Medical Grand Rounds

Geriatrics update 2015: Vaccination, frailty, chronic disease guidelines, and cognition

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ABSTRACTThis paper discusses recent developments and recommendations for elderly patients concerning immunizations, heart failure, lipid therapy, blood pressure control, and dementia.


  • Vaccination costs will increase—with unclear added value—with new guidelines for influenza and pneumococcal vaccines.
  • Multiple simultaneous interventions for heart failure have additive value. These are education, a beta-blocker, an angiotensin-converting enzyme inhibitor, and, in some, an aldosterone antagonist, anticoagulation for atrial fibrillation, and an implantable cardioverter-defibrillator or cardiac resynchronization therapy.
  • Statin therapy should be intensified with an eye to goals of care and tolerability rather than a specific lipid goal.
  • Exercise improves physical and mental health in all, including the elderly.
  • Dementia still has no magic bullet. Selective serotonin reuptake inhibitors might help behavior issues, and vitamin E might bring modest cognitive improvement but with possible risk.



Guidelines for the management of chronic disease are starting to recognize vulnerable elderly patients. The topics in this review, culled from recent studies and recommendations, were chosen because they may change geriatric care. They include the newest influenza and pneumococcal vaccines; recommendations for managing chronic heart failure, cholesterol, and blood pressure; preventing frailty; drug treatments for dementia; and the impact of cognitive impairment on health outcomes.


Three classes of influenza vaccines have been available for some time:

  • The standard-dose, trivalent inactivated injectable vaccine (IIV3-SD) contains H1N1, H3N2, and influenza B strains and is approved for all ages over 6 months.
  • The quadrivalent vaccine (available mostly for nasal administration) has the same strains as the trivalent vaccine plus a second, different influenza B strain. The inactivated vaccine is injectable for all persons over the age of 6 months; the live-attenuated vaccine is available as a nasal spray only for ages 2 through 49.
  • The high-dose injectable vaccine (IIV3-HD) contains the same strains as the trivalent vaccine plus four times as much hemagglutinin—the influenza virus antigen that stimulates immunity.

Although IIV3-HD has been available since 2010, no clinical data existed until 2014 showing it to be superior to standard-dose vaccine.

DiazGranados et al1 randomized nearly 32,000 adults age 65 and older to receive either the standard-dose or the high-dose vaccine. The primary end point was laboratory-confirmed influenza caused by any influenza viral type or subtype, in association with a protocol-defined influenzalike illness.

The primary end point was reached in 1.4% of those with the high-dose vaccine and 1.9% of those with the standard-dose vaccine (relative efficacy 24.2%, 95% confidence interval 9.7–36.5). There was also a 26% reduction in respiratory illness regardless of laboratory confirmation. Mortality rates were identical and low (0.5%) in both groups. In those without laboratory confirmation of respiratory illness, there was a 26% lower rate of pneumonia but no statistical difference in rates of hospitalization, medication use, routine office visits, and emergency department visits.

These results can be interpreted as meaning that the high-dose vaccine prevented about a quarter of the laboratory-confirmed influenza cases that would have occurred with the standard-dose vaccine. However, due to the low rate of disease in those given the standard-dose vaccine, the number needed to treat to prevent one influenza infection was about 200 with the high-dose vs the standard-dose vaccine; to prevent one case of pneumonia, more than 270 would need to be treated.

The current price differential as well as the high number needed to treat to prevent one infection may discourage the use of the high-dose vaccine. Medicare Part B pays for one dose of either influenza vaccine per season. For patients who paid out of pocket, the 2014–2015 season cost at a typical pharmacy was about $32 for the standard-dose vaccine and $55 for the high-dose.


Conjugate vaccine now recommended for seniors

The 23-valent polysaccharide vaccine (Pneumovax) has been available since 1983 and is recommended in the United States for all adults age 65 and over. A 13-valent pneumococcal diphtheria conjugate vaccine (Prevnar 13) has been available since 2010. Until recently, the conjugate vaccine was recommended for children; the only adults for whom it was recommended were those age 19 and over who either were immunocompromised or had a cochlear implant, asplenia, a cerebral spinal fluid leak, or renal failure.

The CAPITA trial2 (Community-Acquired Pneumonia Immunisation Trial in Adults) randomized nearly 85,000 people (most 65 and older, and some children) in the Netherlands to receive either the conjugate vaccine or placebo. It found a 46% reduction in community-acquired pneumonia (P = .0006), a 45% reduction in nonbacteremic nonvaccine-type community-acquired pneumonia (P = .0067), and a 75% reduction in vaccine-type invasive pneumococcal disease (P = .0005). Common side effects included pain, swelling at the injection site, limitation of arm movement, fatigue, headache, decreased appetite, chills, and rash.

Based on this one study, the Advisory Committee on Immunization Practices3 recommended that all adults 65 and older receive the conjugate vaccine.

The recommendations for the conjugate vaccine for all ages are complicated. Limited to those age 65 and older, current recommendations are:

  • For those who have already received the polysaccharide vaccine: get the conjugated vaccine at least 1 year later
  • For those who have never received the polysaccharide vaccine: get the conjugate vaccine now, then the polysaccharide vaccine 6 to 12 months later.

Number needed to treat with the high-dose vs the standard-dose vaccine to prevent one case of
influenza: 200

Whether the Netherlands findings fully apply to the United States is under question. At the time of the study, Dutch infants but not adults had received pneumonia conjugate vaccinations since 2002 with a high compliance rate. Unlike in the United States, the polysaccharide pneumococcal vaccine had not been routinely recommended in the Netherlands. There may have been some indirect immunity due to the “herd” effect, but no direct immunity. With a likely higher background immunity to pneumonia in the United States, the dramatic reduction in infection noted in the Netherlands may not be duplicated here.

For those without Medicare coverage, the 2014–2015 winter season cost at a pharmacy was about $95 for the polysaccharide vaccine and about $200 for the conjugate vaccine. As of February 2, 2015, the Centers for Medicare and Medicaid Services are implementing Medicare Part B coverage to allow initial pneumococcal vaccine for Medicare patients who never received a pneumococcal vaccine under Medicare Part B, and then a different, second pneumococcal vaccine, 1 year after the first vaccine was administered.

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