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What's new in geriatrics

What's new in geriatrics
Literature review current through: Jan 2024.
This topic last updated: Jan 29, 2024.

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

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 [1]. 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'.)

Overdiagnosis of breast cancer in older women (October 2023)

Overdiagnosis, the detection of a disease that would not have caused morbidity or mortality if it had not been found, is a concern in breast cancer screening, particularly among older patients. In a 2023 study in over 54,000 women 70 years and older who had recently undergone screening, the percent of overdiagnosed breast cancer cases increased with age from 31 percent among women aged 70 to 74 years to 54 percent among women aged 85 years and older [2]. We utilize a shared decision-making framework for breast cancer screening in older women to balance potential risks and benefits. (See "Screening for breast cancer: Evidence for effectiveness and harms", section on 'Overdiagnosis'.)

Global inappropriate medication use in older adults (September 2023)

Inappropriate medication use is common among older adults. In a meta-analysis of 94 studies representing over 371 million older adults in 17 countries, the prevalence of potentially inappropriate medication (PIM) use was over 37 percent, with benzodiazepines being the most common medication [3]. The study also showed that PIM use has increased over the past 20 years, especially in high-income countries. Deprescribing of inappropriate medications is a priority among older adults. (See "Drug prescribing for older adults", section on 'Inappropriate medications'.)

GERIATRIC ENDOCRINOLOGY AND DIABETES

Investigational transdermal formulation of abaloparatide for the treatment of osteoporosis (November 2023)

In individuals with osteoporosis, the bone anabolic agent abaloparatide increases bone mineral density (BMD) and reduces fracture risk but requires daily subcutaneous injections. Noninjectable formulations may facilitate use of anabolic therapy for the treatment of osteoporosis. In a 12-month trial in 511 postmenopausal women with osteoporosis, participants were randomly assigned to daily treatment with an investigational, transdermal formulation of abaloparatide or subcutaneous abaloparatide. Transdermal abaloparatide increased BMD at the lumbar spine, although not as robustly as subcutaneous abaloparatide (mean increase of 7.14 versus 10.86 percent, respectively) [4]. Transdermal abaloparatide similarly led to a smaller increase in BMD at the total hip (mean increase of 1.97 versus 3.7 percent with subcutaneous abaloparatide). Further studies are needed to determine whether transdermal abaloparatide reduces fracture risk. (See "Parathyroid hormone/parathyroid hormone-related protein analog therapy for osteoporosis", section on 'Dosing'.)

GERIATRIC INFECTIOUS DISEASES

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 [5]. 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) [6]. 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'.)

ACIP recommendations for 2023-24 seasonal influenza vaccination (September 2023)

The Advisory Committee on Immunization Practices (ACIP) issued new recommendations for seasonal influenza vaccination in August 2023 (table 1) [7]. The antigenic composition has been updated. In addition, the ACIP now states that egg allergy alone no longer necessitates additional safety measures for influenza vaccination, including with egg-based vaccines, beyond those recommended for any recipient of any vaccine, regardless of severity of previous reaction to egg. All vaccines should be administered in settings where personnel and equipment needed for prompt recognition and treatment of acute hypersensitivity reactions are available. This is consistent with our previous guidance. (See "Seasonal influenza vaccination in adults", section on 'Antigenic composition'.)

Updated COVID-19 mRNA vaccine recommendations (September 2023)

The US Food and Drug Administration and Centers for Disease Control and Prevention have updated COVID-19 vaccine authorizations and recommendations [8,9]. Available COVID-19 vaccines have been updated to target Omicron variant XBB.1.5 (Moderna COVID-19 vaccine 2023-2024 formula, Pfizer COVID-19 vaccine 2023-2024 formula, and Novavax 2023-2024 formula); bivalent vaccines are no longer available. An updated 2023-2024 formula vaccine is recommended for all individuals aged six months and older. Immunocompetent individuals five years and older should receive one updated vaccine, regardless of prior vaccination history. For individuals who are four years or younger or have an immunocompromising condition (table 2), the number of recommended updated vaccines depends on their vaccination history. Our approach to COVID-19 vaccination is consistent with these recommendations. (See "COVID-19: Vaccines", section on 'Indications and vaccine selection' and "COVID-19: Vaccines", section on 'Benefits of vaccination'.)

GERIATRIC NEUROLOGY

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 ONCOLOGY

Omission of radiation in select patients with favorable-risk breast cancer (August 2023, Modified January 2024)

Trials are examining omission of radiation in early, favorable-risk breast cancer.

In a single-arm trial including 500 females ≥55 years with T1N0, grade 1 or 2, luminal A-breast cancer, breast-conserving surgery and endocrine therapy without radiation were associated with a low incidence of local recurrence at five years (2.3 percent) [12].

A prospective study found that patients ≥50 years with nontriple negative cT1N0 breast cancer that was unifocal on preoperative MRI and pT1N0 or N1mi at the time of surgery could omit adjuvant radiation and experience a low ipsilateral invasive recurrence rate (1 percent at five years) [13].

We consider omission of adjuvant radiation to be an option in women ≥65 years with clinically node-negative, small (tumor size <3 cm), hormone receptor-positive, HER2-negative breast cancer who are willing to take adjuvant endocrine therapy, but we await further data before omitting radiation in other patients. (See "Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer", section on 'Possible omission of RT for select ER-positive, HER2-negative cancers'.)

  1. Xu C, Leung JCN, Shi J, et al. Sedative-hypnotics and osteoporotic fractures: A systematic review of observational studies with over six million individuals. Sleep Med Rev 2024; 73:101866.
  2. Richman IB, Long JB, Soulos PR, et al. Estimating Breast Cancer Overdiagnosis After Screening Mammography Among Older Women in the United States. Ann Intern Med 2023; 176:1172.
  3. Tian F, Chen Z, Zeng Y, et al. Prevalence of Use of Potentially Inappropriate Medications Among Older Adults Worldwide: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2326910.
  4. Lewiecki EM, Czerwinski E, Recknor C, et al. Efficacy and Safety of Transdermal Abaloparatide in Postmenopausal Women with Osteoporosis: A Randomized Study. J Bone Miner Res 2023; 38:1404.
  5. Gordon WJ, Henderson D, DeSharone A, et al. Remote Patient Monitoring Program for Hospital Discharged COVID-19 Patients. Appl Clin Inform 2020; 11:792.
  6. Murthy N, Wodi AP, McNally V, et al. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2023. MMWR Morb Mortal Wkly Rep 2023; 72:141.
  7. Grohskopf LA, Blanton LH, Ferdinands JM, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023–24 Influenza Season. MMWR Recomm Rep 2023; 72:2.
  8. Recommendation for the 2023-2024 Formula of COVID-19 vaccines in the US. https://www.fda.gov/media/169591/download?attachment (Accessed on September 11, 2023).
  9. Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States. https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html (Accessed on April 26, 2023).
  10. Gao Y, Chen W, Pan Y, et al. Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke. N Engl J Med 2023; 389:2413.
  11. Levine SZ, Rotstein A, Kodesh A, et al. Adult Attention-Deficit/Hyperactivity Disorder and the Risk of Dementia. JAMA Netw Open 2023; 6:e2338088.
  12. Whelan TJ, Smith S, Parpia S, et al. Omitting Radiotherapy after Breast-Conserving Surgery in Luminal A Breast Cancer. N Engl J Med 2023; 389:612.
  13. Mann GB, Skandarajah AR, Zdenkowski N, et al. Postoperative radiotherapy omission in selected patients with early breast cancer following preoperative breast MRI (PROSPECT): primary results of a prospective two-arm study. Lancet 2023.
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References

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