).  This is second only to musculoskeletal problems, 17.4%.