What's new in geriatrics

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

GENERAL GERIATRICS

Mortality in older persons after short-term weather disasters (April 2024)

Severe weather events damage infrastructure and disrupt society, leading to direct and indirect impacts on health that can disproportionately affect vulnerable populations, including older adults. In an analysis of 42 short-term weather disasters in the United States between 2011 and 2016, emergency department utilization and mortality were higher among traditional fee-for-service Medicare beneficiaries in affected counties compared with matched control counties in the week following the disaster [1]. Higher rates of mortality persisted for six weeks and translated to an estimated 20 to 31 excess deaths per storm in the post-disaster week. Targeted solutions to minimize disruptions to health care delivery may help reduce adverse health impacts of weather events in older persons and other vulnerable populations. (See "Climate emergencies", section on 'Hurricane and flood risks to health'.)

Point-of-care decision support tool for older adult care (February 2024)

Overtesting and overtreatment can lead to adverse health outcomes in older adults. In a trial conducted among 60 outpatient practices, a point-of-care, clinical decision support tool utilizing behavioral principles plus brief case-based education resulted in lower annual rates of three outcomes (prostate-specific antigen testing in men aged 76 years and older without previous prostate cancer, urine testing for nonspecific reasons in women aged 65 years and older, and overtreatment of diabetes in patients aged 75 years and older) when compared with brief case-based education alone [2]. Clinical decision support tools may aid in preventing unnecessary testing and treatments. (See "Geriatric health maintenance", section on 'Appropriate goals of care for older adults'.)

Risk of fractures with benzodiazepine receptor agonists (January 2024)

Benzodiazepine receptor agonists (BZRAs), including benzodiazepines and nonbenzodiazepine BZRAs such as zolpidem, can cause excess drowsiness and imbalance leading to falls and fractures. In a recent meta-analysis of 20 observational studies in over six million individuals, BZRAs were associated with increased risk of osteoporotic fractures across a range of drug classes and fracture types, with odds ratios ranging from 1.2 to 1.4 [3]. Most but not all studies included adults 50 years of age or older. These data reinforce the need for caution in prescribing BZRAs for insomnia and other indications, particularly in older adults. (See "Pharmacotherapy for insomnia in adults", section on 'Special populations'.)

GERIATRIC INFECTIOUS DISEASES

Second dose of a 2023-2024 COVID-19 vaccine for individuals 65 years and older (April 2024)

In the United States, a single dose of an updated 2023-2024 formula COVID-19 vaccine is recommended for all immunocompetent adults and adolescents, regardless of prior vaccination history. In February 2024, the Centers for Disease Control and Prevention (CDC) updated its guidance to recommend a second dose (at least four months after the prior dose) for individuals 65 years and older [4]. Rates of COVID-19-associated hospitalization and death are higher in this age group than in any other, and the repeat dose is intended to improve protection by restoring the waning immune response; the 2023-2024 vaccine elicits response against currently circulating variants. Our recommendations are consistent with those of the CDC. (See "COVID-19: Vaccines", section on 'Adults 65 years and older'.)

Precautions for individuals with COVID-19 in the community (April 2024)

In March 2024, the United States Centers for Disease Control and Prevention updated guidance for precautions for people with COVID-19 in the community [5]. Such individuals should stay at home until their symptoms are improving and they have been afebrile for 24 hours without the use of antipyretics. They can subsequently resume normal activities but are encouraged to use other precautions (eg, masking, social distancing, good ventilation) for an additional five days to further reduce the risk of transmission to others. These measures are particularly important when around persons who are at increased risk for severe disease (eg, advanced age, immunocompromise, cardiopulmonary disease). (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Simnotrelvir-ritonavir for mild to moderate COVID-19 (January 2024)

Although nirmatrelvir-ritonavir reduces hospitalization and death from COVID-19, the many drug interactions make it difficult to use in some patients. Simnotrelvir-ritonavir is a similar protease inhibitor combination that inhibits viral replication but does not have as many drug interactions. In a randomized, double-blinded study of over 1000 patients with mild to moderate COVID-19 (majority fully vaccinated), 5 days of simnotrelvir-ritonavir reduced time to symptom resolution by 1.5 days [6]. Since no participant progressed to severe disease or died by day 29, it is unknown whether the drug prevents hospitalizations or death from COVID-19. Simnotrelvir-ritonavir has emergency use approval in China but is not yet approved for use in other countries. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Therapies of limited or uncertain benefit'.)

2024 immunization schedule for adults (January 2024)

The United States Centers for Disease Control and Prevention has published the 2024 immunization schedule for adults (figure 1 and figure 2) [7]. Respiratory syncytial virus (RSV) vaccine is a new addition to the schedule; it is recommended for pregnant people 32 to 36 weeks' gestation during RSV season and is an option for adults ≥60 years of age. Mpox vaccine has also been added and is recommended for adults of all ages who are at risk for infection. Other changes include updates to COVID-19, polio, and meningococcal vaccine recommendations. Our approach to immunization is largely consistent with these updated recommendations. (See "Standard immunizations for nonpregnant adults", section on 'Immunization schedule for nonpregnant adults'.)

GERIATRIC NEUROLOGY

Glucagon-like peptide-1 receptor agonists in Parkinson disease (April 2024)

Glucagon-like peptide-1 (GLP-1) receptor agonists have been proposed as neuroprotective agents in Parkinson disease (PD) based on observations that treatment may be associated with lower risk of PD in patients with diabetes. Two recent trials in nondiabetic patients with PD have shown mixed results:

●In a randomized phase II trial of daily subcutaneous lixisenatide versus placebo injections in 156 patients with early PD, the lixisenatide group exhibited stable motor disability scores over 12 months, compared with a 3-point decline (on a 132-point scale) in the placebo group [8]. Nausea was dose limiting in some patients.

●A slightly larger phase III trial of an investigational, pegylated formulation of exenatide failed to show a difference in motor disability progression between groups at 36 weeks [9].

Larger studies with longer follow-up are needed to determine whether this class of agents has meaningful neuroprotective effects in PD. (See "Epidemiology, pathogenesis, and genetics of Parkinson disease", section on 'Protective factors'.)

Time window to start dual antiplatelet therapy for high-risk TIA or minor ischemic stroke (January 2024)

There is evidence from several randomized trials that early initiation of short-term dual antiplatelet therapy (DAPT) for select patients with high-risk transient ischemic attack (TIA) or minor ischemic stroke reduces the risk of recurrent ischemic stroke. The evidence comes from trials that started DAPT within 12 to 24 hours of symptom onset. Results from the recent INSPIRES trial suggest that DAPT is still beneficial when started up to 72 hours after symptom onset [10]. Although the time window is extended by the results from INSPIRES, we start DAPT as soon as possible for patients with high-risk TIA or minor ischemic stroke. (See "Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack", section on 'High-risk TIA and minor ischemic stroke'.)

Adult-onset ADHD and dementia (December 2023)

Individuals with adult-onset attention deficit hyperactivity disorder (ADHD) may have difficulties compensating for deficits from neurodegenerative or cerebrovascular processes, but any association with dementia has been inconsistent. In a prospective study including over 100,000 adults without ADHD or dementia at baseline, those who were subsequently diagnosed with adult-onset ADHD were more likely to receive a diagnosis of dementia (adjusted relative risk 2.8) [11]. Whether symptoms that resulted in the ADHD diagnosis were early or prodromal dementia symptoms is uncertain; nevertheless, these findings suggest that caregivers be alert for signs of dementia in individuals with adult-onset ADHD. (See "Attention deficit hyperactivity disorder in adults: Epidemiology, clinical features, assessment, and diagnosis", section on 'Comorbidity'.)

GERIATRIC RHEUMATOLOGY

Ultrasound for the diagnosis of giant cell arteritis (April 2024)

Vascular ultrasound is being investigated as a substitute for biopsy for the diagnosis of giant cell arteritis (GCA). In a prospective cohort study including 229 patients with suspected GCA, a prediction model using both a clinical prediction algorithm and a quantitative ultrasound was able to classify 74 percent of patients as having either a low or high probability for GCA [12]. The prediction model misclassified 2 percent of patients as low probability who eventually were diagnosed as having GCA; an additional 3 percent of patients classified as high probability for GCA were eventually reclassified as having other diagnoses. Although this study suggests that temporal artery biopsy may not be necessary to evaluate all patients with suspected GCA, it was conducted by rheumatologists who were specifically trained to use ultrasound for GCA. Until such expertise is more broadly available, we continue to evaluate patients with suspected GCA with temporal artery biopsies. (See "Diagnosis of giant cell arteritis", section on 'Patients with a positive biopsy or imaging'.)

OTHER GERIATRICS

Universal decolonization in nursing homes for infection control (February 2024)

Routine decolonization of patients prevents healthcare-associated infections in certain hospital settings (eg, intensive care units), but its value in long-term care facilities has not been thoroughly evaluated. In an 18-month randomized trial of 28 nursing homes in the United States, universal decolonization with chlorhexidine bathing and intranasal povidone iodine reduced infection-related hospitalization rates by 30 percent compared with usual bathing protocols [13]. Colonization with multidrug-resistant organisms also decreased in the decolonization group. However, potential sources of bias in the study (eg, audits and staff training that only occurred in the decolonization arm) reduce confidence in these findings, and lack of resources in nursing homes may impede implementation. (See "Principles of infection prevention and control in long-term care facilities", section on 'Bundled interventions'.)