Evidence based Q&A

1. DEMENTIA

1A. Is plasma glucose a risk factor for dementia?
Yes, according to a 2013 article in the NEJM titled Glucose Levels and the risk of Dementia
As the glucose levels increase in non-diabetics, the risk of developing dementia goes up (an increase of 1.1mmol/L above 5.5mmol/L increases the risk by about 18%.).

1B. Are therapies directed against the protein AB (Amyloid Beta) effective in Alzheimer's disease?
No. They are not. The latest report in 2018 (published in NEJM) described the failure of the human monoclonal antibody Solanezumab to protect against cognitive deterioration in patients who had mild Alzheimer's disease (that is, a MMSE score of 20 to 26).

It was also noted that preventing the formation of Beta Amyloid in selected patients who had "prodromal Alzheimer's" (those with memory issues and raised beta amyloid in CSF but not having dementia) did not help prevent progression to Alzheimer's disease. The drug used was Verubecestat, a drug that prevents amyloid precursor protein from being enzymatically cleaved to beta amyloid. (Ref: NEJM)

1C. Should Donepezil be stopped when Alzheimer's disease deteriorates in severity?
No. It is probably better to continue Donepezil (anticholinesterase inhibitor) even when the disease worsens because those who continue the drug have slightly better cognitive functioning than those who stop the drug. Also, substituting donepezil for memantine (an NMDA receptor antagonist) does not seem to have much benefit. (Ref: NEJM article).

2. GENITOURINARY

2A. Should asymptomatic bacteriuria in the elderly be treated with antibiotics?
No. It does not need treatment unless an invasive genitourinary procedure is planned. In fact, routine urinalysis and urine culture in the asymptomatic elderly are not recommended.

2B. Is there any treatment for urgency urinary incontinence (overactive bladder) for older adults?
Yes. Anticholinergics like solifenacin (brand Vesicare in Malaysia) are effective. Injection of a type of botulinum toxin into the detrusor muscle of the bladder is also effective. (Reference)

2C. Should the elderly be screened for prostate cancer?
Yes, unless life expectancy is judged to be less than 10 years. Statistically, a person between the ages of 60 and 79 years has a one in eight chance of having prostate cancer. But it is also worth knowing that the incidence of prostate cancer is much higher than the mortality from it because many prostate cancers progress very slowly. Active surveillance instead of curative treatment is an option for those who have low risk prostate cancer [PSA level less than 10ng/ml and a Gleason score of 6 or less].

3. CARDIOVASCULAR

3A. Is it useful to prescribe low dose aspirin to healthy older adults? What about in those who have diabetes?
No, it is not. A report in NEJM (2018) showed no benefit of low dose aspirin in disability free survival for up to 5 years in elderly patients (mean age around 70 years) who did not have cognitive impairment or cardiovascular diseases. Ref: Article
Regarding elderly with diabetes, there is a benefit in treating with low dose aspirin but there is also an equally high danger of severe extracranial bleeding. One person will benefit (through prevention of a vascular event) when 91 people with diabetes are treated with low dose aspirin. However, for every 111 people treated, one person will develop significant bleeding. Ref: Article

4. ENDOCRINE

4A. Should subclinical hypothyroidism in older adults be treated with thyroxine?
No. Treatment with thyroxine does not seem to produce any improvement in subjective feelings of tiredness. This was the conclusion of a study reported in NEJM (2017) Reference

5. BONES AND MUSCLES

5A. How should older people be screened for frailty at the bedside or clinic?
Frailty is assessed by a number of factors: weight loss, poor muscle strength, feelings of exhaustion, presence of multiple organ dysfunction, slow movement and low physical activity. The Timed Up and Go test (TUG test) and the various versions of the Sit To Stand Test are useful at the bedside and clinic to assess adequacy of combined muscle strength and predisposition to falls.

6. What are some of the high-risk medications for older adults?
6A. Diabetes. Insulin and sulfonylureas increase risk of hypoglycemia
6B. Anticoagulation. Warfarin increases risk of GI and intracranial bleeding
6C. Cardiac. Digoxin increases risk of impaired cognition and heart block
6D. CNS. Benzodiazepines increase risk of falls. First generation antihistamines like diphenhydramine increase risk of falls. Antipsychotics increase risk of death (in dementia). Opiod analgesics increase risk of constipation, confusion and respiratory depression (morphine, fentanyl and oxycodone may be safer than other opioids).
6E. Antibiotics. Fluoroquinolones increase risk of tendon rupture (if given with steroids) and also increase risk of arrhythmias, hypoglycemia and Clostridioides difficile associated diarrhoea. Nitrofurantoins when given long term increase risk of pulmonary fibrosis and neuropathy. Co-trimoxazole increases risk of hyperkalemia (with ACEI) and hypoglycemia (with sufonylureas).