11/19/2015
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Update in Geriatrics
Holly M. Holmes, MD, MSHolly M. Holmes, MD, MSHolly M. Holmes, MD, MSHolly M. Holmes, MD, MSAssociate Professor and Division DirectorGeriatric and Palliative Medicine
Overview
• Blood pressure targets
• Dementia screening and treatment
• Vaccinations
• Interventions for frailty
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SPRINT Trial
SPRINT Research Group. NEJM 2015. DOI: 10.1056/NEJMoa1511939
SPRINT Trial
4683
standard
4678
intensive
28.2% ≥75 yrs
SPRINT Research Group. NEJM 2015. DOI: 10.1056/NEJMoa1511939
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SPRINT Trial
SPRINT Research Group. NEJM 2015. DOI: 10.1056/NEJMoa1511939
28.2% ≥75
PARTAGE Study
Benetos A. JAMA Intern Med. 2015;175(6):989-995.
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BP targetsfor frail older persons?
Benetos A. JAMA.
2015;314(2):170-180
More controversy: BP and cognition
• Higher blood pressure associated with higher
MMSE score
– Interaction with functional status
• DANTE study: community based RCT to
decrease BP meds
– No effect on improving cognition, psychological
function, or functional status
Ogliari G. J Am Geriatr Soc 63:1741–1748, 2015.
Moonen JE. JAMA Intern Med. 2015;175(10):1622-1630.
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Dementia
• Global prevalence of 47 million, doubling
every 20 years
• If the cost of dementia care represented a
country, it would be the 18th largest global
economy
• Need an investment in research for
prevention, treatment, care and cure
World Alzheimer Report 2015: The Global Impact of Dementia, at http://www.alz.co.uk
Cognitive tests for dementia
Tsoi KKF. JAMA Intern Med. 2015;175(9):1450-1458.
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How useful is the MoCA to diagnose dementia?
• Cross-sectional studies, excluded early-onset,
specific types, and specific settings
• 7 studies / 9422 subjects:
• Dementia in 22-54% clinic, 5-10% in
population-based
• Sensitivity 0.94, specificity 0.6 or less for score
≥26/30
Davis DHJ. The Cochrane Library, issue 10, 2015.
Biomarkers for dementia• 10 plasma biomarkers as possible candidates
of disease severity and likelihood of progression
• IL-1/IL1RAP pathway – carriers had higher rates of amyloid independent of apoE4 and higher rates of conversion from MCI to AD
• CSF amyloid beta levels not recommended to diagnose Alzheimer’s disease in people with MCI Hye A. Alzheimer’s & Dementia. 2014; 10: 799-807
Ramanan VK. BRAIN 2015: 138; 3076–3088
Ritchie C. Cochrane Review, Issue 6, 2014.
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Dementia Treatment
Ngandu T. Lancet 2015; 385: 2255–63
Finger Trial: improved
cognition after a 2-
year multi-domain
intervention:
• nutrition
• exercise
• cognitive training
• vascular risk
monitoring
Dementia TreatmentX No effect with long-chain polyunsaturated
fatty acids, lutein, zeaxanthin with vitamins C,
E, beta carotene, and zinc
? Latrepirdine possibly helpful for behavioral
symptoms but not effective for mild to
moderate dementia
�Dextromethorphan plus quinidine for
behavioral symptoms of dementiaChew EY. JAMA. 2015;314(8):791-801.
Chau S. Latrepirdine for Alzheimer’s Disease. Cochrane Review, Issue 4, 2015.
Cummings JL. JAMA. doi:10.1001/jama.2015.10214.
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Dementia Treatment
Salloway S. N Engl J Med 2014;370:322-33.
Doody RS. N Engl J Med 2014;370:311-21.
Disappointing results
with anti-amyloid
monoclonal antibodies
• Bapineuzumab
• Solanezumab
Dementia treatment on the horizon
Sperling RA. www.ScienceTranslationalMedicine.org 2014; 6(228): fs13
• Aducanumab
• A4 trial
• Amyloid
vaccination
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Vaccination Updates
• Pneumonia
• Herpes Zoster
Messinger-Rappaport, B. Cleveland Clinic J of Med. 2015;82(8):498-505.
Is PCV13 efficacious?
MJM Bonten. N Engl J Med 2015;372:1114-25.
-40
-30
-20
-10
0
10
20
30
40
50
60
% V
acc
ine
Eff
ica
cy
Vaccine Efficacy in the CAPITA Trial by Age and
Immunocompromise for First Episode of Vaccine Type
Community Acquired Pneumonia
Age
Immunocompromised
<75
≥75No
Yes
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Herpes Zoster vaccine
• Live attenuated vaccine
– Efficacy 51.3% for herpes zoster and 66.5% for postherpetic neuralgia
• Efficacy of HZ/su by age:
– 96.9% for 50-59
– 94.1% for 60-69
– 98.3% for 70+ (23.6% of study population)
• Major differences in 7 day adverse effects, including local and systemic reactions
• Possibility for immunostimulation
Lal H. N Engl J Med 2015;372:2087-96.
Herpes Zoster vaccine
Lal H. N Engl J Med 2015;372:2087-96.
Exclusion criteria
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Frailty: the LIFE-P study
Cesari M. J Gerontol A Biol Sci Med Sci. 2015; 70(2):216–222
• PA group: aerobic,
strength, flexibility,
and balance training
• SA group: active
control with weekly
meetings on aging
topics
Frailty: the LIFE-P study
Cesari M. J Gerontol A Biol Sci Med Sci. 2015; 70(2):216–222
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Summary / Key Points
• Treat to lower blood pressure in very fit,
nondiabetic older patients? vs. wait for the
SPRINT-MIND study…
• Continue to wait for developments in
dementia.
• Perhaps, change your vaccination strategy for
pneumonia, but probably not for shingles yet.
• Recommend physical activity in frail patients.
