Frailty and sarcopenia as the basis for the phenotypic manifestation of chronic diseases in older adults

Effect of Physical Activity/Exercise on Oxidative Stress and Inflammation in Muscle and Vascular Aging

Functional status is considered the main determinant of healthy aging. Impairment in skeletal muscle and the cardiovascular system, two interrelated systems, results in compromised functional status in aging. Increased oxidative stress and inflammation in older subjects constitute the background for skeletal muscle and cardiovascular system alterations. Aged skeletal muscle mass and strength impairment is related to anabolic resistance, mitochondrial dysfunction, increased oxidative stress and inflammation as well as a reduced antioxidant response and myokine profile. Arterial stiffness and endothelial function stand out as the main cardiovascular alterations related to aging, where increased systemic and vascular oxidative stress and inflammation play a key role. Physical activity and exercise training arise as modifiable determinants of functional outcomes in older persons. Exercise enhances antioxidant response, decreases age-related oxidative stress and pro-inflammatory signals, and promotes the activation of anabolic and mitochondrial biogenesis pathways in skeletal muscle. Additionally, exercise improves endothelial function and arterial stiffness by reducing inflammatory and oxidative damage signaling in vascular tissue together with an increase in antioxidant enzymes and nitric oxide availability, globally promoting functional performance and healthy aging. This review focuses on the role of oxidative stress and inflammation in aged musculoskeletal and vascular systems and how physical activity/exercise influences functional status in the elderly.

Effect of a multicomponent exercise program and cognitive stimulation (VIVIFRAIL-COGN) on falls in frail community older persons with high risk of falls: study protocol for a randomized multicenter control trial

BACKGROUND

Falls represent important drivers of intrinsic capacity losses, functional limitations and reduced quality of life in the growing older adult's population, especially among those presenting with frailty. Despite exercise- and cognitive training-based interventions have shown effectiveness for reducing fall rates, evidence around their putative cumulative effects on falls and fall-related complications (such as fractures, reduced quality of life and functional limitations) in frail individuals remains scarce. The main aim of this study is to explore the effectiveness program combining an individualized exercise program and an executive function-based cognitive training (VIVIFRAIL-COGN) compared to usual care in the prevention of falls and fall-related outcomes over a 1-year follow-up.

METHODS

This study is designed as a four-center randomized clinical trial with a 12-week intervention period and an additional 1-year follow-up. Three hundred twenty frail or pre-frail (≥ 1 criteria of the Frailty Phenotype) older adults (≥ 75 years) with high risk of falling (defined by fall history and gait performance) will be recruited in the Falls Units of the participating centers. They will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will participate in a home-based intervention combining the individualized Vivifrail multicomponent (aerobic, resistance, gait and balance and flexibility) exercise program and a personalized executive function-based cognitive training (VIVIFRAIL-COGN). The CG group will receive usual care delivered in the Falls Units, including the Otago Exercise Program. Primary outcome will be the incidence of falls (event rate/year) and will be ascertained by self-report during three visits (at baseline, and 6 and 12 weeks) and telephone-based contacts at 6, 9 and 12 months after randomization. Secondarily, effects on measures of physical and cognitive function, quality of life, nutritional, muscle quality and psychological status will be evaluated.

DISCUSSION

This trial will provide new evidence about the effectiveness of an individualized multidomain intervention by studying the effect of additive effects of cognitive training and physical exercise to prevent falls in older frail persons with high risk of falling. Compared to usual care, the combined intervention is expected to show additive effects in the reduction of the incidence of falls and associated adverse outcomes.

TRIAL REGISTRATION

NCT04911179 02/06/2021.

Preventing and Managing Falls in Adults With Cardiovascular Disease: A Scientific Statement From the American Heart Association

Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record-based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.

Metabolic phenotypes explain the relationship between dysglycaemia and frailty in older people with type 2 diabetes

BACKGROUND

Dysglycaemia (hyperglycaemia and hypoglycaemia) increase the risk of frailty in older people with diabetes, which appears contradictory. However, the characteristics of patients included in these studies are different and may reflect different metabolic phenotypes of frailty that may explain this apparent contradiction.

AIMS

To review the characteristics of frail patients included in clinical studies that reported an association between dysglycaemia and frailty in order to explore whether there is any metabolic differences in the profile of these patients.

METHODS

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Key words around older people, type 2 diabetes mellitus, frailty, hyperglycaemia and low glycaemia were used in the literature search.

RESULTS

Only 8 studies met the inclusion criteria. Four studies investigated the risk of frailty associated with low glycaemia. Two studies showed that hypoglycaemia increased the risk of frailty by 44% (HR 1.60, 95% CI 1.14 to 2.42) and predicted greater level of dependency (p < 0.001), respectively. The other two studies reported that HbA1c inversely correlated with clinical frailty scale (r = -0.31, p < 0.01) and HbA1c < 6.0% was associated with increased risk of disability (3.45, 1.02 to 11.6), respectively. Compared with non-frail patients, those with frailty tended to have lower body weight or body mass index (BMI), have features of malnutrition such as low serum albumin or low total cholesterol and suffer from more comorbidities including dementia. Four studies explored the association of high glycaemia with frailty. Higher HbA1c predicted frailty (OR 1.43, 95% CI 1.045 to 1.97) and positively correlated with Edmonton frail score (r = 0.44, p < 0.001), respectively in two studies. The other two studies found that subjects with HbA1c ≥ 6.5% had the greatest prevalence of frailty (70.3%) and subjects with higher HbA1c at baseline to have a higher frailty level throughout later life, respectively. Compared with non-frail patients, those with frailty tended to have higher body weight, waist circumference and BMI. They also have less physical activity, higher cholesterol level and have more comorbidities.

CONCLUSIONS

Dysglycaemia increases the risk of frailty but the characteristics of patients in these studies suggest different metabolic phenotypes of frailty. Therefore, these metabolic differences in frailty should be taken into consideration in the management of older people with diabetes.

Obesity paradox in joint replacement for osteoarthritis - truth or paradox?

Obesity is associated with an increased risk of cardiovascular disease (CVD) and other adverse health outcomes. In patients with pre-existing heart failure or coronary heart disease, obese individuals have a more favourable prognosis compared to individuals who are of normal weight. This paradoxical relationship between obesity and CVD has been termed the 'obesity paradox'. This phenomenon has also been observed in patients with other cardiovascular conditions and diseases of the respiratory and renal systems. Taking into consideration the well-established relationship between osteoarthritis (OA) and CVD, emerging evidence shows that overweight and obese individuals undergoing total hip or knee replacement for OA have lower mortality risk compared with normal weight individuals, suggesting an obesity paradox. Factors proposed to explain the obesity paradox include the role of cardiorespiratory fitness ("fat but fit"), the increased amount of lean mass in obese people, additional adipose tissue serving as a metabolic reserve, biases such as reverse causation and confounding by smoking, and the co-existence of older age and specific comorbidities such as CVD. A wealth of evidence suggests that higher levels of fitness are accompanied by prolonged life expectancy across all levels of adiposity and that the increased mortality risk attributed to obesity can be attenuated with increased fitness. For patients about to have joint replacement, improving fitness levels through physical activities or exercises that are attractive and feasible, should be a priority if intentional weight loss is unlikely to be achieved.

Adherence to Medication in Older Adults with Type 2 Diabetes Living in Lubuskie Voivodeship in Poland: Association with Frailty Syndrome

Purpose: Diabetic patients aged 65 years or older are more likely to be frail than non-diabetic older adults. Adherence to therapeutic recommendations in the elderly suffering from diabetes and co-existent frailty syndrome may prevent complications such as micro- or macroangiopathy, as well as significantly affect prevention and reversibility of frailty. The study aimed at assessing the impact of frailty syndrome (FS) on the level of adherence to medication in elderly patients with type 2 diabetes (DM2). Patients and Methods: The research was carried out among 175 DM2 patients (87; 49.71% women and 88; 50.29% men) whose average age amounted to 70.25 ± 6.7. Standardized research instruments included Tilburg frailty indicator (TFI) to assess FS and adherence in chronic disease scale questionnaire (ACDS) to measure adherence to medications. Results: The group of 101 (57.71%) patients displayed medium, 39 (22.29%)—low, and 35 (20.00%)—high adherence. As many as 140 of them (80.00%) were diagnosed with frailty syndrome. The median of the average result of TFI was significantly higher in the low adherence group (p ˂ 0.001) (Mdn = 9, Q1–Q3; 7–10 pt.) than in the medium (Mdn = 6, Q1–Q3; 5–9 pt.) or high adherence (Mdn = 6.00, Q1–Q3; 4.5–8 pt.) ones. The independent predictors of the chance to be qualified to the non-adherence group included three indicators: TFI (OR 1.558, 95% CI 1.245–1.95), male gender (OR 2.954, 95% CI 1.044–8.353), and the number of all medications taken daily (each extra pill decreased the chance of being qualified to the non-adherence group by 15.3% (95% CI 0.728–0.954). Conclusion: Frailty syndrome in elderly DM2 patients influenced medical adherence in this group. The low adhesion group had higher overall TFI scores and separately higher scores in the physical and psychological domains compared to the medium and high adhesion groups.

Adiponectin receptor agonist AdipoRon improves skeletal muscle function in aged mice

The loss of skeletal muscle function with age, known as sarcopenia, significantly reduces independence and quality of life and can have significant metabolic consequences. Although exercise is effective in treating sarcopenia it is not always a viable option clinically, and currently, there are no pharmacological therapeutic interventions for sarcopenia. Here, we show that chronic treatment with pan-adiponectin receptor agonist AdipoRon improved muscle function in male mice by a mechanism linked to skeletal muscle metabolism and tissue remodeling. In aged mice, 6 weeks of AdipoRon treatment improved skeletal muscle functional measures in vivo and ex vivo. Improvements were linked to changes in fiber type, including an enrichment of oxidative fibers, and an increase in mitochondrial activity. In young mice, 6 weeks of AdipoRon treatment improved contractile force and activated the energy-sensing kinase AMPK and the mitochondrial regulator PGC-1a (peroxisome proliferator-activated receptor gamma coactivator one alpha). In cultured cells, the AdipoRon induced stimulation of AMPK and PGC-1a was associated with increased mitochondrial membrane potential, reorganization of mitochondrial architecture, increased respiration, and increased ATP production. Furthermore, the ability of AdipoRon to stimulate AMPK and PGC1a was conserved in nonhuman primate cultured cells. These data show that AdipoRon is an effective agent for the prevention of sarcopenia in mice and indicate that its effects translate to primates, suggesting it may also be a suitable therapeutic for sarcopenia in clinical application.

Sarcopenia, Precardial Adipose Tissue and High Tumor Volume as Outcome Predictors in Surgically Treated Pleural Mesothelioma

BACKGROUND

We evaluated the prognostic value of Sarcopenia, low precardial adipose-tissue (PAT), and high tumor-volume in the outcome of surgically-treated pleural mesothelioma (PM).

METHODS

From 2005 to 2020, consecutive surgically-treated PM-patients having a pre-operative computed tomography (CT) scan were retrospectively included. Sarcopenia was assessed by CT-based parameters measured at the level of the fifth thoracic vertebra (TH5) by excluding fatty-infiltration based on CT-attenuation. The findings were stratified for gender, and a threshold of the 33rd percentile was set to define sarcopenia. Additionally, tumor volume as well as PAT were measured. The findings were correlated with progression-free survival and long-term mortality.

RESULTS

Two-hundred-seventy-eight PM-patients (252 male; 70.2 ± 9 years) were included. The mean progression-free survival was 18.6 ± 12.2 months, and the mean survival time was 23.3 ± 24 months. Progression was associated with chronic obstructive pulmonary disease (COPD) (p = <0.001), tumor-stage (p = 0.001), and type of surgery (p = 0.026). Three-year mortality was associated with higher patient age (p = 0.005), presence of COPD (p < 0.001), higher tumor-stage (p = 0.015), and higher tumor-volume (p < 0.001). Kaplan-Meier statistics showed that sarcopenic patients have a higher three-year mortality (p = 0.002). While there was a negative correlation of progression-free survival and mortality with tumor volume (r = 0.281, p = 0.001 and r = -0.240, p < 0.001; respectively), a correlation with PAT could only be shown for epithelioid PM (p = 0.040).

CONCLUSIONS

Sarcopenia as well as tumor volume are associated with long-term mortality in surgically treated PM-patients. Further, while there was a negative correlation of progression-free survival and mortality with tumor volume, a correlation with PAT could only be shown for epithelioid PM.

Circulating Levels of Apelin, GDF-15 and Sarcopenia: Lack of Association in the MAPT Study

OBJECTIVES

Apelin and GDF-15 have been proposed as biomarkers of age-related sarcopenia but evidence in human models is scarce. This study aimed to explore the associations between blood apelin and GDF-15 with sarcopenia incidence and the evolution of sarcopenia components over two years in older adults >70 years.

DESIGN

Secondary longitudinal analysis of the Multidomain Alzheimer Preventive Trial.

PARTICIPANTS

Older adults (>70 years) attending primary care centers in France and Monaco.

SETTING

Community.

MEASUREMENTS

Serum Apelin (pg/mL) and plasma GDF-15 (pg/mL) were measured. Outcomes included sarcopenia defined by the European Working Group on Sarcopenia in Older People (EWGSOP) and its determinants (appendicular lean mass [ALM] evaluated through a Dual-energy X-ray Absorptiometry (DXA) scan, handgrip strength (HGS) and the 4-meter gait speed) measured over 2 years. Linear mixed models and logistic regression were used to explore the longitudinal associations.

RESULTS

We included 168 subjects from MAPT (median age=76y, IQR=73-79; 78% women). Serum apelin was not significantly associated with sarcopenia incidence (OR=1.001;95%CI=1.000,1.001;p-value>0.05 in full-adjusted models) nor with ALM (β=-5.8E-05;95%CI=-1.0E-04,2.12E-04;p>0.05), HGS (β=-1.1E-04;95%CI=-5.0E-04,2.8E-04;p>0.05), and GS (β=-5.1E-06;95%CI=-1.0E-05,2.0E-05;p>0.05) in fully adjusted models. Similarly, plasma GDF-15 was not associated with both the incidence of sarcopenia (OR=1.001,95%CI=1.000,1.002,p>0.05) and the evolution of its determinants ([ALM, β=2.1E-05;95%CI=-2.6E-04,3.03E-04;p>0.05], HGS [β=-5.9E-04;95%CI=-1.26E-03,8.1E-05; p>0.05] nor GS [β=-2.6E-06;95%CI=-3.0E-05, 2.3E-05;p>0.05]) in fully adjusted models.

CONCLUSIONS

Blood apelin and GDF-15 were not associated with sarcopenia incidence or with the evolution of sarcopenia components over a 2-year follow-up in community-dwelling older adults. Well-powered longitudinal studies are needed to confirm or refute our findings.

DXA-Derived Indices in the Characterisation of Sarcopenia

Sarcopenia is linked with increased risk of falls, osteoporosis and mortality. No consensus exists about a gold standard "dual-energy X-ray absorptiometry (DXA) index for muscle mass determination" in sarcopenia diagnosis. Thus, many indices exist, but data on sarcopenia diagnosis agreement are scarce. Regarding sarcopenia diagnosis reliability, the impact of influencing factors on sarcopenia prevalence, diagnosis agreement and reliability are almost completely missing. For nine DXA-derived muscle mass indices, we aimed to evaluate sarcopenia prevalence, diagnosis agreement and diagnosis reliability, and investigate the effects of underlying parameters, presence or type of adjustment and cut-off values on all three outcomes. The indices were analysed in the BioPersMed cohort (58 ± 9 years), including 1022 asymptomatic subjects at moderate cardiovascular risk. DXA data from 792 baselines and 684 follow-up measurements (for diagnosis agreement and reliability determination) were available. Depending on the index and cut-off values, sarcopenia prevalence varied from 0.6 to 36.3%. Height-adjusted parameters, independent of underlying parameters, showed a relatively high level of diagnosis agreement, whereas unadjusted and adjusted indices showed low diagnosis agreement. The adjustment type defines which individuals are recognised as sarcopenic in terms of BMI and sex. The investigated indices showed comparable diagnosis reliability in follow-up examinations.

Oxidative Stress in ICU Patients: ROS as Mortality Long-Term Predictor

Lipid peroxidation, protein oxidation, and mutations in mitochondrial DNA generate reactive oxygen species (ROS) that are involved in cell death and inflammatory response syndrome. ROS can also act as a signal in the intracellular pathways involved in normal cell growth and homeostasis, as well as in response to metabolic adaptations, autophagy, immunity, differentiation and cell aging, the latter of which is an important characteristic in acute and chronic pathologies. Thus, the measurement of ROS levels of critically ill patients, upon admission, enables a prediction not only of the severity of the inflammatory response, but also of its subsequent potential outcome. The aim of this study was to measure the levels of mitochondrial ROS (superoxide anion) in the peripheral blood lymphocytes within 24 h of admission and correlate them with survival at one year after ICU and hospital discharge. We designed an observational prospective study in 51 critical care patients, in which clinical variables and ROS production were identified and correlated with mortality at 12 months post-ICU hospitalization. Oxidative stress levels, measured as DHE fluorescence, show a positive correlation with increased long-term mortality. In ICU patients the major determinant of survival is oxidative stress, which determines inflammation and outlines the cellular response to inflammatory stimuli.

Impact of frailty metabolic phenotypes on the management of older people with type 2 diabetes mellitus

AIMS

To provide a pathophysiological basis for distinguishing metabolic variants of the frailty phenotype in older adults with type 2 diabetes.

METHODS

We have made an in-depth review of the possible mechanisms in diabetes, ageing and frailty that will alter allow us to describe phenotypic changes which might assist in predicting responses to particular glucose-lowering therapy.

RESULTS

Our review has enable us to describe with some confidence a sarcopenic obese phenotype and an anorexic malnourished phenotype.

CONCLUSIONS

By identifying these two phenotypes we can predict which would be most responsive to certain classes of therapy and where therapies may be ill-advised. This represents the first novel approach in this area. Further work is being planned to develop this hypothesis. Geriatr Gerontol Int 2021; 21: 614-622.

Increasing Fracture Risk Associates With Plasma Circulating MicroRNAs in Aging People's Sarcopenia

Aging generally coincides with a gradual decline in mass and strength of muscles and bone mineral density (BMD). Sarcopenia is closely linked to osteoporosis in the elderly, which can lead to abnormal gait, balance disorders, and dysfunctions, as well as increase in the risks of falls, fractures, weakness, and death. MicroRNAs (miRNAs, miRs) are a kind of short and non-coding RNA molecules but can regulate posttranscriptional protein expression. However, we have known little about their participation in age-associated osteoporosis and sarcopenia. The current study aims to confirm those miRNAs as biomarkers for age-related reduction in muscular atrophy associated with human blood fractures. In our study, 10 fracture-risk-related miRNAs (miR-637, miR-148a-3p, miR-125b-5p, miR-124-3p, miR-122-5p, miR-100-5p, miR-93-5p, miR-21-5p, miR-23a-3p, and miR-24-3p) were analyzed. For the initial screening, we determined the abundance of fracture-risk-associated miRNAs by RT-PCR most frequently detected in enrolled 93 elderly with sarcopenia and non-sarcopenia, respectively. Statistically, the relative expression levels of plasma miR-23a-3p, miR-93-5p, and miR-637 in the sarcopenia group were significantly lower than that in the non-sarcopenia group, while the levels of other miRNAs did not change significantly. Moreover, we showed that the levels of ASM/height², handgrip strength, and 4-m velocity in the sarcopenia group were significantly lower than in the non-sarcopenia group. Whereafter, we expanded the sample for further detection and analysis and revealed that the levels of plasma miR-23a-3p, miR-93-5p, and miR-637 in the sarcopenia group were significantly lower than that in the non-sarcopenia group, which is consistent with the initial screening experiment. From our analysis, changes in levels of plasma miR-93-5p and miR-637 were dramatically related to ASM/height². Furthermore, changes in miR-23a and miR-93-5p were significantly affected by ASM/height² in female individuals, with no significant correlations between miRNAs changes and these diagnostic indexes in male individuals after adjusting sex. The study showed that plasma miRNAs changed in an aging-related sarcopenia manner and were associated with increased fracture risk. In aging patients, plasma miR-23a-3p, miR-93-5p, and miR-637 have the potential as biomarkers of sarcopenia, which can affect the development of physiological dysfunction and may be also used in the fracture risk assessment of these patients.

A robust machine learning framework to identify signatures for frailty: a nested case-control study in four aging European cohorts

Phenotype-specific omic expression patterns in people with frailty could provide invaluable insight into the underlying multi-systemic pathological processes and targets for intervention. Classical approaches to frailty have not considered the potential for different frailty phenotypes. We characterized associations between frailty (with/without disability) and sets of omic factors (genomic, proteomic, and metabolomic) plus markers measured in routine geriatric care. This study was a prevalent case control using stored biospecimens (urine, whole blood, cells, plasma, and serum) from 1522 individuals (identified as robust (R), pre-frail (P), or frail (F)] from the Toledo Study of Healthy Aging (R=178/P=184/F=109), 3 City Bordeaux (111/269/100), Aging Multidisciplinary Investigation (157/79/54) and InCHIANTI (106/98/77) cohorts. The analysis included over 35,000 omic and routine laboratory variables from robust and frail or pre-frail (with/without disability) individuals using a machine learning framework. We identified three protective biomarkers, vitamin D3 (OR: 0.81 [95% CI: 0.68-0.98]), lutein zeaxanthin (OR: 0.82 [95% CI: 0.70-0.97]), and miRNA125b-5p (OR: 0.73, [95% CI: 0.56-0.97]) and one risk biomarker, cardiac troponin T (OR: 1.25 [95% CI: 1.23-1.27]). Excluding individuals with a disability, one protective biomarker was identified, miR125b-5p (OR: 0.85, [95% CI: 0.81-0.88]). Three risks of frailty biomarkers were detected: pro-BNP (OR: 1.47 [95% CI: 1.27-1.7]), cardiac troponin T (OR: 1.29 [95% CI: 1.21-1.38]), and sRAGE (OR: 1.26 [95% CI: 1.01-1.57]). Three key frailty biomarkers demonstrated a statistical association with frailty (oxidative stress, vitamin D, and cardiovascular system) with relationship patterns differing depending on the presence or absence of a disability.

Dual effects of insulin resistance on mortality and function in non-diabetic older adults: findings from the Toledo Study of Healthy Aging

Insulin signalling declines with increasing age and impacts skeletal muscle function and longevity in animal models. Our aim was to assess the relationships between insulin resistance (IR) and frailty and mortality in a unique community-dwelling cohort of older people. 991 non-diabetic subjects from the Toledo Study of Healthy Ageing (TSHA) cohort were included. IR was estimated by the homeostasis model assessment index (HOMA-IR) at baseline while frailty was determined by frailty phenotype (FP) and Frailty Trait Scale (FTS) at baseline and after 5-year follow-up. Deaths were also determined. Multivariate regression models were used to analyze the effects of HOMA-IR on outcomes. Age, gender, BMI, education level, cardio- and cerebro-vascular disease, glomerular filtration rate, and disability were included as potential confounding variables in progressive adjustment models. IR determined as increasing log HOMA-IR was inversely associated with risk of mortality. The association remained significant for all adjustment models (HR: 0.64-0.69). When we analyzed survival curves, the higher the HOMA-IR tertile, the lower the mortality rate (highest vs lowest tertile, p = 0.0082). In contrast, IR increased the risk of incident frailty determined by FP (OR 1.81 [1.14-2.87]) as well as deterioration of frailty status determined by worsening in FTS score (OR 1.28 [1.01-1.63]) at 5-year follow-up. In non-diabetic older subjects, IR significantly increases the risk for frailty and functional decline but decreased the risk of death at 5-year follow-up. This finding raises the need of assessing the effect of biomarkers on different outcomes before establishing their role as biomarkers of aging.

Frailty transitions and cognitive function among South Korean older adults

Frailty is considered a multidimensional geriatric syndrome, manifested by the accumulation of age-associated deficits. The consequences of frailty transitions are still understudied. This study evaluated the influence of frailty transitions on cognitive function in the older adult population. We used data derived from the Korean Longitudinal Study of Aging (KLoSA) (2008–2018) on older adults aged ≥ 65 years. Frailty was assessed using a validated Korean frailty measure known as the frailty instrument (FI), and cognitive function was measured using the Korean version of the Mini-Mental State Examination (K-MMSE). Transitions in frailty and their relationship with cognitive function were investigated using lagged generalized estimating equations (GEE), t-tests, and ANOVA. Respondents who experienced frailty transitions (those with ameliorating frailty), those who developed frailty, and whose frailty remained constant, were more likely to have a lower cognitive function than those who were consistently non-frail. Older age, activities of daily living (ADL) disability, and instrumental ADL disability were more negatively associated with declining cognitive function, especially in the “frail → frail” group. Changes in all individual components of the frailty instrument were significantly associated with impaired cognitive function. The results suggest an association between frailty transitions and cognitive impairment. Over a 2-year span, the remaining frail individuals had the highest rate of cognitive decline in men, while the change from non-frail to frail state in women was significantly associated with the lowest cognitive function values. We recommend early interventions and prevention strategies in older adults to help ameliorate or slow down both frailty and cognitive function decline.

Blood-based biomarkers and long-term risk of frailty - experience from the Swedish AMORIS cohort

BACKGROUND

Frailty is associated with reduced quality of life, poor health outcomes, and death. Past studies have investigated how specific biomarkers are associated with frailty but understanding biomarkers in concert with each other and the associated risk of frailty is critical for clinical application.

METHODS

Using a sample aged ≥59 years at baseline from the Swedish AMORIS cohort (n=19341), with biomarkers measured at baseline (1985-1996), we conducted latent class analysis with 18 biomarkers and used Cox models to determine the association between class and frailty and all-cause mortality.

RESULTS

Four classes were identified. Compared to the largest class, the Reference class (81.7%), all other classes were associated with increased risk of both frailty and mortality. The Anemia class (5.8%), characterized by comparatively lower iron markers and higher inflammatory markers, had HR=1.54, 95% CI 1.38, 1.73 for frailty and HR=1.76, 95% CI 1.65, 1.87 for mortality. The Diabetes class (6.5%) was characterized by higher glucose and fructosamine, and had HR=1.59, 95% CI 1.43, 1.77 for frailty and HR=1.74, 95% CI 1.64, 1.85 for mortality. Finally, the Liver class (6.0%), characterized by higher liver enzyme levels, had HR=1.15, 95% CI 1.01, 1.30 for frailty and HR=1.40, 95% CI 1.31, 1.50 for mortality. Sex-stratified analyses did not show any substantial differences between men and women.

CONCLUSIONS

Distinct sets of commonly available biomarkers were associated with development of frailty and monitoring these biomarkers in patients may allow for earlier detection and possible prevention of frailty, with the potential for improved quality of life.

Low serum klotho concentration is associated with worse cognition, psychological components of frailty, dependence, and falls in nursing home residents

Serum alpha-klotho (s-klotho) protein has been linked with lifespan, and low concentrations of s-klotho have been associated with worse physical and cognitive outcomes. Although its significance in aging remains unclear, s-klotho has been proposed as a molecular biomarker of frailty and dependence. This study is a secondary analysis of data from a clinical trial performed in a population of 103 older individuals living in 10 nursing homes in Gipuzkoa (Spain). We aimed to elucidate associations between s-klotho (as measured by enzyme-linked immunosorbent assay) and body composition, physical fitness, and cognition, as well as frailty and dependence (determined using validated tests and scales). In addition, we investigated the association of s-klotho concentration with falls in the six months following the initial assessment. Low s-klotho levels were associated with a lower score in the psychological component of the Tilburg Frailty Indicator, a worse score in the Coding Wechsler Adult Intelligence Scale, and a greater dependence in activities of daily living. Moreover, participants with lower s-klotho concentrations suffered more falls during the 6 months after the assessment. Future translational research should aim to validate klotho's putative role as a biomarker that could identify the risk of aging-related adverse events in clinical practice.

How gait influences frailty models and health-related outcomes in clinical-based and population-based studies: a systematic review

Aging is often associated with a decline in physical function that eventually leads to loss of autonomy in activities of daily living (ADL). Walking is a very common ADL, important for main determinants of quality of life in older age, and it requires the integration of many physiological systems. Gait speed has been described as the 'sixth vital sign' because it is a core indicator of health and function in aging and disease. We reviewed original studies up to June 2020 that assessed frailty in both longitudinal and cross-sectional observational studies, paying particular attention to how gait is measured in older population and how the gait parameter adopted may influence the estimated frailty models and the health-related outcomes of the various studies (i.e. clinical, cognitive, physical, and nutritional outcomes). Eighty-five studies met the search strategy and were included in the present systematic review. According to the frailty tools, more than 60% of the studies used the physical phenotype model proposed by Fried and colleagues, while one-third referred to multi-domain indexes or models and only 5% referred to other single-domain frailty models (social or cognitive). The great heterogeneity observed in gait measurements and protocols limited the possibility to directly compare the results of the studies and it could represent an important issue causing variability in the different outcome measures in both clinical-and population-based settings. Gait appeared to be an indicator of health and function also in frail older adults, and different gait parameters appeared to predict adverse health-related outcomes in clinical, cognitive, and physical domains and, to a lesser extent, in nutritional domain. Gait has the potential to elucidate the common basic mechanisms of cognitive and motor decline. Advances in technology may extend the validity of gait in different clinical settings also in frail older adults, and technology-based assessment should be encouraged. Combining various gait parameters may enhance frailty prediction and classification of different frailty phenotypes.

Prevalence and Associated Factors of Frailty and Mortality in Patients with End-Stage Renal Disease Undergoing Hemodialysis: A Systematic Review and Meta-Analysis

Hemodialysis is the most common type of treatment for end-stage renal disease (ESRD). Frailty is associated with poor outcomes such as higher mortality. ESRD patients have a higher prevalence of frailty. This systematic review and meta-analysis aimed to identify the prevalence and associated factors of frailty and examine whether it is a predictor of mortality among ESRD patients undergoing hemodialysis. Five electronic databases including PubMed, Embase, CINAHL, Web of Science, and Cochrane Library were searched for relevant studies up to 30 November 2020. A total of 752 articles were found, and seven studies with 2604 participants in total were included in the final analysis. The pooled prevalence of frailty in patients with ESRD undergoing hemodialysis was 46% (95% Confidence interval (CI) 34.2−58.3%). Advanced age, female sex, and the presence of diabetes mellitus increased the risk of frailty in ESRD patients undergoing hemodialysis. Our main finding showed that patients with frailty had a greater risk of all-cause mortality compared with those without (hazard ratio (HR): 2.02, 95% CI: 1.65−2.48). To improve ESRD patient outcomes, healthcare professionals need to assess the frailty of older ESRD patients, particularly by considering gender and comorbidities. Comprehensive frailty screening tools for ESRD patients on hemodialysis need to be developed.

Relationships Between Age, Frailty, Length of Care Home Residence and Biomarkers of Immunity and Inflammation in Older Care Home Residents in the United Kingdom

Aging is associated with changes to the immune system, collectively termed immunosenescence and inflammageing. However, the relationships among age, frailty, and immune parameters in older people resident in care homes are not well described. We assessed immune and inflammatory parameters in 184 United Kingdom care home residents aged over 65 years and how they relate to age, frailty index, and length of care home residence. Linear regression was used to identify the independent contribution of age, frailty, and length of care home residence to the various immune parameters as dependent variables. Participants had a mean age (±SD) of 85.3 ± 7.5 years, had been residing in the care home for a mean (±SD) of 1.9 ± 2.2 years at the time of study commencement, and 40.7% were severely frail. Length of care home residence and frailty index were correlated but age and frailty index and age and length of care home residence were not significantly correlated. All components of the full blood count, apart from total lymphocytes, were within the reference range; 31% of participants had blood lymphocyte numbers below the lower value of the reference range. Among the components of the full blood count, platelet numbers were positively associated with frailty index. Amongst plasma inflammatory markers, C-reactive protein (CRP), interleukin-1 receptor antagonist (IL-1ra), soluble E-selectin and interferon gamma-induced protein 10 (IP-10) were positively associated with frailty. Plasma soluble vascular cell adhesion molecule 1 (sVCAM-1), IP-10 and tumor necrosis factor receptor II (TNFRII) were positively associated with age. Plasma monocyte chemoattractant protein 1 was positively associated with length of care home residence. Frailty was an independent predictor of platelet numbers, plasma CRP, IL-1ra, IP-10, and sE-selectin. Age was an independent predictor of activated monocytes and plasma IP-10, TNFRII and sVCAM-1. Length of care home residence was an independent predictor of plasma MCP-1. This study concludes that there are independent links between increased frailty and inflammation and between increased age and inflammation amongst older people resident in care homes in the United Kingdom. Since, inflammation is known to contribute to morbidity and mortality in older people, the causes and consequences of inflammation in this population should be further explored.

Frailty Among Non-Elderly Patients Undergoing Cardiac Surgery

Fundamento:

Geralmente vista como uma característica da velhice, a fragilidade também pode ocorrer em pessoas não idosas, principalmente naquelas que sofrem de doenças crônicas. A fragilidade pode aumentar o risco operatório.

Objetivos:

Determinar a prevalência de fragilidade em pacientes submetidos à cirurgia de revascularização do miocárdio (CRM) e/ou troca ou reconstrução valvar e/ou cirurgia valvar, bem como a influência da fragilidade nos desfechos pós-operatórios.

Métodos:

Nosso estudo incluiu 100 adultos que foram submetidos a operações cardíacas eletivas consecutivas. A fragilidade foi avaliada por meio da escala de Fried. Os pacientes também realizaram um teste de caminhada de 6 minutos, e medimos as pressões inspiratória e expiratória máximas. Um valor de p < 0,05 foi considerado significativo.

Resultados:

De uma coorte de 100 pacientes, com base nos critérios de fragilidade de Fried, 17 pacientes (17%) foram considerados frágeis, 70 (70%) pré-frágeis e apenas 13 (13%) não frágeis. Entre os portadores de valvopatia, 11 (18,6%) foram considerados frágeis e 43 (73%) pré-frágeis. Cinquenta e três por cento dos pacientes considerados frágeis tinham menos de 60 anos (mediana=48 anos). As diferenças no fenótipo de fragilidade entre os pacientes com valvopatia e doença arterial coronariana não foram estatisticamente significativas (p=0,305). A comparação entre pacientes não frágeis, pré-frágeis e frágeis não mostrou diferença significativa na distribuição das comorbidades e do estado funcional cardíaco, independentemente da doença cardíaca. No entanto, a mortalidade hospitalar mostrou-se significativamente maior em pacientes frágeis (29,4%, p=0,026) que em pacientes pré-frágeis (8,6%) e não frágeis (0%).

Conclusões:

A fragilidade é prevalente mesmo entre pacientes não idosos submetidos a CRM ou cirurgia cardíaca valvar e está associada a maior mortalidade hospitalar pós-operatória.

Frailty measurement, prevalence, incidence, and clinical implications in people with diabetes: a systematic review and study-level meta-analysis

Background

Frailty, a state of increased vulnerability to adverse health outcomes, is important in diabetes management. We aimed to quantify the prevalence of frailty in people with diabetes, and to summarise the association between frailty and generic outcomes (eg, mortality) and diabetes-specific outcomes (eg, hypoglycaemia).

Methods

In this systematic review and study-level meta-analysis, we searched MEDLINE, Embase, and Web of Science for observational studies published between Jan 1, 2001 (the year of the original publication of the Fried frailty phenotype), to Nov 26, 2019. We included studies that assessed and quantified frailty in adults with diabetes, aged 18 years and older; and excluded conference abstracts, grey literature, and studies not published in English. Data from eligible studies were extracted using a piloted data extraction form. Our primary outcome was the prevalence of frailty in people with diabetes. Secondary outcomes were incidence of frailty and generic and diabetes-specific outcomes. Data were assessed by random-effects meta-analysis where possible and by narrative synthesis where populations were too heterogeneous to allow meta-analysis. This study is registered with PROSPERO, CRD42020163109.

Findings

Of the 3038 studies we identified, 118 studies using 20 different frailty measures were eligible for inclusion (n=1 375 373). The most commonly used measures of frailty were the frailty phenotype (69 [58%] of 118 studies), frailty (16 [14%]), and FRAIL scale (10 [8%]). Studies were heterogenous in setting (88 studies were community-based, 18 were outpatient-based, ten were inpatient-based, and two were based in residential care facilities), demographics, and inclusion criteria; therefore, we could not do a meta-analysis for the primary outcome and instead summarised prevalence data using a narrative synthesis. Median community frailty prevalence using frailty phenotype was 13% (IQR 9-21). Frailty was consistently associated with mortality in 13 (93%) of 14 studies assessing this outcome (pooled hazard ratio 1·51 [95% CI 1·30-1·76]), with hospital admission in seven (100%) of seven, and with disability in five (100%) of five studies. Frailty was associated with hypoglycaemia events in one study (<1%), microvascular and macrovascular complications in nine (82%) of 11 studies assessing complications, lower quality of life in three (100%) of three studies assessing quality of life, and cognitive impairment in three (100%) of three studies assessing cognitive impairment. 13 (11%) of 118 studies assessed glycated haemoglobin finding no consistent relationship with frailty.

Interpretation

The identification and assessment of frailty should become a routine aspect of diabetes care. The relationship between frailty and glycaemia, and the effect of frailty in specific groups (eg, middle-aged [aged <65 years] people and people in low-income and lower-middle-income countries) needs to be better understood to enable diabetes guidelines to be tailored to individuals with frailty.

Funding

Medical Research Council.

Genomic instability as a main driving factor of unsuccessful ageing: Potential for translating the use of micronuclei into clinical practice

Genome instability denotes an increased tendency to alterations in the genome during cell life cycle, driven by a large variety of endogenous and exogenous insults. Ageing is characterized by the presence of damage to various cellular constituents, but genome alterations, randomly accumulating with age in different tissues, constitute the key target in this process, and are believed to be the main factor of ageing. Age-related failure of DNA repair pathways allows DNA lesions to occur more frequently, and their accumulation over time contributes to the age-associated decrease in genome integrity in somatic cells. The micronucleus (MN) test is one of the most widely used assays to evaluate genomic instability in different surrogate tissues. A large number of studies has consistently shown a progressive increase in MN frequency with age, starting from very young age groups onwards. Therefore, MN frequency is a suitable biomarker of genomic instability in ageing. Frailty is a multidimensional geriatric syndrome of unsuccessful ageing, characterized by decreased biological reserves and increased vulnerability to external stressors, involving a higher risk of negative health outcomes. Although there is a well-founded belief that genome instability is involved in the frailty syndrome, only two studies investigated the relationship between MN frequency and frailty, not allowing to draw a definite conclusion on the utility of this biomarker for frailty detection. The use of MN and other genomic biomarkers in the detection and follow-up of patients affected by or at risk of frailty has the potential to accumulate evidence on the clinical impact of this approach in the identification and control of frailty in older people.

Association between telomere length, frailty and death in older adults

Frailty is considered a clinical marker of functional ageing. Telomere length (TL) has been proposed as a biomarker of biological age but its role in human ageing is controversial. The main aim of the study was to evaluate the longitudinal association of TL with incident frailty and mortality in two cohorts of Spanish community-dwelling older adults. TL was determined at baseline in blood samples from older adults included in Toledo Study for Healthy Aging and ENRICA cohorts while frailty was determined by frailty phenotype (FP) at baseline and at follow-up (3.5 years). Deaths occurring during follow-up were also recorded. Associations of TL with frailty and mortality were analysed by logistic regression with progressive adjustment. Data were separately analysed in the two cohorts and in all subjects by performing a meta-analysis. TL was not different between frail and non-frail subjects. Longer telomeres were not associated with lower risk of prevalent frailty. Similarly, TL at baseline failed to predict incident frailty (OR: 1.04 [0.88-1.23]) or even the development of a new FP criterion (OR: 0.97 [0.90-1.05]) at follow-up. Lack of association was also observed when analysing the development of specific FP criteria. Finally, while frailty at baseline was significantly associated with higher risk of death at follow-up (OR: 4.08 [1.97-8.43], p < 0.001), TL did not significantly change the mortality risk (OR: 1.05 [0.94-1.16]). Results show that TL does not predict incident frailty or mortality in older adults. This suggests that TL is not a reliable biomarker of functional age.

Instrumented Analysis of the Sit-to-Stand Movement for Geriatric Screening: A Systematic Review

The Sit-to-Stand (STS) is a widely used test of physical function to screen older people at risk of falls and frailty and is also one of the most important components of standard screening for sarcopenia. There have been many recent studies in which instrumented versions of the STS (iSTS) have been developed to provide additional parameters that could improve the accuracy of the STS test. This systematic review aimed to identify whether an iSTS is a viable alternative to a standard STS to identify older people at risk of falling, frailty, and sarcopenia. A total of 856 articles were found using the search strategy developed, with 12 articles retained in the review after screening based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Six studies evaluated the iSTS in fallers, five studies in frailty and only one study in both fallers and frailty. The results showed that power and velocity parameters extracted from an iSTS have the potential to improve the accuracy of screening when compared to a standard STS. Future work should focus on standardizing the segmentation of the STS into phases to enable comparison between studies and to develop devices integrated into the chair used for the test to improve usability.

The clinical and therapeutic challenge of treating older patients in clinical practice

Due to the demographic shift complex care management of older multimorbid patients with changing functional capacities has become core clinical business for many stakeholders in western health care systems. It is the aim of the mini-review to summarise evidence to be translated into clinical practice for pharmacists and medical doctors and interested readers. The review is based upon a comprehensive literature review in PubMed and EMBASE from 2000 to 2018 and grey literature. Interprofessional exchange and discussion among stakeholders from geriatric medicine and the International Association for Pharmaceutical Technology during a meeting in Graz, Austria 2018, led to the narrowing of the review addressing complex care needs of geriatric patients. In this mini-review, attention is drawn to a comprehensive therapeutic goal setting according to evidence-based guidelines: clinical, disease-related care aspects, functional capacities, evaluated by comprehensive geriatric assessment, and patient's wishes and perspectives as main drivers for personalised complex care of geriatric patients.

Reductive stress in striated muscle cells

Reductive stress is defined as a condition of sustained increase in cellular glutathione/glutathione disulfide and NADH/NAD+ ratios. Reductive stress is emerging as an important pathophysiological event in several diseased states, being as detrimental as is oxidative stress. Occurrence of reductive stress has been documented in several cardiomyopathies and is an important pathophysiological factor particularly in coronary artery disease and myocardial infarction. Excess activation of the transcription factor, Nrf2-the master regulator of the antioxidant response-, consequent in most cases to defective autophagy, can lead to reductive stress. In addition, hyperglycemia-induced activation of the polyol pathway can lead to increased NADH/NAD+ ratio, which might translate into increased levels of hydrogen sulfide-via enhanced activity of cystathionine β-synthase-that would fuel reductive stress through inhibition of mitochondrial complex I. Reductive stress may be either a potential weapon against cancer priming tumor cells to apoptosis or a cancer's ally promoting tumor cell proliferation and making tumor cells resistant to reactive oxygen species-inducing drugs. In non-cancer pathological states reductive stress is definitely harmful paradoxically leading to reactive oxygen species overproduction via excess NADPH oxidase 4 activity. In face of the documented occurrence of reductive stress in several heart diseases, there is much less information about the occurrence and effects of reductive stress in skeletal muscle tissue. In the present review we describe relevant results emerged from studies of reductive stress in the heart and review skeletal muscle conditions in which reductive stress has been experimentally documented and those in which reductive stress might have an as yet unrecognized pathophysiological role. Establishing whether reductive stress has a (patho)physiological role in skeletal muscle will hopefully contribute to answer the question whether antioxidant supplementation to the general population, athletes, and a large cohort of patients (e.g. heart, sarcopenic, dystrophic, myopathic, cancer, and bronco-pulmonary patients) is harmless or detrimental.

The relationship between frailty and serum alpha klotho levels in geriatric patients

BACKGROUND

Frailty is a medical syndrome resulting in loss of endurance, strength and physiological function. There is insufficient data to understand the process of frailty formation at the gene level, however one of the product of Klotho gene known as an anti-aging gene with many functions that prolong lifespan is alpha klotho protein. We aimed to investigate the relationship between frailty and the serum alpha klotho protein levels.

METHODS

In this cross-sectional analysis, there were 89 patients aged 65 years old and older, 45 of whom were frail and 44 of whom were not frail, were included in the study. Within the scope of the study, a sociodemographic and clinical information form, the Turkish version of the FRAIL scale and a comprehensive geriatric assessment were evaluated. In addition to routine laboratory tests, plasma alpha klotho protein levels were measured.

RESULTS

The mean alpha klotho protein levels of the patients were 0.76 ± 1.01 ng/ml in the control group and 0.54 ± 0.61 ng/ml in the frail group, however, there was no statistically significant difference between the two groups (p = 0.286). C-reactive protein (CRP) levels were significantly higher and hemoglobin (Hb) levels were significantly lower in the frail patients compared to the control group (p < 0.05). It was observed that alpha klotho protein level was inversly correlated with increased CRP levels but association was weak (p = 0.022, R: -0.245). Hb levels (p = 0.018, R: 0.250) was weakly correlated with alpha klotho protein level.

CONCLUSION

No significant relationship was found between frailty and alpha klotho protein levels in the geriatric patients. Further comprehensive studies are needed to explore this subject.

[Anemia increases mortality risk associated with frailty or disability in older adults. The FRADEA Study]

OBJECTIVE

To analyze if anemia increases 10-year mortality risk associated to frailty and disability in older adults.

DESIGN

Substudy of the FRADEA population-based concurrent cohort study (Frailty and dependence in Albacete), with a 10-year follow-up (2007-2017) in people older than 69years.

SETTING

Albacete city, Spain.

PARTICIPANTS

Of the 993 participants included in the first wave, 790 were selected with valid data on function (frailty and disability), anemia and vital status at 10years.

MAIN MEASUREMENTS

Anemia was defined according to the criteria of the World Health Organization (hemoglobin <13g/dL in men and <12g/dL in women). A functional classification variable was created, including frailty and disability, identifying four progressive functional levels: robust, prefrail, frail and disabled in basic activities of daily life, using frailty phenotype and Barthel index respectively. A new eight categories variable was constructed combining the four functional groups with the presence or absence of anemia. The association with mortality was determined by Kaplan-Meier and Cox proportional hazards analysis adjusted for age, sex, comorbidity, polypharmacy, institutionalization and creatinine.

RESULTS

Mean age was 79years and 59.6% were women. 393 participants (49.7%) died during the follow-up period. The median survival was 98.4months (interquartile range 61). The risk of mortality increased from the levels with better functionality to those with worse functionality, and for each subgroup it was higher in the participants with anemia. Prefrail without anemia HR [hazard ratio] 1.59 (95%CI 1.07-2.36) and with anemia HR 2.37 (95%CI 1.38-4.05). Frail without anemia HR 3.18 (95%CI 1.68-6.02) and with anemia HR 4.42 (95%CI 1.99-9.84). Disabled without anemia HR 3.81 (95%CI 2.45-5.84) and with anemia HR 5.48 (95%CI 3.43-8.76).

CONCLUSION

Anemia increases the risk of mortality associated with frailty and disability in older adults.

Physical activity and exercise: Strategies to manage frailty

Frailty, a consequence of the interaction of the aging process and certain chronic diseases, compromises functional outcomes in the elderly and substantially increases their risk for developing disabilities and other adverse outcomes. Frailty follows from the combination of several impaired physiological mechanisms affecting multiple organs and systems. And, though frailty and sarcopenia are related, they are two different conditions. Thus, strategies to preserve or improve functional status should consider systemic function in addition to muscle conditioning. Physical activity/exercise is considered one of the main strategies to counteract frailty-related physical impairment in the elderly. Exercise reduces age-related oxidative damage and chronic inflammation, increases autophagy, and improves mitochondrial function, myokine profile, insulin-like growth factor-1 (IGF-1) signaling pathway, and insulin sensitivity. Exercise interventions target resistance (strength and power), aerobic, balance, and flexibility work. Each type improves different aspects of physical functioning, though they could be combined according to need and prescribed as a multicomponent intervention. Therefore, exercise intervention programs should be prescribed based on an individual's physical functioning and adapted to the ensuing response.

Screening for sarcopenia and frailty in patients with chronic ulcers: a cross-sectional study

BACKGROUND

Patients with venous ulcers report multiple comorbidities and are more likely to be physically inactive. Sarcopenia and frailty increase vulnerability to dependence and/or death.

OBJECTIVES

To investigate the occurrence of sarcopenia and frailty in patients with chronic venous ulcers.

METHODS

Observational study with cross-sectional design. Nine patients (67.4 ± 8.42 years) with lower limb venous ulcers classified as CEAP 6 according to International Consensus on Chronic Venous Diseases criteria (open and active ulcer) were evaluated. Sarcopenia was assessed and classified by assessment of strength (manual dynamometry), gait speed (10-meter walk test), and muscle mass (calf circumference). Frailty screening was based on the Fried criteria, consisting of five components: unintentional weight loss; exhaustion; weakness; slow gait speed; and low physical activity.

RESULTS

Frailty was more frequent (n=9; 100%) than sarcopenia (n=1; 11,1%). The most common Fried criterion was exhaustion (n=9; 100%), followed by low physical activity (n=8; 88,8%), muscle weakness (n=5; 55%), and unintentional weight loss. Finally, the least frequent criterion was slow walking speed (n=2; 22.2%). In the subject diagnosed with sarcopenia, both weakness and reduced muscle mass were observed (n=1; 11,1%).

CONCLUSIONS

Patients with chronic venous ulcers exhibit frailty or pre-frailty and the components that comprise the condition of frailty in this population are exhaustion, low physical activity, and muscle weakness. Sarcopenia was identified in a small proportion of the patients.

Physical Function and Cardio-Ankle Vascular Index in Elderly Heart Failure Patients

The number of heart failure patients is increasing rapidly in Japan because of its large elderly population. As age increases, arterial stiffness and physical dysfunction progress. This study aimed to evaluate the association between the physical function and arterial stiffness in elderly heart failure patients.This retrospective, observational study includes data from 100 heart failure patients aged ≥ 65 years who were admitted to our hospital and underwent cardiac rehabilitation. The Cardio-Ankle Vascular Index (CAVI) was measured as an indicator of arterial stiffness. Body composition was assessed by bioelectrical impedance analysis. To determine the degree of physical function, we assessed handgrip strength, five-meter walk speed (5MWS), five-repetition sit-to-stand time (5RSST) and six-minute walk distance (6MWD). Sarcopenia was defined using Asian guidelines based on physical function and body composition.Among 100 patients, 47.0% of patients had sarcopenia. After adjustments for age, sex, atrial fibrillation, and ischemic cardiomyopathy, CAVI was significantly higher in with sarcopenia patients than those without sarcopenia. Age, handgrip strength, 5MWS, 5RSST, and 6MWD were associated with CAVI, and 6MWD was as an independent determinant factor of CAVI.6MWD was recognized as an accurate physical function indicator. These findings suggested that physical function and arterial stiffness complement each other. To restore cardiac dysfunction, improving both arterial stiffness and physical function might be useful.

Frailty and cognitive decline

Frailty and cognitive impairment are among the 2 most common geriatric syndromes. Their presence poses major risks to the elderly including greater disability, reduced quality of life, and higher morbi-mortality. Recent evidence suggest that frailty can be a risk factor for incident dementia. The opposite is also true since subjects with Alzheimer's disease and other dementia also present with more severe frailty measures. The mechanisms for the association between frailty and cognitive impairment is not clear, but possibly involves abnormalities in biological processes related to aging. Here, we will review the current evidence of the association between frailty and cognitive impairment. We will also review the possible biological mechanistic links between the 2 conditions. Finally, we will address potential therapeutic targets and interventions that can mitigate both conditions.

The Relationship Between Health Literacy, Social Support, Depression, and Frailty Among Community-Dwelling Older Patients With Hypertension and Diabetes in China

Population aging is one of the major challenges facing modern society and has attracted global attention. With population aging becoming a global phenomenon, the impact of age-related diseases on health is increasing rapidly. Frailty is one of the most pressing issues facing older adults. The purpose of this study was to explore the interrelationship between health literacy, social support, depression, and frailty among older patients with hypertension and diabetes in China. No studies have investigated the mediating effects of social support and depression between health literacy and frailty. The findings of this study can be applied to help ameliorate frailty in older hypertensive and diabetic patients. Data were collected from 637 older hypertensive and diabetic patients aged 65 years and older in Sichuan Province, China. We used structural equation modeling (SEM) to test the hypothesized relationship among the variables. The results showed that 42.4% of the participants suffered from frailty. The mean scores for health literacy, social support, depression, and frailty were 13.6 ± 5.7, 35.7 ± 6.5, 4.0 ± 3.4, and 3.5 ± 2.1, respectively. Social support had a direct negative association with frailty (β = −0.128, 95%CI: [−0.198, −0.056]), and depression had a direct positive association with frailty (β = 0.326, 95%CI: [0.229, 0.411]), while social support had no direct association with depression. Health literacy had a direct positive association with social support (β = 0.151, 95%CI: [0.077, 0.224]) and a direct negative association with depression (β = −0.173, 95%CI: [−0.246, −0.1]), while health literacy had an indirect negative association with frailty through the mediating effect of social support and depression. To mitigate frailty in older patients with hypertension and diabetes, measures that provide social support, and enhance health literacy, while alleviating depression, should be considered, along with greater attention to patients who are divorced, widowed, or unmarried, those with comorbidities, and those with lower socioeconomic status.

Edmonton frail score is associated with diabetic control in elderly type 2 diabetic subjects

Purpose

We aimed to observe clinical and laboratory indices of the diabetic subjects who were either frail or not according to Edmonton frail score. We also aimed to study whether Edmonton frail score was correlated with metabolic and other parameters of the diabetic subjects.

Methods

Patients with T2DM visited our clinic were enrolled to the study and grouped as either frail or not frail according to the Edmonton score. Clinical and laboratory parameters of the groups were compared.

Results

Serum triglyceride (p = 0.04), serum albumin (p = 0.006) and Glomerular Filtration Rate (GFR) (p = 0.01) were significantly lower, while fasting blood glucose (FBG) (p = 0.02), HDL cholesterol (p = 0.005) and glycated hemoglobin (HbA1c) (p = 0.04) were significantly higher in frail group compared to the not frail patients. Edmonton frail score was positively correlated with HbA1c, age, duration of T2DM, FBG, and negatively correlated with serum albumin and GFR levels.

Conclusions

We think that frailty is associated with poor glucose control in subjects with T2DM and better control of the disease may prevent or slow down the development of frailty, as well as microvascular complications in subjects with type 2 diabetes mellitus.

Triad of impairment in older people with diabetes-reciprocal relations and clinical implications

Frailty is emerging as a new category complication of diabetes in older people. Clinically, frailty is still not well defined and mostly viewed as a decline in solely the physical domain. However, frailty is a multidimensional syndrome and the newly introduced concept of "triad of impairment" (physical, cognitive and emotional) may be a more representative of the broad nature of frailty. The components of the triad of impairment (TOI) commonly coexist and demonstrate a reciprocal relation. Diabetes in old age appears to increase the risk of the triad of impairment, which may eventually progress to disability. Therefore, older people with diabetes should be regularly assessed for the presence of these three key components. Adequate nutrition and regular resistance exercise training have been shown to have a positive impact on the long-term outcome in this population. However, the role of good glycaemic control and the use of current hypoglycaemic medications in reducing the incidence of this triad are less clear. Future research is needed to develop novel hypoglycaemic medications that not only focus on glycaemic control and cardiovascular safety but also on reducing the risk of the triad of impairment.

Frailty as a phenotypic manifestation of underlying oxidative stress

Oxidative stress plays a key role in the aging process. Lifestyle behaviours including low physical activity and inadequate nutritional habits in addition to genetic susceptibility and some chronic diseases compromise physiological response to free radicals and promote oxidative damage. Reduced resilience (referred to the ability to respond to stressors or adverse conditions) or functional reserve in isolated organs or systems determines clinical manifestations as the age-related chronic diseases while multisystemic dysfunction results in the frailty phenotype. In older adults, frailty, but not age, is associated with elevation of oxidative stress markers and reduction of antioxidant parameters. Mitochondrial dysfunction related to oxidative stress plays a prominent role in this process affecting not only skeletal muscle but also other potential tissues and organs. Increasing endogenous antioxidant capacity in different systems by exercise outstand among therapeutic interventions with potential ability to prevent or delay frailty phenotype and to promote healthy aging.

Mitochondrial Mechanisms of Neuromuscular Junction Degeneration with Aging

Skeletal muscle deteriorates with aging, contributing to physical frailty, poor health outcomes, and increased risk of mortality. Denervation is a major driver of changes in aging muscle. This occurs through transient denervation-reinnervation events throughout the aging process that remodel the spatial domain of motor units and alter fiber type. In advanced age, reinnervation wanes, leading to persistent denervation that accelerates muscle atrophy and impaired muscle contractility. Alterations in the muscle fibers and motoneurons are both likely involved in driving denervation through destabilization of the neuromuscular junction. In this respect, mitochondria are implicated in aging and age-related neurodegenerative disorders, and are also likely key to aging muscle changes through their direct effects in muscle fibers and through secondary effects mediated by mitochondrial impairments in motoneurons. Indeed, the large abundance of mitochondria in muscle fibers and motoneurons, that are further concentrated on both sides of the neuromuscular junction, likely renders the neuromuscular junction especially vulnerable to age-related mitochondrial dysfunction. Manifestations of mitochondrial dysfunction with aging include impaired respiratory function, elevated reactive oxygen species production, and increased susceptibility to permeability transition, contributing to reduced ATP generating capacity, oxidative damage, and apoptotic signaling, respectively. Using this framework, in this review we summarize our current knowledge, and relevant gaps, concerning the potential impact of mitochondrial impairment on the aging neuromuscular junction, and the mechanisms involved.

Is it possible to reverse frailty in patients with chronic obstructive pulmonary disease?

In recent years, frailty has attracted increasing attention from clinicians and health care workers. The influence of frailty on the elderly, especially those with chronic diseases of the respiratory system, is highly significant. Frailty is particularly more common in patients with chronic obstructive pulmonary disease (COPD). Frailty and COPD share many risk factors and pathophysiological mechanisms. As a comprehensive interventional method for chronic respiratory diseases, pulmonary rehabilitation is an important basic measure for the management of patients with COPD. Frailty in these patients can be reversed using pulmonary rehabilitation by targeting five components of the frailty phenotype at the entry point. The present review discusses the benefits of pulmonary rehabilitation in patients with COPD complicated by frailty and provides a theoretical basis for pulmonary rehabilitation treatment in this population. In addition, the timing of pulmonary rehabilitation is also addressed, with the prefrail stage being the "golden" period. The implementation of pulmonary rehabilitation must vary among individuals, and individualized treatment strategies will help maximize benefits.

Associations of fat-soluble micronutrients and redox biomarkers with frailty status in the FRAILOMIC initiative

BACKGROUND

A poor fat-soluble micronutrient (FMN) and a high oxidative stress status are associated with frailty. Our aim was to determine the cross-sectional association of FMNs and oxidative stress biomarkers [protein carbonyls (PrCarb) and 3-nitrotyrosine] with the frailty status in participants older than 65 years.

METHODS

Plasma levels of vitamins A (retinol), D3 , E (α-tocopherol and γ-tocopherol) and carotenoids (α-carotene and β-carotene, lycopene, lutein/zeaxanthin, and β-cryptoxanthin), PrCarb, and 3-nitrotyrosine were measured in 1450 individuals of the FRAILOMIC initiative. Participants were classified into robust, pre-frail, and frail using Fried's frailty criteria. Associations between biomarkers and frailty status were assessed by general linear and logistic regression models, both adjusted for cohort, season of blood sampling, gender, age, height, weight, and smoking.

RESULTS

Robust participants had significantly higher vitamin D3 and lutein/zeaxanthin concentrations than pre-frail and frail subjects; had significantly higher γ-tocopherol, α-carotene, β-carotene, lycopene, and β-cryptoxanthin concentrations than frail subjects, and had significantly lower PrCarb concentrations than frail participants in multivariate linear models. Frail subjects were more likely to be in the lowest than in the highest tertile for vitamin D3 (adjusted odds ratio: 2.15; 95% confidence interval: 1.42-3.26), α-tocopherol (2.12; 1.39-3.24), α-carotene (1.69; 1.00-2.88), β-carotene (1.84; 1.13-2.99), lycopene (1.94; 1.24-3.05), lutein/zeaxanthin (3.60; 2.34-5.53), and β-cryptoxanthin (3.02; 1.95-4.69) and were more likely to be in the highest than in the lowest tertile for PrCarb (2.86; 1.82-4.49) than robust subjects in multivariate regression models.

CONCLUSIONS

Our study indicates that both low FMN and high PrCarb concentrations are associated with pre-frailty and frailty.

Fidelity of muscle fibre reinnervation modulates ageing muscle impact in elderly women

KEY POINTS

Susceptibility to age-related muscle atrophy relates to the degree of muscle denervation and the capacity of successful reinnervation. However, the specific role of denervation as a determinant of the severity of muscle aging between populations with low versus high physical function has not been addressed. We show that prefrail/frail elderly women exhibited marked features of muscle denervation, whereas world class octogenarian female master athletes showed attenuated indices of denervation and greater reinnervation capacity. These findings suggest that the difference in age-related muscle impact between low- and high-functioning elderly women is the robustness of the response to denervation of myofibers.

ABSTRACT

Ageing muscle degeneration is a key contributor to physical frailty; however, the factors responsible for exacerbated vs. muted ageing muscle impact are largely unknown. Based upon evidence that susceptibility to neurogenic impact is an important determinant of the severity of ageing muscle degeneration, we aimed to determine the presence and extent of denervation in pre-frail/frail elderly (FE, 77.9 ± 6.2 years) women compared to young physically inactive (YI, 24.0 ± 3.5 years) females, and contrast these findings to high-functioning world class octogenarian female masters athletes (MA, 80.9 ± 6.6 years). Muscle biopsies from vastus lateralis muscle were obtained from all three groups to assess denervation-related morphological and transcriptional markers. The FE group displayed marked grouping of slow fibres, accumulation of very small myofibres, a severe reduction in type IIa/I size ratio, highly variable inter-subject accumulation of neural cell adhesion molecule (NCAM)-positive myofibres, and an accumulation of pyknotic nuclei, indicative of recurring cycles of denervation/reinnervation and persistent denervation. The MA group exhibited a smaller decline in type IIa/I size ratio and fewer pyknotic nuclei, accompanied by a higher degree of type I fibre grouping and larger fibre group size, suggesting a greater reinnervation of denervated fibres. Consistent with this interpretation, MA had higher mRNA levels of the reinnervation-promoting cytokine fibroblast growth factor binding protein 1 (FGFBP1) than FE. Our results indicate that the muscle of FE women has significant neurogenic atrophy, whereas MA muscle exhibit superior reinnervation capacity, suggesting that the difference in age-related muscle impact between low- and high-functioning elderly women is the robustness of the response to denervation of myofibres.

Perioperative outcomes in elderly patients undergoing nephrectomy for renal cell carcinoma

Purpose

To determine if age should be considered a relative contraindication to surgery for safety reasons.

Methods

Renal cell carcinoma (RCC) patients who underwent nephrectomy from January 2007 to December 2017 were analyzed retrospectively. Patients were grouped into age<65 and age≥65 years. The demographic data, surgical outcomes, complication, hospital stay, blood loss, and survival were compared between the two groups.

Results

A total of 101 patients were included; 74 in the younger group, and 27 in the older group. Compared to the young group, lower BMI, higher anemia, higher ASA grade, and comorbidities were frequent in the elderly. The operative time, blood loss, and renal function decline were comparable between two age groups. The complication rates in the older and younger group were 22% and 12%, respectively. The survival time was shorter in older patients compared to the younger ones; hazard ratio 2.25; 95%CI 1.08–4.69, p-value=0.031.

Conclusion

Nephrectomy in elderly patients is safe and feasible and preoperative assessment along with diligent postoperative care may further increase survival. Age alone cannot be regarded as a contraindication for nephrectomy in RCC.

Plasma Klotho and Frailty in Older Adults: Findings From the InCHIANTI Study

BACKGROUND

The hormone klotho, encoded by the gene klotho, is primarily expressed in the kidney and choroid plexus of the brain. Higher klotho concentrations have been linked to better physical performance; however, it is unknown whether klotho relates to frailty status in older adults.

METHODS

Plasma klotho was measured in 774 participants aged ≥65 years enrolled in InCHIANTI, a prospective cohort study comprising Italian adults. Frailty status was assessed at 3 and 6 years after enrollment. Frailty was defined as presence of at least three out of five criteria of unintentional weight loss, exhaustion, sedentariness, muscle weakness, and slow walking speed; prefrailty was defined as presence of one or two criteria; and robustness was defined as zero criteria. We assessed whether plasma klotho concentrations measured at the 3-year visit related to frailty.

RESULTS

Each additional natural logarithm of klotho (pg/mL) was associated with lower odds of frailty versus robustness after adjustment for covariates (odds ratio [OR] 0.46; 95% confidence interval 0.21, 0.98; p-value = .045). Higher klotho was particularly associated with lower odds of exhaustion (OR 0.57; 95% CI 0.36, 0.89; p-value = .014). Participants with higher klotho also had lower estimated odds of weight loss and weakness, but these findings were not statistically significant.

CONCLUSIONS

Higher plasma klotho concentrations were associated with lower likelihoods of frailty and particularly exhaustion. Future studies should investigate modifiable mechanisms through which klotho may affect the frailty syndrome.

Involvement of plasma miRNAs, muscle miRNAs and mitochondrial miRNAs in the pathophysiology of frailty

Frailty is a geriatric syndrome that leads not only to the loss of physical functions, but also to a generalized decline of the organism and a high risk of disability and dependency. Frailty's detection and management represent important goals for current gerontology. The advance in its rapid diagnosis could play a relevant role in taking measures to reduce the negative consequences it exerts on the body and to take preventive measures. microRNAs are the one of multiple epigenetic biomarkers that reflect functional changes in aged subject. In this review we analyze microRNAs as molecules involved in the control of the pathways leading to the development of frailty. miRNAs can be present in different body fluids, including plasma/serum and saliva, can be associated with organelles like the mitochondria, and can be expressed in tissues. Based on the multifactorial physiopathology of frailty, we analyzed here the microRNAs linked to "inflammaging" (inflamma-miRs), to musculoskeletal health (myomiRs), and microRNAs that can directly or indirectly affect the mitochondria (mitomiRs). Subsequently, we analyze those microRNAs that can be modified by physical exercise. In this review we will analyze the latest experimental studies carried out in animals, cell cultures, and human samples, with the aim to identify gaps in the research and in order to try to dazzle the information about the pathways regulated by each miRNA. Multiple studies revised here suggest that several miRs can be considered as possible markers of frailty, including miR-1, miR-21, miR-34a, miR-146a, miR-185, and miR-206, miR-223, among others. Normalization of miRNAs data and standardization of the protocols used for their measurement to avoid confounding variables influencing the results, are important to use miRNAs as disease biomarkers.

Urinary Sex Steroid and Glucocorticoid Hormones Are Associated With Muscle Mass and Strength in Healthy Adults

CONTEXT

Sex steroid hormones exhibit anabolic effects whereas a deficiency engenders sarcopenia. Moreover, supraphysiological levels of glucocorticoids promote skeletal muscle atrophy, whereas physiologic levels of glucocorticoids may improve muscle performance.

OBJECTIVE

To study the relationship between both groups of steroid hormones at a physiological range with skeletal muscle mass and function in the general population.

DESIGN

Cross-sectional analysis of the associations between urinary excreted androgens, estrogens, glucocorticoids, and steroid hormone metabolite ratios with lean mass and handgrip strength in a population-based cohort.

SETTING

Three centers in Switzerland including 1128 participants.

MEASURES

Urinary steroid hormone metabolite excretion by gas chromatography-mass spectrometry, lean mass by bioimpedance analysis, and isometric handgrip strength by dynamometry.

RESULTS

For lean mass a strong positive association was found with 11β-OH-androsterone and with most glucocorticoids. Androsterone showed a positive association in middle-aged and older adults. Estriol showed a positive association only in men. For handgrip strength, strong positive associations with androgens were found in middle-aged and older adults, whereas positive associations were found with cortisol metabolites in young to middle-aged adults.

CONCLUSIONS

Sex steroids and glucocorticoids are strongly positively associated with skeletal muscle mass and strength in the upper limbs. The associations with muscle strength appear to be independent of muscle mass. Steroid hormones exert age-specific anabolic effects on lean mass and handgrip strength. Deficits in physical performance of aged muscles may be attenuated by androgens, whereas glucocorticoids in a physiological range increase skeletal muscle mass at all ages, as well as muscle strength in particular in younger adults.