Geriatric Update Jun 9, 2025

The CDC reports 1168 confirmed measles cases in 34 states, up from 1088 in 33 states last week. This slowing may be due to less heat and dry air in homes, leading to less airborne transmission, similar to COVID. No new updates on the Ohio Department of Health website.

Coughing into your shirt significantly reduced the maximal plume area as compared to the unobstructed condition by 95.4% and by 35.75% compared to “into the elbow” maneuver (P = 0.15), which was not statistically significant. Comparing “into the shirt” maneuver to the “into the mask” maneuver, the maximal plume area was not different 2.24% (P = 0.66).

Getting shingles leads to heart problems, in addition to the painful rash. The shingles vaccine was associated with 23% lower risk of cardiovascular events, including stroke, heart failure, and coronary heart disease, among those who were vaccinated for shingles. The protective effect of the vaccine lasts for up to eight years and is particularly pronounced for men, people under the age of 60 and those with unhealthy lifestyles, such as smoking, drinking alcohol and being inactive.

Piperacillin cured mice of Lyme disease using a dose 100 times lower than the current treatment, doxycycline. The problem is that it is not orally absorbed, has to be given parentally and I could only find it in combination with tazobactam, and that makes it broad spectrum and costly.

Antithrombotic therapy resumed 4-8 days after burr hole evacuation of chronic subdural hematoma did not increase recurrent intracranial hemorrhage compared to not resuming antiplatelets, warfarin or DOACs in 786 Danish patients, age 76. Other studies have shown reduced stroke risk when anticoagulants were restarted after 10 weeks of the bleed.

Use of methotrexate did not improve knee osteoarthritis pain and effusion-synovitis compared to placebo over 52 weeks (between-group difference, 0.3 mm [95% CI, −6.7 to 7.3 mm] for visual analog scale (VAS) pain; 0.1 cm2 [95% CI, −0.8 to 1.0 cm2] for effusion-synovitis maximal area). In contrast, in October I reported a study that showed improved function, stiffness and decreased pain on an 8 point scale, from 6.4 at baseline to 5.1 at 6 months. Correction, it was a 10 point numeric pain scale, not 8 point. But that study showed statistically significant changes, while the new study did not show a difference. Either way, it may not be clinically different, but could be discussed with a patient.

Breast cancer patients on hormone treatments, such as tamoxifen have on average 11.5 severe vasomotor symptoms (hot flashes) daily. Elinzanetant, a neurokinin NK-1 and NK-3 receptor antagonist, blocks the upregulated receptors on the kisspeptin–neurokinin–dynorphin (KNDy) neurons in the hypothalamus, and decreased daily vasomotor frequency by −6.5 episodes (95% CI, −7.2 to −5.8) compared to −3.0 episodes (95% CI, −3.9 to −2.2) among those on placebo at week 4.

Healthier lifestyles were associated with improved overall survival in all of 2603 patients with nonmetastatic prostate cancer followed up for a median of 10.9 years. Prostate cancer–specific survival was improved in African-American men but not other racial or ethnic groups. 

In patients with prostate cancer, 6 months of supervised, group-based resistance and aerobic exercise (n = 39) 3 times per week, (2) the same exercise program plus psychosexual education and self-management intervention (PESM) (n = 36), improved International Index of Erectile Function (IIEF) compared with usual care (n=37) (3.5; 95% CI, 0.3-6.6; P = .04). PESM did not make a difference, and intercourse satisfaction was not different (1.7; 95% CI, 0.1-3.2; P = .05).

In patients with uncontrolled diabetes, with A1c levels >11.3%, cataract surgery was not associated with an increased risk for postoperative endophthalmitis or serious systemic adverse events.

Patients who underwent cataract surgery had significantly lower odds of falls (odds ratio [OR], 0.83; P < .0001), also fewer fractures of the proximal humerus (OR, 0.95), distal radius (OR, 0.93), hip (OR, 0.93), and ankle (OR, 0.91; P < .05 for all) than those who did not undergo cataract surgery, and lower bleeds: subdural (OR, 0.89) and epidural (OR, 0.77; P < .01 for both). This is based on TriNetX database review over 10 years, and propensity matching. Keep in mind that within the first 6 months of cataract surgery, fall risk increases the older the patient, and in those age >85, the risk is 6.8 fold increased.

From the Research in Vision and Ophthalmology (ARVO) 2025 Annual Meeting, summarized by Medscape:

A dropless protocol, assigned to 279 eyes, consisted of an intracameral After cataract surgery, an into the eye injection of 0.2 mL of moxifloxacin 0.5% and a 10 mg/mL subconjunctival injection of the glucocorticoid triamcinolone (Kenalog) on completion of the operation avoided the 4 week multiple eye drop taper afterwards, and saved a couple of hundred $$$ for each patient.

Cataract surgeries performed in a surgery suite in the ophthalmologist’s office had significantly lower complication rates than operations performed in an ambulatory surgery center, a study of more than 1300 operations performed by the same surgeon in both settings.

In the US, about 790,000 total knee replacements and 549,000 hip replacements are performed each year and is projected to increase by 2060, to nearly 3 million and 2 million, respectively. 

Complications, superficial wound infection, and postoperative cellulitis were greater in people who did not receive vitamin D supplementation prior to surgery. In older adults, the majority of patients undergoing total joint arthroplasty, deficiency is common and the prevalence of vitamin D insufficiency (20-30 ng/mL) was 53.4% and vitamin D deficiency (<20 ng/mL) 39.4%, and resulted in poorer outcomes, including increased risk for revision surgery, joint infection, and postoperative stiffness. Taking a vitamin D supplement may help prevent infection, and I recommend a multivitamin for seniors that contains slightly higher levels of Vitamin D and B-12, to all >50 years old to prevent insufficiency.

Subclinical hyperthyroidism significantly increased hip fractures in both females and males,  even though it only reduced bone mineral density at the hip in females.  It did not reduce hip BMD in males, nor lumbar spine BMD in females or males. The mechanism is that thyroid hormone stimulates bone resorption through its direct effect on osteoclast function. This systematic review and meta-analysis did not list the age of patients, but we know that in those >50 years, TSH should be 4-6 mIU/L and not replaced if <10 mIU/L.

Discontinuation of oral anticoagulants after successful catheter ablation for atrial fibrillation was associated with increased thromboembolic events 0.86 [95% CI, 0.45-1.35] vs 0.37 [95% CI, 0.22-0.54] per 100 person-years; and decreased bleeding events incidence rate, 0.10 [95% CI, 0.02-0.19] vs 0.65 [95% CI, 0.43-0.90] per 100 person-years compared to those who continued for 12 months,  in this retrospective cohort study of 1821 patients, age 63.6, over 4.8 years.

Higher intake of olive oil >3 tbsp./day vs. ≤2  tbsp./d had reduced multivariable‐adjusted hazard ratios (HRs): 0.71 (95% CI, 0.48-1.05) for overall breast cancer, and 0.70 (95% CI, 0.46-1.08) for postmenopausal breast cancer. Each additional tablespoon of olive oil per day was associated with a reduced risk for ER− breast cancer (HR, 0.32; 95% CI, 0.15-0.69) and progesterone receptor–negative (PR−) breast cancer (HR, 0.59; 95% CI, 0.35-1.01) over 13.1 years follow up of this prospective study of 11,442 women, avg age 54.7 .

Electronic decision support increased the proportion of patients with 1 or more potentially inappropriate medications (PIM) deprescribed from 12.7% to 36.4% during the intervention (AOR, 1.58; 95% CI, 1.07-2.34).  The median number of medications was 10, and the median number of PIMs was 3, in 725 residents, age 84, of 5 nursing homes. 

At the AGS conference last month, the presentation on Pharmacology Update, reviewed 3 new meds:

Cobenfy (xanomeline and trospium chloride) is an antipsychotic not involving the dopamine system. Xanomeline is a muscarinic agonist at M1 and M4 receptors in the brain, while trospium is a muscarinic antagonist that crosses the blood brain barrier the least, and blocks the muscarinic agonist side effects in the periphery. Cost $37 per pill, dosed twice daily.  Older adults were not included, and the anticholinergic effect is concerning for our older adults.

Journavx (Suzetrigine) Nav1.8 inhibitor, a nonopioid analgesic to treat moderate to severe acute pain in adults. The studies that led to FDA approval in January 2025 included only 8% of older adults and only covered short term pain management, therefore, it is not indicated for chronic pain. The 50 mg tablet costs $18.60 ad is dosed every 12 hours. Side effects were rash and muscle spasms, lower eGFR and increased creatinine kinase, which all resolved spontaneously.

Blujepa (gepotidacin) is a new antibiotic in a new class called triazaacenaphthylene for uncomplicated UTIs in women that works by inhibiting bacterial DNA replication, targeting two essential enzymes, DNA gyrase and topoisomerase IV, effectively killing the bacteria. The 750 tablet is dosed 2 pills (1500 mg) twice daily and cost is not available as it will go on market later this year, again only limited amount of older adults were included in the studies.

Despite the White House and Secretary Robert F. Kennedy Jr promising “radical transparency,” on March 3, 2025, HHS revived the 1982 proposal, rescinding the Richardson Waiver and avoiding public notice for rulemaking and eliminated public comments.

Nitrites can be used to narrow down the spectrum of bacteria when a patient has urinary symptoms indicative of a urinary tract infection (UTI) but can happen with asymptomatic bacteriuria. The article “Urinary Tract Infection—Time to Say Goodbye?” advocates against using it as a diagnostic criterion. We in geriatrics have been practicing this for decades. I go into greater detail in my new UTI presentation.

The OMDA conference on Thu June 12th at 8 am is:  Urinary Tract Infection, by me.