Geriatric Update Dec 29, 2024

The SELECT trial showed that weekly semaglutide 2.4 mg reduced the incidence of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke by 20% at a mean follow-up of 39.8 months in obese patients without diabetes, age 45. The expanded use in patients with obesity led to a shortage of GLP-1 meds.

The American Diabetes Association (ADA)’s Standards of Care — 2025 offer new guidance on:

• Broader use of continuous glucose monitoring (CGM),

• Use of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for heart and kidney health, to maintain weight loss, and how to manage drug shortage alternatives

• Antibody-based screening for presymptomatic T1D

• Management of metabolic dysfunction-associated liver disease (MAFLD),

• Strong endorsement for drinking water instead of sugar or nonnutritive sweetened soda

• Screen for psychosocial issues

The shortage of GLP-1 meds allowed compounding pharmacies to sell copies. This article makes some recommendations for using compounded GLP-1 meds: 

• Use a copy of an FDA approved drug rather than a semaglutide salt with other ingredients and no safety profile. 

• Compounded by a 503B pharmacy, which is subject to an additional layer of FDA regulation over 503A, offering greater quality assurance, in wake of the meningitis outbreak in 2012 with compounded drugs.

• Use a physical rather than online pharmacy and request a certificate of analysis. 

Semaglutide more than doubles the risk of the rare condition NAION (non-arteritic anterior ischemic optic neuropathy), which can lead to severe and permanent loss of vision through damage to the optic nerve of the eye. Two Danish studies 424,152 persons with type 2 diabetes showed an increase from 67.6 to 148.0 following the introduction of semaglutide, and confirmed an earlier US study. And an incidence of 2.19/10,000 person-years among Danish semaglutide initiators, compared to 1.18 among SGLT-2i initiators. In contrast, 9.60 million people in the US have diabetic retinopathy (26.43% of those with diabetes), Of these, 1.84 million were living with vision-threatening diabetic retinopathy.

The FDA approved tirzepatide, a glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) med for the treatment of moderate to severe obstructive sleep apnea (OSA) in adults with obesity, to be used in combination with a reduced-calorie diet and increased physical activity.

Lower oxygen levels (mean SpO2) during sleep, such as during sleep apnea, were associated with enlarged white matter hyperintensities (WMH) volumes (bWMH = −0.095 [−0.164 to −0.025]) and larger hippocampal volumes on MRI, indicating dementia, over 10 years in Hispanic/Latino adults, mean age 67.6 years, with a body mass index of 29.7. 

FDA adds warning about rare occurrence of serious liver injury with use of Veozah (fezolinetant) for hot flashes due to menopause.

Heart failure/cardiomyopathy-related mortality increased among patients with obesity from 0.41 in 1999 to 0.94 in 2019, corresponding to an alarming average annual increase of 3.78%. Men, Black patients, and patients in rural areas had higher age-adjusted mortality rates.

A Swedish study showed higher sugar intake associated with higher mortality from stroke and abdominal aortic aneurysm, but the associations were not strong. Sweden’s sugar consumption doesn’t even rank in the top 10.

With 126 grams of sugar per person per day, the US is the country that consumes the most sugar, followed by Germany with 103 grams.

Physical health rehabilitation programs with aerobic exercise regimens, and cognitive behavioral therapy, were most effective in improving both mental health and physical symptoms among patients with long COVID. Other interventions, such as various medications and vitamin supplements, inspiratory muscle training, transcranial direct current stimulation, hyperbaric oxygen, and education sessions were not effective in reducing the symptoms of long COVID.

Tests for osteoarthritis, usually x-rays have high rates of false positive and negative results. The cartilage oligomeric matrix protein concentration and the cartilage oligomeric matrix protein to Interleukin-8 ratio were established and validated using 171 human knee synovial fluid specimens and demonstrated clinical sensitivity and specificity of 87.0% and 88.9%, respectively.

Triamcinolone Acetonide (TA) knee injections in patients who have knee osteoarthritis and type 2 diabetes mellitus, extended release had better glucose outcomes at postinjection days 1 to 3: the TA-extended release (ER) (n=18) versus TA-immediate release (IR) group (n = 15) had:  

• Lower median change from baseline in maximum glucose level (92.3 versus 169.1 mg/dL),

• Reduced percentage of time with a glucose level >250 mg/dL (12 versus 26%),

• Smaller proportion of patients who had a maximum glucose level >250 mg/dL (50 versus 93%),

• Greater percentage of time in the target glucose range (62 versus 48%)

• Less glycemic variability and lower glucose spikes

This article discusses presentations of the most common forms of dementia.

• Alzheimer's disease, most common dementia, presents with mainly memory issues and word-finding deficits early in its course; depression, apathy, irritability, and poor sleep are also common.

• Vascular dementia often occurs concurrently with other dementia forms. However, in isolation, its features include deficits in attention, processing speed, and executive function as well as mood disorders.

• Lewy body dementia is the only common dementia form associated with visuospatial and motor deficits early on, parkinsonism symptoms and has a high concurrence with disordered mood.

• Frontotemporal dementia prompts family members to report personality changes and aggression, increases in impulsivity and poor judgement. Seen mostly in younger patients (age 45–60 years) and not associated with depression.