Geriatric Update June 10, 2024

 A 15-day course of Paxlovid in a population of 194 patients with postacute sequelae of SARS-CoV-2 infection (PASC), started on avg 17 months after infection, was generally safe but did not demonstrate a significant benefit for improving select PASC symptoms over placebo in a mostly vaccinated cohort with protracted symptom duration.

 In a Korean study of 322,289 patients with COVID-19, after adjusting for covariates, a 1-μg/m3 increase in air pollution with particulate matter PM10 and PM2.5 exposure was associated with 4% (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.03-1.05; P < 0.001) and 6% (OR, 1.06; 95% CI, 1.04-1.07; P < 0.001) increased risk of in-hospital mortality, respectively. In addition, a 1-μg/m3 increase in PM10 and PM2.5 was associated with 5% (OR, 1.05; 95% CI, 1.04-1.07; P < 0.001) increased risks of intensive care unit (ICU) admission and 8% (OR, 1.08; 95% CI, 1.06-1.10; P < 0.001) for mechanical ventilation.

The incubation period for human bird flu infection with A(H5N1) virus is generally 3-5 days, but has been reported to be as long as 10 days. Transmission is by aerosol and droplet, and treatment is oseltamivir, optimally within 48 hours. While no human to human transmission has occurred so far, U.S. Department of Health and Human Services’ assistant secretary for preparedness and response is moving ahead with a plan to produce 4.8 million doses of H5N1 avian flu vaccine for pandemic preparedness.

 Lolamicin, a new oral Gram-negative-only oral antibiotic acts by disrupting the Lol lipoprotein transport system. In addition to its Gram-negative spectrum of activity, lolamicin has high specificity for certain Gram-negative ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter) over commensal bacteria and is active in mouse models of infection while sparing the gut microbiome and preventing C. difficile infection.

 Magnesium has been shown to protect from dementia, and plasma levels are inversely proportional to the risk of cardiovascular and metabolic diseases, and death. This article describes new knowledge about absorption, storage in bone and immune effects. Hypomagnesemia is more common in patients with diabetes (10-30%), alcoholism, hospitalized (10-60%), in ICU (>65%) and those taking diuretics  and proton pump inhibitors (PPIs). Low calcium and potassium levels may only improve with magnesium normalization. Because most of it is intracellular, it may take a long time to replace the deficit.

 People who engaged in ≥1 sessions of vigorous physical activity per week had lower

• Rates of mild cognitive impairment (MCI) (13.9 vs 19.7 per 1,000 person-years), probable dementia (6.3 vs 9.0), and MCI/probable dementia (18.5 vs 25.8). 

• Lower risk of MCI (hazard ratio [HR] = 0.81; 95% confidence interval [CI], 0.68-0.97), probable dementia (HR = 0.80; 95% CI, 0.63-1.03), and MCI/probable dementia (HR = 0.82; 95% CI, 0.70-0.96). 

Nearly 60% of study participants reported vigorous physical activity at least once a week, even among those aged 75 years and older. The protective impact was more pronounced in younger patients, <75 years.

 In patients with obesity, compared to anti-obesity medications, semaglutide was associated with a significantly lower risk of recurrent alcohol use disorder (AUD) diagnosis (22.6% vs 43.0%; HR: 0.44, 95% CI: 0.38–0.52), which was consistent across gender, age group, race and regardless if diabetes was a diagnosis. Compared to naltrexone or topiramate, semaglutide was associated with a significantly lower risk of incident (new) AUD diagnosis (21.5% vs 59.9%; HR: 0.25, 95% CI: 0.21–0.30), also regardless of demographics. In patients with diabetes, compared to non-GLP-1RA anti-diabetes medications, semaglutide was associated with a significantly lower risk of incident AUD diagnosis (0.32% vs 0.52%; HR: 0.56, 95% CI: 0.43–0.74), also in recurrent AUD diagnosis (23.4% vs 33.2%; HR: 0.61, 95% CI: 0.50–0.75), regardless of obesity status and other demographics. This is based on a large database review of TriNetX over 12 months, and at f/up over 2 and 3 years the numbers slightly attenuated but remained significant.

 The US Preventive Services Task Force (USPSTF) concluded with moderate certainty that exercise interventions provide a moderate net benefit in preventing falls and fall-related morbidity in Community Living older adults, age >65, at increased risk for falls and moderate certainty that multifactorial interventions provide a small net benefit.

 The Endocrine Society published updated guidelines on Vitamin D supplementation.

• There was no significant effect on select outcomes in healthy adults aged 19 to 74 years with variable certainty of evidence.

• There was a very small reduction in mortality among adults older than 75 years with high certainty of evidence.

• In pregnant women, low-certainty evidence suggested possible benefit on various maternal, fetal, and neonatal outcomes.

• In adults with prediabetes, moderate certainty of evidence suggested reduction in the rate of progression to diabetes.

Administration of high-dose intermittent vitamin D may increase falls, compared to lower-dose daily dosing.

 The 2024 Guideline for the Management of Lower Extremity Peripheral Artery Disease (PAD) was established by 11 national associations!  Dr. Rakel summarized the findings nicely in a commentary:

• Diagnose using ankle brachial index measurement (ABI) that can be done in clinic.

• Support smoking cessation.

• Manage diabetes to reduce chronic blood sugar elevation.

• Aggressively treat hypertension with a blood pressure goal of less than 130/80 mm Hg

• Manage elevated lipids.

• Treat depression.

• Strongly encourage avoidance of highly processed food.

• Exercise: walking has the best evidence and helps mobilize edema fluid.

 A small study of 90 men aged 47, BMI 25.7 kg/m2, showed total volumetric bone mineral density was significantly lower in patients with OSA than in controls and in severe vs mild or moderate OSA. Hypopnea index and percentage of total sleep time with SpO2 < 90% were both positively correlated with alkaline phosphatase, a marker of bone turnover. I would like to see a larger study and a trial if treatment with CPAP, etc. would attenuate bone loss.

 Xylitol, often used to lose weight or control diabetes, is associated with an increased risk of a major adverse cardiovascular event such as a heart attack 1.57 (1.12–2.21). The mechanism may be through clotting as the study found that those who drank the xylitol beverage showed a marked increase in clotting ability of their blood right after they ingested it.

 Thank you, Joe for this study that showed  that a 1-g increase in 24-hour urine sodium excretion was associated with increased odds of atopic dermatitis/ eczema (AD) (adjusted odds ratio [AOR], 1.11; 95% CI, 1.07-1.14), increased odds of active AD (AOR, 1.16; 95% CI, 1.05-1.28), and increased odds of increasing severity of AD (AOR, 1.11; 95% CI, 1.07-1.15), based on 215,832 UK biobank participants age 56.5. Similar results from a validation cohort of 13,014 participants from the National Health and Nutrition Examination Survey, a 1 g per day higher dietary sodium intake estimated using dietary recall questionnaires was associated with a higher risk of current AD (AOR, 1.22; 95% CI, 1.01-1.47).

 The American Geriatrics Society (AGS) wrote a letter in preparation to an upcoming meeting of the Food and Drug Administration (FDA) advisory committee to review the safety and efficacy of donanemab’s Phase 3 trial, an anti-amyloid drug that is being investigated for early Alzheimer’s disease. The AGS expresses concern around the adverse effects, most notably amyloid-related imaging abnormalities (brain swelling and bleeding), seen in 37% of the donanemab group vs. 15% with placebo. AGS outlines additional gaps in knowledge that the advisory committee should consider, including diversity of trial participants and meaningful outcomes.

 Canada legalized cannabis for non-medical use 2018-2020, the rate of ED visits was substantially higher for older Canadians, age 69.5, than prelegalization (15.4 vs 5.8 per 100 000 person-years; adjusted IRR, 2.00; 95% CI, 1.29-3.10). After additional legalization of edible cannabis in 2020, the rate of ED visits (21.1 per 100 000 person-years) was even greater (adjusted IRR, 3.08; 95% CI, 2.04-4.65).

 The uninsured rate among Black Americans fell from 20.9% in 2010 to 10.8% in 2022, among Latinos from 32.7% to 18% and among American Indians and Alaska Natives from 32.4% to 19.9% during that time.

 Use of a virtual scribe was associated with significant decreases in total electronic health record (EHR) time per appointment (mean [SD] of 5.6 [16.4] minutes; P < .001) in the 3 months after vs the 3 months prior to scribe use. Scribe use was also associated with significant decreases in note time per appointment and pajama time per appointment (mean [SD] of 1.3 [3.3] minutes; P < .001 and 1.1 [4.0] minutes; P = .004).

 A Canadian study showed reduction in hospitalization and ED use among patients with the highest rate of primary care continuity, who were older and had more medical complexity, and even more if the patient was seen at the same clinic by the PCP's partners, building a relationship. This reduction in ED use was also observed among younger patients with less complexity. In a commentary, Dr. Rakel wrote: The average amount of healthcare payment that goes to primary care in the US is 5 cents per dollar. When this is doubled, there is a fivefold return on investment in reducing healthcare costs. Investing 5 cents more per dollar in primary care results in a fivefold return on investment (5 for 5!).

 Night before last I was awoken by a dozen gunshots behind my house that sent 3 people to the hospital. Sharing my trauma, someone suggested I get a gun for protection. I did a literature search and found on average, guns did not protect those who possessed them from being shot in an assault. After adjustment, individuals in possession of a gun were 4.46 (P < .05) times more likely to be shot in an assault than those not in possession. Among gun assaults where the victim had at least some chance to resist, this adjusted odds ratio increased to 5.45 (P < .05).

 Here is my practice Update commentary on inappropriate medications prescription and health-related quality of life, and emergency room and hospital readmissions.

 At the AMDA conference in San Antonio, I was interviewed for an AMDA On-The-Go podcast: Deprescribing of Anticoagulants: The IF, WHEN and HOW, a Discussion with a Cardiologist.