The low dose dexamethasone suppression test: effect of time of administration and dose

Biological markers in clinical psychological research - A systematic framework applied to HPA axis regulation in PTSD

Biological markers, particularly endocrine measurements, are increasingly being integrated into clinical psychological research. We introduce a systematic framework that classifies different functions of such biomarkers. The framework distinguishes between diagnostic biomarkers which add a biological perspective to conventional clinical assessments, prognostic biomarkers that inform about an individual’s risk to develop or maintain a mental health disorder, and intervention-related biomarkers. Regarding interventions, including prevention and treatment, it further distinguishes between prescriptive biomarkers which predict an individual’s response to an intervention, outcome biomarkers which evaluate intervention-related changes on a biological level and indicators of change mechanisms. We demonstrate how to apply the framework by exemplarily classifying and describing previously published systematic reviews and primary empirical studies on endogenous, peripheral cortisol concentrations as a biomarker for posttraumatic stress disorder (PTSD). The evidence on cortisol’s diagnostic and prognostic value is heterogeneous and still sparse regarding parameters based on multiple cortisol measurements, such as the cortisol awakening response. With regard to interventions, most research focused on trauma-focused psychotherapy and cortisol reactivity to trauma reminders. This field of research appears to be growing and very promising due to its potential to optimize PTSD-related interventions. The proposed framework can help in gaining a systematic overview of existing research. It can assist in structuring, comparing, summarizing and evaluating empirical studies, and in identifying research gaps.

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Iagnostic biomarkers can inform about biological alterations in mental disorders.

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Prognostic biomarkers can help to predict the development of a mental disorder.

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Biomarkers can indicate the outcome, differential effects, or mechanisms of change of clinical psychological interventions.

Association between control status of blood pressure and frailty among middle-aged and older adults with hypertension in China: a longitudinal study

OBJECTIVE

To assess the association between blood pressure (BP) control and frailty among middle-aged and older populations with hypertension in China from 2013 to 2018.

DESIGN

Prospective longitudinal study.

SETTING

This study analysed data from the China Health and Retirement Longitudinal Study, a nationally representative survey administered in 28 provinces of China.

PARTICIPANTS

A total of 3254 participants diagnosed with hypertension previous to 2013 were taken into analysis. 1932 participants who were not frail in 2013 were enrolled to calculate relative risk.

OUTCOME MEASURES

The frailty score was constructed following Rookwood's Cumulative deficit frailty index, with a score >0.25 defined as frailty (outcome variable). The self-reported status of BP control (exposure variable) represented the general status of the participant's BP level. A fixed-effects model was used to analyse the association between BP control and frailty. A Cox proportional hazard model was further used to further calculate the relative risk of frailty for different BP control levels.

RESULTS

The fixed-effects model showed that compared with well-controlled BP, poorly controlled BP exhibited a positive association with frailty score (β=0.015; 95% CI 0.011 to 0.019; p<0.001). The Cox proportional hazard model also revealed a higher risk of frailty in the poorly controlled group (HR=1.96; 95% CI 1.49 to 2.56; p<0.001). Based on subgroup analyses, poorly controlled BP was positively associated with frailty in respondents aged <60 years old (fix-effects model: β=0.015, p=0.021; Cox model: HR=2.25, p<0.001), but not significant among those aged ≥75 years old.

CONCLUSIONS

We provide new evidence of a negative association between BP control and frailty risk, but the findings differ among different age groups. Individualised strategies for BP management should be developed, especially for older hypertension patients.

Blood pressure, frailty status, and all-cause mortality in elderly hypertensives; The Nambu Cohort Study

Antihypertensive therapy is pivotal for reducing cardiovascular events. The 2019 Guidelines for the Management of Hypertension set a target blood pressure (BP) of <140/90 mmHg for persons older than 75 years of age. Optimal BP levels for older persons with frailty, however, are controversial because evidence for the relationship between BP level and prognosis by frailty status is limited. Here, we evaluated the relationship between systolic BP and frailty status with all-cause mortality in ambulatory older hypertensive patients using data from the Nambu Cohort study. A total of 535 patients (age 78 [70-84] years, 51% men, 37% with frailty) were prospectively followed for a mean duration of 41 (34-43) months. During the follow-up period, 49 patients died. Mortality rates stratified by systolic BP and frailty status were lowest in patients with systolic BP < 140 mmHg and non-frailty, followed by those with systolic BP ≥ 140 mmHg and non-frailty. Patients with frailty had the highest mortality regardless of the BP level. The adjusted hazard ratios (95% confidence intervals) of each category for all-cause mortality were as follows: ≥140 mmHg/Non-frailty 3.19 (1.12-11.40), <140 mmHg/Frailty 4.72 (1.67-16.90), and ≥140 mmHg/Frailty 3.56 (1.16-13.40) compared with <140 mmHg/Non-frailty as a reference. These results indicated that frail patients have a poor prognosis regardless of their BP levels. Non-frail patients, however, with systolic BP levels <140 mmHg had a better prognosis. Frailty may be a marker to differentiate patients who are likely to gain benefit from antihypertensive medication among older hypertensives.

Relationship between self-reported visual impairment and worsening frailty transition states in older people: a longitudinal study

BACKGROUND

Visual impairment (VI) may lead to worsening functional status and disability. Although disability is very difficult to reverse, it is usually preceded by frailty that may be reverted more easily. It is possible that VI is also related to frailty.

AIMS

To assess the relationship between VI and worsening of the frailty status.

METHODS

Data were taken from the Toledo Study for Healthy Aging (TSHA), a cohort study of community-dwelling people older than 65 years living in one Spanish province who were followed for 5 years. 1181 participants were included. VI was self-reported and frailty was operationalized using the Fried's phenotype adapted to a Spanish population. Models of multivariate logistic regression were built to assess the associations.

RESULTS

The mean age was 73.9 (Standard Deviation (SD) = 5 years) and 58.5% were females. Pre-frailty/frailty prevalence at baseline and follow-up were 41.2/5% and 36.2/12.5%, respectively, and VI was reported by 14.1%. After adjusting for age, gender, education level, tobacco consumption, type 2 diabetes mellitus, high blood pressure, cardiovascular disease, depressive symptoms and cognitive status, odds ratios for the development of frailty by VI were 2.5 (95% Confidence Interval (CI) 1.5-4.4) for non-frail, 2.7 (95% CI 1.3-5.7) for pre-frail and 1.9 (CI 0.6-6.00) for robust participants. The frailty domains whose appearance was most increased by VI were slowness, low energy, low physical activity and weakness.

DISCUSSION

Our findings support that VI worsens frailty in the early stages of its development (pre-frailty). VI impairs several frailty items at the same time.

CONCLUSIONS

Our study highlights the need to assess both VI and frailty for the prevention of frailty and disability in older people.

Cardiovascular risk profile and frailty in Japanese outpatients: the Nambu Cohort Study

Epidemiologic findings indicate that unfavorable cardiovascular (CV) risk profiles, such as elevated systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and overweight, decelerate with aging. Few studies, however, have evaluated the association between the CV risk profile and frailty. We performed a cross-sectional analysis using the baseline data of a prospective cohort study. A total of 599 subjects (age, 78 [range: 70-83] years; men, 50%) were analyzed in an outpatient setting. Frailty was diagnosed in 37% of the patients according to the Kihon Checklist score. An unfavorable CV risk profile was associated with a lower risk of frailty. The adjusted odds ratios (ORs; 95% confidence interval [CI]) of each CV risk factor for frailty were as follows: SBP (each 10 mmHg increase) 0.83 (0.72-0.95), LDL-C (each 10 mg/dl increase) 0.96 (0.86-1.05), and body mass index (each 1 kg/m² increase) 1.03 (0.97-1.10). Moreover, the total number of CV risk factors within the optimal range was significantly associated with the risk of frailty with the following ORs (95% CI): 1, 2.30 (0.75-8.69); 2, 3.22 (1.07-11.97); and 3, 4.79 (1.56-18.05) compared with patients having no risk factors within optimal levels (p for trend 0.008). Abnormal homeostasis might lead to lower levels of CV risk factors, which together result in "reverse metabolic syndrome." Our findings indicate that a favorable CV risk profile is associated with frailty.

Individual and cumulative association of commonly used biomarkers on frailty: a cross-sectional analysis of the Mexican Health and Aging Study

Frailty has been recognized as a common condition in older adults, however, there is scarce information on the association between frailty and commonly used biomarkers. The aim of this study was to assess the individual and cumulative association of biomarkers with frailty status. This is a cross-sectional analysis of the 2012 wave of the Mexican Health and Aging Study. A sub-sample of 60-year or older adults with anthropometric measurements was analyzed. Frailty was defined with a 31-item frailty index and those considered frail had a score ≥ 0.21. Biomarkers were further categorized as normal/abnormal and tested both one by one and grouped (according to their usual cutoff values). Adjusted logistic models were performed. A total of 1128 older adults were analyzed and their mean age was 69.45 years and 51.24% of them were women. 26.7% (n = 301) were categorized as frail. Individual biomarkers associated with frailty after adjusting for confounding were: hemoglobin [odds ratio (OR) 1.67, 95% confidence interval (CI) 1.13-2.46, p = 0.009], glycated hemoglobin (OR 2.04, 95% CI 1.54-2.7, p < 0.001) and vitamin D (OR 1.53, 95% CI 1.13-2.07, p = 0.005). Those with ≥ 4 abnormal biomarkers had an independent association with frailty when compared to those without any abnormal biomarker (OR 2.64, 95% CI 1.3-5.25, p = 0.005). Aside from the individual associations of specific biomarkers, our findings show that an incremental association of abnormal biomarkers increases the probability of frailty, accounting for the multidimensional nature of frailty and the possible interplay between components of the system that potentiate to give rise to a negative condition such as frailty.

Frailty and Rejuvenation with Stem Cells: Therapeutic Opportunities and Clinical Challenges

Frailty, one appealing target for improving successful aging of the elderly population, is a common clinical syndrome based on the accumulation of multisystemic function declines and the increase in susceptibility to stressors during biological aging. The age-dependent senescence, the frailty-related stem cell depletion, chronic inflammation, imbalance of immune homeostasis, and the reduction of multipotent stem cells collectively suggest the rational hypothesis that it is possible to (partially) cure frailty with stem cells. This systematic review has included all of the human trials of stem cell therapy for frailty from the main electronic databases and printed materials and screened the closely related reviews themed on the mechanisms of aging, frailty, and stem cells, to provide more insights in stem cell strategies for frailty, one promising method to recover health from a frail status. To date, a total of four trials about this subject have been registered on clinicaltrials.gov. The use of mesenchymal stem cells (MSCs), doses of 100 million cells, single peripheral intravenous infusion, follow-up periods of 6–12 months, and a focus primarily on safety and secondarily on efficacy are common characteristics of these studies. We conclude that intravenous infusion of allogenic MSCs is safe, well tolerated, and preliminarily effective clinically. More preclinical experiments and clinical trials are warranted to precisely elucidate the mechanism, safety, and efficacy of frailty stem cell therapy.

Association between HOMA-IR and Frailty among U.S. Middle-aged and Elderly Population

Previous literatures revealed that homeostasis model assessment-estimated insulin resistance (HOMA-IR) was one of the cardio-metabolic risk factors. This study was conducted to access the association between HOMA-IR and frailty in the United States of America (U.S.) middle-aged and elderly high-risk insulin-resistant population. In the National Health and Nutrition Examination Survey (NHANES III) from 1988 to 1994, the study included 3,893 participants. In order to exam the association between HOMA-IR and frailty in the middle-aged and elderly population through the regression model adjusted for multiple covariates, we divided the participants into middle aged group (Age <65 years) and elderly group (Age > = 65 years) in this study. Each group was then divided into tertiles depending on their HOMA-IR levels. Higher level of HOMA-IR was significantly associated with frailty in the elderly group, but this association was not seen in the middle-aged population. These results demonstrated that the HOMA-IR level can be a novel risk assessment of frailty in elderly high-risk insulin-resistant individuals (Age > = 65 years).

Association of pre-chemotherapy peripheral blood pro-inflammatory and coagulation factors with reduced relative dose intensity in women with breast cancer

Background

Chemotherapy decreases the risk of relapse and mortality in early-stage breast cancer (BC), but it comes with the risk of toxicity. Chemotherapy efficacy depends on relative dose intensity (RDI), and an RDI < 85% is associated with worse overall survival. The pro-inflammatory (interleukin (IL)-6, C-reactive protein (CRP)) and coagulation factors (D-dimer) serve as biomarkers of aging. The purpose of this study is to determine if these biomarkers are associated with reduced RDI in women with stage I–III BC.

Methods

This study enrolled women with stage I–III BC. Prior to adjuvant or neoadjuvant chemotherapy, peripheral blood was collected for biomarker measurement. Dose reductions and delays were captured and utilized to calculate the RDI delivered. Univariate and multivariate analyses were performed to describe the association between pre-chemotherapy IL-6, CRP, and D-dimer levels and an RDI < 85%, controlling for relevant tumor and patient factors (age, stage, receptor status, chemotherapy regimen, and pre-chemotherapy physical function and comorbidity).

Results

A total of 159 patients (mean age 58 years, range 30–81, SD 11.3) with stage I–III BC were enrolled. An RDI < 85% occurred in 22.6% (N = 36) of patients and was associated with higher pre-chemotherapy IL-6 (OR 1.14, 95% CI 1.04–1.25; p = 0.006) and D-dimer (OR 2.32, 95% CI 1.27–4.24; p = 0.006) levels, increased age (p = 0.001), increased number of comorbidities (p = 0.01), and decreased physical function by the Medical Outcomes Survey Activities of Daily Living (ADL) Scale (p = 0.009) in univariate analysis. A multivariate model, including two biomarkers (IL-6 and D-dimer), age, ADL, BC stage, and chemotherapy regimen, demonstrated a significant association between the increased biomarkers and reduced RDI < 85% (OR 2.54; p = 0.04).

Conclusions

Increased pre-chemotherapy biomarkers of aging (IL-6 and D-dimer) are associated with reduced RDI (<85%). Future studies are underway to validate these findings.

Trial registration

ClinicalTrials.gov, NCT01030250. Registered on 3 November 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13058-017-0895-5) contains supplementary material, which is available to authorized users.

Gender difference in adrenal sensitivity to ACTH is abolished in type 2 diabetes

OBJECTIVE

Dysfunction of the hypothalamus-pituitary-adrenal (HPA) axis has been implicated in type 2 diabetes (T2D). The aim of this study was to investigate the impact of T2D and gender on the HPA axis.

METHODS

Synthetic ACTH (1 μg) was administered to 21 subjects with T2D (age 62 (54-70) years, 11 men/ten women, HbA1c 49±2 mmol/mol, treated with diet or oral antidiabetic drugs) and 38 controls (age 58 (41-67) years, 20 men/18 women). Fasting basal B-glucose, serum cortisol, insulin, IGF1 and IGFBP1 concentrations were measured, and sampling for all but IGF1 was repeated 30, 60, and 90 min after ACTH injection. Patients took 0.25 mg dexamethasone at 2200-2300 h and returned the next morning for the measurement of serum cortisol concentration.

DESIGN

Cross-sectional study.

RESULTS

Patients with T2D had similar fasting serum cortisol, IGF1 and IGFBP1 concentrations; however, serum cortisol concentration after administration of dexamethasone did not differ between the groups. Healthy women exhibited higher peak cortisol levels compared with healthy men (675±26 vs 582±21 nmol/l, P=0.014), while the peak levels were equally high in men and women with T2D, resulting in a higher peak level in men with T2D compared with healthy men (691±42 vs 582±21 nmol/l, P=0.024). Serum cortisol concentration after administration of dexamethasone did not differ between the groups, nor did IGF1 and IGFBP1.

NOVELTY OF THE FINDINGS

Some studies have previously indicated disturbed regulation of the hypothalamus-pituitary-adrenal (HPA) axis in subjects with type 2 diabetes (T2D); however, much remains unknown in this area. To the best of our knowledge, this is the first study to show that the gender difference in the adrenal response to ACTH (with greater reactivity in women) is abolished in T2D. While the clinical implications cannot be determined by this paper, it is known that gender differences exist in the pathogenesis and complications of T2D. Thus, our findings suggest that further research into gender differences in the HPA axis is warranted.

CONCLUSIONS

Gender differences in adrenal response to ACTH were abolished in T2D. Men with T2D had a higher peak cortisol compared with controls. Further studies are needed to elucidate the clinical implications.

Incorporating biomarkers into cancer and aging research

The challenge in treating the older adult with cancer is accurately accounting for and adapting management to the heterogeneity in health status of the individual patient. Many oncologists recognize that chronological age alone should not be the determinant when deciding on a treatment regimen. Easily measurable markers that provide an assessment of functional age would be ideal to assess frailty, which may predispose the patient to complications from cancer treatment, including increased toxicity, functional decline, decreased quality of life, and poorer survival. Several categories of potential markers, including chronic inflammatory markers, markers of cellular senescence, and imaging to assess muscle mass to detect sarcopenia, may provide insight into the likelihood of treatment-related complications. This article discusses candidate markers and strategies to evaluate these markers in cancer treatment trials, with the aim of developing a method to assess risk of oncologic outcomes and guide management decisions for both the physician and patient.

Incorporating biomarkers of frailty and senescence in cancer therapeutic trials

As the population ages, oncologists are faced with the quandary of how to efficiently identify frail individuals that may have more difficulty tolerating and recovering from systemic therapy for cancer. Recent advances have been made in recognizing frailty via clinical geriatric assessment of older patients with cancer. These advances appear to allow for better prediction of toxicity than physician-rated performance status. Although the development of these tools is a large step forward in geriatric oncology, we still lack an understanding of how the underlying biologic processes of aging affect tolerance of cancer treatment. Determining specific biologic causes underlying frailty may allow oncologists to become even more adept at identifying patients at risk for excessive toxicity and provide the opportunity to therapeutically target these processes to help improve tolerability and survival outcomes for older patients with cancer. This article provides a background on potential biologic factors that may identify frail individuals at increased risk for toxicity related to cancer treatment. Potential methods to incorporate these factors into cancer therapeutic trials are discussed.

Frailty and safety: the example of diabetes

Frailty is considered a syndrome of decreased reserve and resistance to stressors and is clinically expressed as muscle weakness, poor exercise tolerance, factors related to body composition, sarcopenia and disability. In addition, there is a close relationship between age-related metabolic changes and the occurrence of comorbidities that may in turn lead to frailty.Even though the downward spiral of frailty is activated more quickly in older persons with type 2 diabetes, it is reversible with appropriate interventions before reaching a high level of severity. The hazard for geriatric patients with type 2 diabetes is that frailty encompasses diverse complications already associated with or caused by diabetes. Frailty is also associated with cognitive impairment, reduced ability to perform activities of daily living and increased expression of inflammatory and coagulation markers that may contribute to the adverse microvascular effects of diabetes. Although glycaemic control remains the main targeting achievement in type 2 diabetes, especially in well-functioning older persons, this is not appropriate for those with frailty. Frail elderly people with type 2 diabetes are a specific group in need of treatment parameters for both initial and maintenance therapy with oral antidiabetic agents. Therefore, the prescription of an antidiabetic agent in such individuals must take into consideration not only the standard goal of lowering hyperglycaemic levels, but also improving the quality of life and life expectancy. The clinical management of this population is currently particularly demanding, requiring special considerations with good medical decision making. Clinical aspects complicating diabetes care in older people include cognitive decline, physical functional decline and frailty. Available oral antidiabetic drugs include insulin secretagogues (meglitinides and sulfonylureas), biguanides (metformin), α-glucosidase inhibitors, thiazolidinediones and inhibitors of glucagon-like peptide 1 (GLP-1) degrading enzyme dipeptidyl peptidase 4. In addition, we will discuss injection treatment with GLP-1 analogues. This review will underline the association between diabetes and some frailty components in old patients and how specific antidiabetic agents may play a specific role in improving outcomes.

The role of glucocorticoids in naturally fasting grey seal (Halichoerus grypus) pups: dexamethasone stimulates mass loss and protein utilisation, but not departure from the colony

Seals must manage their energy reserves carefully while they fast on land to ensure they go to sea with sufficient fuel to sustain them until they find food. Glucocorticoids (GC) have been implicated in the control of fuel metabolism and termination of fasting in pinnipeds. Here we tested the hypothesis that dexamethasone, an artificial GC, increases fat and protein catabolism, and induces departure from the breeding colony in wild, fasting grey seal pups. A single intramuscular dose of dexamethasone completely suppressed cortisol production for 24-72 hours, demonstrating activation of GC receptors. In experiment 1, we compared the effects of a single dose of dexamethasone or saline administered ten days after weaning on fasting mass and body composition changes, cortisol, blood urea nitrogen (BUN) and glucose levels, and timing of departure from the colony. In experiment 2, we investigated the effects of dexamethasone on short-term (5 days) changes in mass loss, body composition and BUN. In experiment 1, dexamethasone induced a short-lived increase in mass loss, but there was no difference in timing of departure between dexamethasone and saline treated pups (n = 10). In experiment 2, dexamethasone increased protein and water loss and prevented a decrease in BUN levels (n = 11). Our data suggest changes in cortisol contribute to regulation of protein catabolism in fasting seal pups, irrespective of the sex of the animal, but do not terminate fasting. By affecting the rate of protein depletion, lasting changes in cortisol levels could influence the amount of time seal pups have to find food, and thus may have important consequences for their survival.

Cortisol response to acute trauma and risk of posttraumatic stress disorder

This study sought to characterize the variability of the acute cortisol response following trauma and its relationship to posttraumatic stress disorder (PTSD). Forty eight participants were recruited within 24h of a traumatic accident requiring hospital admission. A saliva sample was collected at 08.00 h and 16.00 h 2 days, 1 month and 6 months after hospital admission, together with 24-h urine collection. Participants completed a dexamethasone suppression test (0.5mg DEX at 21.00 h) at each follow up, together with self-report questionnaires. The Clinician Administered PTSD Scale (CAPS) was administered at 1 and 6 months to identify PTSD. Prevalence of PTSD was 27% at 1 month and 21% at 6 months. PTSD symptoms at 6 months were negatively correlated with salivary cortisol at 08.00 h on day 2 (r=-0.36, p=0.04), but positively correlated with 16.00 h cortisols (r=0.41, p=0.03). A lower rise in cortisol at 08.00 h on day 2 was associated with an increase in risk of PTSD at both 1 month (OR=1.411 (1.017, 1.957)) and 6 months (OR=1.411 (1.066, 1.866)). At 1 month, 70% of participants with PTSD suppressed cortisol to more than 90% of pre-dex levels compared with 25% without PTSD (χ(2)=6.77, p=0.034). Urinary cortisol excretion was not different between groups at any time point. The findings support a hypothesis that sensitization of the HPA axis and enhanced suppression of cortisol following the dexamethasone suppression test are established early in the disease process.

Frailty and its association with disability and comorbidity in a community-dwelling sample of seniors in Montreal: a cross-sectional study

BACKGROUND AND AIMS

The term frailty is used to describe older persons at high risk for adverse health outcomes. In 2001, Fried et al. proposed a now widely cited definition which suggests that frailty is a clinical entity related to, but distinct from, ADL disability and comorbidity. Frailty status was assessed based on the presence of any three of the following five characteristics: shrinking, weakness, poor endurance, slowness, and low activity. The objectives of the current study are to estimate the prevalence of frailty in a sample of community-dwelling older persons, to identify sociodemographic and health variables associated with frailty, and to examine the complex relationships between frailty and comorbidity, ADL disability and IADL disability.

METHODS

This study is based on cross-sectional analysis of 740 community-dwelling seniors from the Montreal Unmet Needs Study (MUNS). The five characteristics of frailty were operationalised using measures available in MUNS. The Cochran-Mantel-Haenszel test was used to identify variables associated with frailty. Overlaps between frailty, comorbidity and disability were assessed using proportions.

RESULTS

Overall, 7.4% were classified as frail, 49.7% prefrail and 42.8% non-frail. Frailty was associated with age, sex, income, education, number of chronic diseases, ADL disability, and IADL disability. Among those classified as frail, 29.1% had disabilities in ADLs, 92.7% in IADLs and 81.8% had comorbidity.

CONCLUSION

Findings on the relationship between frailty and sociodemographic variables, morbidity and disability, support previous studies, providing further evidence that although frailty seems to be a distinct geriatric concept, it also overlaps with other concepts.

Inflammation in Aging Part 2: Implications for the Health of Older People and Recommendations for Nursing Practice

Aging is accompanied by declining function and remodeling of body systems. In particular, changes to the immune and endocrine systems have far-reaching effects that cause an increase in cytokine release and decrease in anti-inflammatory feedback systems. The chronic inflammation that ensues has been named ‘‘inflammaging.’’ Inflammaging is associated with many detrimental effects that combine to increase morbidity and mortality. The sickness behavior that arises from inflammatory processes and the side effects of chronic diseases lead to a constellation of symptoms that decrease quality of life and affect the well-being of the individual. Part 2 of this two-part article provides an overview of the health effects of inflammaging, addressing the extent to which it contributes to the syndromes of frailty and disability with aging.

Frailty syndrome is associated with altered circulating redox balance and increased markers of oxidative stress

Frailty syndrome (FS) is a condition described in aging and characterized by physical vulnerability to stress and lack of physiological reserve. In this study we aim to define whether circulating oxidative stress correlates to frailty in terms of glutathione balance and oxidative protein damage. In 62 elderly outpatients, classified as frail patients according to Fried's criteria, evaluation of reduced glutathione (GSH), oxidized glutathione (GSSG), tumor necrosis factor-alpha, malonaldehyde-(MDA) and 4-hydroxy-2,3-nonenal-(HNE) protein plasma adducts were performed. A significant increase in the GSSG was observed in patients with FS when compared to non-frail. No difference was shown in the GSH amount, suggesting a glutathione oxidation more than impairment of the synthesis. TNF-alpha, MDA- and HNE-adducts, were significantly higher in FS as compared to non-frail patients. A logistic regression model correlating FS with redox balance showed a close relationship between glutathione ratio (OR=1.8, 95% CI=1.2-2.5) and MDA adducts (OR=2.8, 95% CI=1.6-4.7) to frailty. Our findings show an association between oxidative imbalance and Frailty Syndrome. GSSG/GSH ratio and plasma protein adducts strongly predict the frailty conditions and seem to be reliable and easily measurable markers in the context of the multidimensional analysis of elderly patients.

Enhanced cortisol suppression in eating disorders with impulsive personality features

Evidence of both blunted and enhanced cortisol suppression with the dexamethasone test (DST) is available in eating disorders (ED), suggesting that different subtypes of ED might be characterized by distinct neurobiological stress response dysfunctions. Other evidence indicates that ED patients with impulsive clinical features might have enhanced cortisol suppression similar to patients with impulsive personality disorders. A group of 52 patients with restrictive anorexia, binge eating-purging anorexia and bulimia nervosa were studied with a very low dose (0.25 mg) dexamethasone test and measures of phenomenology, personality and impulsivity. Patients with bulimic symptoms had significantly higher rates of cortisol suppression than controls and than restrictive anorectic patients. Percent cortisol suppression showed a strong and significant correlation with the patient's score on the Barratt Impulsiveness Scale. A hypersensitive cortisol response to dexamethasone, which might reflect hypothalamic-pituitary-adrenal axis dysfunctions might be specifically associated with impulsive subtypes of eating disorders.

Immunosupportive therapies in aging

The primary role of the immune system is to protect the organism against pathogens, but age-associated alterations to immunity increase the susceptibility of the elderly to infectious disease. The exact nature of these changes is still controversial, but the use of screening procedures, such as the SENIEUR protocol to exclude underlying illness, helped to better characterize the changes actually related to physiological aging rather than pathology. It is generally agreed that the most marked changes occur in the cellular immune response reflecting profound alterations in T cells. Much of this is due to thymic involution as well as changes in the proportions of T cell subpopulations resulting from antigen exposure, and altered T cell activation pathways. However, a body of data indicates that innate immune responses, including the critical bridge between innate and adaptive immunity, and antigen presenting capacity are not completely resistant to senescence processes. The consequences of all these alterations are an increased incidence of infections, as well as possibly cancers, autoimmune disorders, and chronic inflammatory diseases. The leading question is what, if anything, can we do to prevent these deleterious changes without dangerously dysregulating the precarious balance of productive immunity versus immunopathology? There are many potential new therapeutic means now available to modulate immunosenescence and many others are expected to be available shortly. One main problem in applying these experimental therapies is ethical: there is a common feeling that as ageing is not a disease; the elderly are not sick and therefore do not require adventurous therapies with unpredictable side-effects in mostly frail individuals. Animal models are not helpful in this context. In this chapter we will first briefly review what we think we know about human immunosenescence and its consequences for the health status of elderly individuals. We will then discuss possible interventions that might one day become applicable in an appropriate ethical environment.

Contribution of Mitochondrial Dysfunction and Oxidative Stress to Cellular Premature Senescence Induced by Antiretroviral Thymidine Analogues

Objectives

Treatment of HIV-infected patients is associated with early onset of aging-related comorbidities. Some of the adverse effects of antiretroviral therapy have been attributed to the mitochondrial toxicity of nucleoside reverse transcriptase inhibitors (NRTI), and it is of note that mitochondrial dysfunction and oxidative stress are involved in the aging processes. In this regard, we examined whether NRTIs could accelerate the senescence of cultured cells.

Methods

Human fibroblasts were exposed to NRTIs from culture passage 1 to 14. Cytochrome c-oxidase (COX) subunits 2 and 4, mitochondrial potential and mass, and reactive oxygen species (ROS) were quantified at each passage. Proliferation, cell-cycle arrest, senescence-associated β-galactosidase activity, and morphology were assessed in parallel. Mitochondrial and senescence markers were assessed in cultured murine preadipocytes and in fat samples from lipodystrophic HIV-infected patients.

Results

Stavudine and zidovudine induced mitochondrial dysfunction and increased ROS levels in fibroblasts at early culture passages, while cell division gradually slowed. At passages 8–12, fibroblasts exposed to stavudine or zidovudine but not abacavir, didanosine, lamivudine and tenofovir were senescent, on the basis of p16INK4 and p21WAF-1 protein expression, cell morphology and senescence-associated-β-galactosidase activity. Senescence markers and COX2 underexpression were also found in 3T3-F442A preadipocytes exposed for 7 weeks to stavudine or zidovudine, but not lamivudine, and in adipose tissue samples from lipodystrophic HIV-infected patients on antiretroviral regimens containing stavudine or zidovudine.

Conclusions

Mitochondrial changes and oxidative damage could partly explain the premature senescence of fibroblasts and adipose cells induced by stavudine and zidovudine. This suggests that thymidine analogues might be involved in the early aging-related diseases observed in some HIV-infected patients taking antiretroviral drugs.

Evolving definitions of frailty

This article presents the current status of the definitions of frailty. The theoretical definitions are summarized, and the main elements of these definitions are developed. Frailty as a geriatric syndrome is briefly put into debate, and a model showing the relationships between the factors involved and the outcomes of frailty is proposed. The dynamics of functional decline and geriatric syndromes are put into the perspective of different stages of frailty. For the practical use of the concept, the operational definitions and the principal tools, indices and scales from the literature are briefly described, along with their main characteristics.

Findings with 0.25 mg dexamethasone suppression test in eating disorders: association with childhood trauma

INTRODUCTION

While both blunted and enhanced cortisol suppression following a dexamethasone suppression test (DST) are described in eating disorders, some evidence suggests that enhanced cortisol suppression might be associated with the presence of trauma history. The objective of this study is to investigate hypothalamic-pituitary-adrenal axis response to a modified DST in eating disorders and its relationship with childhood trauma.

METHODS

Fifty-two patients with eating disorders were studied with a 0.25 mg DST and with measures of childhood trauma.

CONCLUSION

Patients with bulimia symptoms had significantly greater cortisol suppression than controls and restrictive anorexia patients (F=8.2, P<.05). Cortisol suppression was significantly correlated with intensity of childhood traumatic events (F=0.32, P<.05). Hypersensitive hypothalamic-pituitary-adrenal axis response to DST in eating disorders may be related with a history of childhood trauma and suggests some biological similarities with posttraumatic syndromes that should be further explored.

Antioxidant ceruloplasmin is expressed by glomerular parietal epithelial cells and secreted into urine in association with glomerular aging and high-calorie diet

Biologic aging is accelerated by high-calorie intake, increased free radical production, and oxidation of key biomolecules. Fischer 344 rats that are maintained on an ad libitum diet develop oxidant injury and age-associated glomerulosclerosis by 24 mo. Calorie restriction prevents both oxidant injury and glomerulosclerosis. Ceruloplasmin (Cp) is a copper-containing ferroxidase that functions as an antioxidant in part by oxidizing toxic ferrous iron to nontoxic ferric iron. Glomerular Cp mRNA and protein expression were measured in ad libitum-fed and calorie-restricted rats at ages 2, 6, 17, and 24 mo. In ad libitum-fed rats, Cp mRNA expression increased six-fold (P < 0.01) and protein expression increased five-fold (P = 0.01) between 2 and 24 mo of age. In calorie-restricted rats, Cp mRNA expression increased three-fold (P < 0.01) and protein expression increased 1.6-fold (NS) between 2 and 24 mo of age. Both the cell-associated alternately spliced variant and secreted variants of Cp were expressed. Immunofluorescent analysis showed that Cp was expressed by the parietal epithelial cells that line the inner aspect of Bowman's capsule in the glomerulus. Cp also was present in urine, particularly of old ad libitum-fed rats with high tissue Cp expression. Cp expression by Bowman's capsule epithelial cells therefore occurred in direct proportion to known levels of oxidant activity (older age and high-calorie diet) and is secreted into the urine. It is suggested that Cp expression at this site may be part of the repertoire of the glomerular parietal epithelial cell to protect the glomerular podocytes and the downstream nephron from toxic effects of filtered molecules, including ferrous iron.

Grenzen und Bedeutung der Labordiagnostik bei Mangelernährung im Alter

Despite the widespread interest in malnutrition in the elderly, the utility of laboratory tests is limited. This is because their diagnostic significance can be impaired by undercurrent diseases, pre-analytical effects and unsatisfactory standardization. This survey summarizes the most important parameters of malnutrition. Thus, "nitrogen balance" is considered the golden standard of nutrition status, while the diagnostic significance of serum proteins depends on their biological half-time. Albumin is seen as the most reliable malnutrition marker, but cholinesterase and cholesterol-decrease must also be mentioned. The so-called "low-T3-phenomenon" which is caused by the production of "reverse T3", seems to be the unique parameter for the "catabolic" state of metabolism. Of special interest are also prognostic markers of mortality, such as orosomucoid. Cytokines, other signal peptides, trace elements and vitamins are from the diagnostic point of view of rather limited significance. In sum, the diagnosis and monitoring of malnutrition in the elderly represents an important challenge for laboratory medicine.

Moderation of psychosocial risk factors through dysfunction of the hypothalamic–pituitary–adrenal stress axis in the onset of chronic widespread musculoskeletal pain : Findings of a population-based prospective cohort study

OBJECTIVE

To test the hypothesis that abnormalities in the hypothalamic-pituitary-adrenal (HPA) stress-response system would act as an effect moderator between HPA function and the onset of chronic widespread pain (CWP).

METHODS

We conducted a population-based prospective cohort study. Current pain and psychosocial status were ascertained in 11,000 subjects. Of the 768 eligible subjects free of CWP but at future risk based on their psychosocial profile, 463 were randomly selected, and 267 (57.7%) consented to assessment of their HPA axis function. Diurnal function was measured by assessing levels of salivary cortisol in the morning (9:00 AM) and evening (10:00 PM). Serum cortisol levels were measured after an overnight low-dose (0.25 mg) dexamethasone suppression test and a potentially stressful clinical examination. All subjects were followed up 15 months later to identify cases of new-onset CWP.

RESULTS

A total of 241 subjects (94.9%) completed the followup study, and 28 (11.6%) reported the new onset of CWP. High levels of cortisol post-dexamethasone (odds ratio [OR] 3.53, 95% confidence interval [95% CI] 1.17-10.65), low levels in morning saliva (OR 1.43, 95% CI 0.52-3.94), and high levels in evening saliva (OR 2.32, 95% CI 0.64-8.42) were all associated with CWP. These 3 factors were found to be independent and additive predictors of CWP (OR for all 3 factors 8.5, 95% CI 1.5-47.9) in analyses controlling for age, sex, depression, sleep disturbance, recent traumatic life events, and pain status. One or more of these 3 HPA factors identified 26 (92.9%) cases of new-onset CWP.

CONCLUSION

Among a group of psychologically at-risk subjects, dysfunction of the HPA axis helps to distinguish those who will and will not develop new-onset CWP.

The effect of frailty on residential/nursing home admission in the Netherlands independent of chronic diseases and functional limitations

The aim of this study was to determine the effect of frailty on the risk of residential/nursing home admission independently of chronic diseases and functional limitations. Frailty consists of multisystem decline and is considered to be a consequence of changes in neuromuscular, endocrine and immune system functioning that occur as people age. Frailty is a combination of multiple impairments in functioning that might lead to functional limitations and disability but it is not clear whether frailty has an independent effect on residential/nursing home admission. Data were used from the Longitudinal Aging Study Amsterdam. The respondents participated at both T₁ (1992/1993) and T₂ (1995/1996), lived independently at T₂, and were aged 65 and over (n=1,503). Nine frailty markers were assessed at two cycles (T₁ and T₂). The frailty markers were defined in two ways: low functioning at T₂ (static frailty); and change in functioning between T₁ and T₂ (dynamic frailty). The outcome variable was residential/nursing home admission between T₂ and T₄ (2001/2002). Cox proportional hazard analyses were used adjusting for chronic diseases, functional limitations, care received, partner status, income, age and sex. Static (RR 1.93, 95%CI 1.36-2.74) and dynamic frailty (RR 1.69, 95%CI 1.19-2.39) were associated with institutionalization in both men and women independently of the effect of chronic diseases and functional limitations. Additional analyses of the total number of both sets of frailty markers present revealed an increased risk of institutionalization when the number increased. In conclusion, frailty is associated with institutionalization, independently of the effect of chronic diseases and functional limitations.

Endocrine and inflammatory markers as predictors of frailty

OBJECTIVE

To examine the association of serum concentrations of 25-hydroxyvitamin D [25(OH)D], interleukin-6 (IL-6), C-reactive protein (CRP) and IGF-1 with prevalent and incident frailty.

DESIGN

The Longitudinal Aging Study Amsterdam (LASA), a prospective cohort study with 3-yearly measurement cycles. Setting General population-based sample.

PARTICIPANTS

The respondents were men and women aged 65 and over, who participated at T1 (1995/1996, N = 1720) and T2 (1998/1999, N = 1509). Blood samples were obtained at T1 (N = 1271). Measurements The presence of frailty at T1 and 3-year incidence of frailty. Frailty is defined as the presence of three out of nine frailty indicators.

RESULTS

At T1, 242 (19.0%) of all respondents were frail. Those who were frail at T1 had higher CRP and lower 25(OH)D levels. Serum 25(OH)D remained associated with frailty after adjustment for potential confounders with an odd ratios (OR) of 2.60 [95% confidence interval (95% CI) 1.60-4.21] for 25(OH)D < 25 nmol/l and 1.72 (95% CI 1.19-2.47) for 25(OH)D 25-50 nmol/l vs. high levels of 25(OH)D. Of the nonfrail at T1, 125 respondents (14.1%) became frail at T2. After adjustment, moderately elevated CRP levels (3-10 microg/ml) (OR 1.69, 95% CI 1.09-2.63) and low 25(OH)D (OR 2.04, 95% CI 1.01-4.13) were associated with incident frailty. No consistent associations were observed for IL-6 and IGF-1.

CONCLUSION

Low 25(OH)D levels were strongly associated with prevalent and incident frailty; moderately elevated levels of CRP were associated with incident frailty.

From bedside to bench: research agenda for frailty

The American Geriatrics Society sponsored a working conference in January 2004, funded by the National Institute on Aging, to establish the state of the art in frailty research and to set a research agenda for the future. The invited participants included senior basic biologists, epidemiologists, geneticists, and clinical investigators who study aging-related issues. This article summarizes the central theoretical observations on frailty and research needs and opportunities presented and discussed at this conference, and lays out an agenda for future research on frailty.

A flame burning within

Inflammation is a human being's primary defense against threats to homeostasis that are encountered every day. Especially in old age, when regulatory mechanisms responsible for inflammatory responses may be ineffective or damaged, the result can be adverse pathological conditions, and an increased risk of morbidity and mortality. The inflammation response is a plastic network composed of redundant signaling among several different mediators. These mediators have a reciprocal relationship with other biological sub-systems, including hormone regulation, the autonomic nervous system, and oxidative/anti-oxidant balance. Studying this complex architecture requires parallel and multiple research strategies from epidemiological to biochemical level, from observational studies to innovative intervention approaches. Given that the inflammatory response is a critical age-related process, understanding its regulatory action is essential in avoiding hazardous consequences in old age.