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What's new in geriatrics

What's new in geriatrics
Authors:
Lisa Kunins, MD
Jane Givens, MD, MSCE
Literature review current through: Feb 2022. | This topic last updated: Feb 22, 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.

GENERAL GERIATRICS

Additional COVID-19 vaccine primary series dose for immunocompromised individuals (August 2021, Modified February 2022)

COVID-19 vaccines are less effective among patients with certain immunocompromising conditions than in the general population; additional vaccine doses have been associated with improved effectiveness in this population. We agree with recommendations from the Advisory Committee on Immunization Practices (ACIP) in the United States that individuals with such conditions (table 1) receive an additional mRNA vaccine dose as part of their primary COVID-19 vaccine series (eg, following two doses of an mRNA vaccine or one dose of Ad26.COV2.S vaccine) [1,2]. This additional primary series dose is distinct from the booster dose, which such patients should additionally receive, although at a shorter interval than recommended for the general population. (See "COVID-19: Vaccines", section on 'Immunocompromised individuals'.)

Spinal versus general anesthesia for hip fracture surgery (December 2021)

Whether the use of spinal versus general anesthesia for hip fracture surgery affects outcomes is uncertain. In a multicenter randomized trial (REGAIN) comparing the two techniques in 1600 patients who underwent hip fracture surgery, both groups had similar mortality, ability to walk at 60 days postoperatively, postoperative delirium, and time to discharge [3]. The spinal anesthesia group had lower rates of in-hospital mortality, acute kidney injury, and critical care admission, but statistical analysis was not performed for these outcomes. For patients in whom either type of anesthesia would be appropriate, we suggest spinal anesthesia to reduce the need for mechanical ventilation and achieve a more rapid return to baseline mental status. (See "Anesthesia for orthopedic trauma", section on 'Choice of anesthetic technique for hip fracture'.)

Avoiding delay in indicated cataract surgery (November 2021)

Although many patients with cataracts are older adults with comorbidities, few conditions preclude proceeding with indicated cataract surgery for those who can tolerate the required positioning because no blood loss or fluid shifts occur. Moreover, significant delays (ie, more than four months) for cataract surgery have been associated with increased morbidity due to greater likelihood of falls, automobile accidents, and worsening cognitive impairment. We agree with the new Society for Ambulatory Anesthesia position statement that recommends against postponing cataract surgery unless the patient has an acute condition that requires time to achieve optimal medical management [4]. (See "Anesthesia for elective eye surgery", section on 'Anesthetic considerations'.)

Prophylactic treatment for airway secretions at the end of life (October 2021)

Excess airway secretions in patients at the end of life (death rattle) can be a troublesome symptom for caregivers and loved ones, but recommendations for treatment have been limited by lack of clinical trial data. In a randomized trial conducted in 162 patients in six hospices in the Netherlands, patients entering the dying phase were assigned to receive either prophylactic subcutaneous scopolamine butylbromide (not available in United States) or placebo [5]. Death rattle occurred in a smaller percentage of patients in the scopolamine group (13 versus 27 percent). These results support the efficacy of anticholinergic agents for palliative management of airway secretions in patients nearing the end of life. We prefer glycopyrrolate. (See "Palliative care: The last hours and days of life", section on 'Airway secretions'.)

GERIATRIC ENDOCRINOLOGY AND DIABETES

Dietary calcium and fracture prevention in institutionalized older adults (October 2021)

Evidence supporting a benefit of calcium and/or vitamin D supplementation in older adults is conflicting. Fracture benefit of nutrient supplementation appears to be greater among institutionalized or hospitalized than community-dwelling individuals. In a cluster randomized trial evaluating the initiation of dairy products (eg, milk, yogurt, or cheese to provide an additional 562 mg/day of calcium and 12 g/day of protein) in over 7000 institutionalized, vitamin D-supplemented, older adults (mean age 86 years) who were consuming approximately 700 mg of calcium/day, the incidence of total fractures, hip fractures, and falls was lower in the dairy product than control group (mean follow-up 12.6 months) [6]. This supports our recommendation to increase intake of dairy products or calcium-rich foods if dietary calcium intake is below recommended levels (1200 mg/day for older adults). If not possible, optimal intake can be achieved with a combination of diet plus supplements. (See "Calcium and vitamin D supplementation in osteoporosis", section on 'Calcium and vitamin D'.)

Defining subclinical hypothyroidism in older adults (October 2021)

There is disagreement about the appropriate upper limit of normal for serum thyroid stimulating hormone (TSH) in older adults. Although there is an age-related shift toward higher TSH concentrations in older adults, age-based normal ranges for TSH are not widely implemented. In one study of over 2000 adults >70 years of age, the likelihood of a diagnosis of subclinical hypothyroidism (defined as an elevated TSH with a normal free T4) decreased from 29 to 3 percent if age-specific rather than uniform normal reference ranges were used [7]. We suggest not treating older adults for subclinical hypothyroidism for a TSH above the upper limit of normal up to and including 6.9 mU/L, since TSH values in the range are age appropriate. (See "Subclinical hypothyroidism in nonpregnant adults", section on 'Epidemiology'.)

GERIATRIC INFECTIOUS DISEASES

Booster doses of COVID-19 vaccines for individuals 12 years or older (October 2021, Modified February 2022)

Several countries have introduced booster doses of COVID-19 vaccines because of potentially attenuated vaccine effectiveness due to waning efficacy and variants. The US Food and Drug Administration has authorized and the Centers for Disease Control and Prevention (CDC) recommends a booster dose for all individuals 12 years or older [8-11]. The booster dose is given five months after a primary BNT162b2 (Pfizer) or mRNA-1273 (Moderna) series for most patients (or three months after the primary series for immunocompromised patients) and two months after a primary Ad26.COV2.S (Johnson & Johnson) series. Any vaccine authorized for the patient's age group can be used for the booster dose, regardless of the vaccine used for the primary series; in general, we favor one of the mRNA vaccines over Ad26.COV2.S. We recommend booster doses for eligible individuals, based on trials and observational evidence suggesting improved vaccine efficacy following a booster dose. (See "COVID-19: Vaccines", section on 'Role of booster vaccinations/waning efficacy'.)

Staff vaccination in nursing homes impacts resident COVID-19 outcomes (January 2022)

Vaccination of nursing home (NH) staff against COVID-19 has lagged behind resident vaccination but impacts resident outcomes when community transmission is high. In a study of over 12,000 NHs, among facilities with the lowest versus highest staff vaccination coverage, there were an estimated 1.6 additional COVID-19 cases and 0.19 COVID-19-related deaths per hundred beds in counties with the highest prevalence of COVID-19 [12]. Efforts to improve staff acceptance of COVID-19 vaccination should continue to be a priority in the NH setting. (See "COVID-19: Management in nursing homes", section on 'Vaccination'.)

Missed opportunities for influenza vaccination (January 2022)

Influenza vaccination rates remain suboptimal. In a retrospective study including more than 31 million Medicare beneficiaries >19 years of age in the United States during the 2018 to 2019 influenza season, vaccination claims were filed for only 50 percent of individuals [13]. Vaccination uptake was higher among White beneficiaries than Black or Hispanic beneficiaries (53, 35, and 30 percent, respectively), and was higher for those with high-risk conditions than for those without (56 versus 27 percent, respectively). Among unvaccinated beneficiaries overall, 77 percent visited a provider during influenza season. A comprehensive strategy leveraging all opportunities for vaccination is needed to improve influenza vaccine uptake. (See "Seasonal influenza vaccination in adults", section on 'Improving vaccination rates'.)

COVID-19: Updated CDC recommendations for isolation and quarantine in the community (January 2022)

In December 2021, the United States Centers for Disease Control and Prevention (CDC) updated recommendations on home isolation for individuals with SARS-CoV-2 infection and post-exposure precautions in the community [14]. For select immunocompetent patients with infection (eg, those who are asymptomatic; those with mild, improving infection), the duration of isolation was reduced from 10 to 5 days, followed by strict mask-wearing when around others for another 5 days. Following exposure, people should monitor for symptoms and wear masks when around others for 10 days; those not up-to-date on vaccination should quarantine at home for the first 5 days. Additional details on the role of testing and other restrictions during the post-infection or post-exposure period, as well as updated recommendations for quarantine and isolation for healthcare personnel can be found on the CDC website. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Testing and quarantine' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'In the community setting'.)

Updated ACIP guidance on influenza vaccination in the United States (September 2021)

In August 2021, the United States Advisory Committee on Immunization Practices (ACIP) issued recommendations for prevention of seasonal influenza [15]. During the 2021-22 influenza season, the following vaccine types are expected to be available: inactivated influenza vaccines (IIV4s), recombinant influenza vaccine (RIV4), and live attenuated influenza vaccine (LAIV4) (table 2 and table 3); all vaccines are expected to be quadrivalent. For the IIV4s produced from cell culture, the approved age indication has been expanded from ≥4 years to ≥6 months of age [16,17]. Influenza vaccination may be co-administered with COVID-19 vaccination, at different anatomic sites. We agree with the ACIP guidance. (See "Seasonal influenza vaccination in adults", section on 'Available formulations' and "Seasonal influenza in children: Prevention with vaccines", section on 'Influenza vaccines'.)

GERIATRIC NEUROLOGY

Updated guidelines for management of restless legs syndrome (October 2021)

Updated consensus-based guidelines for the management of restless legs syndrome (RLS) have been published by the RLS Foundation [18]. For chronic persistent RLS in adults despite appropriate iron supplementation, the guideline suggests first-line therapy with an alpha-2-delta calcium channel ligand (gabapentin, gabapentin enacarbil, or pregabalin), except when certain comorbidities are present (eg, obesity, moderate to severe depression, gait instability, respiratory disease, or a history of substance use disorder). In such cases, a non-ergot dopamine agonist (pramipexole, ropinirole, rotigotine) is preferred initially, with monitoring for complications such as augmentation and impulse control disorders. Our approach is consistent with these guidelines (algorithm 1). (See "Management of restless legs syndrome and periodic limb movement disorder in adults", section on 'Choice of therapy'.)

Palliative care and hospice referral guidance in Parkinson disease (September 2021)

In patients with advanced Parkinson disease (PD), it can be difficult to determine the most appropriate timing for hospice referral, and there are no validated end-of-life prognostic tools. A working group sponsored by the Parkinson's Foundation has proposed guidance to identify patients who would likely benefit from hospice/palliative care [19]. Referral should be considered in patients with critical nutrition impairment, life-threatening complications, or poorly responsive motor symptoms causing impaired self care in the prior year; rapid or accelerating motor or nonmotor disease progression and disability; or advanced dementia meeting hospice referral criteria based on Medicare eligibility guidelines or other prognostic tools. (See "Palliative approach to Parkinson disease and parkinsonian disorders", section on 'Life expectancy and hospice eligibility'.)

Clinical use of pimavanserin in patients with neurodegenerative dementias (September 2021)

Pimavanserin is a newer antipsychotic agent that has been approved in the United States (US) since 2016 for treatment of psychosis in patients with Parkinson disease (PD). Two new reports expand information on both efficacy and potential risks in patients with neurodegenerative diseases:

In a randomized discontinuation trial of pimavanserin in 351 patients with dementia-related psychosis, among those who responded initially to treatment, relapses were approximately half as common in patients assigned to continued pimavanserin compared with placebo [20].

In a retrospective cohort study of >20,000 older adults with PD living in long-term care facilities in the US, pimavanserin use, compared with nonuse, was associated with an increased adjusted risk of 30-day hospitalization and mortality at multiple time points [21]. Residual confounding is possible, although other studies have raised similar safety concerns for antipsychotic agents as a class.

Like other antipsychotic agents, pimavanserin should be used selectively in patients with dementia and/or PD after discussing potential risks and benefits of treatment, alternative therapies for psychosis (algorithm 2 and algorithm 3), and risks related to ongoing symptoms. (See "Management of nonmotor symptoms in Parkinson disease", section on 'Refractory psychotic symptoms' and "Management of neuropsychiatric symptoms of dementia", section on 'Antipsychotic drugs'.)

GERIATRIC ONCOLOGY

Comprehensive geriatric analysis in cancer patients (November 2021)

Comprehensive geriatric assessment (CGA) is being evaluated to decrease toxicity from chemotherapy in older adults. In a randomized trial among patients age ≥70 with incurable solid tumors or lymphoma starting a new systemic therapy, the CGA intervention reduced grade ≥3 adverse events compared with usual care (51 versus 71 percent) [22]. Based on these and other data, we utilize a CGA prior to initiation of anticancer therapy in patients ≥65 years. (See "Comprehensive geriatric assessment for patients with cancer", section on 'Supporting evidence'.)

GERIATRIC PULMONOLOGY

Long-term bleeding rates with direct oral anticoagulants (September 2021)

For patients with unprovoked venous thromboembolism (VTE), accurate information about bleeding rates are needed to inform decision-making. A recent meta-analysis of 27 studies (including 14 randomized trials) and >17,000 adults with unprovoked VTE reported a lower rate of bleeding among those receiving direct oral anticoagulants (DOACs) compared with patients receiving warfarin (1.12 versus 1.74 events per 100 person-years) [23]. Rates of bleeding were highest among patients >65 years of age and those with a creatinine clearance <50 mL/min, a history of bleeding, concomitant use of antiplatelet therapy, or a hemoglobin level <10 mg/L. These findings support our suggested choice of a DOAC rather than warfarin for most patients in whom indefinite anticoagulant therapy is indicated. (See "Selecting adult patients with lower extremity deep venous thrombosis and pulmonary embolism for indefinite anticoagulation", section on 'Baseline risk'.)

GERIATRIC RHEUMATOLOGY

Rapidly destructive hip disease after intraarticular glucocorticoid injection (January 2022)

Intraarticular glucocorticoid injections are sometimes used for symptom management for hip osteoarthritis (OA), but there is a concern that intraarticular glucocorticoids can also accelerate joint degeneration. In a case-control study comparing 40 patients with rapidly destructive hip disease (RDHD) and 717 controls who underwent total hip arthroplasty for OA, at least one intraarticular glucocorticoid injection was associated with a higher risk of RDHD (odds ratio 8.6) [24]. A dose-response effect was also observed, in which the risk of RDHD was higher with increasing doses of glucocorticoids as well as with the number of injections received. These findings support our approach of avoiding routine use of intraarticular glucocorticoid injections for patients with hip OA. (See "Management of hip osteoarthritis", section on 'Limited role of intraarticular glucocorticoids'.)

REFERENCES

  1. CDC - An Additional Dose of mRNA COVID-19 Vaccine Following a Primary Series in Immunocompromised People. Available at: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-08-13/02-COVID-Dooling-508.pdf (Accessed on August 14, 2021).
  2. 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 February 24, 2022).
  3. Neuman MD, Feng R, Carson JL, et al. Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. N Engl J Med 2021; 385:2025.
  4. Sweitzer B, Rajan N, Schell D, et al. Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement. Anesth Analg 2021; 133:1431.
  5. van Esch HJ, van Zuylen L, Geijteman ECT, et al. Effect of Prophylactic Subcutaneous Scopolamine Butylbromide on Death Rattle in Patients at the End of Life: The SILENCE Randomized Clinical Trial. JAMA 2021; 326:1268.
  6. Iuliano S, Poon S, Robbins J, et al. Effect of dietary sources of calcium and protein on hip fractures and falls in older adults in residential care: cluster randomised controlled trial. BMJ 2021; 375:n2364.
  7. Zhang Y, Sun Y, He Z, et al. Age-specific thyrotropin references decrease over-diagnosis of hypothyroidism in elderly patients in iodine-excessive areas. Clin Endocrinol (Oxf) 2021.
  8. 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 December 09, 2021).
  9. 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 November 20, 2021).
  10. US Food and Drug Administration. 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 February 03, 2022).
  11. CDC Expands Eligibility for COVID-19 Booster Shots to All Adults https://www.cdc.gov/media/releases/2021/s1119-booster-shots.html (Accessed on November 20, 2021).
  12. McGarry BE, Barnett ML, Grabowski DC, Gandhi AD. Nursing Home Staff Vaccination and Covid-19 Outcomes. N Engl J Med 2022; 386:397.
  13. Cho BH, Weinbaum C, Tsai Y, Koppaka R. Influenza Vaccine Uptake and Missed Opportunities Among the Medicare-Covered Population With High-Risk Conditions During the 2018 to 2019 Influenza Season : A Retrospective Cohort Study. Ann Intern Med 2022; 175:1.
  14. United States Centers for Disease Control and Prevention. What We Know About Quarantine and Isolation. https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine-isolation-background.html (Accessed on January 05, 2022).
  15. Grohskopf LA, Alyanak E, Ferdinands JM, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2021-22 Influenza Season. MMWR Recomm Rep 2021; 70:1.
  16. Nolan T, Fortanier AC, Leav B, et al. Efficacy of a Cell-Culture-Derived Quadrivalent Influenza Vaccine in Children. N Engl J Med 2021; 385:1485.
  17. US Food and Drug Administration. Flucelvax quadrivalent. https://www.fda.gov/vaccines-blood-biologics/vaccines/flucelvax-quadrivalent (Accessed on October 18, 2021).
  18. Silber MH, Buchfuhrer MJ, Earley CJ, et al. The Management of Restless Legs Syndrome: An Updated Algorithm. Mayo Clin Proc 2021; 96:1921.
  19. Akbar U, McQueen RB, Bemski J, et al. Prognostic predictors relevant to end-of-life palliative care in Parkinson's disease and related disorders: a systematic review. J Neurol Neurosurg Psychiatry 2021.
  20. Tariot PN, Cummings JL, Soto-Martin ME, et al. Trial of Pimavanserin in Dementia-Related Psychosis. N Engl J Med 2021; 385:309.
  21. Hwang YJ, Alexander GC, An H, et al. Risk of Hospitalization and Death Associated With Pimavanserin Use in Older Adults With Parkinson Disease. Neurology 2021; 97:e1266.
  22. Mohile SG, Mohamed MR, Xu H, et al. Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): a cluster-randomised study. Lancet 2021.
  23. Khan F, Tritschler T, Kimpton M, et al. Long-Term Risk for Major Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism : A Systematic Review and Meta-analysis. Ann Intern Med 2021; 174:1420.
  24. Okike K, King RK, Merchant JC, et al. Rapidly Destructive Hip Disease Following Intra-Articular Corticosteroid Injection of the Hip. J Bone Joint Surg Am 2021; 103:2070.
Topic 16437 Version 10977.0

References

1 : CDC - An Additional Dose of mRNA COVID-19 Vaccine Following a Primary Series in Immunocompromised People. Available at: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-08-13/02-COVID-Dooling-508.pdf (Accessed on August 14, 2021).

2 : 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 February 24, 2022).

3 : Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults.

4 : Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement.

5 : Effect of Prophylactic Subcutaneous Scopolamine Butylbromide on Death Rattle in Patients at the End of Life: The SILENCE Randomized Clinical Trial.

6 : Effect of dietary sources of calcium and protein on hip fractures and falls in older adults in residential care: cluster randomised controlled trial.

7 : Age-specific thyrotropin references decrease over-diagnosis of hypothyroidism in elderly patients in iodine-excessive areas.

8 : Age-specific thyrotropin references decrease over-diagnosis of hypothyroidism in elderly patients in iodine-excessive areas.

9 : Age-specific thyrotropin references decrease over-diagnosis of hypothyroidism in elderly patients in iodine-excessive areas.

10 : Age-specific thyrotropin references decrease over-diagnosis of hypothyroidism in elderly patients in iodine-excessive areas.

11 : Age-specific thyrotropin references decrease over-diagnosis of hypothyroidism in elderly patients in iodine-excessive areas.

12 : Nursing Home Staff Vaccination and Covid-19 Outcomes.

13 : Influenza Vaccine Uptake and Missed Opportunities Among the Medicare-Covered Population With High-Risk Conditions During the 2018 to 2019 Influenza Season : A Retrospective Cohort Study.

14 : Influenza Vaccine Uptake and Missed Opportunities Among the Medicare-Covered Population With High-Risk Conditions During the 2018 to 2019 Influenza Season : A Retrospective Cohort Study.

15 : Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2021-22 Influenza Season.

16 : Efficacy of a Cell-Culture-Derived Quadrivalent Influenza Vaccine in Children.

17 : Efficacy of a Cell-Culture-Derived Quadrivalent Influenza Vaccine in Children.

18 : The Management of Restless Legs Syndrome: An Updated Algorithm.

19 : Prognostic predictors relevant to end-of-life palliative care in Parkinson's disease and related disorders: a systematic review.

20 : Trial of Pimavanserin in Dementia-Related Psychosis.

21 : Risk of Hospitalization and Death Associated With Pimavanserin Use in Older Adults With Parkinson Disease.

22 : Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): a cluster-randomised study

23 : Long-Term Risk for Major Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism : A Systematic Review and Meta-analysis.

24 : Rapidly Destructive Hip Disease Following Intra-Articular Corticosteroid Injection of the Hip.