Geriatric Update Aug 4, 2025

The CDC reports 1333, confirmed measles cases in 40 states, up from 1319 in 40 states last week.

mRNA-1283 is a new COVID-19 vaccine that encodes only the immunodominant regions of the SARS-CoV-2 spike protein-the receptor-binding domain (RBD) and the N-terminal domain rather than the full-length spike used in currently authorized mRNA vaccines. Comparing the new mRNA-1283 vs. mRNA-1273 (old Moderna vaccine), had fewer injection-site pain reactions and similar adverse reactions. The vaccine efficacy and immunogenicity was non-inferior, with higher antibody responses for mRNA-1283 versus mRNA-1273 among the 11,454 participants. The potential clinical benefits, patient oriented outcomes, of mRNA-1283 versus mRNA-1273 need to be confirmed in post-marketing evaluation. 

At least 41 pediatric cases of influenza-associated acute necrotizing encephalopathy (ANE) have been reported, a rare but severe neurologic complication of the flu, occurring within 3 days of symptom onset. All but one case was in unvaccinated children and 76% in healthy children. This past season has been very deadly, possibly as vaccination rates decline.

Respiratory infections, such as influenza or COVID activate dormant disseminated cancer cells (DCCs), leading to 100–1,000-fold increase, by inducing inflammatory, IFNα, IFNγ, TNF and IL-6–JAK–STAT3 signaling pathways, leading to increased interleukin (IL)-6 production. IL-6 and IL-1 are known to promote cancer malignancy and metastases. DCCs impair lung T cell activation and that CD4+ T cells sustain the pulmonary metastatic burden after the influenza infection by inhibiting CD8+ T cell activation and cytotoxicity.  DCC proliferation occurs within days of infection and can lead to a massive expansion of carcinoma cells into metastatic lesions within two weeks.

A new guideline suggests that the diagnosis of UTI should be primarily based on clinical symptoms in primary care. In women presenting to outpatient clinics with at least two symptoms of UTI and absence of vaginal discharge, there was a greater than 90% likelihood of having acute cystitis. Nitrofurantoin for 5 days is a reasonable first-line agent, also trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days or Fosfomycin (oral) single dose.

Deprescribing blood pressure medications led to a 12% reduction in the odds of progressing dementia over a 12-week period (odds ratio, 0.88; 95% CI, 0.78-0.99) compared to the stable user group. Among residents with dementia, deprescribing was associated with 16% reduced odds of cognitive decline (odds ratio, 0.84; 95% CI, 0.72-0.98), based on an observational study of 45,183 long-term care veterans, age 77.7. This study did not control for dehydration, and in my experience, aggressive BP control in a well hydrated patient has the best outcome. 

Hot off the press is this anxiously awaited article on deprescribing alternatives to the Beers criteria. Medications are often prescribed based on symptoms rather than clear diagnoses. To address this, many alternatives in the AGS Beers Criteria are organized by symptom and 21 conditions rather than disease: itching, pain, insomnia, etc. It is a practical, evidence-informed approach to create feasible alternatives that reflect real-world clinical complexities, while also noting when evidence is limited, and to treat the underlying causes of symptoms, not just the symptoms themselves. If you cannot access the article, let me know and I will send it to you.

Metabolic syndrome, defined as three or more: Excess belly fat, high blood pressure, high fasting blood glucose, increased triglycerides, or reduced levels of high-density lipoprotein (LDL), in middle age 40-60 years old, was associated with a 24% higher risk of all-cause young onset dementia (adjusted HR 1.24, 95% CI 1.19–1.30), a 12.4% increased risk of Alzheimer’s (HR 1.12, 95% CI 1.03–1.22), and a 20.9% increased risk of vascular dementia (HR 1.21, 95% CI 1.08–1.35) over 7.75 years. Significant interactions were noted with younger age (40–49 vs 50–59), female sex, drinking status, obesity, and depression in this national database review of nearly 2 million Koreans.

Structured lifestyle intervention of regular moderate- to high-intensity physical exercise, adherence to the MIND diet, cognitive challenge and social engagement, and cardiovascular health monitoring led to a statistically significant greater improvement in global cognition over 2 years relative to a lower-intensity self-guided intervention (mean composite z-score increase of 0.243 SD per year vs 0.213 SD per year, respectively). The US Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (US POINTER) clinical trial randomized 2111 older adults at risk of cognitive decline and dementia. Both groups had improvements, indicating that a self guided improvement of modifiable risk factors is almost as effective as the guided intervention. An editorial summarizes the study well. Results were similar to the 2015 Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) and showed greater improvement than the amyloid antibody treatments that only slow decline.

Greater sedentary time, as measured by accelerometer worn 7 consecutive days, related to faster hippocampal volume reductions on MRI, declines in naming, processing speed and episodic memory over 7 years, more so in APOE-ε4 carriers. The study was part of the Vanderbilt Memory and Aging Project participants (n=404), age 71. Participants average sedentary time was 13 hours a day, and 87% were physically active with an average of 61 min a day. I would be interested in the activities participants did during sedentary times, watching TV, playing cards, reading with children in school, writing a manuscript…?

The sit less arm reduced total sitting time by 58 minutes a day, and the sit-to-stand (STS) arm significantly increased STS by 26 STS a day. Each of 3 study arms, , received 7 individual health coach sessions across 12 weeks, including healthy living control) in 388 postmenopausal women. All 3 arms decreased systolic blood pressure (-3.33 mm Hg) without significant differences. The sit-to-stand arm had significant decreases in diastolic blood pressure compared with the healthy living arm (-2.24 mm Hg).

The optimal number of steps seem to be 7000, with inflection points at around 5000–7000 steps per day. An inverse linear association was found for cardiovascular disease mortality, cancer incidence, cancer mortality, type 2 diabetes incidence, and depressive symptoms. Based on our meta-analyses, compared with 2000 steps per day, 7000 steps per day was associated with a 47% lower risk of all-cause mortality, a 25% lower risk of cardiovascular disease incidence, a 47% lower risk of cardiovascular disease mortality, a 37% lower risk of cancer mortality, a 14% lower risk of type 2 diabetes (HR 0·86 [0·74–0·99]; I2=48·5%; four studies), a 38% lower risk of dementia, a 22% lower risk of depressive symptoms, and a 28% lower risk of falls. Based on a systematic review and meta-analysis.

Aligning workouts with an individual’s personality can significantly boost enjoyment and reduce stress, potentially improving long-term adherence. Neuroticism specifically predicted a significant reduction in self-reported stress with exercise, extraversion predicted enjoyment in high intensity sessions, agreeableness predicted more enjoyment of the easy long rides, conscientious folks did better with endurance club, and openness predicted a greater likelihood to attend sessions.

The ACHIEVE Randomized Clinical Trial showed no benefit of hearing intervention vs. health education over 3 years, on physical or mental health-related quality of life. While there was a decline in quality of life over time, the improvement in communication attenuated the decline by half, with a number needed to treat of 2.4. This was a well done study with intensive hearing aid adjustments in the intervention group of 977 older adults aged 70 to 84 years, evaluated every 6 months. Previous observational studies have shown a small benefit in slowing cognitive decline, but while the difference was statistically significant, it was not large enough to be clinically significant, yet hearing aid use is critical for communication.

A left hemisphere stroke leading to right-sided paralysis usually also causes speech difficulty, called aphasia. C7 nerve transfer surgery for spastic arm paralysis plus three weeks of intensive SLT was associated with a greater improvement in language function compared to iSLT alone, particularly naming, on the Boston naming test (BNT, scores 0-60), 11.16 points in the neurotomy plus iSLT group and 2.72 points in the control group. 

Alteplase changed ischemic stroke care almost 30 years ago. The recent approval of TNKase (tenecteplase), a tissue plasminogen activator is delivered as a single 5-sec IV bolus, while alteplase is administered as an IV bolus followed by a 60-min infusion. No outcome difference was found between tenecteplase and alteplase on effectiveness, function, intracranial hemorrhage within 36 hours and combined in-hospital mortality or hospice discharge. 

Starting new antihypertensive (BP) medication more than doubled the risk of fractures from falls 5.4 vs. 2.2 in the control group per 100 person-years, aHR 2.42 (95% CI, 1.43-4.08) in veterans living in nursing homes, age 78. The meds cause vasodilation and can lead to syncope or at least dizziness or ataxia, so I have been instructing my patients to double their fluid intake for 3 days after starting or increasing a BP med and avoided many side effects.

Over 3 years, the group starting dialysis survived 770 days and the group continuing medical management survived 761 days (difference, 9.3 days [95% CI, −17.4 to 30.1

days]) but had 13.6 fewer days at home. Home time was counted as the number of days the patient was alive and not receiving inpatient care in a hospital, skilled nursing facility, nursing home, or rehabilitation facility, possibly due to dialysis complications. Compared with the group continuing medical management and forgoing dialysis completely, the group starting dialysis had longer survival by 77.6 days (CI, 62.8 to 91.1 days) and 14.7 fewer days at home (CI, 11.2 to 16.5 fewer days at home). The calculation did not include the time required for dialysis, 3 hours, 3 times per week, and transportation time and cost.

Almost half of hospitals surveyed (49%) failed to identify ‘harm events’ among hospitalized Medicare patients in October 2018, according to the Health and Human Services Department Office of Inspector General (OIG). The OIG found that only 16% (15 of 94) of harm events were investigated even though they were required to be reported externally per [Centers for Medicare and Medicaid Services] and/or state requirements.

In patients with cancer, age 65, direct oral anticoagulants (DOACs) reduced the incidence of venous thromboembolism more (IRR 0.66, 95% CI 0.56 to 0.79) vs. low-molecular-weight heparin (LMWH). Total bleeding and mortality were not different.

We breathe in as much microplastic as we eat or drink, and more indoors. Microplastics have been found to cause DNA damage and promote genetic mutations, increasing the risk for neoplasms. They can alter the immune function of the respiratory system, reducing its ability to eliminate pathogenic microorganisms. In addition, unknown compounds leaching from nylon microplastics are responsible for the detrimental effect on airway repair.

A meta-analysis found that it takes an average of three-and-a-half years after symptoms first appear for a patient to be properly diagnosed with dementia. That lag stretched to just over four years when the person was younger and experiencing early-onset dementia or had frontotemporal dementia.

In a series of >50,000 brain MRI scans from people aged 22-98 years across multiple datasets, those whose calculated biological age outpaced their chronological age not only had poorer cognition, faster hippocampal atrophy, and greater dementia risk but also worse general health, including greater frailty, poorer self-reported health, and greater risk for chronic disease and premature death.

For patients with vs without diabetes, adverse financial outcomes were all significantly higher (64.5% vs 49.9%), below-prime credit score (59.7% vs 45.9%) medical collections (36.9% vs 23.9%), nonmedical collections (38.4% vs 27.7% ), delinquent debt (23.3% vs 15.6%), debt charge-offs (15.4% vs 10.1%), bankruptcy filings (2.1% vs 1.4%), and foreclosures (0.5% vs 0.3%) in 166,285 patients, age 52 years.

The MISSION Act was implemented about 6 years ago to improve Healthcare and access for veterans by paying providers outside the VA, and was associated with approximately 30 minutes less travel time for veterans living more than 60 minutes from VA hospitals, but was also associated with worsened rates of major adverse cardiovascular events: mean (percutaneous coronary intervention) PCI MACE (major adverse coronary events) rates decreased by 0.5 percentage points for near patients and increased by 2.3 percentage points for far patients (difference in differences, 2.8 percentage points; P <.001). Mean (coronary artery bypass graft) CABG MACE rates decreased by 6.5 percentage points for near patients and increased by 1.6 percentage points for far patients (difference in differences, 8.1 percentage points; P < .001). In a book "Best Care Anywhere: Why VA Healthcare is Better Than Yours (2007)," now in its 3rd edition, lays out VA’s better healthcare at lower cost than private insurance. 

The OMDA conference on Thu Aug 7th at 8 am is: Current Survey Trends, by Liz Wheeler, BSN, RN, CHPN, IPCO, QCP, CDP, Proactive LTC Consulting

Tomorrow is the deadline for early bird sign up for OMDA’s 8th Annual Symposium on Post-Acute and Long-Term Care Medicine, September 5-6, 2025 in Dublin, OH. CME and CMD credit will be provided.

If there is no struggle, there is no progress. Those who profess to favor freedom and yet deprecate agitation are men who want crops without plowing the ground. They want rain without thunder and lightning. (Frederick Douglass)