I attended the historic AGS 2021 virtual annual meeting (May 13-15, with a pre-conference on May 12). AGS 2021 was historic and unique in many aspects; one aspect was that it was the first-ever virtual meeting in the society’s history. A historic conference during a brutal pandemic, which targeted the frail and vulnerable geriatric patients as its main victims and putting nursing homes and skilled nursing facilities on the spot. Here are some takeaway points in some of the most controversial hot topics presented at AGS 2021.
COVID-19 and Geriatrics
COVID-19 has had a devastating impact on our frail older adults (OAs). About 61% of the deaths happened among those above age 65, 31% of deaths among those above age 85, and 34% of the death happened in long-term care homes. Among many atypical presentations of COVID-19 in geriatric patients, delirium is one of the most common signs and should be a standard part of the diagnostic algorithm. Among risk factors associated with all-cause 30-day mortality rates in nursing home residents with COVID-19, cognitive and activities of daily living impairments were among the decisive prognostic factors besides age, presence of dyspnea, and cough.
Recommendations for treatment of hypertension in geriatric patients
Aligned with the SPRINT trial results, treatment of hypertension with systolic blood pressure(SBP) treatment goal of less than 130 mmHg is recommended for noninstitutionalized ambulatory community-dwelling geriatric patients with an average SBP of 130 or higher. For geriatric patients with hypertension with multiple comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit are prudent for a decision regarding the strength of blood pressure reduction. Also, there is growing evidence that intensive blood pressure control decreases the risk of mild cognitive impairment and may decrease the risk of dementia in OAs.
Deprescribing in geriatrics and the prescribing cascade
Prescribing cascade has been one of the hot topics in the AGS conferences. One common clinical scenario is the prescribing cascade of calcium channel blockers and diuretics in OAs with hypertension, which leads to over diuresis in a euvolemic state. Another topic was the decision regarding deprescribing the cardiac medications of OAs, knowing the fact that many OAs with heart failure with preserved ejection fraction (HFpEF) have multiple comorbidities, which promotes deprescribing based on a holistic approach, considering evidence-based interventions such as ASA discontinuation, while on concurrent anticoagulation medications, dose adjustment of novel oral anticoagulants in chronic kidney disease, and down-titration /discontinuation of beta-blockers for their chronotropic incompetence in OAs with HFpEF are prudent. Deprescribing acetylsalicylic acid for primary prevention of ASCVD in geriatric patients or deprescribing statins in palliative care or hospice settings should not be overlooked.
Latest developments in dementia
One of the novel topics in AGS 2021 was the growing utilization of newer imaging modalities in the diagnosis and management of Alzheimer’s disease. Recent studies explicitly support the use of amyloid PET. On the horizon is the emerging novel drug, Aducanumab, which, though it still has not been approved by the FDA for the treatment of early Alzheimer’s disease, has substantial evidence to support its approval according to the FDA’s clinical review.
There is an inevitable necessity for a more holistic approach and optimal collaboration between all the stakeholders in geriatric patient care to tackle important geriatric challenges such as dementia, falls, and COVID-19.
In the end, I believe focusing on the four main elements of cognition, functional status, deprescribing, and shared decision-making in our geriatric patients and improving the four pillars of the quadruple aim in health care could be a game-changer in the future of our geriatric care.