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What's new in geriatrics

What's new in geriatrics
Authors:
Lisa Kunins, MD
Jane Givens, MD
Literature review current through: Mar 2021. | This topic last updated: Apr 02, 2021.

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

Effectiveness of strength training in older adults (January 2021)

Strength training is an important health intervention that can help to prevent sarcopenia, osteopenia, frailty, and insulin resistance in older adults, but the effectiveness of such training among the very old has been questioned. In a systematic review and meta-analysis of 22 randomized trials involving more than 800 adults over 75 years of age, strength training produced statistically significant and clinically meaningful increases in strength and muscle size [1]. These results held true even for the subgroup of patients 80 years or older. No major adverse effects were reported. Older subjects represent a far more heterogenous training population than younger adults, and thus a high degree of individualization is necessary when selecting exercises and designing a strength program. Nevertheless, the same general principles of strength training apply across all populations. (See "Practical guidelines for implementing a strength training program for adults", section on 'Important considerations for strength training in older adult patients'.)

GERIATRIC CARDIOVASCULAR MEDICINE

Cellular phones with powerful magnets and defibrillators (February 2021)

There is a long-standing concern that electromagnetic devices can interfere with the normal function of pacemakers and implantable cardioverter-defibrillators (ICD). In a recent report, a cellular phone with a magnetic array (eg, iPhone 12) was placed over an ICD generator and temporarily induced magnet mode, thereby suspending normal defibrillator function [2]. Patients with a pacemaker or an ICD should be aware of the effects of magnets on medical devices. In general, we advise all patients to use cellular telephones at the ear on the side opposite the cardiac device and to carry telephones in a pocket or bag below the waist. (See "Cardiac implantable electronic device interactions with electromagnetic fields in the nonhospital environment".)

Rhythm-control for high-risk, early atrial fibrillation (September 2020)

Among patients with atrial fibrillation (AF), a survival benefit from a rhythm-control rather than a rate-control strategy has never been demonstrated. The EAST-AFNET 4 trial randomly assigned nearly 2800 patients with early AF (defined as AF diagnosed ≤12 months before enrollment) and at high risk for cardiovascular complications to early rhythm control with antiarrhythmic drugs or catheter ablation, or to usual care, which was a rate-control strategy for most patients [3]. High risk was defined as age >75 years, prior transient ischemic attack or stroke, or meeting two of the following criteria: age >65 years, female sex, heart failure, hypertension, diabetes, severe coronary artery disease, chronic kidney disease, or left ventricular hypertrophy. After a median follow-up of 5.1 years, the group assigned to rhythm control had lower rates of death from cardiovascular causes (1.0 versus 1.3 percent) and stroke (0.6 versus 0.9 percent) compared with the group assigned to rate control. Based on these results, we now prefer early initiation of a rhythm-control strategy for most early AF patients meeting the criteria for high risk as defined in the trial. Previously, we preferred rate control for many of these patients, particularly if they were older and minimally symptomatic. (See "Rhythm control versus rate control in atrial fibrillation", section on 'EAST-AFNET 4'.)

GERIATRIC INFECTIOUS DISEASES

Liberalizing visitation restriction for fully vaccinated nursing home residents (March 2021)

During the COVID-19 pandemic, most nursing homes restricted visitation, which can be associated with psychological harm in both residents and their loved ones. In the United States, the Centers for Disease Control and Prevention supports relaxing restrictions on indoor visits for fully vaccinated residents [4]. However, policies in individual institutions may vary and should be made in conjunction with local public health departments. In addition, visitors should still use precautions, such as wearing a mask and physically distancing from other people in the facility. (See "COVID-19: Management in nursing homes", section on 'Restricting visitors'.)

Impact of COVID-19 vaccination in nursing home residents and staff (March 2021)

Vaccination to prevent SARS-CoV-2 infection may be contributing to a decrease in the risk of COVID-19 in the nursing home (NH) setting. In a comparison of NHs based on vaccination status, there was a greater decrease in COVID-19 cases among both residents and staff in NHs that had administered the first dose of vaccine compared with facilities that had not yet initiated vaccination (48 versus 21 percent decline in resident cases, 33 versus 18 percent decline in staff cases) [5]. However, standard infection control measures may have also contributed to the decrease, and remain important components of COVID-19 prevention strategies. (See "COVID-19: Management in nursing homes", section on 'Scope of the problem'.)

ACIP 2021 immunization schedule for adults in the United States (February 2021)

The Advisory Committee on Immunization Practices (ACIP) has released its 2021 immunization schedule for adults in the United States (figure 1 and figure 2) [6]. The updates to the schedule include a number of previously announced recommendations, including use of a booster dose of serogroup B meningococcal vaccine for certain groups at increased risk. Although they are not included in the 2021 schedule, the ACIP has also issued interim recommendations for use of COVID-19 vaccines within the scope of the Emergency Use Authorizations of Biologics License Application. (See "Standard immunizations for nonpregnant adults", section on 'Immunization schedule for nonpregnant adults'.)

Vaccines to prevent SARS-CoV-2 infection (November 2020, Modified February 2021)

Various vaccines to prevent SARS-CoV-2 infection are becoming available in different countries. In the United States, the COVID-19 mRNA vaccines BNT162b2 (Pfizer-BioNTech COVID-19 vaccine) and mRNA 1273 (Moderna COVID-19 vaccine) and the COVID-19 adenovirus vector vaccine Ad26.COV2.S (Janssen COVID-19 vaccine) have received emergency use authorization [7-9]. The mRNA vaccines are each given as two intramuscular doses separated by a few weeks; the adenovirus vector vaccine is a single intramuscular dose. In large placebo-controlled trials, these vaccines were highly effective in preventing laboratory-confirmed COVID-19, especially severe/critical disease [10-12]. Local and systemic adverse effects (pain, fever, fatigue, headache) are common but usually nonsevere. Initial vaccine supplies are limited; in the United States, allocation priorities are determined at the state level. (See "COVID-19: Vaccines to prevent SARS-CoV-2 infection".)

Doses per vial of Pfizer-BioNTech COVID-19 mRNA vaccine (December 2020)

To maximize doses from available supplies, the US Food and Drug Administration prescribing information and health care provider fact sheet for Pfizer-BioNTech's COVID-19 mRNA vaccine was revised to support extraction of an additional dose from each vial after dilution according to manufacturer instructions [13]. Each vial of this vaccine contains at least five doses after dilution. With use of low dead-space syringes, the volume in each vial may be sufficient to supply six full doses; in such cases, all six doses can be administered. However, any residual volume less than a full dose (<0.3 mL) should be discarded and should not be pooled with residuals from other vials. (See "COVID-19: Vaccines to prevent SARS-CoV-2 infection", section on 'Administration' and "COVID-19 mRNA vaccines (United States and Canada: Authorized for use): Drug information".)

Convalescent plasma for COVID-19 (August 2020, Modified December 2020)

Convalescent plasma with high titer neutralizing antibodies to SARS-CoV-2 is an investigational therapy for reducing the likelihood or severity of COVID-19. In the United States, convalescent plasma can be obtained for hospitalized patients with COVID-19 through an emergency use authorization [14]. However, randomized trials do not demonstrate a clear clinical benefit of convalescent plasma in hospitalized patients with severe COVID-19 [15-17]; thus, we suggest not routinely using it in such patients outside a clinical trial. In contrast, among select high-risk outpatients with mild COVID-19, high-titer plasma administered within 72 hours of symptom onset has been shown in a randomized trial to reduce the risk of progression to severe disease [18]. Although the limited window of opportunity for administration poses operational challenges in many outpatient settings, high-titer convalescent plasma may have a practical role in managing mild COVID-19 in older adults in skilled nursing settings. (See "COVID-19: Convalescent plasma and hyperimmune globulin" and "COVID-19: Management in hospitalized adults", section on 'Convalescent plasma and other antibody-based therapies' and "COVID-19: Outpatient evaluation and management of acute illness in adults", section on 'Monoclonal antibodies and convalescent plasma therapy'.)

GERIATRIC NEUROLOGY

Intracerebral hemorrhage outcomes in patients taking oral anticoagulants (March 2021)

Prior studies have shown that patients with intracerebral hemorrhage (ICH) while taking anticoagulation have worse outcomes than those taking no anticoagulation, but the impact of the type of anticoagulation has been uncertain. In a registry-based cohort study of more than 200,000 patients with ICH including nearly 20,000 with anticoagulation-associated ICH, the risk of mortality was lower in those taking a direct oral anticoagulant (DOAC) than in those taking warfarin [19]. Rates of disability or dependence at discharge were also lower with DOACs than warfarin and similar for DOACs versus no anticoagulation. These results support the view that patients taking DOACs at the time of ICH may have a lower risk of poor outcome than those taking warfarin.

Probiotics for constipation in Parkinson disease (March 2021)

Patients with Parkinson disease (PD) commonly experience constipation related to autonomic dysfunction and slowed colonic transit time. Probiotics plus fiber had favorable effects in one small prior trial in this population. In a new trial in 72 patients with PD and constipation, a daily multistrain probiotic capsule for four weeks improved spontaneous bowel movements, stool consistency, and quality of life compared with placebo [20]. Although larger trials in patients with PD are needed and similar trials in adults with chronic constipation had mixed results, these findings support use of probiotics for PD-related constipation as part of a multifaceted approach that generally includes behavior modification, dietary changes, and bulk-forming laxative therapy. (See "Management of nonmotor symptoms in Parkinson disease", section on 'Constipation'.)

Screening not recommended for asymptomatic carotid artery stenosis (February 2021)

The 2021 United States Preventive Services Task Force (USPSTF) has reaffirmed its 2014 recommendation against screening for asymptomatic carotid artery stenosis in the general population [21,22]. The rationale includes the likelihood of more false-positive than true-positive results when screening the general population with duplex ultrasonography for a low prevalence condition such as asymptomatic carotid stenosis, lack of evidence that screening reduces stroke or death rates, and the likelihood of harms related to additional testing and treatment of asymptomatic stenosis. In agreement with the USPSTF, we suggest not screening for asymptomatic carotid artery stenosis with vascular imaging tests. (See "Screening for asymptomatic carotid artery stenosis", section on 'Recommendations of others'.)

GERIATRIC RHEUMATOLOGY

American College of Rheumatology gout management guidelines (October 2020)

The American College of Rheumatology has issued new detailed guidelines and evidence review for the management of gout [23]. Further evidence to support a treat-to-target approach to urate-lowering therapy is provided. Among the new guidelines is an expanded list of patient groups for whom HLA-B*5801 screening is advised prior to allopurinol use in order to identify patients with an elevated risk of severe cutaneous reactions. In addition to Chinese, Thai, and Korean populations, African Americans should now also be tested, and allopurinol should be avoided if the genetic variant is present. Our management approach is consistent with these recommendations. (See "Pharmacologic urate-lowering therapy and treatment of tophi in patients with gout", section on 'Recommendations of major groups' and "Pharmacologic urate-lowering therapy and treatment of tophi in patients with gout", section on 'Adverse effects'.)

REFERENCES

  1. Grgic J, Garofolini A, Orazem J, et al. Effects of Resistance Training on Muscle Size and Strength in Very Elderly Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Sports Med 2020; 50:1983.
  2. Greenberg JC, Altawil MR, Singh G. Letter to the Editor-Lifesaving Therapy Inhibition by Phones Containing Magnets. Heart Rhythm 2021.
  3. Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med 2020; 383:1305.
  4. United States Centers for Disease Control and Prevention. Updated healthcare infection prevention and control recommendations in response to COVID-19 vaccination. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html (Accessed on March 11, 2021).
  5. https://www.ahcancal.org/Data-and-Research/Center-for-HPE/Documents/CHPE-Report-Vaccine-Effectiveness-Feb2021.pdf (Accessed on March 04, 2021).
  6. Freedman MS, Bernstein H, Ault KA. Recommended Adult Immunization Schedule, United States, 2021. Ann Intern Med 2021; 174:374.
  7. Emergency Use Authorization (EUA) of the Pfizer-BioNTech COVID-19 Vaccine to Prevent Coronavirus. Fact sheet for healthcare providers administering vaccine. https://www.fda.gov/media/144413/download (Accessed on February 25, 2021).
  8. Emergency Use Authorization (EUA) of the Moderna COVID-19 Vaccine to prevent Coronavirus Disease 2019 (COVID-19). Factsheet for healthcare providers administering vaccine. https://www.fda.gov/media/144637/download?utm_medium=email&utm_source=govdelivery (Accessed on December 18, 2020).
  9. US FDA. Emergency use authorization (EUA) of the Janssen COVID-19 vaccine to prevent coronavirus disease 2019 (COVID-19). https://www.fda.gov/media/146304/download (Accessed on March 01, 2021).
  10. Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med 2020; 383:2603.
  11. Baden LR, El Sahly HM, Essink B, et al. Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine. N Engl J Med 2021; 384:403.
  12. FDA Briefing Document. Janssen Ad26.COV2.S Vaccine for the Prevention of COVID-19. Vaccines and Related Biological Products Advisory Committee Meeting, February 26, 2021 https://www.fda.gov/media/146217/download (Accessed on February 24, 2021).
  13. US Food and Drug Administration. Emergency use authorization (EUA) of the Pfizer-Biontech COVID-19 vaccine to prevent coronavirus disease 2019 (COVID-19). https://www.fda.gov/media/144413/download (Accessed on December 29, 2020).
  14. US Food and Drug Administration. Emergency use authorization for convalescent plasma. August 23, 2020 https://www.fda.gov/media/141477/download (Accessed on August 24, 2020).
  15. Simonovich VA, Burgos Pratx LD, Scibona P, et al. A Randomized Trial of Convalescent Plasma in Covid-19 Severe Pneumonia. N Engl J Med 2021; 384:619.
  16. Li L, Zhang W, Hu Y, et al. Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial. JAMA 2020; 324:460.
  17. Piechotta V, Chai KL, Valk SJ, et al. Convalescent plasma or hyperimmune immunoglobulin for people with COVID-19: a living systematic review. Cochrane Database Syst Rev 2020; 7:CD013600.
  18. Libster R, Pérez Marc G, Wappner D, et al. Early High-Titer Plasma Therapy to Prevent Severe Covid-19 in Older Adults. N Engl J Med 2021; 384:610.
  19. Xian Y, Zhang S, Inohara T, et al. Clinical Characteristics and Outcomes Associated With Oral Anticoagulant Use Among Patients Hospitalized With Intracerebral Hemorrhage. JAMA Netw Open 2021; 4:e2037438.
  20. Tan AH, Lim SY, Chong KK, et al. Probiotics for Constipation in Parkinson Disease: A Randomized Placebo-Controlled Study. Neurology 2021; 96:e772.
  21. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for Asymptomatic Carotid Artery Stenosis: US Preventive Services Task Force Recommendation Statement. JAMA 2021; 325:476.
  22. Guirguis-Blake JM, Webber EM, Coppola EL. Screening for Asymptomatic Carotid Artery Stenosis in the General Population: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 325:487.
  23. FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Rheumatol 2020; 72:879.
Topic 16437 Version 10221.0

References

1 : Effects of Resistance Training on Muscle Size and Strength in Very Elderly Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

2 : Letter to the Editor-Lifesaving Therapy Inhibition by Phones Containing Magnets.

3 : Early Rhythm-Control Therapy in Patients with Atrial Fibrillation.

4 : Early Rhythm-Control Therapy in Patients with Atrial Fibrillation.

5 : Early Rhythm-Control Therapy in Patients with Atrial Fibrillation.

6 : Recommended Adult Immunization Schedule, United States, 2021.

7 : Recommended Adult Immunization Schedule, United States, 2021.

8 : Recommended Adult Immunization Schedule, United States, 2021.

9 : Recommended Adult Immunization Schedule, United States, 2021.

10 : Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine.

11 : Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine.

12 : Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine.

13 : Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine.

14 : Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine.

15 : A Randomized Trial of Convalescent Plasma in Covid-19 Severe Pneumonia.

16 : Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial.

17 : Convalescent plasma or hyperimmune immunoglobulin for people with COVID-19: a living systematic review.

18 : Early High-Titer Plasma Therapy to Prevent Severe Covid-19 in Older Adults.

19 : Clinical Characteristics and Outcomes Associated With Oral Anticoagulant Use Among Patients Hospitalized With Intracerebral Hemorrhage.

20 : Probiotics for Constipation in Parkinson Disease: A Randomized Placebo-Controlled Study.

21 : Screening for Asymptomatic Carotid Artery Stenosis: US Preventive Services Task Force Recommendation Statement.

22 : Screening for Asymptomatic Carotid Artery Stenosis in the General Population: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

23 : 2020 American College of Rheumatology Guideline for the Management of Gout.