Geriatric Update Sep 15, 2025

The CDC reports 1,454 confirmed measles cases in 42 states, up from 1,431 in 43 states 1 week ago. Johns Hopkins has tracked and reported a county map of measles cases.

PALTMed provided and excellent summary of the evidence and status of COVID-19 vaccine. Currently, only patients >65 are eligible and those with underlying conditions at high risk of complications. Obesity with a BMI of >30 is considered high risk and covers about half of the US population.

Driving distances after critical illness were significantly lower than prehospitalization estimates (median [IQR], 60 [25-150] vs 105 [58-250] miles per week; P < .001) in 151 ICU survivors, age 59. Driving skill (median [IQR], 34 [26-38] on a 48-point scale; P < .001) and safety orientation measures (median [IQR], 38 [35-46] on a 48-point scale; P < .001) were significantly lower upon return to driving. Independent of delirium or self regard of safety, which 82.8% rated as good or excellent. For more info watch my Driving video.

As a stand-alone blood test, plasma p-tau217 achieved a positive predictive value (PPV) of 79% (95% CI, 74-84) and an overall accuracy of 81% (95% CI, 80-82). In a 2-step workflow with either spinal fluid or PET scan, the PPV and accuracy significantly increased to 91% (95% CI, 86-95).

Individuals with advanced dementia, age 89, initiated on nasogastric tube feeding do not have meaningfully improved survival (AHR= 0.85, 95% CI, 0.59-1.23, P =.38), and have a higher risk of pneumonia (AHR 1.60, 95% CI, 1.06-2.42, P =.03), compared to those propensity matched to receive careful hand feeding.

Exposure to higher levels of fine particulate matter air pollution (PM2.5) was associated with significantly, 63% more advanced Alzheimer disease neuropathologic change (ADNC) based on 602 autopsy cases, and more advanced clinical measures of dementia on Clinical Dementia Rating Sum of Boxes (CDR-SB) test (β = 0.48; 95% CI, 0.22-0.74), based on 287 cases with CDR-SB records, avg age at death 79.

Plastic concentrations in decedent tissues upon autopsy were not influenced by age, sex, race/ethnicity or cause of death; the time of death (2016 versus 2024) was a significant factor, with logarithmic increasing microscopic nano particles (MNP) concentrations over time in kidney median 404 µg/g, liver 433 µg/g, and brain samples 4917 µg/g (P = 0.01). Finally, even greater accumulation of MNPs was observed in the brains with documented dementia diagnosis, with notable deposition in cerebrovascular walls and immune cells, (median = 26,076 µg/g).

Frontotemporal Dementia (FTD) pooled incidence was 2.28 (95% CI, 1.55-3.36) per 100,000 person-years, and pooled prevalence was 9.17 (95% CI, 3.59-23.42) per 100,000 people, based on a systematic review and meta-analysis of population-based studies with approximately 31 million person-years for incidence and 6 million individuals for prevalence spread in more than 12 regions around the world.

Care from a skilled nursing facility specialists (SNFists) vs a non-SNFist was associated with a 7% decrease in the odds of a hospitalization and a 7% decrease in the odds of an emergency department visit for an ambulatory care–sensitive condition among residents with dementia, based on 417,378 nursing home (NH) residents with dementia, age 84, which is about 20% of NH dwellers.

The addition of aspirin in patients with chronic coronary syndrome at high atherothrombotic risk who were receiving an oral anticoagulant, led to a higher risk of cardiovascular death (HR 1.72), myocardial infarction, stroke, systemic embolism, coronary revascularization, major bleeding (HR 1.87), or acute limb ischemia than in the group randomized to placebo, as well as higher risks of death from any cause and major bleeding, among 872 French patients, avg age 72.

Patients after myocardial infarction and decreased function were randomized: 342 patients to the cardiac rehab intervention group and 170 to the control group, median age was 80 years. A primary-outcome event occurred in 12.6% in the cardiac rehab group and in 20.6% in the control group (hazard ratio, 0.57; 95% confidence interval [CI], 0.36 to 0.89; P = 0.01) after 1 year. Cardiovascular death occurred in 4.1% in the rehab group and in 5.9% in the control group (hazard ratio, 0.69; 95% CI, 0.31 to 1.55, non-significant, probably due to small number). Unplanned hospitalization for cardiovascular causes occurred in 9.1% in the rehab group and in 17.6% in the control group (hazard ratio, 0.48; 95% CI, 0.29 to 0.79). There were no serious adverse events associated with the intervention.

Epicardial adipose tissue (EAT), the visceral fat depot surrounding the myocardium, may play a distinct role in new onset, incidence of atrial fibrillation (AF). The proximity to the myocardium permits local inflammation and fibrotic effects, including the secretion of adipo-fibrokines potentially contributing to AF development.

The new ACC/AHA/AMA… Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure (BP) in Adults define normal <120/80, elevated 120-129/80 and hypertension >130/80, and recommends earlier BP control, if lifestyle changes of diet, exercise and sodium <1500 mg or salt <3750 mg or ½ tsp daily do not achieve <130 systolic in 3-6 months. It also moved from “think” to “know” that hypertension contributes to dementia and recommends home BP monitoring, early urine albumin/creatinine checks for earlier detection of kidney disease.

High dose statin use was significantly associated with reduced abdominal aortic aneurysm (AAA) growth rate of −0.22 mm/year [95% CI, −0.39 to −0.06]; P=0.009). The 5-year adjusted hazard ratio for undergoing repair per doubling of statin dose presented a significantly reduced adjusted hazard ratio (HR) of 0.82 ([95% CI, 0.70–0.97]; P=0.023), which was significant after 2.5 years. The composite outcome (surgery, rupture, and death) was lower in a dose-dependent manner. Metformin also looks promising and 4 randomized trials are ongoing and will be reported soon.

For some good news: from 2001 to 2019, chronic disease deaths declined in about 80% of the world’s countries, home to more than 70% of the global population. Among the 25 high-income Western countries in the study, Denmark had the largest decline in chronic disease deaths. The United States had the smallest, -5% in 2001-2010 and -1.3% in 2010-2019, and Germany did only slightly better than the United States.

Deprescribing blood pressure meds with an antihypertensive treatment step-down strategy did not reduce all-cause mortality than usual care in a randomized controlled trial of 1048 older frail nursing home residents >80 years old, on blood pressure (BP) meds, who had a systolic BP <130 mm Hg, over 38.4 months. This contrasts with some previous observational studies that showed benefit from reducing blood pressure medications, but this study showed benefit of BP control in frail patients.

Prior mammogram screening was associated with 54% lower odds of later-stage breast cancer diagnosis (adjusted odds ratio, 0.46; 95% CI, 0.42-0.50) and 36% lower hazard of breast cancer–specific death (adjusted hazard ratio, 0.63; 95% CI, 0.52-0.76) compared with no prior screening in 13,028 women aged 70-79 years, of whom 77.5% had recent screenings. I still aggressively screen women with good life expectancy, but stop screening in patients with moderate dementia, not only because of limited life expectancy, but also because they may not understand why they have to undergo this painful procedure. 

Over 30 years, 90% of men, avg age 67, with nonmetastatic prostate cancer (Pca) treated in line with current National Comprehensive Cancer Network (NCCN) guidelines, were likely to survive their cancer and die from other causes over their life expectancy. While men with high-risk disease had higher death rates from prostate cancer, they were still at least twice as likely to die from other causes. Men with low or intermediate risk PCa had 12% (95% CI, 10%–14%) PCa mortality and 77% (95% CI, 74%–80%) mortality from other causes. Men with high-risk cancer, PCa mortality was 20% (95% CI, 18%–22%), and mortality from other causes was 67% (95% CI, 61%–73%); with very high-risk cancer, PCa mortality was 30% (95% CI, 29%–32%), and mortality from other causes was 63% (95% CI, 59%–67%). 

Men with high risk prostate cancer, radiotherapy plus androgen deprivation therapy (ADT) for was associated with a 32% relative reduction in distant metastases at 8 years, compared with radical prostatectomy followed by personalized postoperative therapy. However, the risk for death after distant spread was similar between the two strategies.

The use of sodium-glucose cotransporter 2 inhibitors (SGLT2) inhibitors was associated with a nearly twofold higher risk for phimosis than the use of GLP-1 RAs at 1 year (risk ratio [RR], 1.88; 95% CI, 1.43-2.47) and remained elevated even after 8 years of follow-up (RR, 1.36; 95% CI, 1.14-1.61). Although the absolute risk for penile cancer was very low, initiating SGLT2 inhibitors had a higher 8-year cumulative risk for penile cancer 0.09% than those initiating GLP-1 Ras 0.01%, corresponding to an RR of 6.34 (95% CI, 1.16-34.52).

Idiopathic intracranial hypertension (IIH), which I learned as pseudotumor cerebri, is associated with obesity, and weight loss, including a relatively modest reduction of around 10% of body weight, can clinically ameliorate IIH, but cerebrospinal fluid (CSF) pressure normalization occurred only after 25% body weight reduction.  The use of glucagon-like peptide 1 receptor agonist (GLP-1) improved symptoms in 555 GLP-1 users propensity score matched, compared with 555 nonusers, leading to lower medication use (RR, 0.53; 95% CI, 0.46-0.61; P < .001) and reduced headaches (RR, 0.45; 95% CI, 0.35-0.58; P < .001), visual disturbances or blindness (RR, 0.60; 95% CI, 0.41-0.88; P = .007), and papilledema (RR, 0.19; 95% CI, 0.10-0.34; P < .001). Procedures (RR, 0.44; 95% CI, 0.30-0.63; P < .001) and mortality (RR, 0.36; 95% CI, 0.18-0.73; P = .003) were lower in the GLP-1 group, but mean (SD) body mass index (BMI) did not differ at follow-up (40.6 [9.2] vs 39.5 [8.7]; P = .10). Bariatric surgery was associated with greater weight loss, but GLP-1 RA therapy was associated with better outcomes.

For early syphilis treatment, one dose of 2.4 million units of benzathine penicillin G was noninferior to treatment with three doses with regard to serologic response 6 months after treatment: 76% of people in the single-dose group responded to the penicillin, based on blood tests, compared to 70% of those in the three-dose group, in 249 randomized patients, including 61% HIV infected.

Women with hysterectomy  showed 9% higher stroke risk (HR: 1.09, 95% CI: 1.04-1.15) compared with no hysterectomy and for bilateral oophorectomy (HR: 1.13, 95% CI: 1.09-1.17) compared with no bilateral oophorectomy. The difference does not reach clinical significance, which would be a HR of 2 in this observational study. And the confounder of obesity may have contributed to both and was not controlled in this meta-analysis of >2 million.

Medicare Advantage patients accounted for an estimated 1.8 million additional hospital bed-days, equivalent to 288,000 additional admissions with average length of stay compared to fee for service Medicare between 2017-2023. Most of it was driven by delayed skilled nursing facility transfer due to approval denials.

At the Ohio PALTMed symposium last weekend, the National PALTMed President, Dr. von Preyss Friedman talked about the in March revised Ftag– F841 Responsibilities of the Medical Director is being really focused on by surveyors in Ohio, but probably across the nation. PALTMed has made it easier to become a Certified Medical Director (CMD) with online courses, and removing the 2 year waiting period before the course can be taken. California since 2021, and by January 1, 2026 Florida will require, nursing home medical directors must hold, or be actively pursuing, certification as a Certified Medical Director through PALTmed or an equivalent credential recognized by the state’s Agency for Health Care Administration (AHCA).

The conference was an excellent and included a presentation on dental care in long term care. Smiles for Life curriculum recommends to apply topical silver diamine flouride (SDF) for caries prevention and early stage caries in patients who cannot see a dentist or would be traumatized with a drill, such as patients with dementia.

The COCA call on Thu Sept 18 at 2-3 pm is: The Path of Yeast Resistance: Drug-resistant Candida on the Rise. Click here to join. Registration is not required, it is free and provides continuing education credit. As all COCA calls, it will be recorded for later viewing.

The OMDA call on Thu Sep 18th at 8 am is: Obesity, Weight Loss and Cardiometabolic Health, Katrina Mattingly, MD, Options Medical Weight Loss