Geriatric Update Sep 30, 2024

Free COVID test are again available. Order online, or by calling 1-800-232-0233 (TTY 1-888-720-7489).

A new nasal vaccine raised nasal spike-specific secretory IgA against 10 strains of SARS-CoV-2, 4.5 fold of after the first dose, and much higher to 51.5 fold after the second dose. Serum neutralizing titers also increased modestly. While the first dose didn’t offer high protection from COVID or transmission (43 of 75 participants got infected), after the second nasal dose 86% remained uninfected 3 months out, at a time with high levels of circulating virus in high-risk healthcare professionals. 

In comparison, high-dose, adjuvanted and recombinant influenza vaccines ("enhanced influenza vaccines") were more effective than standard-dose unadjuvanted influenza vaccines for prevention of influenza-associated hospitalizations among 71 million persons aged ≥65 years. No significant difference in efficacy was found between enhanced vaccines.

Hearing aids and counseling by an audiologist improved communication skills as measured with the Hearing Handicap Inventory-Elderly Screening (HHIE-S), by −8.9 (95% CI: −10.4, −7.5) points between intervention and control groups, who received health information, from baseline to 6 months, −9.3 (95% CI: −10.8, −7.9) to Year 1, −8.4 (95% CI: −9.8, −6.9) to Year 2, and − 9.5 (95% CI: −11.0, −8.0) to Year 3. HHIE-S is a 10-item subjective questionnaire that assesses how hearing loss affects an individual's social and emotional life and yields a total score between 0–40, higher scores indicate greater impairment.

Some patients with atrial fibrillation (A-fib) on anticoagulation, still experience ischemic stroke. This study showed that left atrial appendage occlusion (LAAO) lowered ischemic stroke per year to 2.8% vs 8.9% in the control group (hazard ratio, 0.33; 95% CI, 0.19-0.58; P < .001). Anticoagulation was discontinued in 290 patients (67%), and the remaining 143 patients (33%) continued it as an adjunctive therapy.

Finerenone reduced the worsening of heart failure in patients with preserved or mildly reduced ejection fraction (rate ratio, 0.82; 95% CI, 0.71 to 0.94; P=0.006), and reduced death from cardiovascular causes was 8.1% and 8.7%, respectively (hazard ratio, 0.93; 95% CI, 0.78 to 1.11), over 32 months, in a randomized trial of 6001 patients, age 72. There was an increased risk of hyperkalemia and a reduced risk of hypokalemia, so making sure our patients drink enough water will optimize our kidneys’ ability to clear excess potassium.  I would like to see a comparison trial between generic spironolactone, another mineralocorticoid, and finerenone because of the difference in cost, $10 vs. $700 a month.

A drug for schizophrenia, Cobenfy (xanomeline and trospium chloride), also influences dopamine levels, like current meds, but it does so indirectly, by adding an anticholinergic to block the neurotransmitter, acetylcholine. The new approach is hoped to address some of the most intractable aspects of the disease, like lack of motivation,  inability to feel pleasure and weight gain.

Body Roundness Index (BRI) is a better predictor of risk than body mass index (BMI), and those whose BRI increased during a six-year period had a 163% increased risk of heart disease, and even a moderate BRI was linked with a 61% increased risk. The multivariable adjusted HR for stroke incidence in the moderate‐stable group versus low‐stable group was 1.29 (95% CI, 1.08–1.54) and that for cardiac events was 1.14 (95% CI, 1.01–1.29). The HR for the high‐stable group versus low‐stable group was 1.46 (95% CI, 1.10–1.95) for stroke and 1.35 (95% CI, 1.09–1.67) for cardiac events The article includes the complicated formula, but here is a calculator.

Low grade systemic inflammation detected by high resolution C-reactive protein (hsCRP) was a stronger predictor of future cardiovascular events over the next 30 years than either LDL-C or Lp(a), yet in clinical practice hsCRP is the least likely biomarker to be measured by most clinicians, probably because we don’t have treatments. I would like to see long-term data on patient oriented outcomes, e.g. stroke or heart attack, with low-dose colchicine that has now been approved by the US FDA as the first targeted anti-inflammatory drug to prevent atherosclerotic events.

After a median of 78 days of dual antiplatelet therapy (DAPT) after coronary stenting in patients with acute coronary syndrome (ACS), continuing with only ticagrelor reduced bleeding by 57.0% (2.1% vs 0.9%; HR, 0·43; 95% CI, 0·34–0·54; P < ·0001 for superiority; τ² = 0·079) compared with aspirin and ticagrelor for 12 months. The incidence of all-cause death was 2.1% for DAPT compared with 0.9% for ticagrelor (HR, 0·76; 95% CI, 0·59–0·98). Continuation with ticagrelor was chosen because 20% of patients do not have an antiplatelet effect from aspirin. 

In patients on anticoagulation for A-fib, who experienced ischemic stroke: left atrial appendage occlusion (LAAO) lowered the event rate of ischemic stroke to 2.8% per patient-year vs 8.9% per patient-year in the control group (hazard ratio, 0.33; 95% CI, 0.19-0.58; P < .001). After LAAO, anticoagulation was discontinued in 290 patients (67%), and the remaining 143 patients (33%) continued OAT after LAAO as an adjunctive therapy. 

Deprescribing led to fewer hospitalizations by 8% in one study (HR, 0.92; 95% CI, 0.85–0.99) and 16% in another (HR, 0.84; 95% CI; 0.73–0.97) that shrank to 6% after 3 months. Even though these studies showed only a small benefit, in an individual patient, it is worthwhile to suggest deprescribing inappropriate medications, as this can significantly improve quality of life. Even if patients or their families do not agree with deprescribing at the first visit, it is worth readdressing to emphasize the importance and explain the reasons again. The Beers list is a good resource and the latest update from 2023 recommends the avoidance of anticholinergics, which include categories of muscle relaxants, antihistamines, and tricyclic antidepressants. Other categories include gabapentinoids, tramadol, benzodiazepines, and sleep medications. For more detail, see my commentary.

In 50–60-year-old men with PSA >3 ng/ml, followed for up to 8 years (median 3.9 years), omitting biopsy in patients with negative MRI results eliminated more than half of diagnoses of clinically insignificant prostate cancer, and the associated risk of having incurable cancer diagnosed at screening or as interval cancer was very low, 15 in the MRI-targeted biopsy group and 23 in the systematic biopsy group, of 6575 Swedish men (relative risk, 0.65; 95% CI, 0.34 to 1.24).

Happy International Older Person Day.