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What's new in geriatrics

What's new in geriatrics
Jane Givens, MD, MSCE
Literature review current through: Nov 2022. | This topic last updated: Dec 12, 2022.

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.


Vitamin D supplementation in community-dwelling individuals did not show a fracture benefit (August 2022)

In the VITAL trial, in which 25,871 community-dwelling men and women (mean age 67 years) were randomly assigned to vitamin D (2000 units daily) or placebo, the two groups had similar rates of total fractures (5.9 versus 6 percent), nonvertebral fractures (5.6 versus 5.7 percent), and hip fractures (0.44 versus 0.43 percent) [1]. The participants were not selected on the basis of vitamin D deficiency, low bone mass, or osteoporosis; approximately 10 percent of the total group had a history of a fragility fracture, and approximately 5 percent were taking osteoporosis medications. The mean 25-hydroxyvitamin D level (in a subset of participants) was 30 ng/mL (75 nmol/L). Community-dwelling adults who are getting adequate vitamin D and calcium from dietary intake as well as sun exposure do not need to take additional supplements. Vitamin D supplementation is typically suggested as part of the treatment of osteoporosis, particularly for patients who are receiving osteoporosis medications. (See "Calcium and vitamin D supplementation in osteoporosis", section on 'Calcium and/or vitamin D'.)


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 [2]. 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'.)

Improved outcomes and adherence with a polypill in older patients with myocardial infarction (September 2022)

In patients with recent myocardial infarction (MI), a polypill strategy may simplify treatment and improve treatment adherence, but its efficacy in preventing a secondary cardiovascular event is uncertain. In a trial that randomly assigned nearly 2500 older patients with an MI in the prior six months to either a polypill (containing aspirin, ramipril, and atorvastatin) or usual care, those receiving a polypill had a lower rate of a composite of cardiovascular events (death, nonfatal MI, nonfatal ischemic stroke, or urgent revascularization; 9.5 versus 12.7 percent) over a mean of 36 months [3]. Blood pressure, low-density lipoprotein cholesterol levels, and adverse events were similar between the two groups, and medication adherence was higher in the polypill group. While these results are promising, further studies are needed to confirm these findings. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk", section on 'Polypill'.)

Low-dose aspirin for primary cardiovascular disease prevention (June 2022)

Low-dose aspirin may prevent cardiovascular disease (CVD) in some patients but also increases the risk of bleeding. The 2022 United States Preventive Services Task Force (USPSTF) statement concluded that among people 40 to 59 years of age with a ≥10 percent risk of CVD over the next ten years, there is a small potential benefit of low-dose aspirin [4]. The USPSTF did not recommend starting low-dose aspirin in persons over 60 years without heart disease. We believe the decision to prescribe aspirin for primary prevention should be made by the patient and their provider after discussing individual risks and benefits. (See "Aspirin in the primary prevention of cardiovascular disease and cancer", section on 'Recommendations of others'.)


Lifestyle intervention in older adults with type 2 diabetes (September 2022)

Lifestyle modification is important for improving glycemia in type 2 diabetes mellitus, but there have been few randomized trials evaluating glycemic benefits in older adults. In a recent trial, 100 older adults (mean age approximately 72 years) were randomly assigned to an intensive lifestyle intervention (diet and exercise to achieve a 10 percent body weight loss) for six months or a control intervention (monthly educational group sessions) [5]. After one year, intensive lifestyle modification led to greater reductions in A1C (mean difference 0.9 percent) and body weight (mean difference 8.1 kg), but also caused more episodes of mild hypoglycemia than the control intervention. This trial supports our practice of providing older adults with counseling regarding lifestyle modification, provided the risk of hypoglycemia is minimized through close monitoring and empiric reductions in glucose-lowering therapy in selected individuals. (See "Treatment of type 2 diabetes mellitus in the older patient", section on 'Lifestyle modification'.)


Booster doses with the bivalent COVID-19 mRNA vaccines (September 2022, Modified December 2022)

Booster doses of COVID-19 vaccines are a strategy to improve effectiveness in the setting of waning immunity and immune evasion from circulating SARS-CoV-2 variants. The US Food and Drug Administration authorized two bivalent mRNA booster vaccines that target the spike proteins of both the original SARS-CoV-2 strain and the Omicron B.4/B.5 variants (figure 1 and figure 2) [6,7]. The Centers for Disease Control and Prevention (CDC) now recommends that all individuals ≥5 years old who have completed a primary COVID-19 vaccine series (including those who already received booster doses with monovalent vaccines) receive a single booster dose with one of the bivalent vaccines at least two months after the last vaccine dose; bivalent booster recommendations for children younger than five years old depend on the primary series vaccine received (table 1) [8]. Our approach is consistent with CDC recommendations. Although clinical data evaluating bivalent vaccines are limited, their use is supported by indirect evidence from trials and observational studies in which monovalent booster doses improved vaccine efficacy against infection and severe disease and by studies that indicate at least comparable immunogenicity with bivalent versus monovalent formulations. (See "COVID-19: Vaccines", section on 'Role of booster vaccinations'.)

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) [9]. 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 [10]. 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'.)

New ACIP recommendations for seasonal influenza vaccination (September 2022)

In August 2022, the Advisory Committee on Immunization Practices (ACIP) issued new recommendations for seasonal influenza vaccination in the United States [11]. The ACIP now recommends that adults aged ≥65 years preferentially receive any one of the following higher dose or adjuvanted influenza vaccines: quadrivalent high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4) (table 2). In addition, the approved age indication for the cell culture–based inactivated influenza vaccine has been changed from ≥2 years to ≥6 months. We are in agreement with this guidance. (See "Seasonal influenza vaccination in adults", section on 'Choice of vaccine formulation' and "Seasonal influenza in children: Prevention with vaccines", section on 'Influenza vaccines'.)

COVID-19 vaccine booster in nursing home residents (August 2022)

COVID-19 vaccination reduces the risk of infection and the threat of serious illness or death among nursing home (NH) residents. The benefit of a fourth dose (second booster) of BNT162b2 (Pfizer monovalent COVID-19) vaccine was demonstrated in a cohort study of over 50,000 NH residents in Israel [12]. Compared with those who only had three doses, residents who received a fourth dose had greater protection against infection and significantly greater protection against hospitalization and death during the Omicron surge. Although these findings support the use of a second booster for NH residents in settings where only monovalent boosters are available, in the United States, a single booster dose with a bivalent vaccine (that targets the spike proteins of both the original SARS-CoV-2 strain and the Omicron B.4/B.5 variants) has replaced prior booster recommendations for adults. (See "COVID-19: Management in nursing homes", section on 'Vaccination'.)


Remote monitoring of self-measured blood pressure and blood pressure control (July 2022)

Self-measurement of blood pressure (at home) may improve blood pressure control in patients with hypertension, especially if integrated with other supportive interventions. In a meta-analysis of 18 randomized trials, blood pressure self-measurement combined with mobile or web-based telemonitoring led to greater decreases in systolic and diastolic blood pressure compared with usual care,, possibly due to increased patient engagement and adherence [13]. Patients who are interested in self-monitoring should be provided with adequate training in the machine's use, and the device should be checked for accuracy approximately once yearly. (See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring", section on 'Possible improvement in blood pressure control with SMBP'.)


No benefit of anti-synuclein monoclonal antibodies in patients with Parkinson disease (August 2022)

Anti-synuclein strategies are being investigated as potential disease-modifying therapies for Parkinson disease (PD) and related disorders, but results have been disappointing thus far. In patients with early-stage PD, trials of two different monoclonal antibodies directed at alpha-synuclein, cinpanemab and prasinezumab, each showed similar clinical and radiographic outcomes in the active treatment and placebo groups at 52 weeks [14,15]. The cinpanemab trial also reported no clear differences at 104 weeks in a blinded extension phase, which was halted due to lack of efficacy. Studies of other therapies directed against alpha-synuclein in earlier stages of development are ongoing. (See "Epidemiology, pathogenesis, and genetics of Parkinson disease", section on 'Alpha-synuclein misfolding, aggregation, and toxicity'.)

Dosing of dopamine agonists for restless legs syndrome (June 2022)

Dopamine agonists (eg, pramipexole, ropinirole) are an effective treatment for restless legs syndrome (RLS) but require monitoring and precautions to avoid serious side effects such as confusion, excessive daytime sleepiness, and impulse control disorders. Use of higher doses also increases the risk of paradoxical worsening of RLS symptoms (augmentation). In a United States prescription database study that included nearly 400,000 patients with RLS receiving treatment with dopamine agonists, 19 percent of patients were prescribed higher than recommended doses of dopamine agonists for RLS [16]. To reduce the risk of augmentation and other side effects, doses for RLS should not generally exceed the limits in the table (table 3); effective doses for RLS are lower than those used in Parkinson disease. (See "Management of restless legs syndrome and periodic limb movement disorder in adults", section on 'Side effects and monitoring'.)


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) [17]. 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'.)

Gout flare and risk of subsequent cardiovascular event (August 2022)

Gout is known to be associated with cardiovascular disease; however, the temporal association of cardiovascular events after an acute gout flare had not previously been studied. In a case-control study that included over 62,500 patients with gout in a longitudinal primary care database, of whom nearly 10,500 experienced a cardiovascular event (ie, stroke or myocardial infarction), acute gout flare was associated with increased risk of a cardiovascular event in the next 0 to 60 days (adjusted odds ratio [aOR] 1.93) and 61 to 120 days (aOR 1.57) [18]. These findings highlight the importance of managing cardiovascular risk factors among patients with gout. (See "Lifestyle modification and other strategies to reduce the risk of gout flares and progression of gout", section on 'Treatment of comorbidities'.)

Add-on low-dose glucocorticoids in older patients with rheumatoid arthritis (August 2022)

Although short-term use of low-dose glucocorticoids is common in the management of rheumatoid arthritis (RA), evidence is conflicting regarding its efficacy and safety when used on a chronic basis. In a randomized trial of 451 patients with RA aged 65 years and older, the addition of prednisolone 5 mg daily to disease-modifying therapy resulted in lower measures of disease activity (0.37 points lower on a 10-point scale) and joint damage progression (1.7 points lower on a 10-point scale) compared with placebo after two years of follow-up [19]. However, patients in the prednisolone arm experienced more adverse events (60 versus 49 percent), which consisted mostly of nonserious infections. Thus, while some patients may experience modest benefit with add-on low-dose glucocorticoids, the lowest effective dose should be used to minimize harms, if it is not possible to discontinue glucocorticoid therapy. (See "Use of glucocorticoids in the treatment of rheumatoid arthritis", section on 'Efficacy of chronic use'.)

  1. LeBoff MS, Chou SH, Ratliff KA, et al. Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults. N Engl J Med 2022; 387:299.
  2. Mackenzie IS, Hawkey CJ, Ford I, et al. Allopurinol versus usual care in UK patients with ischaemic heart disease (ALL-HEART): a multicentre, prospective, randomised, open-label, blinded-endpoint trial. Lancet 2022; 400:1195.
  3. Castellano JM, Pocock SJ, Bhatt DL, et al. Polypill Strategy in Secondary Cardiovascular Prevention. N Engl J Med 2022; 387:967.
  4. US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement. JAMA 2022; 327:1577.
  5. Celli A, Barnouin Y, Jiang B, et al. Lifestyle Intervention Strategy to Treat Diabetes in Older Adults: A Randomized Controlled Trial. Diabetes Care 2022; 45:1943.
  8. Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States. (Accessed on December 13, 2022).
  9. Ganatra S, Dani SS, Ahmad J, et al. Oral Nirmatrelvir and Ritonavir in Non-hospitalized Vaccinated Patients with Covid-19. Clin Infect Dis 2022.
  10. Arbel R, Wolff Sagy Y, Hoshen M, et al. Nirmatrelvir Use and Severe Covid-19 Outcomes during the Omicron Surge. N Engl J Med 2022; 387:790.
  11. 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, 2022-23 Influenza Season. MMWR Recomm Rep 2022; 71:1.
  12. Muhsen K, Maimon N, Mizrahi AY, et al. Association of Receipt of the Fourth BNT162b2 Dose With Omicron Infection and COVID-19 Hospitalizations Among Residents of Long-term Care Facilities. JAMA Intern Med 2022; 182:859.
  13. Kalagara R, Chennareddy S, Scaggiante J, et al. Blood pressure management through application-based telehealth platforms: a systematic review and meta-analysis. J Hypertens 2022; 40:1249.
  14. Lang AE, Siderowf AD, Macklin EA, et al. Trial of Cinpanemab in Early Parkinson's Disease. N Engl J Med 2022; 387:408.
  15. Pagano G, Taylor KI, Anzures-Cabrera J, et al. Trial of Prasinezumab in Early-Stage Parkinson's Disease. N Engl J Med 2022; 387:421.
  16. Winkelman JW. High national rates of high-dose dopamine agonist prescribing for restless legs syndrome. Sleep 2022; 45.
  17. Devauchelle-Pensec V, Carvajal-Alegria G, Dernis E, et al. Effect of Tocilizumab on Disease Activity in Patients With Active Polymyalgia Rheumatica Receiving Glucocorticoid Therapy: A Randomized Clinical Trial. JAMA 2022; 328:1053.
  18. Cipolletta E, Tata LJ, Nakafero G, et al. Association Between Gout Flare and Subsequent Cardiovascular Events Among Patients With Gout. JAMA 2022; 328:440.
  19. Boers M, Hartman L, Opris-Belinski D, et al. Low dose, add-on prednisolone in patients with rheumatoid arthritis aged 65+: the pragmatic randomised, double-blind placebo-controlled GLORIA trial. Ann Rheum Dis 2022; 81:925.
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