The association between dehydroepiandosterone and frailty in older men and women

Effectiveness of Home-Based Exercise and Nutrition Programs for Senior Adults on Muscle Outcomes: A Scoping Review

This scoping review investigates the volume of evidence for home-based exercise and nutrition programs and their effect on muscle quality among senior adults to inform implementation and future research. It aims to answer the research question: What are the evidence, challenges, and needs for research regarding a home-based exercise and nutrition intervention program to improve muscle outcomes in senior adults? This scoping review was conducted following the PRISMA extension for Scoping Review. The following databases were searched: PubMed, Scopus, MEDLINE, CINAHL, EMBASE, and the Cochrane Library. Applied filters were used to help condense the research articles. A total of 13 studies met the inclusion criteria for this scoping review. Most exercise interventions were either resistance or multi-component exercise programs. The nature of the nutrition intervention varied between different supplements, foods, education, or counseling. Muscle outcomes included muscle mass in nine studies, muscle function in all the studies, muscle strength in ten studies, and biochemical analyses in two studies. Two studies found improvements in muscle mass; two studies revealed improvements in all their muscle function tests; and three studies revealed improvements in muscle strength. Muscle biopsy in a study revealed enhanced muscle fibers, but both studies did not reveal any biomarker improvements. The scoping review findings revealed mixed results on the effectiveness of a home-based exercise and nutrition program. However, the current evidence does have many gaps to address before recommending this form of intervention for senior adults as an effective way to prevent and manage sarcopenia. Since this review identified multiple knowledge gaps, strengths, and limitations in this growing field, it can be a starting point to help build future study designs and interventions in this population.

Frail OLDER ADULTS are more likely TO have autonomic dysfunction: A systematic review and META-ANALYSIs

Autonomic dysfunction and frailty are two common and complex geriatric syndromes. Their prevalence increases with age and they have similar negative health outcomes. In PubMed and Web of Science we screened studies identifying a relationship between autonomic function (AF) and frailty in adults aged ≥65 years. Twenty-two studies of which two prospective and 20 cross-sectional were included (n=8375). We performed a meta-analysis for the articles addressing orthostatic hypotension (OH). Frailty was associated with 1.6 higher odds of suffering from consensus OH (COH) {OR=1.607 95%CI [1.15-2.24]; 7 studies; n=3488}. When measured for each type of OH the largest trend was seen between initial OH (IOH) and frailty {OR=3.08; 95%CI [1.50-6.36]; 2 studies; n=497}. Fourteen studies reported other autonomic function alterations in frail older adults with 4-22% reduction in orthostatic heart rate increase, 6% reduction in systolic blood pressure recovery, 9-75% reduction in most common used heart rate variability (HRV) parameters. Frail older adults were more likely to have impaired AF. Diagnosis of frailty should promptly lead to orthostatic testing as OH implicates specific treatment modalities, which differ from frailty management. As IOH is most strongly correlated with frailty, continuous beat to beat blood pressure measurements should be performed when present at least until cut-off values for heart rate variability testing are defined.

Serum levels of dehydroepiandrosterone sulfate are associated with a lower risk of mobility-subtype frailty in older Japanese community-dwellers

PURPOSE

Previous studies suggest that lower serum levels of dehydroepiandrosterone sulfate (DHEA-S) are associated with physical frailty. Associations with subtypes of physical frailty have not been studied. This study aimed to investigate associations between serum DHEA-S levels and physical frailty and its subtypes in older Japanese community-dwellers using panel data.

METHODS

This study was conducted within the National Institute for Longevity Sciences-Longitudinal Study of Aging (NILS-LSA). Repeated measurement data were collected from 1,886 older community-dwellers (60-91 years). Frailty was identified according to modified Cardiovascular Health Study criteria (weight loss, weakness, slowness, exhaustion, low physical activity) and was classified into following subtypes: mobility (weakness/slowness), non-mobility (weight loss/exhaustion), and low physical activity. Associations with serum DHEA-S (sex-specific tertiles [T1-T3]) were estimated by random-effects logistic regression models adjusting for age, sex, education, disease history (stroke, hypertension, heart disease, diabetes), smoking status, depressive symptoms, and survey wave.

RESULTS

We found an average prevalence of 6.0% for frailty (mobility subtype, 7.0%; non-mobility subtype, 34.8%; low physical activity subtype, 9.4%) across survey waves. Mean (SD) sex-specific DHEA-S levels (μg/dL) at T1, T2, and T3 were 46.8 (20.8), 88.7 (28.4), and 158.0 (58.9), respectively. Compared with T1, the adjusted ORs (95% CIs) for frailty were 0.69 (0.44, 1.08) for T2 and 0.50 (0.30, 0.83) for T3 (P trend = 0.007). The corresponding values for mobility subtype were 0.80 (0.51, 1.24) for T2 and 0.55 (0.33, 0.90) for T3.

CONCLUSION

Higher serum DHEA-S levels were associated with lower risk of frailty, especially mobility-subtype frailty, in older community-dwellers.

The physical frailty syndrome as a transition from homeostatic symphony to cacophony

Frailty in aging marks a state of decreased reserves resulting in increased vulnerability to adverse outcomes when exposed to stressors. This Perspective synthesizes the evidence on the aging-related pathophysiology underpinning the clinical presentation of physical frailty as a phenotype of a clinical syndrome that is distinct from the cumulative-deficit-based frailty index. We focus on integrating the converging evidence on the conceptualization of physical frailty as a state, largely independent of chronic diseases, that emerges when the dysregulation of multiple interconnected physiological and biological systems crosses a threshold to critical dysfunction, severely compromising homeostasis. Our exegesis posits that the physiology underlying frailty is a critically dysregulated complex dynamical system. This conceptual framework implies that interventions such as physical activity that have multisystem effects are more promising to remedy frailty than interventions targeted at replenishing single systems. We then consider how this framework can drive future research to further understanding, prevention and treatment of frailty, which will likely preserve health and resilience in aging populations.

Frailty in Rheumatic Diseases

Frailty is a syndrome characterized by the decline in the physiologic reserve and function of several systems, leading to increased vulnerability and adverse health outcomes. While common in the elderly, recent studies have underlined the higher prevalence of frailty in chronic diseases, independent of age. The pathophysiological mechanisms that contribute to frailty have not been completely understood, although significant progresses have recently been made. In this context, chronic inflammation is likely to play a pivotal role, both directly and indirectly through other systems, such as the musculoskeletal, endocrine, and neurological systems. Rheumatic diseases are characterized by chronic inflammation and accumulation of deficits during time. Therefore, studies have recently started to explore the link between frailty and rheumatic diseases, and in this review, we report what has been described so far. Frailty is dynamic and potentially reversible with 8.3%-17.9% of older adults spontaneously improving their frailty status over time. Muscle strength is likely the most significant influencing factor which could be improved with training thus pointing at the need to maintain physical activity. Not surprisingly, frailty is more prevalent in patients affected by rheumatic diseases than in healthy controls, regardless of age and is associated with high disease activity to affect the clinical outcomes, largely due to chronic inflammation. More importantly, the treatment of the underlying condition may prevent frailty. Scales to assess frailty in patients affected by rheumatic diseases have been proposed, but larger casuistries are needed to validate disease-specific indexes, which could allow more accurate prognostic estimates than demographic and disease-related variables alone. Frail patients can be more vulnerable and more difficult to treat, due to the risk of side effects, therefore frailty should be taken into account in clinical decisions. Clinical trials addressing frailty could identify patients who are less likely to tolerate potentially toxic medications and might benefit from more conservative regimens. In conclusion, the implementation of the concept of frailty in rheumatology will allow a better understanding of the patient global health, a finest risk stratification and a more individualized management strategy.

Circulating biomarkers characterizing physical frailty: CRP, hemoglobin, albumin, 25OHD and free testosterone as best biomarkers. Results of a meta-analysis

INTRODUCTION

During aging, individuals can be classified as being in one of 3 different states: robust, frail or dependent. Frailty is described as reversible, so early detection offers the potential of returning the subject to a robust status. There are multiple clinical frailty scales but no gold standard and frailty is not systematically assessed in clinicians' daily practice. Reliable biomarkers of frailty are lacking, however, while their identification and systematic use would make this simple scale a useful clinical tool.

OBJECTIVE

To conduct a review of the literature concerning the biomarkers associated with frailty and to compare in a meta-analysis the plasmatic values of each biomarker in the frail with the robust group.

RESULTS

503 articles were identified on PubMed, 467 on Scopus and 369 on Web Of Science. 67 articles were included, collecting a total of 32,934 robust subjects and 6864 frail subjects. C-reactive protein (CRP) (Standardized Mean Difference (SMD): 0.49 CI 95% [0.37-0.61]) was significantly higher in the frail group whereas hemoglobin (SMD: -0.67[-0.90; -0.44]), albumin (SMD: -0.62[-0.84; -0.41]), 25-hydroxyvitamin D (25OHD) (SMD: -0.43 [-0.64; -0.21]) and, in men, free testosterone (SMD: -0.77 [-1.05; -0.49]) were significantly lower in the frail group.

CONCLUSION

We found 5 biomarkers that were associated with frailty (CRP, hemoglobin, albumin, 25OHD and free testosterone in men) belonging to multiple physiological systems. Further cohort studies are needed to verify their ability to screen for frailty.

Low serum albumin, aspartate aminotransferase, and body mass are risk factors for frailty in elderly people with diabetes-a cross-sectional study

Background

Frailty is broadly characterized by vulnerability and decline in physical, mental and social activities and is more common in elderly patients with type 2 diabetes mellitus (T2DM). Frailty is closely associated with nutrition, muscle strength, inflammation, and hormones etc. In hormones, dehydroepiandrosterone sulfate (DHEA-S) and cortisol are suggested to be such candidates affecting frailty. Little investigation has been performed using a wider range of measures of frailty to clarify risk factors for frailty including the above two hormones.

Methods

We performed a cross-sectional study to investigate the risk factors for frailty in elderly T2DM patients (n = 148; ≥65 years), using a broad assessment, the clinical frailty scale. We compared parameters between the non-frail and frail groups using the unpaired t and Mann-Whitney U tests. The Jonckheere-Therpstra test was used to identify relationships with the severity of frailty, and risk factors were identified using binary regression analysis.

Results

Simple regression analysis identified a number of significant risk factors for frailty, including DHEAS < 70 μg/dL and cortisol/DHEA-S ratio ≥ 0.2. Multiple regression analysis showed that low albumin (< 4.0 g/dl) (odds ratio [OR] = 5.79, p < 0.001), low aspartate aminotransferase (AST) activity (< 25 IU/L) (OR = 4.34, p = 0.009), and low body mass (BM) (< 53 kg) (OR = 3.85, p = 0.012) were independent risk factors for frailty. A significant decrease in DHEA-S and a significant increase in the cortisol/DHEA-S ratio occurred alongside increases in the severity of frailty. DHEA-S concentration positively correlated with both serum albumin and BM.

Conclusions

Hypoalbuminemia, low AST, and low BM are independent risk factors for frailty in elderly T2DM patients, strongly implying relative malnutrition in these frail patients. DHEA-S may be important for the maintenance of liver function and BM. A decrease in DHEA-S and an increase in the cortisol/DHEAS ratio may be involved in the mechanism of the effect of malnutrition in elderly T2DM patients.

Metabolic dysregulation in vitamin E and carnitine shuttle energy mechanisms associate with human frailty

Global ageing poses a substantial economic burden on health and social care costs. Enabling a greater proportion of older people to stay healthy for longer is key to the future sustainability of health, social and economic policy. Frailty and associated decrease in resilience plays a central role in poor health in later life. In this study, we present a population level assessment of the metabolic phenotype associated with frailty. Analysis of serum from 1191 older individuals (aged between 56 and 84 years old) and subsequent longitudinal validation (on 786 subjects) was carried out using liquid and gas chromatography-mass spectrometry metabolomics and stratified across a frailty index designed to quantitatively summarize vulnerability. Through multivariate regression and network modelling and mROC modeling we identified 12 significant metabolites (including three tocotrienols and six carnitines) that differentiate frail and non-frail phenotypes. Our study provides evidence that the dysregulation of carnitine shuttle and vitamin E pathways play a role in the risk of frailty.

Risk of age-related chronic disorders and decrease in resilience is associated with ageing. Here the authors analyse the human blood metabolome and identify metabolites associated with frailty.

Frailty Status Predicts All-Cause and Cause-Specific Mortality in Community Dwelling Older Adults

OBJECTIVES

To examine the relationship between frailty status and risk of all-cause and cause-specific mortality.

DESIGN

Longitudinal cohort study with an 11-year follow up.

SETTING AND PARTICIPANTS

Data from the Survey on Health, Aging and Retirement in Europe (SHARE) were used. In the analysis, we included data from 11 European countries. We included men and women older than 50 years residing in Europe. Overall, 24,634 participants were analyzed with a mean age of 64.2 (9.8), 53.6% female, where 14.7% and 6.9% were found to be prefrail or frail, respectively, at the baseline.

METHODS

Frailty status was calculated using the SHARE-Frailty Instrument, categorizing the participants as robust, prefrail, and frail. Multivariate Cox regression models were used to estimate the risk of all-cause and cause-specific (stroke, heart attack, other cardiovascular disease, cancer, respiratory illness, infectious, and digestive and other) mortality.

RESULTS

During the follow-up, and after adjusting for sex, age, education, body mass index, smoking, alcohol consumption, and number of comorbidities, frailty was associated with a higher risk of all-cause (HR 2.17, 95% CI 1.90-2.48) and mortality due to stroke (HR 2.06, 95% CI 1.37-3.10), heart attack (HR 1.67, 95% CI 1.19-2.34), other cardiovascular disease (HR 2.77, 95% CI 1.87-4.12), cancer (HR 2.11, 95% CI 1.63-2.73), respiratory disease (HR 2.76, 95% CI 1.66-4.60), infectious diseases (HR 1.79, 95% CI 1.03-3.11), and digestive and other causes (HR 2.02, 95% CI 1.51-2.71). Prefrailty was associated with a higher risk of all-cause (HR 1.47, 95% CI 1.31-1.63), heart attack (HR 1.31, 95% CI 1.01-1.72), other cardiovascular disease (HR 2.03, 95% CI 1.46-2.81), respiratory disease (HR 1.70, 95% CI 1.09-2.65), and digestive and other causes (HR 1.50, 95% CI 1.18-1.91) mortality.

CONCLUSIONS AND IMPLICATIONS

Baseline prefrailty and frailty are associated with increased all-cause and cause-specific mortality over an 11-year follow up. Public health policy should include preventive programs aimed at older adults to prevent frailty and reduce mortality.

Osteoprotegerin as a biomarker of geriatric frailty syndrome

The lack of a univocal definition of frailty, a condition frequently found in the elderly population which is correlated with an increased risk of mortality, has prompted the search for clinical and laboratory parameters associated with this condition. Whereas OPG is a protein involved in different pathophysiological conditions including bone, vascular, immune and tumor disease and studies found a positive linear correlation between OPG and age we hypothesized that it may represent a frailty marker in the elderly.We conducted an observational study of 172 elderly subjects, with and without hip fracture, including a multidimensional geriatric evaluation and a laboratory evaluation, aimed to evaluate the association between OPG and frailty.Frailty Score was associated with FT3 and osteoprotegerin (OPG), regardless of fracture event. Excluding subjects with hip fracture, in whom the acute event had a direct effect on bone production of OPG, the Frailty Score showed a linear correlation with circulating levels of osteoprotegerin.In the elderly, an increase in osteoprotegerin levels may reflect a progressive accumulation of organ damage leading to the development of frailty. The correlation between OPG and Frailty Score found in our study points to its potential use as a biomarker for geriatric frailty syndrome.

Steroid secretion in healthy aging

Nowadays, people spend a considerable amount of their lives as older adults, but this longer lifespan is often accompanied by an increase in chronic conditions and disease, resulting in reduced quality of life and unprecedented societal and economic burden. Healthy aging is therefore increasingly recognized as a healthcare priority. Physical and mental adaptations to changes over the life course, and the maintenance of well-being, represent pivotal challenges in healthy aging. To capture the complexity of healthy aging, we propose a specific phenotype based on body composition, cognition, mood, and sexual function as indicators of different dimensions of healthy aging. With increasing age, sex hormones as well as glucocorticoids undergo significant alterations, and different patterns emerge for women and men. This review describes age-related patterns of change for women and men, and sheds light on the underlying mechanisms. Furthermore, an overview is provided of the challenges for healthy aging resulting from these age-related steroid alterations. While clinical practice guidelines recommend hormonal treatment only in the case of consistently low hormone levels and symptoms of hormone deficiency, physical exercise and a healthy lifestyle emerge as preventive strategies which can counter age-related hormonal changes and at best prevent chronic conditions.

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.

A High Serum Cortisol/DHEA-S Ratio Is a Risk Factor for Sarcopenia in Elderly Diabetic Patients

Context

Elderly patients with type 2 diabetes mellitus (T2DM) have a high prevalence of frailty and/or sarcopenia. Sarcopenia is thought to be related to discordant secretions of the adrenal hormones cortisol and dehydroepiandrosterone (DHEA), as well as the sulfate ester of DHEA (DHEA-S). The current study sought to evaluate the risk factors for sarcopenia in elderly patients with T2DM.

Design and Patients

We enrolled 108 consecutive elderly patients aged ≥65 years with T2DM (mean age, 76.2 ± 7.3 years; 43.5% males). Sarcopenia was assessed and diagnosed based on the Asian version of the diagnostic criteria regarding muscular strength, physical function, and muscle mass. We assessed various physical parameters, blood tests, and atherosclerosis markers and statistically determined the risk factors for sarcopenia.

Results

Multiple regression analysis showed that the independent risk factors for sarcopenia were a serum cortisol/DHEA-S ratio ≥0.2, diastolic blood pressure <70 mm Hg, Hb concentration <13 g/dL, and an ankle brachial index <1.0. The strongest risk factor for sarcopenia was a serum cortisol/DHEA-S ratio ≥0.2. An increase in the serum cortisol/DHEA-S ratio reflected higher cortisol values and lower DHEA-S values in patients with sarcopenia compared with those in nonsarcopenic patients. The concentrations of cortisol and DHEA-S, as well as the cortisol/DHEA-S ratio, changed in accordance with the severity of sarcopenia.

Conclusions

A relative increase in cortisol may reflect the presence of stress and stimulate muscle catabolism, whereas a relative decrease in DHEA-S may cause a decrease in the anabolic action of DHEA on muscle; the combination of these factors may lead to sarcopenia.

Current and emerging biomarkers of frailty in the elderly

The term “frailty” is used to describe a subset of older adults who appear weaker and more vulnerable than their age-matched counterparts, despite having similar comorbidities, demography, sex, and age. The diagnosis of frailty is usually clinical and based on specific criteria, which are sometimes inconsistent. Therefore, there is an increasing need to identify and validate robust biomarkers for this condition. In this review, we summarize current evidence on the validity and practicality of the most commonly used biomarkers for frailty, while also comparing them with new upcoming strategies to identify this condition.

Sex Differences in Aging and Associated Biomarkers

Aging is a natural process defined by the gradual, time-dependent decline of biological and behavioural functions, for which individuals of the same chronological age show variability. The capacity of biological systems to continuously adjust for optimal functioning despite ever changing environments is essential for healthy aging, and variability in these adaptive homeostatic mechanisms may reflect such heterogeneity in the aging process. With an ever-increasing aging population, interest in biomarkers of aging is growing. Although no universally accepted definition of biomarkers of healthy aging exists, mediators of homeostasis are consistently used as measures of the aging process. As important sex differences are known to underlie many of these systems, it is imperative to consider that this may reflect, to some extent, the sex differences observed in aging and age-related disease states. This chapter aims to outline sex differences in key homeostatic domains thought to be associated with the pathophysiology of aging, often proposed as biomarkers of aging and age-related disease states. This includes considering sex-based differences and hormonal status with regards to the gonadal and adrenal endocrine systems and immune function.

Higher levels of tumor necrosis factor β are associated with frailty in socially vulnerable community-dwelling older adults

Background

The complex physiology underpinning the frailty syndrome is responsible for the absence of robust biomarkers that can be used for screening, diagnostic and/or prognostic purposes and has made clinical implementation difficult. Considering socially vulnerable populations, who have poor health status and increased morbidity and mortality, this scenario is even more complex. However, to the best of our knowledge, there are no studies available to investigate frailty biomarkers in socially vulnerable populations. Thus, the aim of this cross-sectional study was to identify potential blood-based biomarkers of frailty in a socially vulnerable population.

Methods

A sample consisting of 347 community-dwelling older people living in a context of high social vulnerability was divided into non-frail (robust), pre-frail and frail groups, according to modified Fried frailty phenotype criteria. Blood samples were collected and analyzed for basic metabolic parameters and for inflammatory cytokines.

Results

Levels of Interleukin-1α (IL-1α) and Tumor Necrosis Factor α (TNF-α) were significantly higher in pre-frail subjects, compared to non-frail ones. Tumor Necrosis Factor β (TNF-β) levels presented higher values in the frail compared to non-frail individuals. Interleukin-6 (IL-6) levels in pre-frail and frail subjects were significantly higher compared to the levels of non-frail subjects. Using an ordinal regression analysis, we observed that socially vulnerable older people at higher risk of developing frailty were subjects above 80 years old (OR: 2.5; 95% CI: 1.1–5.6) and who presented higher levels of TNF-β (≥0.81 pg/mL, OR: 2.53; 95% CI: 1.3–4.9).

Conclusion

As vulnerable populations continue to age, it is imperative to have a greater understanding of the frailty condition, identifying novel potential blood-based biomarkers. The results presented here could help to implement preventive healthcare strategies by evaluating frailty and at the same time measuring a set of inflammatory biomarkers, paying special attention to TNF-β plasmatic levels.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0961-6) contains supplementary material, which is available to authorized users.

Frailty and the endocrine system

Frailty is a condition characterised by loss of biological reserves, failure of homoeostatic mechanisms, and vulnerability to adverse outcomes. The endocrine system is considered particularly important in frailty, because of its complex inter-relationships with the brain, immune system, and skeletal muscle. This Review summarises evidence indicating a key role for the hypothalamic-pituitary axis in the pathogenesis of frailty through aberrant regulation of glucocorticoid secretion, insulin-like growth factor signalling, and androgen production. Evidence also indicates a potential role for vitamin D and insulin resistance in the pathogenesis of frailty. The role of thyroid hormones in the pathogenesis of frailty remains uncertain. Key convergent pathological effects of frailty include loss of muscle mass and strength, with consequent impact on mobility and activities of daily living. Future translational research should focus on the understanding of endocrine mechanisms, to identify potential biomarkers of the condition, modifiable targets for treatment, and novel pharmacological drugs targeted at the endocrine components of frailty.

Frailty assessment in older adults with chronic obstructive respiratory diseases

The number of patients with chronic obstructive pulmonary disease (COPD) has been rising with continued exposure to environmental risk factors and aging of populations around the world. Frailty is a geriatric syndrome with a decline in physiological reserve and often coexists with chronic diseases such as COPD. Frailty is an independent risk factor for the development and progression of COPD, and COPD can lead to frailty; treating one might improve the other. Thus, there is an increasing interest in the assessment of frailty in patients with COPD. Furthermore, early identification and assessment of frailty in patients with COPD may affect the choice of intervention and improve its effectiveness. Based on the current literature, the intent of this review was to summarize and discuss frailty assessment tools used for COPD patients and the relevant clinical practices for predicting outcomes. We ascertain that using suitable frailty assessment tools could facilitate physicians to screen and stratify physically frail patients with COPD. Screening appropriately targeted population can achieve better intervention outcomes and pulmonary rehabilitation among frail COPD patients.

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.

Age-related differences in stress responsiveness of the hypothalamic-pituitary-adrenal axis of nonhuman primates with various types of adaptive behavior

Aging is characterized by disturbances in the functioning of the hypothalamic-pituitary-adrenal (HPA) axis, associated with disturbances in the adaptation processes and increase of the probability of the onset of post-stress syndrome. However, the individual features of age-related disorders stress reactivity of HPA axis have not been studied. The purpose was to study individual characteristics of the HPA axis responsiveness to acute psycho-emotional stress exposure (restraint, ASE) at different age periods on the model of the young adult and old physically healthy female rhesus monkeys that differ in their behavioral responses to stress, i.e., with depression-like and anxiety-like behavior (DAB) on the one hand and healthy standard (control) adaptive behavior (SB) on the other hand. No significant intergroup differences were observed in HPA axis responses to ASE in young animals. During aging the monkeys with SB showed reduced ACTH response to the ASE, whereas the monkeys with DAB demonstrated its increase. The old animals with DAB in response to ASE demonstrated the most pronounced HPA axis disorders, such as the highest levels of corticotrophin (ACTH), the lowest levels of dehydroepiandrosterone sulfate (DHEAS), reduced cortisol (F) levels and the highest values of the F/DHEAS molar ratio. The ratio F/DHEAS positively correlates with the malondialdehyde concentration in erythrocytes that is considered as the biomarker of oxidative stress. Thus, these data allow us to consider the old monkeys with DAB as individuals with higher vulnerability to the adverse effects of ASE. In addition, depression-like and anxiety-like behavior of aged primates under mild/moderate stress along with reduced DHEAS plasma concentration and increased values of F/DHEAS ratio can be used to identify individuals with increased vulnerability to ASE and accelerated aging.

Characteristics and diagnostic workup of the patient at risk to sustain fragility fracture

The human body undergoes several physiological adaptations as a result of the aging process. Amongst other organs, the skeleton is also affected and when bone fragility is present, an increase in both morbidity and mortality has been reported. Identification of risk factors to calculate the probability for a given patient to develop a fragility fracture it is therefore of paramount importance. Moreover, the existence of an in house protocol for diagnostic work up using biochemical tests and imaging investigations is essential. In the herein study we discuss a diagnostic protocol that has been developed in our clinic based on knowledge from the literature and our clinical experience.

Nonandrogenic Anabolic Hormones Predict Risk of Frailty: European Male Ageing Study Prospective Data

CONTEXT

Low levels of nonandrogenic anabolic hormones have been linked with frailty, but evidence is conflicting and prospective data are largely lacking.

OBJECTIVE

To determine associations between nonandrogenic anabolic hormones and prospective changes in frailty status.

DESIGN/SETTING

A 4.3-year prospective observational study of community-dwelling men participating in the European Male Ageing Study.

PARTICIPANTS

Men (n = 3369) aged 40 to 79 years from eight European centers.

MAIN OUTCOME MEASURES

Frailty status was determined using frailty phenotype (FP; n = 2114) and frailty index (FI; n = 2444).

ANALYSIS

Regression models assessed relationships between baseline levels of insulinlike growth factor 1 (IGF-1), its binding protein 3 (IGFBP-3), dehydroepiandrosterone sulfate (DHEA-S), 25-hydroxyvitamin D (25OHD), and parathyroid hormone (PTH), with changes in frailty status (worsening or improving frailty).

RESULTS

The risk of worsening FP and FI decreased with 1 standard deviation higher IGF-1, IGFBP-3, and 25OHD in models adjusted for age, body mass index, center, and baseline frailty [IGF-1: odds ratio (OR) for worsening FP, 0.82 (0.73, 0.93), percentage change in FI, -3.7% (-6.0, -1.5); IGFBP-3: 0.84 (0.75, 0.95), -4.2% (-6.4, -2.0); 25OHD: 0.84 (0.75, 0.95); -4.4%, (-6.7, -2.0)]. Relationships between IGF-1 and FI were attenuated after adjusting for IGFBP-3. Higher DHEA-S was associated with a lower risk of worsening FP only in men >70 years old [OR, 0.57 (0.35, 0.92)]. PTH was unrelated to change in frailty status.

CONCLUSIONS

These longitudinal data confirm the associations between nonandrogenic anabolic hormones and the changes in frailty status. Interventional studies are needed to establish causality and determine therapeutic implications.

Sexual dimorphism of frailty and cognitive impairment: Potential underlying mechanisms (Review)

The aim of the present study was to assess systematically gender differences in susceptibility to frailty and cognitive performance decline, and the underlying mechanisms. A systematic assessment was performed of the identified reviews of cohort, mechanistic and epidemiological studies. The selection criteria of the present study included: i) Sexual dimorphism of frailty, ii) sexual dimorphism of subjective memory decline (impairment) and atrophy of hippocampus during early life, iii) sexual dimorphism of late‑onset Alzheimer's disease and iv) sexual dimorphism mechanisms underlying frailty and cognitive impairment. Males exhibit a susceptibility to poor memory performance and a severe atrophy of the hippocampus during early life and females demonstrate a higher prevalence for frailty and late‑life dementia. The different alterations within the hypothalamic‑pituitary‑gonadal/adrenal axis, particularly with regard to gonadal hormones, cortisol and dehydroepiandrosterone/sulfate‑bound dehydroepiandrosterone prior to and following andropause in males and menopause in females, serve important roles in sexual dimorphism of frailty and cognitive impairment. These endocrine changes may accelerate immunosenescence, weaken neuroprotective and neurotrophic effects, and promote muscle catabolism. The present study suggested that these age‑associated endocrine alterations interact with gender‑specific genetic and epigenetic factors, together with immunosenescence and iron accumulation. Environment factors, including psychological factors, are additional potential causes of the sexual dimorphism of frailty and cognitive impairment.

Precipitous Dehydroepiandrosterone Declines Reflect Decreased Physical Vitality and Function

Dehydroepiandrosterone (DHEA) and its sulfated form, DHEA-S, peak in young adulthood and then decrease dramatically with age. However, there is extensive variation in this age-related hormone decline, suggesting an early decrement may be associated with lower vitality and be prognostic of poor health in old age. To determine whether DHEA-S and DHEA are correlated with physical indices of vitality, hormone levels were analyzed with respect to clinical health histories, physical functioning including grip strength, gait speed and repetitive standing, and self-reported chronic pain. The participants (N = 1,214) were 35-86 years of age from a nationally representative survey, Midlife Development in the United States. DHEA-S and DHEA below age-expected levels were associated with more chronic illness conditions and self-reported persistent pain and pain sensitivity upon manual palpation. Additionally, lower DHEA-S and DHEA correlated with poorer performance on tests of physical functioning by middle age suggesting a more precipitous decline is already indicative of reduced vigor and physical strength. When considered with respect to age- and gender-typical norms, larger decrements in DHEA-S and DHEA may be causally related to the loss of physical vitality. Conversely, when hormone secretion is sustained in older adults, it conveys reduced risk for the physical weakness and ailments that precede frailty.

Inflammation, Immune Activation, Immunosenescence, and Hormonal Biomarkers in the Frailty-Related Phenotype of Men With or at Risk for HIV Infection

Background

The extent to which inflammation, immune activation/immunosenescence, and hormonal abnormalities are driven by human immunodeficiency virus (HIV) or frailty is not clear.

Methods

HIV-infected frail men (n = 155) were matched to nonfrail, HIV-infected (n = 141) and HIV-uninfected (n = 150) men by age, calendar year, and antiretroviral therapy use (HIV-infected men only). Frailty was defined by ≥3 frailty-related phenotype criteria (weight loss, exhaustion, low activity, slowness) at ≥2 visits, or at 1 visit with ≥1 criteria at ≥2 visits. The following measurements were obtained: interleukin 6, high-sensitivity C-reactive protein, soluble receptors for tumor necrosis factor α 1 and 2, the percentages of CD4+CD28-, CD8+CD28-, CD4+CD38+HLA-DR+, and CD8+CD38+HLA-DR+ T cells, dehydroepiandrosterone sulfate, free testosterone, homeostatic model assessment of insulin resistance, and insulin-like growth factor 1. Log-linear regressions were adjusted for a priori selected covariates to determine differences by frailty and HIV status.

Results

In multivariate analyses adjusted for covariates, frailty was associated among HIV-infected men with higher interleukin 6 and high-sensitivity C-reactive protein and lower free testosterone and dehydroepiandrosterone levels. In contrast, HIV infection but not frailty was associated with significantly greater immune senescence (percentage of CD4+CD28- or CD8+CD28- T cells) and immune activation (percentages of CD4+CD38+HLA-DR+ and CD8+CD38+HLA-DR+ T cells).

Conclusions

Frailty among HIV-infected men was associated with increased inflammation and lower hormone levels, independent of comorbid conditions. Interventions targeting these pathways should be evaluated to determine the impact on prevention or reversal of frailty among HIV-infected men.

Biomarkers for physical frailty and sarcopenia: state of the science and future developments

Physical frailty and sarcopenia are two common and largely overlapping geriatric conditions upstream of the disabling cascade. The lack of a unique operational definition for physical frailty and sarcopenia and the complex underlying pathophysiology make the development of biomarkers for these conditions extremely challenging. Indeed, the current definitional ambiguities of physical frailty and sarcopenia, together with their heterogeneous clinical manifestations, impact the accuracy, specificity, and sensitivity of individual biomarkers proposed so far. In this review, the current state of the art in the development of biomarkers for physical frailty and sarcopenia is presented. A novel approach for biomarker identification and validation is also introduced that moves from the 'one fits all' paradigm to a multivariate methodology.

Novel dehydroepiandrosterone troche supplementation improves the serum androgen profile of women undergoing in vitro fertilization

Dehydroepiandrosterone (DHEA) is the most abundant steroid hormone in the circulation and has potent multifunctional activity. Epidemiological evidence suggests that levels of serum DHEA decrease with advancing age, and this has been associated with onset or progression of various age-related ailments, including cognitive decline and dementia, cardiovascular disease, and obesity. Consequently, these findings have sparked intense research interest in DHEA supplementation as an "antiaging" therapy. Currently, DHEA is being used by 25% of in vitro fertilization (IVF) clinicians as an adjuvant in assisted reproductive programs, yet the therapeutic benefit of DHEA is unclear. Here, we examined the use of novel DHEA-containing oral troches in patients undertaking IVF and investigated the impact of these troches on their serum androgen profile. This retrospective study determined the androgen profile of 31 IVF patients before (baseline) and after DHEA supplementation (with DHEA). Baseline serum measurements of testosterone (total and free), DHEA sulfate (DHEAS), sex hormone-binding globulin (SHBG), and androstenedione were made before and after supplementation. Each patient received DHEA troches containing 25 mg of micronized DHEA, and troches were administered sublingually twice daily for a period of no greater than 4 months. Adjuvant treatment with DHEA boosted the serum concentration of a number of androgen-related analytes, including total and free testosterone, androstenedione, and DHEAS, while serum SHBG remained unchanged. Supplementation also significantly increased the free-androgen index in IVF patients. Interestingly, the increase in serum analyte concentration following DHEA supplementation was found to be dependent on body mass index (BMI), but not individual age. Patients with the lowest BMI (<20.0 kg/m(2)) tended to have lower testosterone and DHEAS, but higher SHBG and androstenedione levels in comparison with other BMI groups postsupplementation. However, patients in the highest BMI group (>30.0 kg/m(2)) tended to have lower androgen responses following DHEA supplementation, but these were not statistically different from the corresponding baseline level. This method of DHEA administration results in a similar enhancement of testosterone, DHEAS, and androstenedione levels in comparison with other methods of administration. Furthermore, we showed that BMI significantly influences DHEA uptake and metabolism, and that BMI should be carefully considered during dosage calculation to ensure a significant and robust androgen-profile boost.

Low Levels of Dehydroepiandrosterone Sulfate in Younger Burnout Patients

Objective

Dehydroepiandrosterone sulphate (DHEA-s) is an anabolic protective hormone of importance for maintenance of health. DHEA-s levels peak in young adults and decline thereafter with age. DHEA-s has previously been shown to be lower in individuals reporting prolonged stress. This study investigates DHEA-s levels in patients with clinical burnout, a disorder caused by long-term psychosocial stress.

Methods

122 patients (51% men) and 47 controls (51% men) in the age 25–54 years were included in the study. DHEA-s levels were compared between patients and controls in the whole sample and within each of the three 10-year-interval age groups.

Results

In the youngest age group (25–34 years), DHEA-s levels were on average 25% lower in the patients (p = 0.006). The differences in DHEA-s levels between patients and controls were more pronounced among female than male participants (on average 32% and 13% lower, respectively). There were no differences in DHEA-s levels between patients and controls in the age group 35–44 years (p = 0.927) or 45–54 years (p = 0.897) or when analyzing all age groups together (p = 0.187).

Conclusion

The study indicates that levels of the health promoting “youth” hormone DHEA-s are low in younger burnout patients. The fact that younger adults have much higher DHEA-s levels and more pronounced inter-subject variability in DHEA-s levels than older individuals might explain why burnout status differentiates patients from controls only among the youngest patients included in this study.

Hypothalamic-pituitary-adrenal (HPA) axis and aging

Human aging is associated with increasing frailty and morbidity which can result in significant disability. Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis may contribute to aging-related diseases like depression, cognitive deficits, and Alzheimer's disease in some older individuals. In addition to neuro-cognitive dysfunction, it has also been associated with declining physical performance possibly due to sarcopenia. This article reviews the pathophysiology of HPA dysfunction with respect to increased basal adrenocorticotropic hormone (ACTH) and cortisol secretion, decreased glucocorticoid (GC) negative feedback at the level of the paraventricular nucleus (PVN) of the hypothalamus, hippocampus (HC), and prefrontal cortex (PFC), and flattening of diurnal pattern of cortisol release. It is possible that the increased cortisol secretion is secondary to peripheral conversion from cortisone. There is a decline in pregnolone secretion and C-19 steroids (DHEA) with aging. There is a small decrease in aldosterone with aging, but a subset of the older population have a genetic predisposition to develop hyperaldosteronism due to the increased ACTH stimulation. The understanding of the HPA axis and aging remains a complex area with conflicting studies leading to controversial interpretations.

The implication of frailty on preoperative risk assessment

PURPOSE OF REVIEW

Frailty, a state of decreased homeostatic reserve, is characterized by dysregulation across multiple physiologic and molecular pathways. It is particularly relevant to the perioperative period, during which patients are subject to high levels of stress and inflammation. This review aims to familiarize the anesthesiologist with the most current concepts regarding frailty and its emerging role in preoperative assessment and risk stratification.

RECENT FINDINGS

Current literature has established frailty as a significant predictor of operative complications, institutionalization, and death among elderly surgical patients. A variety of scoring systems have been proposed to preoperatively identify and assess frail patients, though they differ in their clinical utility and prognostic ability. Additionally, evidence suggests an evolving potential for preoperative intervention and modification of the frailty syndrome.

SUMMARY

The elderly are medically complex and heterogeneous with respect to operative risk. Recent advances in the concept of frailty provide an evidence-based framework to guide the anesthesiologist in the perioperative management, evaluation, and risk stratification of older surgical patients.

Dehydroepiandrosterone sulfate levels in Turkish obese patients

PURPOSE

Obesity is well known to be linked to higher morbidity and mortality. Elevated plasma levels of free dehydroepiandrosterone (DHEA) are associated with reduced obesity and more limited accumulation of abdominal body fat. In contrast, the relationship between the DHEA sulfate ester (DHEAS) and adiposity is inconsistent and contradictory.

METHODS

The aim of this study was to compare DHEAS levels in obese Turkish individuals, 37 men and 246 women. A variety of fatness, hormone, and blood parameters were measured.

RESULTS

Statistically significant differences were found between male and female individuals with respect to weight, waist circumference, fat %, insulin, and DHEAS levels.

CONCLUSIONS

We found that in the Turkish population, while a correlation between obesity parameters and DHEAS levels exists in both female and male individuals, DHEAS levels are significantly higher in obese male individuals than in obese female individuals.

Clinical features of prefrail older individuals and emerging peripheral biomarkers: a systematic review

Frailty is a geriatric syndrome characterized by the clinical presentation of identifiable physical alterations such as loss of muscle mass and strength, energy and exercise tolerance, and decreased physiological reserve. Individuals with one or two of these alterations are defined as prefrail. The clinical features of prefrail older individuals have been investigated to a lesser extent compared to the frail population, even though this intermediate stage may provide insights into the mechanisms involved in the physical decline associated with aging and it is considered to be potentially reversible. We performed searches in the Medline, Embase, Scopus, Cinahl, and Cochrane databases from January 1995 to July 2013 for papers about the identification of prefrail people aged 65 and older published either in English or Spanish, and the reference lists of from the articles retrieved were pearled in order to identify any which may have been missed in the initial search. Two independent reviewers extracted descriptive information on frailty criteria and outcomes from the selected papers: of the 277 articles retrieved from the searches and 25 articles retrieved from pearling, 84 met the study inclusion criteria. The prevalence of prefrailty ranges between 35% and 50% in individuals aged over 60, is more common in women, and the age and the number of comorbidities in these individuals is similar to their frail counterparts. Weakness is the most prevalent symptom in prefrail individuals although there are some sex differences. Some serum biomarkers seem to discriminate prefrail from non-frail individuals but further research would be required to confirm this.

Inflammatory markers and incident frailty in men and women: the English Longitudinal Study of Ageing

Cross-sectional studies show that higher blood concentrations of inflammatory markers tend to be more common in frail older people, but longitudinal evidence that these inflammatory markers are risk factors for frailty is sparse and inconsistent. We investigated the prospective relation between baseline concentrations of the inflammatory markers C-reactive protein (CRP) and fibrinogen and risk of incident frailty in 2,146 men and women aged 60 to over 90 years from the English Longitudinal Study of Ageing. The relationship between CRP and fibrinogen and risk of incident frailty differed significantly by sex (p for interaction terms <0.05). In age-adjusted logistic regression analyses, for a standard deviation (SD) increase in CRP or fibrinogen, odds ratios (95% confidence intervals) for incident frailty in women were 1.69 (1.32, 2.17) and 1.39 (1.12, 1.72), respectively. Further adjustment for other potential confounding factors attenuated both these estimates. For an SD increase in CRP and fibrinogen, the fully-adjusted odds ratio (95% confidence interval) for incident frailty in women was 1.27 (0.96, 1.69) and 1.31 (1.04, 1.67), respectively. Having a high concentration of both inflammatory markers was more strongly predictive of incident frailty than having a high concentration of either marker alone. In men, there were no significant associations between any of the inflammatory markers and risk of incident frailty. High concentrations of the inflammatory markers CRP and fibrinogen are more strongly predictive of incident frailty in women than in men. Further research is needed to understand the mechanisms underlying this sex difference.

Reduced circulating androgen levels after gastric bypass surgery in severely obese women

BACKGROUND

Previous studies have shown a reduction of elevated androgen levels in premenopausal women after marked weight loss induced by bariatric surgery. In this study, we aimed to assess whether circulating androgen levels also decline after bariatric surgery in women displaying normal values preoperatively as well as in postmenopausal women.

METHODS

In 36 severely obese women (six postmenopausal), levels of total testosterone, dehydroepiandresterone sulfate (DHEA-S), and sex hormone-binding globulin (SHBG) were assessed before and at ~1 year after gastric bypass. Free and bioavailable testosterone levels as well as the free androgen index were calculated by established formulas.

RESULTS

After the surgery, women had lost on average 43.1 ± 1.8 kg. Independently of the pre/postmenopausal state, women showed a marked reduction in all testosterone-related androgen markers and DHEA-S levels, while SHBG levels markedly increased (all P < 0.001). Respective changes were found in both women with and without preoperatively elevated levels. Changes after the surgery in testosterone-related markers as well as in SHBG levels but not in DHEA-S levels were correlated with changes in insulin levels independently of body weight changes.

CONCLUSIONS

Data show a marked reduction of androgen levels in severely obese women after a surgically induced weight loss, which is independent from the menopausal state and preoperative levels. The mechanisms and consequences of these hormonal changes induced by bariatric surgery should be addressed in further studies.

Measures of frailty in population-based studies: an overview

Background

Although research productivity in the field of frailty has risen exponentially in recent years, there remains a lack of consensus regarding the measurement of this syndrome. This overview offers three services: first, we provide a comprehensive catalogue of current frailty measures; second, we evaluate their reliability and validity; third, we report on their popularity of use.

Methods

In order to identify relevant publications, we searched MEDLINE (from its inception in 1948 to May 2011); scrutinized the reference sections of the retrieved articles; and consulted our own files. An indicator of the frequency of use of each frailty instrument was based on the number of times it had been utilized by investigators other than the originators.

Results

Of the initially retrieved 2,166 papers, 27 original articles described separate frailty scales. The number (range: 1 to 38) and type of items (range of domains: physical functioning, disability, disease, sensory impairment, cognition, nutrition, mood, and social support) included in the frailty instruments varied widely. Reliability and validity had been examined in only 26% (7/27) of the instruments. The predictive validity of these scales for mortality varied: for instance, hazard ratios/odds ratios (95% confidence interval) for mortality risk for frail relative to non-frail people ranged from 1.21 (0.78; 1.87) to 6.03 (3.00; 12.08) for the Phenotype of Frailty and 1.57 (1.41; 1.74) to 10.53 (7.06; 15.70) for the Frailty Index. Among the 150 papers which we found to have used at least one of the 27 frailty instruments, 69% (n = 104) reported on the Phenotype of Frailty, 12% (n = 18) on the Frailty Index, and 19% (n = 28) on one of the remaining 25 instruments.

Conclusions

Although there are numerous frailty scales currently in use, reliability and validity have rarely been examined. The most evaluated and frequently used measure is the Phenotype of Frailty.

Immune-endocrine biomarkers as predictors of frailty and mortality: a 10-year longitudinal study in community-dwelling older people

Frailty is a multidimensional geriatric syndrome characterised by a state of increased vulnerability to disease. Its causes are unclear, limiting opportunities for intervention. Age-related changes to the immune-endocrine axis are implicated. This study investigated the associations between the immune-endocrine axis and frailty as well as mortality 10 years later among men and women aged 65 to 70 years. We studied 254 participants of the Hertfordshire Ageing Study at baseline and 10-year follow-up. At baseline, they completed a health questionnaire and had collection of blood samples for immune-endocrine analysis. At follow-up, Fried frailty was characterised and mortality ascertained. Higher baseline levels of differential white cell counts (WCC), lower levels of dehydroepiandosterone sulphate (DHEAS) and higher cortisol:DHEAS ratio were all significantly associated with increased odds of frailty at 10-year follow-up. Baseline WCC and cortisol:DHEAS clearly discriminated between individuals who went on to be frail at follow-up. We present the first evidence that immune-endocrine biomarkers are associated with the likelihood of frailty as well as mortality over a 10-year period. This augments our understanding of the aetiology of frailty, and suggests that a screening programme at ages 60-70 years could help to identify individuals who are at high risk of becoming frail and who would benefit from early, targeted intervention, for example with DHEA supplementation or anti-inflammatory strategies. Progress towards the prevention of frailty would bring major health and socio-economic benefits at the individual and the population level.

Frailty, sarcopenia, and hormones

Frailty is now a definable clinical syndrome with a simple screening test. Age-related changes in hormones play a major role in the development of frailty by reducing muscle mass and strength (sarcopenia). Selective Androgen Receptor Molecules and ghrelin agonists are being developed to treat sarcopenia. The role of Activin Type IIB soluble receptors and Follistatin-like 3 mimetics is less certain because of side effects. Exercise (resistance and aerobic), vitamin D and protein supplementation, and reduction of polypharmacy are keys to the treatment of frailty.

Frailty in elderly people

Frailty is the most problematic expression of population ageing. It is a state of vulnerability to poor resolution of homoeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime. This cumulative decline depletes homoeostatic reserves until minor stressor events trigger disproportionate changes in health status. In landmark studies, investigators have developed valid models of frailty and these models have allowed epidemiological investigations that show the association between frailty and adverse health outcomes. We need to develop more efficient methods to detect frailty and measure its severity in routine clinical practice, especially methods that are useful for primary care. Such progress would greatly inform the appropriate selection of elderly people for invasive procedures or drug treatments and would be the basis for a shift in the care of frail elderly people towards more appropriate goal-directed care.

Frailty

Frailty is an emerging geriatric syndrome that refers to a state of increased vulnerability to adverse events including mortality, morbidity, disability, hospitalization, and nursing home admission. Despite its long conceptual and operational history in research and publications, frailty and mechanisms of frailty development are still poorly understood. In this review, we describe a number of conceptual models—reliability, allostatic load, and complexity—that have been put forward to explain the dynamic nature of frailty. We illustrate a consolidated pathophysiological model of frailty, taking into consideration the large and exponentially growing body of studies regarding predictors, indicators, and outcomes of frailty. The model addresses cellular (e.g., oxidative damage and telomere length) and systemic mechanisms (e.g., endocrinal, inflammatory, coagulatory, and metabolic deficiencies) of frailty, moderating or risk factors (e.g., ethnicity, lifestyle, and comorbidities), and outcomes (morbidity, disability, and cognitive decline). Finally, we identify the weaknesses of traditional epidemiological approaches for studying complex phenomena related to frailty and propose areas for future methodological and physiological inquiry.

Serum dehydroepiandrosterone sulfate and adverse health outcomes in older men and women

Low serum dehydroepiandrosterone sulfate (DHEAS) is common in older persons with poor health. The geriatric syndrome of physical frailty is associated with a higher risk of developing fatal and nonfatal health outcomes. However, the association of DHEAS with frailty is uncertain. This study investigated the association of serum DHEAS with frailty and its related adverse outcomes in 416 men and 504 women aged ≥65 years from an Italian prospective population-based cohort study. At baseline, frailty status was defined according to the physical phenotype, and serum DHEAS was measured in a fasting venous blood sample. After 4 years, subjects were reassessed for incident frailty and occurrence of nonfatal frailty-related outcomes (hospital admission, nursing home placement, disability, falls, and fractures). All-cause mortality after 8 years was also recorded. Incident frailty was inversely associated with baseline log-transformed DHEAS in men (odds ratio [OR]=0.35, 95% confidence interval [CI] 0.14-0.88, p=0.026) but not in women. Independent of baseline frailty status, women in the lowest DHEAS quartile compared to the upper three quartiles had a higher risk of hospital admission (OR=0.44, 95% CI 0.21-0.91, p=0.027) and nursing home placement (OR=0.27, 95% CI 0.08-0.95, p=0.041). Baseline log-transformed serum DHEAS was also inversely associated with mortality risk, but limited to women with concurrent frailty (hazard ratio [HR]=0.27, 95% CI 0.11-0.68, p=0.005) or preexisting major diseases (HR=0.57, 95% CI 0.33-0.98, p=0.041). These findings suggest that DHEAS is associated with incident frailty in older men and with fatal and nonfatal frailty-related adverse outcomes in older women.

The frailty syndrome: a comprehensive review

The frailty syndrome is defined as unintentional weight and muscle loss, exhaustion, and declines in grip strength, gait speed, and activity. Evidence with respect to the clinical definition, epidemiology, mechanisms, interactions, assessment, prevention, and treatment of frailty in the older adult is reviewed.

Aging and the effects of vitamins and supplements

Vitamin supplements are commonly consumed by elderly patients. This article reviews the evidence behind vitamin supplementation in preventing disease states common in older age, with an emphasis on randomized controlled trials. In addition to vitamins, some commonly used supplements, such as ginkgo, DHEA, and omega-3 fatty acids, are also discussed.

Ageing, physical function, and the diurnal rhythms of cortisol and dehydroepiandrosterone

The present study examined the relationship between ageing, physical function and the diurnal rhythms of cortisol and dehydroepiandrosterone (DHEA). Participants were 36 community dwelling older adults aged between 65 and 86 years old. Salivary cortisol and DHEA were measured over the course of one day: immediately upon awakening, 30 min later, and then 3 h, 6 h, 9 h and 12 h post-awakening. Participants completed the Nottingham extended activities of daily living index, the Berg Balance Scale and their handgrip strength was assessed. Older participants had a significantly higher cortisol area under the curve (AUC), lower overall DHEA levels, lower DHEA AUC, a decreased diurnal slope of decline and increased cortisol:DHEA ratio. Lower diurnal cortisol levels were associated with poorer performance on the Berg Balance Scale and lower handgrip strength, and those with a flattened DHEA diurnal profile reported less independence in carrying out daily tasks. These associations withstood adjustment for age. In conclusion, this study suggests an association between cortisol, DHEA, ageing and physical function.