Geriatric Update Dec 9, 2024

Life expectancy at birth rose in high-income nations by approximately 30 years from 1900 to 1990, from 50 to 80 years, largely driven by advances in public health and medicine. In the eight countries with the longest-lived populations (Australia, France, Italy, Japan, South Korea, Spain, Sweden and Switzerland) and in Hong Kong and the United States from 1990 to 2019, improvements overall in life expectancy have decelerated, probability of current birth cohorts surviving to age 100 is 5.1% for females and 1.8% for males. Survival to age 100 years is unlikely to exceed 15% for females and 5% for males by the end of the century, unless the processes of biological aging can be markedly slowed (DNA methylation, epigenetic aging, inflammation, the accumulation of senescent cells, and changes in mitochondrial function) radical human life extension is implausible in this century. Certain interventions have looked very promising, such as GLP-1s, metformin, rapamycin, polyphenols, and others. 

Life expectancy in the United States is expected to increase to 79.9 years in 2035 and 80.4 years by 2050, up from 78.3 years in 2022. This improvement is slower than other countries, dropping the US ranking from 49th in 2022 to 66th in 2050 among 204 countries around the world.

In the 30-year period before type 2 diabetes diagnosis, 14,179 (11.2%) individuals with diabetes and 17,871 (4.7%) comparisons experienced cardiovascular disease (CVD) evens, MI or stroke, odds ratio (OR)s ranging from 2.18 (95% CI: 1.91-2.48) in the earliest period (25-30 years before diagnosis) to 2.96 (95% CI: 2.85-3.08) in the latest period (<5 years before diagnosis). After diabetes diagnosis, 5-year CVD incidence was also increased in individuals with diabetes vs comparisons (HR: 2.20; 95% CI: 2.12-2.27).

Those who consumed at least five servings of dark chocolate per week had a 21% lower risk of developing Type 2 diabetes than those who consumed dark chocolate less than once per month. Milk chocolate did not protected from Type 2 diabetes and led to more weight gain.

Some clinical trials showed that dark chocolate or cocoa can reduce blood pressure and improve insulin sensitivity and insulin resistance, which influence the risk of developing Type 2 diabetes.

Diabetes and pre-diabetes led to a higher risk of all-cause mortality (RR, 1.61 and 1.08, respectively), through cancer, respiratory diseases, liver diseases, and diabetic ketoacidosis or coma, and CVD mortality rates (RR, 1.59 and 1.10, respectively). Life expectancy was shorter in individuals with prediabetes and diabetes (0.7 and 4.2 years, respectively) at age 40 years.

Greater meat consumption was associated with increased incidence of type 2 diabetes, with HRs of 1·10 (95% CI 1·06–1·15) per 100 g/day of unprocessed red meat (I2=61%), 1·15 (1·11–1·20) per 50 g/day of processed meat (I2=59%), and 1·08 (1·02–1·14) per 100 g/day of poultry (I2=68%). Replacing processed meat with unprocessed red meat or poultry was associated with a lower incidence of type 2 diabetes. Among 1,966,444 adults eligible for participation, 107,271 incident cases of type 2 diabetes were identified during a median follow-up of 10 (IQR 7–15) years.

Among those with employer-sponsored insurance, adults avg age 46.3 years with a baseline BMI of 30 were estimated to spend 7% less following the loss of 5% of BMI and 30% less following the loss of 25% of BMI. Similar results were found for Medicare adults.

In patients with atrial fibrillation (a-fib), direct anticoagulation compared to antiplatelet use showed higher risk of intracranial hemorrhage, but this was driven only by rivaroxaban OR, 2.09 (95% CI, 1.20-3.64); dabigatran, OR, 1.00 (95% CI, 0.61-1.64); and apixaban, OR, 0.72 (95% CI, 0.44-1.17) and similar results for major hemorrhage.  Hemorrhage risk should not be an argument for not using apixaban in the treatment of a-fib in older adults.

In Korean patients with a-fib, age 72, and stable coronary artery disease, edoxaban monotherapy led to a lower risk of a composite of death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, or major bleeding or clinically relevant nonmajor bleeding at 12 months than therapy with edoxaban plus a single antiplatelet agent, (hazard ratio, 0.44; 95% confidence interval [CI], 0.30 to 0.65; P<0.001).

The antiviral drug molnupiravir, given early, halved the risk of COVID-19 death and reduced all-cause deaths among 74,541 older COVID patients, >65 years, in a nationwide cohort study of the Czech Republic in 2022: 30-day all-cause mortality, adjusted HR 0.58 (95% CI, 0.53 to 0.64; p<0.001) and 30-day COVID-19-related mortality: adjusted HR 0.50 (95% CI, 0.42 to 0.58; p<0.001). Effect was highly significant regardless of sex, DCCI score, hospitalization status, COVID-19 vaccination status, and age. While not as effective as Paxlovid, molnupiravir is an option for patients with drug interactions to Paxlovid.

A clinical trial initiated in early 2020 investigated the effect of the BCG vaccine injected during active infection, within 14 days of symptom onset, now looked on the effect on long-COVID symptoms: reduced hearing, concentration, memory, vision and sleeping problems, and long COVID-19 symptoms.

A systematic review of 18 randomized clinical trials (out of 1464 studies), interventions of increased water intake (or decreased intake in 1 study) were associated with statistically significant greater weight loss and fewer kidney stones,  and single studies suggested benefits related to migraine prevention, urinary tract infection, diabetes control, and hypotension but did not reach statistical significance. The review did not list the ages of participants, and in this video, the commentator recommended using thirst as a guide. Neither the study nor the commentator acknowledged that most older adults do not feel thirsty and do not drink enough.  I find 2 liters of water daily to be safe and beneficial for my patients, but struggle to get them to drink this much that they need, as they cannot concentrate their urine as effectively as younger patients and thus lose more fluid.

Supplementation with 2000 IU/d vitamin D and/or 1 g/d marine omega-3s and/or exercise, strength-training exercise program of 30 min three times per week, did not reduce the incidence of sarcopenia in a randomized trial of 2157 community-dwelling, healthy adults aged 75, from 2012 to 2018. 

Overall, 31% of adults aged ≥65 years were acetaminophen users. Compared with non-users, users had higher risks for peptic ulcer bleeding (adjusted hazard ratio, 1.24), uncomplicated peptic ulcers (1.20), lower gastrointestinal bleeding (1.36), heart failure (1.09), hypertension (1.07), and chronic kidney disease (1.19). I have not seen an increased risk of GI, kidney or heart problems with acetaminophen in my practice and wonder if some used NSAIDs, or avoided NSAIDs because of previous problems?