Geriatric Update Sep 1, 2025
The CDC reports 1,408, confirmed measles cases in 43 states, up from 1,375 in 42 states 1 week ago.
The FDA suspended the Ixchiq Chikungunya vaccine after serious adverse events have been reported including 21 hospitalizations and 3 deaths, 1 related to the vaccine, in over 43,000 doses administered in the US. The vaccine contains a live, weakened version of the chikungunya virus. The disease causes severe long-term bone pain, and while the general mortality rate is 1 in 10,000 an Indian outbreak caused mortality of 1 in 1,000.
Of 414 adults >65 years, avg age76, presenting for surgery, patients with overweight, BMI, 25.0-29.9, was associated with lower odds of 30-day all-cause mortality, while BMIs higher than 40.0 had the highest complication rate, with 79% experiencing at least 1 complication, with 33% requiring reintubation, an upgrade in care, or developing pneumonia during their hospitalization. The rate of unintentional weight loss was 45% in those with BMI <18.5 and 14% in those with BMI 18.5-24.9, indicating possibly occult or confirmed cancer leading to higher mortality. The article did not mention the percentage of BMI categories undergoing surgery compared to population ratios as there may be an overrepresentation of mostly healthy overweight patients requiring elective surgery.
Within 1 year after unprovoked venous thromboembolism (VTE, blood clot), the risk of cancer is very high (HR 5.63, 95% CI 4.67-6.77). We should be looking for cancer in patients with unprovoked VTE.
This cohort study including 433 patients with ischemic stroke while on anticoagulation for atrial fibrillation (AF), left atrial appendage occlusion led to lower ischemic stroke, 2.8% per patient-year compared with 8.9% in the control cohort, (hazard ratio, 0.33; 95% CI, 0.19-0.58).
Frail older ≥75 years, avg age 80, vitamin K antagonist (warfarin)-experienced patients with AF switched to standard dose direct oral anticoagulant (SD-DOAC) experienced significant reductions in stroke or systemic embolism, fatal and intracranial bleeding, and death. Gastrointestinal (GI) bleeding was increased with SD-DOAC, while major bleeding and the primary net clinical outcome were similar. Rivaroxaban is on the Beers list due to GI bleeding risk, was used by 18.4% of participants, and Dabigatran is on the list because increased bleeding due to renal clearance. Time in therapeutic range was 65%-69%, in my clinic it was 85% and I would not have kept my patients on warfarin if it had been that low. If your patient is on warfarin and well maintained in therapeutic range, the outcomes would be better, but if that is not possible, use apixaban, the preferred DOAC for older adults.
Adjusting rivaroxaban for kidney function <50 ml/min from 20 mg to 15 mg, did not reduce the twofold GI bleeding risk in a study comparing it to the factor XI inhibitor Abelacimab, which has only limited FDA approval for cancer-associated thrombosis and stroke in AF.
Transcatheter aortic valve implantation (TAVI) was associated with significantly lower 1-year risk for all-cause death or any stroke compared to surgical aortic valve replacement (SAVR) 0.73 (95% CI, 0.56-0.95). Based on a meta-analysis of 4 investigator-initiated randomized clinical trials with patient level data in 2873 patients, age 76.7. It was complemented by an aggregate data meta-analysis of 4 industry-sponsored trials, for which the authors requested but did not receive patient level data access. Industry sponsored trials should be required to make their data available, like NIH sponsored trials are.
Of 1445 patients, age 80, with MI and multivessel disease who received physiology-guided complete revascularization of culprit and nonculprit lesions, death, MI, stroke, and ischemia-driven revascularization occurred in 165 patients (22.9%) at 3 years, and in 216 patients (29.8%) in the culprit lesion only group.
Patients presenting with symptoms suggestive of coronary artery disease (CAD), mostly chest pain, had similar outcomes over 10 years from evaluation with stress test or coronary computed tomographic angiography (CTA), in a randomized control trial of 9916 participants, avg age 61.
Hands free stationary bicycling, receiving perturbations with real-time implicit sensorimotor feedback, improved reactive balance measures in standing, voluntary stepping test and 6-Minute Walk Test (6MWT), among 56 community-dwelling older adults, age 76, in a single blind randomized trial. It probably strengthened balance muscles and core muscle strength.
Exposure to air pollution was associated with an increased risk for akinetic rigid presentation of Parkinson’s disease (PD) (OR per each 1-μg/m3 increase in PM2.5, 1.36). Among individuals with PD only, higher PM2.5 exposure was associated with a greater risk for developing dyskinesia (hazard ratio [HR] per 1-μg/m3 increase in PM2.5, 1.42), as was increased NO2 exposure (HR per 1-μg/m3 increase in NO2, 1.13). Previous data linked pollution with lung cancer in non-smokers, brain aging, dementia, hypertension and stroke. In 2024, the U.S. Environmental Protection Agency (EPA) reduced the annual PM2.5 standard from 12 μg/m3 to 9 μg/m3 due to growing evidence of negative health effects at levels below the previously set standard, this study not only supports the findings that led to this change, but the authors suggests that the upper limit should be lowered to 8 μg/m3.
Higher intakes of lignans in the form of bran, such as in oatmeal, were associated with a reduced risk for gout (adjusted hazard ratio [aHR], 0.78). Eating at least one serving of whole-grain cold breakfast cereal daily was associated with a 38% lower risk for gout than eating less than one serving per month (aHR, 0.62; 95% CI, 0.53-0.73).
Acceptance and commitment therapy plus exercise for older adults with chronic low back pain improved physical function similar to education and exercise at the 6-month follow-up among 40 community-dwelling older adults (62–85 years) in a randomized controlled trial.
Over 50% of individuals with overweight and obesity are emotional eaters. The non-meditation mindfulness practice RAIN in previous studies reduced smoking and in this study, emotional eating, reactivity to food cravings, perceived loss of control around food, by half and improved distress tolerance, over 3 weeks. The study used an app that I couldn't find but the RAIN exercise can be integrated into daily life and can be used anywhere, the acronym stands for:
Recognize what is happening;
Allow the experience to be there, just as it is;
Investigate with interest and care;
Non-identify with the experience so that your self-concept is not defined by or fused with your thoughts or emotions.
Initiators of semaglutide, age 70, had substantially lower risk of the hospitalization for heart failure or all-cause mortality (HR, 0.58 [95% CI, 0.51-0.65]) and tirzepatide (HR, 0.42 [95% CI, 0.31-0.57]) compared with sitagliptin. Tirzepatide had a non-significantly lower risk compared with semaglutide (HR, 0.86 [95% CI, 0.70-1.06]). The study was a clinical trial emulation of observational data, adequately powered with 1.67 million diabetes medication initiators. The podcast comments on the emulation analysis if interested, at 19 min.
Bariatric surgery achieved greater weight loss than GLP-1 meds, yet both groups had similar rates of obesity-related cancers, indicating additional anti-inflammatory effects from GLP-1 meds. The research involved 3178 age- and BMI-matched pairs in Israel.
Intuitive eating (IE) is a promising alternative to dieting that is gaining traction. IE based on eating with physiological hunger and satiety cues rather than situational and emotional cues – encourages rejecting the diet mentality and instead cultivating a positive relationship with food and the body.
The FDA approved VIZZ 1.44% drops of aceclidine, which contracts the sphincter of the iris, resulting in a pinhole effect that extends depth of focus to improve near vision without causing a myopic shift and not involving the ciliary muscle. The once daily drop takes effect 30 min after installation, last up to 10 hours and will be available in mid 4th quarter of 2025.
Acetylcholinesterase inhibitors (AChEIs) are effective in reducing occurrence of delirium when used prophylactically in patients undergoing elective surgery (risk ratio = 0.68 [0.47-0.98]; p = 0.039), but did not significantly impact delirium duration, severity, or hospital LOS.
Among 18,466 Swedish patients, median age 71 years, with acute myocardial infarction, routine H pylori screening did not significantly reduce the risk of upper gastrointestinal bleeding.
Implementing a phenobarbital order set for 67 patients with alcohol withdrawal, age 53, AWS symptoms resolved more rapidly, with a 4.2- to 5.0-point reduction in daily maximum CIWA-Ar scores at 24 to 96 hours from hospital presentation, 30.1-hour reduction in AWS treatment duration (95% CI, 16.7-43.5 hours), and 2.2-day reduction in time to hospital discharge (95% CI, 0.7-3.7 days) compared to prior treatment. Safety outcomes did not significantly differ before and after implementation.
Mirtazapine 15-45 mg was thought to improve breathlessness in patients with severe respiratory disease, but did not improve symptoms or mortality and showed more adverse effects over 56 days: 215 adverse reactions in 72 (64%) of 113 participants in the mirtazapine group versus 116 in 44 (40%) of 110 participants in the placebo group. Mirtazapine is an antihistamine in low doses, is sometimes used for appetite stimulation and sleep but is on the Beers list as it contributes to delirium.
Seltorexant, a selective orexin-2 receptor antagonist showed a statistically significant dose-response relationship in latency to persistent sleep and wake after sleep onset vs placebo and in the 20-mg group vs zolpidem, based on a randomized clinical trial including 364 adults, age 58. Treatment-emergent adverse events (TEAEs) were lower across the combined seltorexant doses (73/216 [33.8%]) relative to placebo (37/75 [49.3%]) and zolpidem (31/73 [42.5%]). It is not FDA approved, but 3 other orexin antagonists are, and are not on the Beers list, and I have no experience with them.
The OMDA call on Thu Sep 4th at 8 am is: OMDA Public Policy, by J. Matthew Chase, MD, CMD
The OMDA conference this coming weekend is still open for registration, provides >11 CME and CMD credits, and is close to home, in Columbus, OH.
I wish you a good Labor Day, celebrating our labor protections that brought us humane working conditions and wages to support a family, well summarized in this TED talk.
