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.

GERIATRIC CARDIOVASCULAR MEDICINE

Allopurinol not effective in secondary cardiovascular disease prevention (October 2022)

Some studies have suggested that allopurinol may reduce cardiovascular disease risk in patients with gout. However, in a trial conducted among over 5000 older adults with ischemic heart disease and no history of gout, rates of cardiovascular disease events were essentially equal among those who received allopurinol or usual care over a five-year period [1]. These results do not support the use of allopurinol for secondary prevention of cardiovascular disease. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk", section on 'Therapies with uncertain or no benefit'.)

GERIATRIC INFECTIOUS DISEASES

Updated immunization schedule for adults in the United States (February 2023)

The 2023 United States Advisory Committee on Immunization Practices (ACIP) vaccination schedules for adults have been published by the Centers for Disease Control and Prevention (CDC) (figure 1 and figure 2) [2]. Changes include recommendations for COVID-19 vaccination, quadrivalent influenza vaccine in persons aged ≥ 65, pneumococcal vaccines in previously vaccinated individuals, and poliovirus vaccination for individuals at increased risk of polio exposure. Clarification has been added that zoster vaccination does not require serologic evidence of prior varicella infection. Newly approved vaccines have been included as well (eg, PreHevbrio for hepatitis B and Priorix for MMR vaccination). Healthcare providers in the United States should review these recommendations to guide their vaccination practices for adult patients. (See "Standard immunizations for nonpregnant adults", section on 'Immunization schedule for nonpregnant adults'.)

Nirmatrelvir-ritonavir in vaccinated individuals with COVID-19 (October 2022)

A large randomized trial previously demonstrated that nirmatrelvir-ritonavir (Paxlovid) substantively reduced hospitalization and death in unvaccinated individuals with COVID-19 and risk factors for severe disease; accumulating observational data suggest that high-risk vaccinated individuals also benefit. In a study of 1130 vaccinated adults who received nirmatrelvir-ritonavir within five days of COVID-19 diagnosis and 1130 controls matched for age, gender, race, and comorbidities, nirmatrelvir-ritonavir was associated with a lower rate of emergency department visits, hospitalization, and death (odds ratio 0.5) [3]. All 10 deaths were among those who had not been treated. In another study, nirmatrelvir-ritonavir was associated with a reduction in hospitalization from 59 to 15 cases per 100,000 person-days among mostly vaccinated patients ≥65 years old [4]. Despite the limitations of observational data, these data highlight the potential clinical impact of nirmatrelvir-ritonavir among vaccinated individuals with Omicron subvariant infection and support our recommendations to treat patients at risk for severe disease, including otherwise healthy individuals ≥65 years old, regardless of vaccination status (algorithm 1). (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Efficacy and rationale'.)

GERIATRIC ONCOLOGY

Management of localized, low-risk prostate cancer (March 2023)

Long-term data from trials investigating active monitoring, surgery, and radiation for localized prostate cancer are emerging. At 15 years of follow-up of a randomized trial in over 1600 men with localized prostate cancer, most of whom had low-risk disease, metastases were more frequent among those assigned to active monitoring compared with surgery or radiation (9.4 versus 4.7 and 5.0 percent, respectively); however, the rates of prostate cancer mortality were low in all groups (3.1, 2.2, and 2.9 percent, respectively), and differences were not statistically significant [5]. For most individuals with localized, low-risk prostate cancer, definitive therapy (radical prostatectomy, brachytherapy, or external beam radiation) or active surveillance are all appropriate options. (See "Initial approach to low- and very low-risk clinically localized prostate cancer", section on 'ProtecT trial'.)

Comprehensive geriatric assessment in older patients with cancer (February 2023)

Comprehensive geriatric assessment for patients with cancer has been shown to improve patient satisfaction with overall care and decrease chemotherapy toxicity. However, in a recent randomized trial in 350 older adults with cancer, patients assigned to geriatric assessment experienced similar patient-reported quality of life, functional status, and severe toxicities as usual oncologic care [6]. The COVID-19 pandemic may have affected the intervention and outcomes of this trial; moreover, there were methodologic differences with prior studies. Given these considerations and the multiple prior randomized trials showing benefit, we continue to incorporate comprehensive geriatric assessment into cancer care for older adults. (See "Comprehensive geriatric assessment for patients with cancer", section on 'Supporting evidence'.)

GERIATRIC RHEUMATOLOGY

Role of tocilizumab in patients with polymyalgia rheumatica (October 2022)

While relatively low doses of glucocorticoids are the primary treatment for polymyalgia rheumatica (PMR), interest remains in identifying an effective steroid-sparing agent. In a randomized trial of 100 patients with steroid-dependent PMR, patients who received adjunctive intravenous tocilizumab were more likely to achieve a combined endpoint of lower disease activity score and reduced steroid requirement at 24 weeks (67 versus 31 percent) [7]. Infections were the most frequent adverse events, occurring in 47 and 39 percent of the tocilizumab and placebo groups, respectively. Additional data are needed to confirm these findings and determine the benefits and safety of adjunctive tocilizumab use for PMR. The routine use of steroid-sparing therapies, including adjunctive tocilizumab, is not recommended for patients with PMR. (See "Treatment of polymyalgia rheumatica", section on 'Limited role for glucocorticoid-sparing therapies'.)