Geriatric Update Apr 21, 2025

The CDC reports 800 confirmed measles cases in 25 states, up from 712 last week. In Ohio, the Dept of Health website has not been updated from the 20 cases reported earlier. Mexico’s outbreak as well as Ontario’s outbreak (>600 cases), are the same strain as the Texas outbreak.

In older patients (≥ 70 years) with non-ST segment elevation acute coronary syndromes (NSTE-ACS), reported clinical outcomes with invasive versus conservative strategies were not different for all-cause death, cardiovascular death, stroke, and major bleeding. However, the invasive strategy was associated with a significantly reduced risk of myocardial infarction (RR: 0.74, 95% CI: 0.57–0.96) and unplanned revascularization (RR: 0.29, 95% CI: 0.21–0.40) compared to the conservative strategy. In an analysis of 7 RCTs with 2998 patients; 1490 patients in the invasive group and 1508 patients in the conservatively managed group. 

Another study in patients, age 66, with 3 vessel coronary artery disease, 1500 participants were randomized to PCI and 743 to CABG. At 5 years, there was no significant difference in the composite of death, stroke, or myocardial infarction between the two groups, but myocardial infarction was higher in the PCI group than in the CABG group (60 [8%] vs 38 [5%], 1·57 [1·04−2·36]), as was repeat revascularization (112 [16%] vs 55 [8%], 2·02 [1·46−2·79]).

In patients at low risk, transcatheter aortic valve replacement (TAVR) was equal to surgery for mortality, valve reintervention, and quality of life, after 5 years in 1414 randomized patients, aged 74. The study was funded by the TAVR manufacturer.

The new anticoagulant factor XIa Inhibitor, asundexian (50 mg once daily) was less effective in preventing stroke than the factor Xa inhibitor apixaban (5 mg twice daily, or 2.5 mg twice daily): In the overall trial, there were more stroke or systemic embolic events with asundexian (1.3% [98 of 7415]) than with apixaban (0.4% [26 of 7395]; HR, 3.79; 95% CI, 2.46-5.83). Patients taking asundexian had less bleeding (0.2% [2 of 1228]) than those taking apixaban (0.7% [40 of 6115]; HR, 0.32; 95% CI, 0.18-0.55).

The annual cognitive decline after the index event was faster (P = .001) in the group with transient ischemic attack (TIA) (−0.05; 95% CI, −0.06 to −0.03) than that for asymptomatic controls (−0.02; 95% CI, −0.02 to −0.02) but not different from the group with stroke (−0.04; 95% CI, −0.05 to −0.03; P = .43). Whether the underlying mechanisms are by direct or secondary injury and/or interaction with concomitant neurodegenerative factors is unclear, as the baseline cognitive evaluation scores were lower in the groups with TIA or stroke.

After 28 days, the mean change in sleep diary and actigraphy data were collected during the 1st, 5th and 6th week. The Insomnia Severity Index (ISI) was significantly greater in the mirtazapine group (−6.5 [95%CI; −8.3 to −4.8]) compared to the placebo group (−2.9 [95%CI; −4.4 to −1.4]), with a p-value of 0.003, and subjective, but not objective sleep quality, duration and efficacy, or Pittsburgh Sleep Quality Index (PSQI). None of the 60 randomized participants, age 72, experienced severe adverse events. A total of 6 participants in the mirtazapine group and 1 participant in the placebo group discontinued their treatment due to adverse events. The study did not measure falls or cognitive decline, which may have been affected by the anticholinergic effects of low dose mirtazapine, and follow up was short. I would not advocate for using it in older adults for insomnia.

At current utilization and radiation dose levels, CT exams in 2023 were projected to lead to 100,300 future cancers over the lifetime of exposed patients, 5% of all new cases annually, according to an updated risk model of the 93 million CT examinations performed in 62 million patients. 

If patients controlled 5 risk factors: high blood pressure, high cholesterol, underweight or overweight/obesity, diabetes, or smoking habit at age 50, the estimated number of additional life-years free of death was 14.5 (95% CI, 9.1 to 15.3) for women and 11.8 (95% CI, 10.1 to 13.6) for men. The greatest impact was when risk factor control occurred before age 60.

Physically active members showed lower rates of cancer progression and lower rates of death from all causes. The HR for progression to higher stages or death was 0.84 (95% CI 0.79 to 0.89), comparing low activity with no physical activity, and 0.73 (95% CI 0.70 to 0.77), comparing medium to high physical activity with no physical activity. The HR for all cause mortality was 0.67 (95% CI 0.61 to 0.74), comparing low physical activity with no activity, and 0.53 (95% CI 0.50 to 0.58), comparing medium to high physical activity with no physical activity.

In patients with diabetes and HbA1c 7%-9.5%, switching treatment from dulaglutide <1.5 mg, the glucagon-like peptide-1 receptor agonist (GLP-1) to tirzepatide, the combination glucose-dependent insulinotropic polypeptide and GLP-1, provided additional HbA1c reduction and weight loss compared with increased dose of dulaglutide. At week 40, HbA1c was -1.44% (SE, 0.07) with tirzepatide, 15 mg or maximally tolerated dose (MTD), and -0.67% (SE, 0.08) with dulaglutide, 4.5 mg or MTD (estimated treatment difference, -0.77% [95% CI, -0.98% to -0.56%; P < 0.001]). Change from baseline in weight at week 40 was -10.5 kg (SE, 0.5) with tirzepatide and -3.6 kg (SE, 0.5) with dulaglutide (estimated treatment difference, -6.9 kg [CI, -8.3 to -5.5 kg; P < 0.001]). Adverse effects of nausea and diarrhea were similar in the 282 randomized patients.

The mean US hospital occupancy was 63.9% (range, 63%-66%) from 2009 to 2019 compared with 75.3% (range, 72%-79%) in the year following the end of the COVID-19 public health emergency, driven by a 16% reduction in staffed hospital beds and an aging population. Most affected are patients with dementia, who are held in emergency departments leading to delirium, over patients preferentially admitted for more lucrative procedural admissions. This would correspond to a national hospital occupancy of approximately 85% by 2032 for adult beds and by 2035 for adult and pediatric beds combined, a level considered a hospital bed shortage (a conservative estimate).