Geriatric Update Mar 10, 2025

Measles cases are reported each Friday, and as of 3/7/2025 there are 222 cases in 9 states for the 2+ months of 2025, up from 285 in all of 2024 and 59 in 2023.  All, including the 2 deaths were in unvaccinated patients, 11% had been recently or under-vaccinated, the vaccine takes 2 weeks to take effect. Signs and symptoms are fever, Koplik spots and maculopapular rash.

The 2025 ACC/AHA/… Guideline for the Management of Patients With Acute Coronary Syndromes was released. These are the new and most pertinent points:

• Dual antiplatelet therapy (DAPT) with aspirin and an oral P2Y12 inhibitor for >12 months.

• Ticagrelor, if tolerated, monotherapy is recommended ≥1 month after PCI.

• In long-term anticoagulation, aspirin discontinuation is recommended 1 to 4 weeks after PCI with continued use of a P2Y12 inhibitor (preferably clopidogrel).

• In this high-risk population intensify lipid-lowering therapy to low-density lipoprotein (LDL) cholesterol 55 to <70 mg/dL.

The new 2025 dyslipidemia guideline from the American Association of Clinical Endocrinology (AACE) for adults with evidence-based recommendations focus on outcomes that are important to patients:  

• Lowering low-density lipoprotein cholesterol (LDL-C) treatment goal of <70 mg/dL in adults with dyslipidemia and ASCVD or at increased risk of ASCVD, with little and no benefit of <55 mg/dL. 

• Limited evidence was available to support widespread use of nontraditional risk factors for atherosclerotic cardiovascular disease (ASCVD) risk assessment such as coronary artery calcium, lipoprotein(a), and apolipoprotein B but may be beneficial in individuals who are at intermediate risk and would like additional information in deciding on treatment.

• Use of alirocumab, evolocumab, or bempedoic acid in addition to standard care for adults who have ASCVD or who are at increased risk for ASCVD but not for those without ASCVD. 

• Hypertriglyceridemia and ASCVD or at increased risk for ASCVD, the task force suggested the use of omega-3 eicosapentaenoic acid, but not the addition of docosahexaenoic acid and strongly against the use of niacin.

• There was insufficient evidence for recommendations regarding pharmacologic management in adults with severe hypertriglyceridemia (≥ 500 mg/dL).

The highest butter intake was associated with a 15% higher risk of mortality vs. the lowest intake (hazard ratio [HR], 1.15; 95% CI, 1.08-1.22), while the highest intake of total plant-based oils vs. the lowest intake showed a 16% lower total mortality (HR, 0.84; 95% CI, 0.79-0.90; P for trend < .001) over 33 years of follow-up among 221,054 adults in the Nurses Health and Health Professionals studies, age 56 at baseline. Every 10-g/d increment in plant-based oils intake was associated with an 11% lower risk of cancer mortality and a 6% lower risk of CVD mortality, whereas a higher intake of butter was associated with a 12% higher cancer mortality. Substituting 10-g/d intake of total butter with an equivalent amount of total plant-based oils was associated with an estimated 17% reduction in mortality and cancer.

Intentional weight loss coupled with measured reduction in waist circumference was associated with significantly lower mortality risk over 18.6 years of follow-up for all-cause, cancer, and cardiovascular mortality, based on 58,961 women in the health initiative study, aged 50 to 79 years at baseline. In contrast, measured intentional weight reduction alone was associated only with lower cardiovascular mortality risk, indicating the visceral fat inflammatory effect on cancer. Exercise is the best way to decrease waist circumference.

Waist circumference and height predicted body fat percentage 0.71 (95% CI, 0.59-0.79) as the most significant statistical associations with chronic kidney disease, better than BMI.

In older patients, mean age 58 years, with type 2 diabetes (T2D), the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors is associated with increased cardiovascular benefits but reduced glycemic control, whereas glucagon-like peptide 1 (GLP-1) receptor agonists show the opposite, with better glycemic control but less cardiovascular protection. Dipeptidyl peptidase (DPP-4) inhibitors were half as effective as the GLP-1 agonists.

Of 125,474 patients starting GLP-1 meds, 46.5% of patients with and 64.8% without type 2 diabetes discontinued within 1 year; 47.3% of patients with and 36.3% without type 2 diabetes subsequently reinitiated a GLP-1 med within 1 year. Weight loss, income, and adverse events were significantly associated with discontinuation, while weight regain was significantly associated with reinitiation.

Over 2013-2020, a higher incidence of vertebral fractures occurred in 1,333 Korean women >65 on SGLT2 meds, propensity score matched with 2,626 non-SGLT2 users (incidence rate 19.2 vs. 13.8 per 1,000 person-years; hazard ratio 1.40, 95 % confidence interval 1.00-1.96, p = 0.049). No significant difference was noted in other types of fracture.

Higher psoriasis severity is more likely to be reported by individuals with low vs high adherence to health-promoting dietary patterns: the Dietary Approaches to Stop Hypertension (OR 3.75), and the Plant-based Diet Index (OR 4.04), Mediterranean Diet Score (medium adherence OR 2.39).

Plasma phosphorylated tau 217 concentrations detected Alzheimer’s pathology across neurodegenerative syndromes with an area under the receiver operating characteristic curve (AUC) of 0.95, better than  neurofilament light chain (NfL) AUC 0.73, and glial fibrillary acidic protein (GFAP) AUC 0.75. Last month I mentioned a study: NfL and GFAP levels, but not change in the amyloid-β42/40 ratio or phosphorylated tau 181, predicted cognitive impairment.  I have not seen follow up studies of the anti-amyloid treatments for Alzheimer disease that reported patient improvements, like the GLP-1 meds did for diabetes and obesity, so I question the benefit of biomarkers at this point, with the lack of effective treatment. 

Aspirin prevents cancer metastasis by limiting platelet thromboxane A2 (TXA2) suppression of T cell immunity in mice. I agree with my geriatrics colleague, Dr. Smith that it is not actionable for our patients at this point.  

Geriatricians perform 7 actions when caring for patients through the surgical continuum: conduct risk-benefit analysis of surgical referral, elicit and communicate patient goals, prepare patient and family for surgical consultation, set realistic expectations, assist with decision about surgery, advocate for patient and family, and coordinate postoperative care, as identified in a qualitative analysis.

Multimorbidity, functional impairment, and dementia were more common in the low wealth group and mediated the association of higher symptom burden at the end of life, with functional impairment being the strongest mediator.

Electronic health record (EHR) workload increased during COVID and has remained elevated since. Primary care physicians received the most patient medical advice request messages and patient phone calls, with a mean of 24 patient calls and 16 patient medical advice request messages per week. EHR work consumes about 50% of scheduled clinic time and has been associated with burnout. In 2017 physicians spent 3.08 hours on office visits and 3.17 hours on desktop medicine each day, this has increased, including insurance denials.

The addition of combined oral and topical antimicrobial therapy for male partners to treatment of women for bacterial vaginosis halved the recurrence of bacterial vaginosis within 12 weeks 35% vs. 63% in the control group.

With cuts to Medicaid in the news, it is funded by both states and the federal government, covers about 1 in 5 US adults and 40% of US children. It pays for 40% of births and 60% of nursing home residents. This map shows percentages of residents covered by Medicaid by state.