Geriatric Update May 5, 2025

The CDC reports 935 confirmed measles cases in 30 states, up from 884 in 25 states last week. In Ohio, the Dept of Health website has not been updated from the 20 cases reported in March.

The CDC concludes influenza season and estimates that there have been at least 47 million flu illnesses, 610,000 hospitalizations, and 26,000 deaths from flu so far this season, including 216 pediatric deaths, up from 207 last year.

By day 5, transmission of laboratory-confirmed influenza was significantly lower with baloxavir than with placebo (adjusted incidence, 9.5% vs. 13.4%; adjusted odds ratio, 0.68; 95.38% confidence interval [CI], 0.50 to 0.93). Symptomatic transmission was 5.8% with baloxavir and 7.6% with placebo, not significant (adjusted odds ratio, 0.75; 95.38% CI, 0.50 to 1.12). Drug-resistant viruses occurred in 7.2% of index patients but no resistant viruses were detected in household contacts.

In patients receiving renin-angiotensin-aldosterone system inhibitors (RAASi), initiation of sodium-glucose cotransporter 2 inhibitor (SGLT2i) was associated with a lower risk of hyperkalemia (hazard ratio, 0.89 [95% CI, 0.82-0.96]). and lower rate of RAASi discontinuation compared to nonusers (36% vs 45%; P < .001). Among 20,063 patients who initiated an SGLT2i age, 76.9 vs. 19,781 nonusers age, 76.8.  In the overall cohort, 95% had diabetes, 17% had heart failure, and 32% had stage 3 to 5 chronic kidney disease.

Women >55 with recurrent urinary tract infection (rUTI) who were on vaginal estrogen experienced lower rates of hospitalization, sepsis (10.6% vs 19.4%), and death (0.42% and 1.54%). In premenopausal women with rUTI, these benefits were not seen.

Physical inactivity increased the number of deaths due to chronic kidney disease (CKD) by 197.21% from 1990 to 2021, with a greater increase observed among females (200.39%) than males (193.18%). Age-standardized mortality rates, disability-adjusted life years, age-standardized DALY rates, and estimated annual percentage change all worsened with inactivity over time.

Physical activity decreased the risk of gout in people with hyperuricemia (high uric acid levels). Top 5 risk factors for gout are: hypertension, high serum uric acid, age, , male sex, and BMI. Additional risk factors are: creatinine, sedentary duration, lower PA, and diabetes. Physical activity duration of 1–7 h per week was linked to a lower risk of gout , while sedentary time exceeding 6 h per day increased gout risk, regardless of age, sex, or comorbidities.

In 724,200 middle aged Japanese patients, cataract incidence increased with low- and high-potency statins adjusted HRs [95% CI] were 1.48 [1.30–1.70] and 1.61 [1.44–1.79], respectively, without difference between lipophilic and hydrophilic statins 1.56 [1.39–1.75], except for fluvastatin and simvastatin, possibly due to lower numbers leading to wider confidence intervals and non-significance.

The risk of young-onset dementia, before age 65 was 24% higher in people, avg age 49, with metabolic syndrome over 7.75 years, (adjusted HR 1.24, 95% CI 1.19–1.30), a 12.4% increased risk of AD (HR 1.12, 95% CI 1.03–1.22), and a 20.9% increased risk of VaD (HR 1.21, 95% CI 1.08–1.35). Risk factors are younger age, female sex, drinking status, obesity, and depression.

Nonphysician health workers in India delivered a comprehensive package for weight loss, which included annual screening for cardiovascular risk factors, structured lifestyle modification sessions, referral to a primary health care for individuals with established risk factors, and active follow-up to evaluate self-care adherence in 1,671 participants, age 41, from 750 families. The intervention at the 2-year follow-up showed -2.61 kg in weight (95% CI, -3.95 to -1.26; P <.001), -1.06 kg/m2 in BMI (95% CI, -1.55 to -0.58; P <.001), and -4.17 cm in waist circumference (95% CI, -5.38 to -2.96; P <.001). 

In the 2 years after its approval for weight loss 24,499 people visited the ED for adverse events related to semaglutide, 69% for gastrointestinal symptoms and 59% for nausea and vomiting, and 16.5% of visits involved hypoglycemia, of those 19% did not take other diabetes meds. Considering >5 million people having received semaglutide in 2023, the adverse effects are very low. In patients who do not tolerate GLP-1 meds, I have had good results with DPP-4 inhibitors, smaller effect and milder side effects. 

US Food and Drug Administration Adverse Event Reporting System found 649 reports on intraoperative floppy iris syndrome (IFIS) with these medications: imipramine (reporting odds ratio [ROR], 251.66), alpha-1 blockers, tamsulosin (ROR, 171.44), chlorpromazine, an atypical antipsychotic (ROR, 91.30), tricyclic antidepressants, atypical antipsychotics, carbonic anhydrase inhibitors, corticosteroids, 5-alpha reductase inhibitors, beta-blockers, prostaglandin analogs, and beta-2 agonists. Among women but not among men: Brinzolamide, a carbonic anhydrase inhibitor (ROR, 409.63), and salbutamol, a beta-2 agonist (ROR, 67.12).

Benign paroxysmal positional vertigo (PC-BPPV-cu) occurs when cupuloliths, canaliths, otoconium, statolith, statoconium or otoliths, all synonyms for calcium crystals break loose from the inner ear haircells, causing dizziness.  In 159 patients with posterior canal benign paroxysmal positional vertigo (PC-BPPV-cu) the group randomized to head-shaking showed a greater short-term therapeutic efficacy (38%) than those in the mastoid oscillation (26%) and control (13%) groups, 30 minutes and the day after the procedure, based on symptoms and nystagmus and on Dix-Hallpike. I would have liked to have seen a comparison with the established and highly effective Epley maneuver.

Treatments for low back pain not involving surgery or meds were reviewed in 31 Cochrane reviews of 644 trials that randomized 97,183 adults. Slight improvement in pain and function were found for: acupuncture, physical activity, exercise and multidisciplinary therapies. No benefit in pain and function was found from: spinal manipulation and traction. Psychological therapies slightly improved pain but not function.

Of 24 139 nonexercisers from the 2013 to 2015 UK Biobank accelerometry substudy, age 62, moderate and vigorous incidental physical activity (IPA) such as housework, reduced major adverse cardiovascular events (MACE) and mortality with a plateau of ≈14 minutes per day for vigorous IPA and 34 to 50 minutes per day moderate IPA, hazard ratios of 0.49 (95% CI, 0.39–0.61) for MACE, 0.33 (95% CI, 0.22–0.52) for CVD mortality, and 0.31 (95% CI, 0.25–0.38) for all-cause mortality. Low IPA showed a subtle inverse gradient which was statistically significant only for CVD mortality at levels >130 minutes per day.

Women with increasing 24-hour sleepiness had more than double the risk for dementia as women with stable sleep (odds ratio [OR], 2.21; 95% CI, 1.14-4.26), after adjusting for covariates such as age, comorbidities, and APOE-ε4 allele status. Other sleep parameters that were associated with a significantly increased risk for dementia included changes in sleep efficiency (OR, 2.2), wake after sleep onset (OR, 2.3), nap duration (OR, 2.0), and nap frequency (OR, 2.2), in 733 cognitively unimpaired women, age 82.5, enrolled in the Study of Osteoporotic Fractures who completed wrist actigraphy twice (baseline and follow-up) and had cognitive status evaluated at follow-up using a neuropsychological battery. I feel that sleep changes do not lead to dementia but are a sign of underlying neurodegenerative disease that can lead to sleep disorder and dementia. 

Disability by disability index (eating, showering, using the toilet, dressing, going outside, getting around indoors, and getting out of bed), increased 20% with more frequent insomnia symptoms, by the average frequency of longer sleep onset latency and trouble staying asleep. Sleep medication usage increased disability a further 19%. To manage sleep without medications, watch my full or short 15 min video.  

Among 13,882 adults, age 74, a clear, Alzheimer’s-like profile based on three CSF biomarkers – amyloid-beta 1-42, total tau (t-tau), and phosphorylated tau 181 (p-tau181) measurements – was seen in 68% of people with early-onset Alzheimer’s disease, 65% of late-onset Alzheimer’s, and 52% of people with mixed Alzheimer’s and vascular dementia, and among people without an Alzheimer’s diagnosis, the Alzheimer’s profile emerged in 25% of people with unspecified dementia, 9% of people with Parkinson’s disease dementia, and 8% of people with frontotemporal dementia.

Dextromethorphan is an N-methyl-D-aspartate receptor antagonist and sigma 1 receptor agonist, while bupropion functions as CYP2D6 inhibitor, to prevent the rapid metabolism of dextromethorphan. The combination is FDA approved as AXS-05, and in the ACCORD-2 trial, showed reduction of agitation in dementia, delaying the time to agitation relapse compared with placebo (hazard ratio, 0.276). While behavioral management is first line for agitation in dementia, currently, the only other drug approved is the antipsychotic brexpiprazole, which carries a black box warning due to increased mortality. 

Dextromethorphan in combination with quinidine is FDA approved as Nuedexta for pseudobulbar affect, when patients with dementia have uncontrolled emotional outbursts. I usually start with only dextromethorphan to test efficacy in a patient, as the CYP2D6 induction takes a few days. 

For carotid stenosis, optimized medical therapy (OMT) is as effective as surgery revascularization in reducing stroke risk in the majority of patients, in a planned interim 2-year analysis of a 30 multicenter randomized trial in Europe and Canada. Patients aged 18 years or older with asymptomatic or symptomatic carotid stenosis of 50% or greater, and a 5-year predicted risk of ipsilateral stroke of less than 20% (estimated using the Carotid Artery Risk [CAR] score), were recruited.

Weekly poultry consumption above 300 g was associated with higher risk of death from all causes [HR 1.27; 95% CI (1.00; 1.61)] than those consuming less than 100 g, and higher risk of gastrointestinal cancers 2.27 [95% CI (1.23; 4.17)], a risk that for men increased to 2.61 [95% CI (1.31; 5.19)]. The study did not include beef, a meat rarely used in Italy.

Ultraprocessed foods (UPF) increases premature mortality by 2.7% for each 10% increase in total calories from UPF 1.027 (95 % CI=1.017, 1.037). The US has the highest level of UPF consumption in the world –54.5% of the average American’s diet. Reducing its use to zero would have prevented over 124,000 deaths in the US in 2017. The current study echoes a 2024 study that showed that people who ate more ultraprocessed food had a 50% higher risk of cardiovascular disease-related death and common mental disorders.

Better diet quality in midlife and across middle to older age (48-70 years) was associated with enhanced hippocampal functional connectivity and white matter integrity. Higher waist hip ratio in midlife was associated with poorer working memory and executive function, through a pathway partially mediated by alterations in white matter connectivity, over up to 21 years of follow up.

Aging in America: Survive or Thrive is a n outstanding one-hour documentary. Check the film schedule for your local PBS airing times or stream the film for free starting May 1.