Geriatric Update Oct 21, 2024

Metformin has shown benefit in animal and observational human studies but in a randomized trial of prostate cancer, biopsies at 18 and 36 months showed no difference in 407 patients, age 63. Metformin plus standard treatment, compared to standard treatment alone, did not improve overall prostate cancer survival in 1874 Spaniards, age 69. Animal studies used much higher doses, leading to acidification, but would be toxic in humans. Observational studies showed benefit because of the "immortal time bias." It makes any drug, metformin or otherwise, look like it helps patients to survive because it can only be taken by people who are alive, and journals are more likely to publish studies that show benefit.

People with mild memory issues, whose brain showed a greater number of brain areas with shrinkage on MRI, and more quickly over time,  are more likely to develop Alzheimer’s disease. Consistent with the diverse presentation of dementia, there was no uniform pattern to the way the brain shrank in those who developed Alzheimer’s. My theory is that depending on how many brain cells in a given area we are born with and how fast they atrophy due to unuse, or are destroyed by trauma or inflammation, determines the symptoms.

Guidelines for blood pressure (BP) measurement recommend arm support on a desk with the midcuff positioned at heart level. An unsupported arm at the side overestimated systolic BP by 6.5 mm Hg and diastolic BP by 4.4 mm Hg, and supporting the arm on the lap overestimated systolic BP by 3.9 mm Hg and diastolic BP by 4.0 mm Hg, with consistent results across subgroups in a crossover randomized clinical trial of 133 adults.

This short article on out of hospital cardiopulmonary resuscitation (CPR) was full of useful information I didn't know:

• In the US 40%, but in Norway, for example, 85% of all patients who experience out-of-hospital cardiac arrest receive bystander CPR before an ambulance arrives.

• Women and blacks are less likely to receive CPR, due to bias, but also fewer have a shockable rhythm because of cardiomyopathy, or other diagnoses.

• CPR can change 10% of unshockable rhythms into shockable ones, where an AED, automated external defibrillator, can help.

Pulmonary vein isolation decreased atrial fibrillation from baseline to 6 months by 60.31% in the ablation group and 35.0% in the sham group (geometric mean difference, 0.25; 95% CI, 0.15-0.42; P < .001) and significantly improved quality of life. Pulmonary vein isolation is cardiac ablation that uses heat or cold energy to create tiny scars in the heart to block irregular electrical signals and restore a regular heartbeat.

Eating patterns as a whole were more strongly associated with kidney health than intake of specific nutrients.

Exposure to tramadol was associated with an increased risk of dementia  over 14 years. Use of 15 to 90 days: aHR 1.14, 95% CI 1.10–1.35, >90 days: aHR 1.18, 95% CI 1.00–1.39; among 41,963 propensity matched older adults age >60. Tramadol is on the Beers list and should not be used in older adults. It is also associated with hypoglycemia, even in patients without diabetes, increased mortality, DVT and hip fracture.

Benzodiazepines should not be used by older adults, yet deprescribing is a challenge.  Masked taper plus cognitive behavioral therapy (CBTI)-augmented program (MTcap) increased deprescribing significantly over standard CBTI plus supervised (unmasked) gradual taper (SGT). Discontinuation at 6 months (MTcap = 64 [73.4%], SGT = 52 [58.6%]; odds ratio [OR], 1.95; 95% CI 1.03-3.70; P = .04) and 1 week posttreatment (MTcap = 76 [88.4%], SGT = 62 [67.4%]; OR, 3.68; 95% CI, 1.67-8.12; P = .001) and reduced frequency of benzodiazepine receptor agonist use (nights/week) at 1 week posttreatment (-1.31; 95% CI, -2.05 to -0.57; P < .001). Insomnia Severity Index improved with no significant difference between groups at follow-up among the 188 participants (age, 69.8 years).

Primary open angle glaucoma was associated with higher risk in dihydropyridine calcium channel blocker users (OR: 1.31, 95% CI: 1.14-1.50, P < 0.001) such as amlodipine or nifedipine.

With charges for patient portal messages, patients may expect faster, more detailed replies to their messages and physicians express concern that patients may decide not to share important medical information to avoid charges, based on survey responses from 13 patients and 16 primary care physicians.

Of 744,078 patients, laypersons administered naloxone to 24,990 patients, accounting for 3.4% of all EMS activations with naloxone administration. Over 3 years EMS-documented naloxone administration rates fell 6.1%, but the percentage of people who got naloxone from a layperson before EMS arrival increased 43.5%.