Geriatric Update Mar 9, 2026

In lifetime exposure to cognitive enrichment with intellectually stimulating activities, each 1-point increase in lifetime cognitive enrichment – including reading, writing, or frequently visiting museums – correlated with a 38% lower risk of Alzheimer’s dementia and 33% lower mild cognitive impairment over 7.6 years of follow-up of 1,939 older adults, age 79.6.

Implementing p-tau217 in real-world clinical practice of Spanish general neurology and memory units substantially improved diagnostic accuracy from 75.5% to 94.5% with confidence in all stages of cognitive decline. Although it was a prospective study, the time difference between before and after the p-tau217 test was not described to ascertain the veracity of the result. Without brain biopsy or autopsy findings, hindsight is always better (after seeing the p-tau217 results), and what are we going to do with the results? At this point, all we can do is improve lifestyle factors throughout life to reduce risk factors for dementia in later life. 

Gingko biloba had maybe a small to moderate benefit in people with dementia at six months for global status, cognition, and ADLs, but little to no benefit was seen in patients with mild cognitive impairment, and no benefit was seen for multiple sclerosis. Little or no adverse effects were seen, but gingko can cause bleeding and should be stopped well before surgery. While this Cochrane review showed small statistically significant differences, it did not reach the 10% difference usually thought to be clinically significant in dementia studies.

Individuals with prediabetes and diabetes showed poorer performance on cognitive tests than normoglycemic individuals, i.e., trail-making test B (TMT-B), category fluency, and block design subtest. Longer diabetes duration and higher HbA1c were associated with faster global and domain-specific cognitive decline over a median follow-up of 6.4 years, range 1-19 years.

Nutritional deficit is a concern with GLP-1 meds and lower caloric intake. Vitamin D deficiency was the most common abnormality, occurring in 7.5% at 6 months and 13.6% at 12 months. Lower ferritin levels may reflect lower inflammation rather than iron deficiency. Thiamine and vitamin B-12 were also lower. To prevent vitamin depletion over time, I recommend all adults >50 years old take a senior multivitamin which contains slightly higher levels of vitamins D and B-12 than regular vitamins, as absorption of these vitamins decreases with age.

GLP-1 users showed no significant difference in serious adverse events between older and younger adults (pooled LOR: 0.06, p = 0.9). Older adults had a trend toward lower frequency of nausea (LOR: −0.44, p = 0.06) but higher incidence of constipation (LOR: 0.72, p = 0.02) and hypoglycemia (LOR: 0.97, p < 0.001). Efficacy in metabolic and weight control was comparable.

Oral semaglutide (SEM) has more gastrointestinal side effects, possibly because it is paired with salcaprozate sodium (SNAC) to protect the drug in the stomach and enhance permeability for gastric absorption. In this mouse study, SNAC alone compared to SEM only, reduced gut microbes, especially the ones that break down fiber, increased liver weight, increased pro-inflammatory markers, IL-6 and tumor necrosis factor, and lowered brain derived neurotropic factor. SEM+SNAC did not compare to SEM, so the effect may be due to weight gain in the SNAC-only mice compared to SEM’s weight loss. 

Persistent functional impairment (FI) as measured by 3 Functional Activities Questionnaire items of “preparing a hot beverage,” “preparing a balanced meal,” and “shopping alone” ≥ 1 deficit at >2/3 of pre-dementia visits, was associated with 6.66-fold greater dementia incidence rate (95% CI: 4.98–8.91, p < 0.001), while Transient-FI had a 1.72-fold greater incidence rate (95% CI: 1.09–2.72, p = 0.021) in 1000 patients, age 73, over 4.9 years.

In heart failure with preserved ejection fraction (HFpEF) GLP-1 (HR: 0.73, 95% CI 0.61-0.88) and SGLT2 (HR: 0.79, 95% CI 0.70-0.90; P-score: 0.807) significantly reduced the risk of cardiovascular death and HF hospitalization. GLP-1 RAs elicited the greatest improvement in functional outcomes, including the 6-Minute Walk Test (mean difference: +17.60 m, 95% CI 8.53-26.67) and KCCQ-CSS (mean difference: +7.38 points, 95% CI 5.51-9.26), due to decreased central adiposity. No statistically significant differences in cardiovascular death or all-cause mortality were observed among the treatments. 

Medication reminder technologies among home-dwelling older adults improved clinical health outcomes, in particular systolic blood pressure and physical symptoms, but not patient/carer experiences and cost-effectiveness, in a review of 43 studies. 

A single-pill combination of 1.67 mg amlodipine, 16.67 mg losartan potassium, and 4.17 mg chlorthalidone (LDC-ALC) was superior to standard-dose monotherapy-5 mg amlodipine (-19.1 vs -19.9 mm Hg) or 50 mg losartan (-19.9 vs -16.4 mm Hg) in systolic blood pressure (SBP) reduction at week 8 in 569 Korean patients with mild-to-moderate hypertension.

Angiotensin II-stimulating medicines (ie, angiotensin receptor blockers (ARB), dihydropyridine calcium channel blockers (CCB)s, and thiazide diuretics), were associated with 6% lower risk for arteriolosclerosis (relative risk [RR], 0.94; 95% CI, 0.89-0.99), with long-term use associated with a 24% lower risk (RR, 0.76; 95% CI, 0.63-0.91) vs angiotensin II–inhibiting antihypertensive medications (angiotensin-converting enzyme (ACE) inhibitors, β-blockers, nondihydropyridine CCBs), on autopsy of 756 participants, age at death 89.2 years. Patient Years of angiotensin II–stimulating antihypertensive medications were associated with less phosphorylated tau burden in several brain regions (temporal lobe [adjusted ratio of geometric means, 0.79; 95% CI, 0.62-1.00], hippocampus [adjusted ratio of geometric means, 0.83; 95% CI, 0.71-0.97]), but not with Aβ42 quantitative measures. Although the results are statistically significant, I don't think they are clinically meaningful in this observational study that could not account for quality of long-term BP control. The small difference for an observational study does not prompt me to change my prescribing habits.

Baduanjin, a Chinese eight-movement sequence that combines slow, structured movement, deep breathing and meditation, lowered people’s blood pressure more than self-directed exercise alone at 12 weeks (−3.1 mm Hg; 95% CI: −5.9 to −0.2 mm Hg; P = 0.036) and 52 weeks (−3.3 mm Hg; 95% CI: −6.3 to −0.3 mm Hg; P = 0.031), with no significant difference vs the brisk walking arms (−0.7 mm Hg; 95% CI: −3.9 to 2.6 mm Hg; P = 0.683) at 52 weeks in this randomized trial of 216 participants, age 57.3.

Tai Chi lowered blood pressure −7.01 mm Hg more than aerobic exercise at −4.61 mm Hg, over 12 months, difference −2.40 (95% CI, −4.39 to −0.41) mm Hg (P = .02), in a randomized trial of 342 participants, age 49.3 years.

Cataract surgery is not linked with macular degeneration progression. Some patients have told me that their ophthalmologist did not want to operate on their cataracts for that reason.

Patients who answer yes to either of these questions are likely to have low vision: “In a fast-food restaurant, can you usually read the posted menus?” for the area under the curve (AUC) 0.85 (sensitivity = 0.89; specificity = 0.81), or for legal blindness: “When seated in front of a computer, are you able to read the letters on the keyboard keys?” AUC 0.80 (sensitivity = 0.89; specificity = 0.71).

Gabapentinoids, pregabalin or gabapentin, are on the Beers list due to falls, confusion, and should only be given in low doses. Among 23,544 residents, 994 (4.2%) received a loop diuretic for edema, at a median of 36 days (IQR 15–61) after gabapentinoid initiation. Risk was higher with age 86–90 years (aRR = 1.60) or ≥ 91 years (aRR = 1.38); with a diagnosis of chronic pain or fibromyalgia (aRR = 1.16), or with diabetes (aRR = 1.23); and receipt of potassium-sparing diuretics (aRR = 1.53), thiazide diuretics (aRR = 1.27), or 15 or more unique medications (aRR = 1.18). Higher (versus lower) weekly gabapentin dose during follow-up was associated with a 1.45 times higher prescribing cascade risk over 13 weeks. Those with Alzheimer's Disease and Related Dementias (aRR = 0.79), or moderate (aRR = 0.72) to severe cognitive impairment (aRR = 0.59) had a lower risk versus those with intact cognition. Instead of adding meds, we should taper the gabapentinoid, and in my experience the pain does not get worse.

New persistent opioid use in the US after surgery correlated with: Mood disorders, 1.24 (95% CI, 1.17-1.32), anxiety 1.17 (1.11-1.23), enrollment in Medicaid 1.77 (1.46-2.15), and preoperative use of benzodiazepine use 1.77 (1.53-2.05), based on a systematic review and meta-analysis of 27 retrospective cohort studies, 89% good quality. 

The Canadian CT Head Rule (CCTHR) is validated in adults who hit their head and experience loss of consciousness, amnesia, or disorientation. This study adds that the risk of intracranial bleed is 4.6% in those with unclear history of head injury, to 7.7% in those who hit their head and met the CCTHR criteria. I still question the rationale of imaging an asymptomatic patient because neurosurgery would not evacuate a small bleed that does not cause signs or symptoms, and the trip to the ED may cause delirium, with its complications.

Congress failed to extend enhanced tax credits for Affordable Care Act (ACA) customers, leading to soaring monthly premiums across the U.S. CMS showed that nationally, sign-ups are down more than 800,000 from last year, and many more selected cheaper plans. This can lead to Healthcare debt, bankruptcy, and housing insecurity.

Medical debt was reported by 16.4% of 1515 adults participating in the Cumulative Life Stressors Impact on Mental Health and Well Being Study, a nationally representative, longitudinal panel. Subsequent housing instability was markedly higher among adults with medical debt, compared with those without medical debt (23.5% vs 5.8%). Using doubly robust estimation to adjust for confounders, medical debt was associated with an increase of 7.0% (95% CI, 5.2-8.8) in the probability of housing instability in the subsequent year.

Like the higher dose flu vaccine for those >65 years, Moderna’s higher 100µg COVID vaccine dose mRNA-1273 produced greater immunogenicity than BioNTech’s BNT162b2 30µg by Pfizer in 322 older adults, average age 80 years: 100% in both vaccine arms of those who received their first COVID vaccine reached 2-fold geometric mean titer (GMT) with a higher GMT increase in the mRNA1273 group (ratio 1.64). In those who received subsequent booster shots, 87.2% vs 76.5% attained GMT antibody increase 14 days after vaccination, (ratio 1.38) with higher neutralizing capacity against the virus for mRNA1273. Adverse events (AEs) were similar. In the year after 1st time vaccination, 8 subjects (29.6%) in the mRNA-1273 group and 11 subjects (44%) in the BNT162b2 group reported SARS-CoV-2 infection. In the booster recipients, 34 subjects (25.4%) in the BNT162b2 group and 32 subjects (23.9%) in the mRNA-1273 group reported SARS-CoV-2 infection by month 12. While there is a statistically significant difference, I think it is not clinically meaningful, especially with the booster doses. Let’s take the COVID vaccine we can get and for older adults that is every 6 months.

Patients with atrial fibrillation (A-fib) are at higher risk of stroke, and anticoagulation reduces that risk to 1.5%- 2.5% per year above no A-fib. Adherence to direct oral anticoagulants (DOAC) improves outcomes. Compared to the 57,637 of 92,111 (63%) with 100% adherence, the 16% with 95–99% adherence, adjusted hazard ratio (aHR) 1.02, 95%CI (0.94–1.12) was similar; 1/3 higher risk was seen in the 5% with 85–89% adherence aHR 1.35, 95%CI (1.19–1.54), and 2/3 higher risk in the 2% with < 80% adherence aHR 1.64, 95%CI (1.34–2.01). For those with poor adherence, a watchman may be an alternative.

This podcast on Medical Assistance in Dying (MAID) addresses arguments for and against the bill that is going through the House of Lords’ amendments to England’s and Wales’ assisted dying bill, very informative!

This article on MAID describes the historical context, current legal situation in 10 US states that allow it, other countries laws, and arguments for and against it.

The CDC reports, 1,277 confirmed measles cases in 31 states vs 1,130, cases in 28 states last week.

Ohio’s respiratory dashboard showed 518 flu hospitalizations (659 last week), 316 COVID hospitalizations (372), and 383 RSV (442).

Medicine is a science of uncertainty and an art of probability. 

Dr. William Osler