Geriatric Update Apr 20, 2026
Mentally passive sedentary behavior, such as watching TV, was associated with a higher incidence of dementia in crude (hazard ratio=1.16, 95% CI=1.11- 1.22) but not adjusted models (hazard ratio=1.04, 95% CI=0.98- 1.10). Each additional one hour per day of mentally active sedentary behavior was associated with a 4% lower risk for developing dementia (hazard ratio=0.96, 95% CI=0.93- 0.98) over 19.2 years. There was a significant age interaction, indicating a higher protective effect of mentally active sedentary behavior among older participants (aged 50–64 vs 35-49 years). In the partition models accounting for all behaviors, increasing one hour per day of mentally active sedentary behavior while maintaining passive sedentary behavior, with light and moderate-to-vigorous physical activity constant, was associated with an 11% lower risk for incident dementia (hazard ratio=0.89, 95% CI=0.81, 0.97). Similarly, replacing one hour per day of passive sedentary behavior with the same amount of mentally active sedentary behavior was associated with a 7% reduction in the risk for incident dementia (hazard ratio=0.93, 95% CI=0.87, 0.99).
A quarter (25.7%) of older adults >60 years on hypothyroidism medication were able to wean off of it while maintaining adequate thyroid function, a thyrotropin (TSH) level under 10 mIU/L and a free thyroxine level within the reference range. Going off this medication while staying in TSH range under 10 mIU/L lowers risk of dementia, atrial fibrillation, osteoporosis, anxiety, muscle wasting and skin thinning. Patients maintained a median TSH level of 5.03 mIU/L and a mean free thyroxine level of 1.01 ng/dL after one year, while 48.4% maintained a thyrotropin level under 4.8 mIU/L.
In 793, middle aged (39 years) participants with available serum levels for vitamin D (25(OH)D) and amyloid (n = 424) and/or tau-PET (n = 369), the mean time between blood sampling and PET was 16 ± 2 years. On multivariable linear regression analysis, higher serum 25(OH)D was associated with lower global (β = −0.022; 95% CI −0.040 to −0.004; p = 0.010]) and composite tau-PET deposition (β = −0.023; 95% CI −0.043 to −0.003; p = 0.016]) but was not associated with amyloid-PET burden.
The Scientific Report of the 2025 Dietary Guidelines Advisory Committee (DGAC), based on decades of dietary data, emphasized limiting red and processed meats, added sugars, and sodium-laden foods in favor of fruits, vegetables, whole grains, legumes, nuts, and plant-based proteins to reduce cardiovascular disease, diabetes, cancer, and obesity. However, the new 2025-2030 Dietary Guidelines for Americans (DGAs) deviated substantially by placing saturated fat with red meat and full fat dairy at the top and ignoring the recommendation to lower added sugar and salt intake. A diet high in sodium, saturated fat, fried food, refined grains, animal protein, cholesterol, and added sugar is the leading cause of death and disability in the US, surpassing tobacco and inactivity.
The DGA on page 45 also includes a paragraph on testosterone. Maintaining regular physical activity and a healthy body weight is strongly associated with higher testosterone levels in men. Weight loss in overweight or obese men results in increased testosterone concentrations. Very low-fat diet (hard to do) is associated with modest reductions in serum testosterone, and very high-protein diets >3.4 g/kg/day suppress testosterone levels.
People who followed a high-quality plant-based diet had a 12% lower risk of Alzheimer’s disease and other dementia (HR 0.88; 95% CI 0.85–0.92), while those with a low-quality plant-based diet had a 25% higher risk (HR 1.25; 95% CI 1.15–1.36) in a prospective longitudinal analysis of 92,849 participants, age 59.2 years, over nearly 11 years of follow-up when compared with those who ate the least healthily. Healthy plant-based foods are: legumes, nuts, vegetables, fruit and whole grain breads, rice and pasta. Unhealthy plant-based foods include, for example, white pasta with tomato sauce and garlic bread followed by pastry dessert, or plant based hamburger with French fries and a vegan shake, highly processed.
Overnight fasting, commencing at least 3 hours prior to bedtime, led to significant improvements in key cardiometabolic measures including nighttime blood pressure, autonomic function, and morning oral glucose tolerance. Effects also included lower nighttime heart rate, higher heart rate variability, lower nighttime cortisol, and during the Oral Glucose Tolerance Test, lower glucose level with higher 30-minute insulinogenic index, indicating improved acute insulin response. This may be hard to do in our country where the biggest meal is in the evening, well after the end of the workday.
Of 33 blood metabolites produced by gut microbes, 6 derived from tryptophan identified early cognitive impairment and distinguished cognitively healthy older adults from those with mild cognitive impairment, with an area under the curve (AUC) of 0.79. These 6 tryptophan-derived gut microbes were: indole-3-propionic acid, 5-hydroxyindole acetic acid, choline, indoxyl sulfate, kynurenic acid, and kynurenine.
The non-nutritive sweetener erythritol, found in stevia and monk fruit and commercially produced from fermented corn, is associated with increased risk of blood clots, stroke and heart attack when blood levels are elevated beyond the small amount produced in our red blood cells or eaten in fruits. This endothelial tissue lab study showed that the mechanism is in brain microvascular endothelial cell oxidative stress, diminished nitric oxide (which causes vasodilation) and endothelin-1 production, as well as tissue-type plasminogen activator (t-PA) release.
After controlling for sociodemographic and clinical characteristics, muscle strength by accelerometer-measured physical activity and sedentary behavior as well as timed walk was associated with significantly lower mortality risk in a cohort study of 5472 women aged 63 to 99 years. Muscle strength was associated with lower mortality even in women not meeting guideline-recommended activity levels.
Activity tracker and app-based interventions may cause short-term increases in physical activity, average 912 steps per day, but effects were not sustained. This was based on a systematic review of 29 trials with 3005 older adults.
Participants with vigorous physical activity (VPA) >4% by self report (n = 375,730) and by device-measurement (n = 96,408) when compared with no VPA (0%) had significantly lower risks of 8 chronic diseases: major adverse cardiovascular events (MACE) 31%, atrial fibrillation (AFib) 29%, type 2 diabetes (T2D) 60%, immune-mediated inflammatory diseases 39%, metabolic dysfunction-associated steatotic liver disease (MASLD) 48%, chronic respiratory diseases (CRD) 44%, chronic kidney disease (CKD) 41%, and dementia 63%, as well as all-cause mortality 46%.
Step reduction leads to lowered rates of muscle protein synthesis (MPS) that are accompanied by appearance of a diabetic phenotype with increased inflammatory markers. These are not recovered on return to a normal daily step count in two weeks among healthy older adults compared to young adults. This is partly due to apoptosis (programmed cell death) and thus fewer muscle cells at greater age, requiring continuing daily exercise to maintain muscle protein production.
Potassium-competitive acid blockers (P-CABs) are relatively new agents and only one is approved in the US: Vonoprazan (Voquezna). In patients taking clopidogrel, 536 each were propensity matched (PM) in the clopidogrel plus P-CAB and clopidogrel-only cohorts, while 5847 patients each were PM in the clopidogrel plus proton-pump inhibitor (PPI) and clopidogrel-only cohorts. The clopidogrel plus P-CAB cohort had a higher risk for major adverse cardiovascular events (MACEs) (hazard ratio [HR], 2.40) and stroke recurrence (HR, 2.64) than the clopidogrel-alone cohort, as did the clopidogrel plus PPI cohort (HRs, 1.38 for MACE and 1.41 for stroke) versus the clopidogrel-alone cohort.
In 384 fibromyalgia patients, age 53 years, those randomized to Transcutaneous Electrical Nerve stimulation (TENS) and physical therapy (PT) had less movement-evoked pain than the PT-only group, a dose-response improvement on the Patient Global Impression of Change (120 [72%] vs 86 [51%], P = .001), and a 30% or greater reduction in movement-evoked pain in responder analysis (66 of 161 [41%] vs 22 of 169 [13%]; P < .001). At 6 months, 217 respondents (81%) found TENS helpful and 147 (55%) used TENS daily.
The first American Heart Association/American College of Cardiology guideline for acute pulmonary embolism (PE):
5 severity classifications (A-E with increased severity)
Asymptomatic patients with PE can be discharged home from the emergency room (Category A)
Early hospital discharge is recommended for symptomatic patients with low clinical severity score B
Hospitalization for severity score C-E
Thrombolysis, catheter-based thrombolysis, mechanical thrombectomy, and surgical embolectomy are reasonable for patients with Category E1 and can be considered for patients with Category D1-2
PE response teams (PERTs) are recommended to improve timeliness of care
In patients who require initial parenteral anticoagulant therapy, low-molecular-weight heparin (LMWH) is recommended over unfractionated heparin (UFH).
Patients eligible for oral anticoagulation, direct oral anticoagulants (DOACs) are recommended over vitamin K antagonists (warfarin), unless contraindicated, to prevent recurrence and reduce bleeding
Anticoagulation beyond the initial treatment phase (3-6 months) into the extended phase is recommended for patients with and without a major reversible risk factor
Patients should be asked about PE-related symptoms and functional limitations at every visit for at least 1 year to screen for chronic thromboembolic pulmonary disease (CTEPD).
Two randomized controlled trials evaluated thrombolysis with tenecteplase for ischemic stroke between 4.5 and 24 hours after the onset of symptoms in China and found a significantly greater chance of having no or minimal symptoms at 90 days:
Of 516 patients, age 67, more patients had an optimal modified Rankin scale score (mRSS) of 0 or 1 at 90 days than with standard medical treatment (33.0% vs. 24.2%; relative rate, 1.37; CI 1.04 - 1.81), with higher rate of intracranial hemorrhage (3.0% vs 0.8%) but no difference in mortality rates or rescue thrombectomy.
Of 566 patients, age 68 years, 43.6% receiving tenecteplase and 34.2% receiving standard medical treatment achieved an excellent functional outcome by a mRSS of 0 or 1 at 90 days (risk ratio, 1.28, CI 1.04-1.57). Symptomatic intracranial hemorrhage was higher with tenecteplase 2.8% than with standard medical treatment at 0%, and the mortality was not statistically different.
Conversely, tenecteplase administered within 4.5 hours after onset of central retinal artery occlusion did not result in significantly greater vision recovery at 30 days (20%) than oral aspirin (24%) but was associated with greater intracranial hemorrhage.
Treatment for persons with peripheral artery disease (PAD) should be medical: intensive cholesterol-lowering medications (statins), antiplatelet medications or low-dose aspirin with rivaroxaban, blood-pressure lowering to less than 130/80 mm Hg, and in patients with diabetes, semaglutide and sodium–glucose cotransporter 2 inhibitors. Walking exercise improves walking ability; revascularization in the legs should be reserved for those with persistent disease symptoms that do not respond to exercise.
Fluvoxamine, 100 mg twice a day, reduced long COVID fatigue persisting >90 days and improved quality-of-life scores, while metformin did not, in 399 adults, age 44. When metformin is given during the acute phase, it had a 42% drop in long COVID, and within the first 3 days of infection the drop was 64% because it lowers the viral load.
The fashion industry is embracing “older models”, age >50, it calls them “generational models.” Although this trend has come and gone in the past, this time it may stick because this generation has the power of the bank account. The pull toward “I’m real” includes grey hair and makeup-less faces, not fuzzed out with filters but bared for all to see.
The 2023 reinstatement of the 3-day hospital stay rule for skilled nursing facility (SNF) admission (suspended during COVID) was associated with increased >3-day hospitalization by 5.57 percentage points. No significant changes were observed in the overall probability of SNF discharge, 30-day rehospitalization, 30-day mortality, Medicare spending, or total SNF days. Subgroup analyses showed greater increases in at least 3-day stays among patients hospitalized for hip fractures and patients with dementia. The policy imposes additional costs on hospitals while failing to lower Medicare spending on hospitalized patients.
Direct care workers (DCWs) such as nurse aides provide essential support for millions of older individuals in the US, but high workforce turnover undermines care access and quality. DCW turnover was significantly lower among unionized DCWs than nonunionized DCWs overall (37.4% vs 45.0%; odds ratio [OR], 0.72 [95% CI, 0.64-0.81]), both at nonprofit organizations (33.6% vs 47.1%; OR, 0.56 [95% CI, 0.39-0.80]) and at for-profit organizations (35.2% vs 45.9%; OR, 0.63 [95% CI, 0.54-0.75]). Public ownership was also directly associated with lower turnover (39.1% vs 41.8%; OR, 0.89 [95% CI, 0.80-1.00]) compared with for-profit ownership.
The CDC reports 1,738 confirmed measles cases in 33 states vs 1,704 cases in 33 states last week.
The OMDA call on Thu April 23 is on: Training family medicine residents in elder care: inpatient, outpatient, LTC, and home care, by John DiSabato, MD, FAAFP, Evan Howe, MD, PhD, MPH, John Boltri, MD, FAAFP
There is no medicine to cure hatred. Publius Syrus
