Low Testosterone, but Not Estradiol, Is Associated With Incident Falls in Older Men: The International MrOS Study

Testosterone and resistance training improved physical performance and reduced fatigue in frail older men: 1 year follow-up of a randomized clinical trial

OBJECTIVE

To improve health conditions among hypogonadal men ≥70 years of age using testosterone undecanoate (TU) injections, progressive strength training, and oral supplements of vitamin D, calcium, and protein.

METHODS

This study is a 1-year follow-up of a double-blind RCT lasting 20 weeks, including 148 older men ≥70 years old with low testosterone levels and mobility problems. During 52 weeks, 4 groups received either testosterone therapy (TU) or progressive resistance training (Training), both (Combo), or no intervention (Controls). Physiotherapists supported the training groups until week 20, while these participants continued trained on their own during weeks 21 to 52. The main outcome measure was the 30-s chair stand test.

RESULTS

The following numbers of participants completed the trial: 20 (Combo), 20 (Controls), 24 (TU), and 14 (Training). When examining 30-s chair stand test performance within each group at baseline, and at weeks 4, 20 and 52, only the Combo group improved (p = 0.001, Friedman Test). Compared to controls, only the Combo group experienced reduced fatigue and tiredness (p < 0.05).

CONCLUSIONS

Fifty-two weeks of testosterone supplementation combined with progressive resistance training may enhance physical performance, alleviate fatigue, and had no notable detrimental impacts among males aged ≥70 suffering from mobility issues and testosterone insufficiency.Trial registration - Clinical Trials NCT02873559.

Beneficial effects of exercise, testosterone, vitamin D, calcium and protein in older men-A randomized clinical trial

BACKGROUND

Due to increasing older populations worldwide, injuries, disabilities and deaths caused by falls among the elderly represent a growing human and societal problem. We aimed to improve health among men of at least 70 years of age with low-normal to low testosterone and mobility problems by using testosterone undecanoate (TU) injections, progressive strength training, and oral supplements of vitamin D, calcium and protein.

METHODS

This was a single-centre, randomized, placebo-controlled, double-blind trial with 148 older men with a median age of 77 (73-81) years, testosterone levels at median 8 (5-9) nmol/L (full range from 1.1 to 12.9 nmol/L) and mobility problems, recruited at University Hospital of Copenhagen, Herlev Hospital, Denmark. Participants were randomized into four arms for 20 weeks: (1) TU therapy (n = 37); (2) progressive resistance training with supplements of calcium, vitamin D and protein (n = 36); (3) both interventions combined (n = 36); or (4) no intervention (n = 39). The main outcome measure was the 30-s chair stand test, due to test performance correlating with the risk of serious fall injuries and lower extremity muscle strength. Outcome measurements were performed at baseline and after 20 weeks.

RESULTS

After the intervention, the combination group receiving progressive resistance training, TU and supplements achieved a median score of 13 (11-15) compared to the control group at 10 (0-14) in the 30-s chair stand test (P = 0.003). This median improvement of 3.0 was clinically important. Compared to the control group, participants in the combination group also increased quality of life (P < 0.05) and reduced both tiredness (P < 0.05) and leg fat (P < 0.05) and had higher variability in the RR interval (P < 0.01). The group receiving TU reduced gynoid and leg fat compared to the control group (both P < 0.05). Blood tests improved for several variables, especially in the combination group. There was no statistically significant increase in adverse effects from either the supplements or training.

CONCLUSIONS

In men ≥70 years old with low-normal to low testosterone and mobility problems, supplements of testosterone, calcium, vitamin D and protein combined with progressive resistance training improved 30-s chair stand test performance, muscle strength and quality of life. Both tiredness and leg fat were reduced, and RR interval variability was increased. Significant adverse effects were not observed.

Effects of testosterone and vitamin D on fall risk in pre-frail hypogonadal men: a factorial design RCT

OBJECTIVE

To test whether transdermal testosterone at a dose of 75 mg per day and/or monthly 24'000 IU Vitamin D reduces the fall risk in pre-frail hypogonadal men aged 65 and older.

DESIGN

2 × 2 factorial design randomized controlled trial, follow up of 12 months.

METHODS

Hypogonadism was defined as total testosterone <11.3 nmol/L and pre-frailty as ≥1 Fried- frailty criteria and/or being at risk for falling at the time of screening. The primary outcomes were number of fallers and the rate of falls, assessed prospectively. Secondary outcomes were appendicular lean mass (ALM), sit-to-stand, gait speed, and the short physical performance test battery. Analyses were adjusted for age, BMI, fall history and the respective baseline measurement.

RESULTS

We aimed to recruit 168 men and stopped at 91 due to unexpected low recruitment rate (1266 men were pre-screened). Mean age was 72.2 years, serum total testosterone was 10.8 ± 3.0 nmol/l, and 20.9% had 25(OH)D levels below 20 ng/mL. Over 12 months, 37 participants had 72 falls. Neither the odds of falling nor the rate of falls were reduced by testosterone or by vitamin D. Testosterone improved ALM compared to no testosterone (0.21 kg/m2 [0.06, 0.37]), and improved gait speed (0.11 m/s, [0.03, 0.20]) compared to placebo.

CONCLUSION

Transdermal testosterone did not reduce fall risk but improved ALM and gait speed in pre-frail older men. Monthly vitamin D supplementation had no benefit.

Bone health in ageing men

Osteoporosis does not only affect postmenopausal women, but also ageing men. The burden of disease is projected to increase with higher life expectancy both in females and males. Importantly, osteoporotic men remain more often undiagnosed and untreated compared to women. Sex steroid deficiency is associated with bone loss and increased fracture risk, and circulating sex steroid levels have been shown to be associated both with bone mineral density and fracture risk in elderly men. However, in contrast to postmenopausal osteoporosis, the contribution of relatively small decrease of circulating sex steroid concentrations in the ageing male to the development of osteoporosis and related fractures, is probably only minor. In this review we provide several clinical and preclinical arguments in favor of a 'bone threshold' for occurrence of hypogonadal osteoporosis, corresponding to a grade of sex steroid deficiency that in general will not occur in many elderly men. Testosterone replacement therapy has been shown to increase bone mineral density in men, however data in osteoporotic ageing males are scarce, and evidence on fracture risk reduction is lacking. We conclude that testosterone replacement therapy should not be used as a sole bone-specific treatment in osteoporotic elderly men.

Prognostic significance of frailty in older patients with hip fracture: a systematic review and meta-analysis

PURPOSE

Hip fracture (HF) has become a major healthcare concern associated with higher mortality in older patients. Frailty is one of the most important problems in aging population but its prognostic value in HF remains susceptible. This systematic review and meta-analysis aimed to evaluate the association between frailty and adverse outcomes in older patients with HF.

METHODS

We systematically searched electrical databases including PubMed and Embase to find eligible literature with end-search restriction of February 20, 2021. The main endpoints were all-cause mortality, peri-operative complications, abnormal discharge, and length of stay (LOS). Pooled effect size was calculated by random-effects or fixed-effect model according to study heterogeneity. Three subgroup analyses based on follow-up times, study design, and frailty criteria were conducted.

RESULTS

We screened 22 studies out of 1599 identified studies in our analysis. Compared with normal patients, frail ones had a higher risk of mortality both before (OR = 3.48, 95% CI: 2.50-4.85, I² = 87.2%, P < 0.001) and after (OR = 1.87, 95% CI: 1.44-2.44, I² = 85.5%, P < 0.001) adjustment. The incidence of peri-operative complications, abnormal discharge, and prolonged LOS also significantly increased in frail subjects. There was no publication bias observed and the pooled results were stable based on sensitivity analysis.

CONCLUSION

Overall, more attention needs to be paid to the prognostic effects caused by frailty in seniors with HF. Better understanding of the association between frailty and adverse outcomes in HF could help doctors perform co-management across orthopaedic and geriatric departments.

Effects of bisphosphonates on bone of osteoporotic men with different androgen levels: a case-control study

OBJECTIVE

Osteoporosis in men has been neglected despite its association with disability and mortality. We evaluated effects of bisphosphonates (BPs) on bone mineral density (BMD) and bone turnover biomarkers of osteoporotic men with different androgen levels.

METHODS

This case-control study included 136 men with osteopenia or osteoporosis who were divided into normal androgen group (n=75) and hypogonadism group (n=61) (patients treated with testosterone were excluded) according to serum testosterone levels (cutoff value: 3.5 ng/ml). BMD, serum testosterone, total alkaline phosphatase (ALP) and cross-linked C-telopeptide of type I collagen (β-CTX) were detected. Relationship between testosterone levels and BMD at baseline was evaluated. All patients received BPs, calcium and vitamin D treatment for two years. We evaluated and compared effects of BPs on BMD and bone turnover biomarkers between two groups.

RESULTS

At baseline, there were no significant differences in BMD and bone turnover biomarkers between two groups. Testosterone levels were positively correlated with BMD in hypogonadism group. After treatment, lumbar BMD increased by 7.65±1.54% and 7.47±1.88% in normal and hypogonadism groups (both P<0.01 vs. baseline), and hip BMD increased, without significant differences between two groups. Serum β-CTX and ALP levels decreased by 56.5±6.3% and 16.8±3.5% in normal group and similarly decreased by 51.8±6.4% and 13.8±6.8% in hypogonadism group (all P<0.01 vs. baseline).

CONCLUSION

Testosterone level is positively correlated with BMD in men with hypogonadism. In men with osteoporosis, BPs significantly increase spine and hip BMD and decrease bone resorption, and efficacy of BPs is similar in men with or without hypogonadism.

The importance of association between sexsteroids deficiency, reduction of bone mineral density and falling risk in men with implications in medical rehabilitation

Introduction. Endocrino-metabolic rehabilitation represent one of the most complex sector in clinical medicine, regarding functional rehabilitation. Sex hormones deficiency plays an important role in the etiology of osteoporosis in men. At the same time, with age, the trophic role of androgens on muscle decreases and determines an increased frequency of falls. The objective of our study is to determine the association between sexsteroids deficiency, reduction of bone mineral density (BMD) and falling risk in men. Methods. Our retrospective cross-sectional study included 146 men aged between 65–85 years with low BMD (study group) and 121 men with normal BMD (control group). The measurement of Total testosterone (Tt), free testosterone (Tf) and estradiol (E2) serum levels was performed using the immunoassay or the immunoenzymatic methods. Femoral neck and lumbar spine BMD was determined using Dual-energy X-ray absorptiometry (DEXA). The risk of falls was assessed by Tandem Standing, Up & Go, Chair – Rising and walking speed tests. Results. We found a significantly association between Tf and E2 deficiency and low BMD (p=0.007). Also, in men with reduced BMD (study group) we observed significant lower levels of Tf (p<0.001) and E2 (p=0.003) compared to control group. E2 deficiency was associated significantly with low BMD and increased fall risk (p=0.001). At the same time the results highlighted significant lower levels of Tf in patients with BMD reduction and increased risk of falls (p=0.002). Tt deficiency was not associated with BMD reduction (p=0.088) or increased risk of falling (p=0.277). Conclusions. This research revealed a significant association between male sexsteroids deficiency, low BMD and increase of falling risk, with implications in rehabilitation program. The risk of ostoporosis and for falling in man can be estimated by determining serum Tf and E2 levels. Keywords: sexsteroids deficiency; bone mineral density; falling risk,

Bone Microarchitecture Decline and Risk of Fall and Fracture in Men With Poor Physical Performance-The STRAMBO Study

CONTEXT

High fracture risk in individuals with low muscle strength is attributed to high risk of falls.

OBJECTIVE

This work aims to study the association of muscle mass and physical performance with bone microarchitecture decline and risk of fall and nonvertebral fracture in men.

METHODS

A prospective, 8-year follow-up of a cohort was conducted among the general population. A total of 821 volunteer men aged 60 and older participated. Hip areal bone mineral density (aBMD) and appendicular lean mass (ALM) were assessed at baseline by dual x-ray absorptiometry. Lower-limb relative ALM (RALM-LL) is ALM-LL/(leg length)2. The physical performance score reflects the ability to perform chair stands and static and dynamic balance. Bone microarchitecture was assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT) at baseline and after 4 and 8 years. Statistical analyses were adjusted for shared risk factors. Outcome measurements included the rate of change in the HR-pQCT indices, incident falls, and fractures.

RESULTS

Cortical bone loss and estimated bone strength decline were faster in men with low vs normal RALM-LL (failure load: -0.74 ± 0.09 vs -0.43 ± 0.10%/year; P < .005). Differences were similar between men with poor and those with normal physical performance (failure load: -1.12 ± 0.09 vs -0.40 ± 0.05%/year; P < .001). Differences were similar between men having poor performance and low RALM-LL and men having normal RALM-LL and performance (failure load: -1.40 ± 0.17 vs -0.47 ± 0.03%/year; P < .001). Men with poor physical performance had a higher risk of fall (hazard ratio [HR] = 3.52; 95% CI, 1.57-7.90, P < .05) and fracture (HR = 2.68; 95% CI, 1.08-6.66, P < .05).

CONCLUSION

Rapid decline of bone microarchitecture and estimated strength in men with poor physical performance and low RALM-LL may contribute to higher fracture risk.

Management of osteoporosis in older men

As many as one out of three fragility fractures occur in older men and the outcome of major osteoporotic fractures, in particular hip fractures, is worse in men than in women. Osteoporosis in older men is thus an important threat to the quality of life of individual patients and a considerable burden for society. However, only a small minority of older men with high or very high fracture risk are receiving therapy. This does not need to be so as tools for fracture risk assessment are available and several drugs have been approved for treatment. Nevertheless, the evidence base for the management of osteoporosis in older men remains limited. This narrative review summarises the evidence for older men on the burden of osteoporosis, the pathophysiology of fragility fractures, the clinical presentation, diagnosis and risk assessment, the patient evaluation, and the non-pharmacological and pharmacological management.

Sarcopenia and fall-related injury among older adults in five low- and middle-income countries

Sarcopenia is a common condition in older people and increasing evidence suggests that it can be considered as a potential risk factor for falls and fractures. However, no studies on this topic from low- and middle-income countries (LMICs) are available. Thus, we assessed this association among older adults from five LMICs (China, India, Ghana, Mexico, and Russia). Community-based, nationally representative, cross-sectional data of the Study on Global Aging and Adult Health were analyzed. Sarcopenia was defined as the presence of low skeletal muscle mass based on indirect population formula, and either slow gait or low handgrip strength. The presence of fall-related injury was ascertained through self-reported information. Multivariable logistic regression analysis and meta-analysis were conducted. The sample consisted of 13,101 individuals aged ≥65 years (mean (SD) age 72.6 (11.3) years; 45% males). The prevalence of fall-related injury was higher among those with sarcopenia than in those without this condition (e.g., Mexico 9.8% vs. 2.7%). Adjusted analyses showed that sarcopenia was associated with a 1.85 (95%CI = 1.24-2.77) times higher odds for fall-related injury, with a low level of between-country heterogeneity. Future studies of longitudinal design may shed light on whether sarcopenia in LMICs may be considered as a risk factor for falls.

Osteosarcopenia: where osteoporosis and sarcopenia collide

The coexistence of osteoporosis and sarcopenia has been recently considered in some groups as a syndrome termed 'osteosarcopenia'. Osteoporosis describes low bone mass and deterioration of the micro-architecture of the bone, whereas sarcopenia is the loss of muscle mass, strength and function. With an ageing population the prevalence of both conditions is likely to increase substantially over the coming decades and is associated with significant personal and societal burden. The sequelae for an individual suffering from both conditions together include a greater risk of falls, fractures, institutionalization and mortality. The aetiology of 'osteosarcopenia' is multifactorial with several factors linking muscle and bone function, including genetics, age, inflammation and obesity. Several biochemical pathways have been identified that are facilitating the development of several promising therapeutic agents, which target both muscle and bone. In the current review we outline the epidemiology, pathogenesis and clinical consequences of 'osteosarcopenia' and explore current and potential future management strategies.

High Luteinizing Hormone and Lower Levels of Sex Hormones in Younger Men With Distal Radius Fracture

This study investigates the sex steroid hormone profile in younger men with distal radius fracture (DRF) to elucidate if this could explain the low bone density and osteoporosis previously observed. In a case-control study, 73 men with DRF (mean age 38 ± 9 years; range, 20-51) was compared with 194 age-matched, population controls. Performed assays: total testosterone (TT), calculated free testosterone (cFT), luteinizing hormone (LH), follicle-stimulating hormone (FSH), sex hormone-binding globulin (SHBG), and total estradiol (E2). BMD hip and spine were measured. Fracture cases had lower cFT (298 versus 329 pmol/L; p = 0.008), but not TT, compared with controls. FSH and SHBG were not statistically different. LH was almost 30% higher (5.7 versus 4.5 IU/L; p < 0.001) and a lower E2 was observed (80.0 versus 87.1; p = 0.098). Men with DRF had a lower E2/SHBG ratio compared with controls (2.3 versus 2.9; p = 0.013). A higher proportion of the fracture group had low TT (<10.5 nmol/L; 21% versus 11%; p = 0.052), low cFT (<220 pmol/L; 18% versus 8%; p = 0.017), and low E2 (<73 pmol/L; 48% versus 35%; p = 0.044). Odds ratio (OR) for fracture when having low cFT was 2.3 (95% CI, 1.02-5.49; p = 0.044); with low E2, the OR was 1.7 (95% CI, 0.96-2.96). In this study in young men with DRF exploring sex hormone levels, we find that sex hormone profiles may be disturbed with a lower E2/SHBG ratio, lower cFT, and higher LH. Estrogen is also a strong determinant of bone mass in men; hence, low levels of E2 may be contributing to the observed lower BMD and these differences may be relevant to fracture risk. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Late-onset Hypogonadism: Bone health

BACKGROUND

Bone health is underdiagnosed and undermanaged in men. Bone loss occurs in men with hypogonadism and in aging men. Thus, patients with a diagnosis of late-onset hypogonadism (LOH) are at risk of osteoporosis and osteoporotic fractures.

OBJECTIVES

To provide an update on research data and clinical implications regarding bone health in men with LOH by reviewing literature articles on this issue.

MATERIALS AND METHODS

A thorough search of listed publications in PubMed on bone health in older men with hypogonadism was performed, and other articles derived from these publications were further identified.

RESULTS

Late-onset Hypogonadism may be associated with reduced bone mineral density (BMD). In a pathophysiological perspective, the detrimental effects of testosterone (T) deficiency on BMD are partly ascribed to relative estrogen deficiency and both serum T and serum estradiol (E2) need to be above 200 ng/dL and 20 pg/mL to prevent bone loss. The effects of exogenous T on BMD are controversial, but most of the studies confirm that testosterone replacement therapy (TRT) increases BMD and prevents further bone loss in men with hypogonadism. No data are available on TRT and the prevention of fractures.

DISCUSSION AND CONCLUSION

In men with documented LOH, a specific clinical workup should be addressed to the diagnosis of osteoporosis in order to program subsequent follow-up and consider specific bone active therapy. TRT should be started according to guidelines of male hypogonadism while keeping in mind that it may also have positive effects also on bone health in men with LOH.

Effects of Dietary or Supplementary Micronutrients on Sex Hormones and IGF-1 in Middle and Older Age: A Systematic Review and Meta-Analysis

Observational research suggests that micronutrients may be protective for sarcopenia, a key health issue during ageing, potentially via effects on hormone synthesis and metabolism. We aimed to carry out a systematic review of RCTs investigating effects of increasing dietary or supplemental micronutrient intake on sex hormones and IGF-1 in individuals aged 45 years or older. We searched MEDLINE, EMBASE and Cochrane databases for RCTs reporting the effects of different micronutrients (vitamins A, C, D, or E; carotenoids; iron; copper; zinc; magnesium; selenium; and potassium) on sex hormones or IGF-1. Of the 26 RCTs identified, nine examined effects of vitamin D, nine of multi-nutrients, four of carotenoids, two of selenium, one of zinc, and one of vitamin E. For IGF-1 increasing vitamin D (MD: -0.53 nmol/L, 95% CI: -1.58, 0.52), multi-nutrients (MD: 0.60 nmol/L, 95% CI -1.12 to 2.33) and carotenoids (MD -1.32 nmol/L; 95% CI -2.76 to 0.11) had no significant effect on circulating concentrations. No significant effects on sex hormones of other micronutrients were found, but data were very limited. All trials had significant methodological limitations making effects of micronutrient supplementation on sex hormones unclear. Further high quality RCTs with physiological doses of micronutrients in people with low baseline intakes or circulating concentrations, using robust methodology, are required to assess effects of supplementation adequately.

Aging and the Male Reproductive System

This narrative review presents an overview of current knowledge on fertility and reproductive hormone changes in aging men, the factors driving and modulating these changes, their clinical consequences, and the benefits and risks of testosterone (T) therapy. Aging is accompanied by moderate decline of gamete quality and fertility. Population mean levels show a mild total T decline, an SHBG increase, a steeper free T decline, and a moderate LH increase with important contribution of comorbidities (e.g., obesity) to these changes. Sexual symptoms and lower hematocrit are associated with low T and are partly responsive to T therapy. The relationship of serum T with body composition and metabolic health is bidirectional; limited beneficial effects of T therapy on body composition have only marginal effects on metabolic health and physical function. Skeletal changes are associated primarily with estradiol and SHBG. Cognitive decline is not consistently linked to low T and is not improved by T therapy. Although limited evidence links moderate androgen decline with depressive symptoms, T therapy has small beneficial effects on mood, depressive symptoms, and vitality in elderly patients with low T. Suboptimal T (and/or DHT) has been associated with increased risk of stroke, but not of ischemic heart disease, whereas an association with mortality probably reflects that low T is a marker of poor health. Globally, neither severity of clinical consequences attributable to low T nor the nature and magnitude of beneficial treatment effects justify the concept of some broadly applied "T replacement therapy" in older men with low T. Moreover, long-term safety of T therapy is not established.

Is There Enough Evidence for Osteosarcopenic Obesity as a Distinct Entity? A Critical Literature Review

The co-existence of impaired bone health (osteopenia/osteoporosis), reduced muscle mass and strength (sarcopenia), and increased adiposity (obesity) in middle-aged and older people has been identified in recent studies, leading to a proposal for the existence of "osteosarcopenic obesity" as a distinct entity. Evidence for the pathophysiological overlap of these conditions is mounting, although a causal relationship is yet to be established. Each component condition occurs frequently with increasing age, and with shared risk factors in many instances, thus, an overlap of these three conditions is not surprising. However, whether the concurrent existence of sarcopenia, osteoporosis and obesity leads to an increased risk of adverse musculoskeletal outcomes and mortality above and beyond the risks associated with the sum of the component parts remains to be proven and is a question of research interest. In this article, we review evidence for the existence of osteosarcopenic obesity including the current operational definition of osteosarcopenic obesity, prevalence, pathophysiology, outcomes and exploratory approaches to the management of components. We conclude that, there is insufficient evidence to support a discrete clinical entity of osteosarcopenic obesity at this time. To expand knowledge and understanding in this area, there is a need for consensus on a definition of osteosarcopenic obesity which will allow for identification, further epidemiological studies and comparisons between studies. Additionally, studies should assess whether the clinical outcomes associated with osteosarcopenic obesity are worse than the mere addition of those linked with its components. This will help to determine whether defining a person as having this triad will eventually result in a more effective treatment than addressing each of the three conditions separately.

Testosterone treatment in older men: clinical implications and unresolved questions from the Testosterone Trials

A decrease in the concentration of circulating testosterone in many older men is a biomarker and possibly a rectifiable contributing factor to ill health. Low circulating testosterone concentration has been associated with cardiovascular disease, reduced cognition, fracture risk, and anaemia. However, randomised placebo-controlled trials are essential to clarify the benefits and possible risks of testosterone treatment in men without hypothalamic, pituitary, or testicular disease. The Testosterone Trials (T-Trials) were a coordinated set of trials that, following a screening-to-enrolment ratio of 65:1, randomly assigned 790 men aged 65 years or older who had a baseline testosterone concentration of less than 9·54 nmol/L and symptoms consistent with hypogonadism, but no recognisable hypothalamic-pituitary-testicular axis pathology, to daily transdermal testosterone or placebo for 12 months. In the main trial, testosterone treatment resulted in a modest benefit for sexual function, whereas the other primary outcomes of vitality and physical function were not met. Data from concomitant substudies raised a possible concern over changes in coronary plaque volume, showed a neutral effect on memory and other cognitive functions, and revealed improvements in volumetric bone mineral density and anaemia. Although insufficient to alter the existing clinical equipoise, the T-Trials provided substantial new data on organ-specific outcomes for testosterone treatment in older men. Further clinical trials are necessary to determine whether testosterone treatment will translate into patient-valued health outcomes and to clarify effects on the cardiovascular system.

Serum DHEA and Its Sulfate Are Associated With Incident Fall Risk in Older Men: The MrOS Sweden Study

The adrenal-derived hormones dehydroepiandrosterone (DHEA) and its sulfate (DHEAS) are the most abundant circulating hormones and their levels decline substantially with age. Many of the actions of DHEAS are considered to be mediated through metabolism into androgens and estrogens in peripheral target tissues. The predictive value of serum DHEA and DHEAS for the likelihood of falling is unknown. The aim of this study was, therefore, to assess the associations between baseline DHEA and DHEAS levels and incident fall risk in a large cohort of older men. Serum DHEA and DHEAS levels were analyzed with mass spectrometry in the population-based Osteoporotic Fractures in Men study in Sweden (n = 2516, age 69 to 81 years). Falls were ascertained every 4 months by mailed questionnaires. Associations between steroid hormones and falls were estimated by generalized estimating equations. During a mean follow-up of 2.7 years, 968 (38.5%) participants experienced a fall. High serum levels of both DHEA (odds ratio [OR] per SD increase 0.85; 95% CI, 0.78 to 0.92) and DHEAS (OR 0.88, 95% CI, 0.81 to 0.95) were associated with a lower incident fall risk in models adjusted for age, BMI, and prevalent falls. Further adjustment for serum sex steroids or age-related comorbidities only marginally attenuated the associations between DHEA or DHEAS and the likelihood of falling. Moreover, the point estimates for DHEA and DHEAS were only slightly reduced after adjustment for lean mass and/or grip strength. Also, the addition of the narrow walk test did not substantially alter the associations between serum DHEA or DHEAS and fall risk. Finally, the association with incident fall risk remained significant for DHEA but not for DHEAS after simultaneous adjustment for lean mass, grip strength, and the narrow walk test. This suggests that the associations between DHEA and DHEAS and falls are only partially mediated via muscle mass, muscle strength, and/or balance. In conclusion, older men with high DHEA or DHEAS levels have a lesser likelihood of a fall. © 2018 American Society for Bone and Mineral Research.

Therapist-Assisted Progressive Resistance Training, Protein Supplements, and Testosterone Injections in Frail Older Men with Testosterone Deficiency: Protocol for a Randomized Placebo-Controlled Trial

BACKGROUND

Fall accidents are a major cause of mortality among the elderly and the leading cause of traumatic brain injury. After a fall, many elderly people never completely recover and need help in coping with everyday life. Due to the increasing older population in the world, injuries, disabilities, and deaths caused by falls are a growing worldwide problem. Muscle weakness leads to greatly increased risk of falling, decreased quality of life, and decline in functional capacity. Muscle mass and muscle power decrease about 40% from age 20 to 80 years, and the level of testosterone decreases with age and leads to impaired muscle mass. In addition, 20% of men older than 60 years-and 50% older than 80 years-have low levels of testosterone. Treatments after a fall are significant financial burdens on health and social care, and it is important to find treatments that can enhance function in the elderly people.

OBJECTIVE

The purpose of this study is to investigate whether testosterone and progressive resistance training alone or combined can improve muscle strength and reduce the risk of falls in older men. Additionally, we will examine whether such treatments can improve quality of life, functional capacity, including sexual function, and counteract depression.

METHODS

This is a randomized placebo-controlled, double-blind trial in which frail older men with testosterone deficiency are treated with testosterone supplemental therapy and therapist-assisted progressive resistance training for 20 weeks, with the possibility to continue treatment for 1 year. Four study arms of 48 participants each are provided based on factorial assignment to testosterone supplemental therapy and progressive resistance training. The 4 groups are as follows: controls given placebo injections without physical exercise for 20 weeks, testosterone-alone group given testosterone injections without physical exercise for 20 weeks, training-alone group given placebo injections for 20 weeks combined with 16 weeks of progressive strength training, and combination group given testosterone injections for 20 weeks combined with 16 weeks of progressive strength training. Performance in the 30-second chair stand test to measure improvement of general strength, balance, and power in lower extremities is the primary endpoint. Secondary endpoints comprising tests of cognition, muscle strength, and quality of life are applied before and after the training.

RESULTS

Funding was provided in October 2016. Results are expected to be available in 2020. Sample size was calculated to 152 participants divided into 4 equal-sized groups. Due to age, difficulty in transport, and the time-consuming intervention, up to 25% dropouts are expected; thus, we aim to include at least 192 participants.

CONCLUSIONS

This investigation will evaluate the efficacy of testosterone supplemental therapy alone or combined with progressive resistance training. Additionally, improvements in quality of life and cognition are explored.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02873559; https://clinicaltrials.gov/ct2/show/NCT02873559 (Archived by WebCite at http://www.webcitation.org/6x0BhU2p3).