The Conceptual Definition of Sarcopenia: Delphi Consensus from the Global Leadership Initiative in Sarcopenia (GLIS)

IMPORTANCE

Sarcopenia, the age-related loss of muscle mass and strength/function, is an important clinical condition. However, no international consensus on the definition exists.

OBJECTIVE

The Global Leadership Initiative in Sarcopenia (GLIS) aimed to address this by establishing the global conceptual definition of sarcopenia.

DESIGN

The GLIS steering committee was formed in 2019-21 with representatives from all relevant scientific societies worldwide. During this time, the steering committee developed a set of statements on the topic and invited members from these societies to participate in a two-phase International Delphi Study. Between 2022 and 2023, participants ranked their agreement with a set of statements using an online survey tool (SurveyMonkey). Statements were categorised based on predefined thresholds: strong agreement (>80%), moderate agreement (70-80%) and low agreement (<70%). Statements with strong agreement were accepted, statements with low agreement were rejected and those with moderate agreement were reintroduced until consensus was reached.

RESULTS

107 participants (mean age: 54 ± 12 years [1 missing age], 64% men) from 29 countries across 7 continents/regions completed the Delphi survey. Twenty statements were found to have a strong agreement. These included; 6 statements on 'general aspects of sarcopenia' (strongest agreement: the prevalence of sarcopenia increases with age (98.3%)), 3 statements on 'components of sarcopenia' (muscle mass (89.4%), muscle strength (93.1%) and muscle-specific strength (80.8%) should all be a part of the conceptual definition of sarcopenia)) and 11 statements on 'outcomes of sarcopenia' (strongest agreement: sarcopenia increases the risk of impaired physical performance (97.9%)). A key finding of the Delphi survey was that muscle mass, muscle strength and muscle-specific strength were all accepted as 'components of sarcopenia', whereas impaired physical performance was accepted as an 'outcome' rather than a 'component' of sarcopenia.

CONCLUSION AND RELEVANCE

The GLIS has created the first global conceptual definition of sarcopenia, which will now serve to develop an operational definition for clinical and research settings.

Recruitment methods and yield rates for a multisite clinical trial exploring risk reduction for Alzheimer's disease (rrAD)

INTRODUCTION

The risk reduction for Alzheimer's disease (rrAD) trial was a multisite clinical trial to assess exercise and intensive vascular pharmacological treatment on cognitive function in community-dwelling older adults at increased risk for Alzheimer's disease.

METHODS

Eligibility, consent, and randomization rates across different referral sources were compared. Informal interviews conducted with each site's project team were conducted upon study completion.

RESULTS

Initially, 3290 individuals were screened, of whom 28% were eligible to consent, 805 consented to participate (87.2% of those eligible), and 513 (36.3% of those consented) were randomized. Emails sent from study site listservs/databases yielded the highest amount (20.9%) of screened individuals. Professional referrals from physicians yielded the greatest percentage of consented individuals (57.1%). Referrals from non-professional contacts (ie, friends, family; 75%) and mail/phone contact from a site (73.8%) had the highest yield of randomization.

DISCUSSION

Professional referrals or email from listservs/registries were most effective for enrolling participants. The greatest yield of eligible/randomized participants came from non-professional and mail/phone contacts. Future trials should consider special efforts targeting these recruitment approaches.

Highlights

Clinical trial recruitment is commonly cited as a significant barrier to advancing our understanding of cognitive health interventions.The most cited referral source was email, followed by interviews/editorials on the radio, television, local newspapers, newsletters, or magazine articles.The referral method that brought in the largest number of contacts was email but did not result in the greatest yield of consents or eligible participants.The sources that yielded the greatest likelihood of consent were professional referrals (ie, physician), social media, and mail/phone contact from study site.The greatest yield of eligible/randomized participants came from non-professional contacts and mail/phone contact from a site.Findings suggest that sites may need to focus on more selective referral sources, such as using contact mailing and phone lists, rather than more widely viewed recruitment sources, such as social media or TV/radio advertisements.

Impact of psychological resilience on walking capacity in older adults following hip fracture

BACKGROUND

Community-dwelling older adults experiencing hip fracture often fail to achieve adequate walking capacity following surgery and rehabilitation. Effects of psychological factors on post-fracture walking capacity are poorly understood. Accordingly, this paper investigates effects of psychological resilience on observed walking capacity measures in older adults following hip fracture, controlling for important covariates.

METHODS

Data were drawn from the Community Ambulation Project, a clinical trial of 210 community-dwelling adults aged ≥60 years who experienced a minimal trauma hip fracture and were randomized to one of two 16-week home-based physical therapist-guided interventions. Psychological resilience was measured at study baseline using the 6-item Brief Resilience Scale (BRS); scores were classified into groups in order to distinguish levels of self-reported resilience. Walking capacity was assessed at study baseline and 16 weeks later using 4-Meter Gait Speed (4MGS), 50-Foot Walk Test (50FWT), and 6-Minute Walk Distance (SMWD). In multivariate analyses of covariance in which 16-week follow-up values of each walking measure were outcomes, covariates included clinical trial arm, gender, age, and baseline values of: walking measure corresponding to the outcome; body mass index; depressive symptom severity; degree of psychological optimism; cognitive status; informal caregiver need; and days from hospital admission to randomization.

RESULTS

Increases between baseline and 16 weeks later in mean gait speed in meters/sec (m/s) and walking distance in meters (m) in 4MGS, 50FWT and SMWD were 0.06 m/s (p = 0.061), 0.11 m/s (p < 0.01), and 25.5 m (p = 0.056) greater, respectively, in the most resilient BRS group compared to the least resilient BRS group.

CONCLUSION

Higher levels of psychological resilience were associated with greater walking speed and distance. Psychological resilience represents a potentially clinically important pathway and intervention target, toward the goal of improving walking capacity among older adults known to have substantial residual disability following hip fracture.

Evaluation of noise regression techniques in resting-state fMRI studies using data of 434 older adults

Subject motion is a well-known confound in resting-state functional MRI (rs-fMRI) and the analysis of functional connectivity. Consequently, several clean-up strategies have been established to minimize the impact of subject motion. Physiological signals in response to cardiac activity and respiration are also known to alter the apparent rs-fMRI connectivity. Comprehensive comparisons of common noise regression techniques showed that the "Independent Component Analysis based strategy for Automatic Removal of Motion Artifacts" (ICA-AROMA) was a preferred pre-processing technique for teenagers and adults. However, motion and physiological noise characteristics may differ substantially for older adults. Here, we present a comprehensive comparison of noise-regression techniques for older adults from a large multi-site clinical trial of exercise and intensive pharmacological vascular risk factor reduction. The Risk Reduction for Alzheimer's Disease (rrAD) trial included hypertensive older adults (60-84 years old) at elevated risk of developing Alzheimer's Disease (AD). We compared the performance of censoring, censoring combined with global signal regression, non-aggressive and aggressive ICA-AROMA, as well as the Spatially Organized Component Klassifikator (SOCK) on the rs-fMRI baseline scans from 434 rrAD subjects. All techniques were rated based on network reproducibility, network identifiability, edge activity, spatial smoothness, and loss of temporal degrees of freedom (tDOF). We found that non-aggressive ICA-AROMA did not perform as well as the other four techniques, which performed table with marginal differences, demonstrating the validity of these techniques. Considering reproducibility as the most important factor for longitudinal studies, given low false-positive rates and a better preserved, more cohesive temporal structure, currently aggressive ICA-AROMA is likely the most suitable noise regression technique for rs-fMRI studies of older adults.

Balancing Vision With Pragmatism: The Geriatric Emergency Department Guidelines-Realistic Expectations From Emergency Medicine and Geriatric Medicine

BACKGROUND

In 2014, the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterized the complex needs of the older emergency department (ED) patient and current best practices, with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and most EDs then and now have neither the resources nor the hospital administrative support to provide this additional service.

DISCUSSION

At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline-recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non-GED-accredited institutions.

CONCLUSIONS

In 2014, the GED Guidelines were published, describing the current best practices for GED patients. Unfortunately, most of the EDs worldwide do not provide the level of service recommended by the GED Guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.

A multi-center trial of exercise and testosterone therapy in women after hip fracture: Design, methods and impact of the COVID-19 pandemic

BACKGROUND

Up to 75% of hip fracture patients never recover to their pre-fracture functional status. Supervised exercise that includes strength training can improve functional recovery after hip fracture. The role of testosterone replacement for augmenting the effects of exercise in older women after hip fracture is unknown.

METHODS

The Starting Testosterone and Exercise after Hip Injury (STEP-HI) Study is a 6-month Phase 3 multicenter randomized placebo-controlled trial designed to compare supervised exercise (EX) plus 1% testosterone topical gel, with EX plus placebo gel, and with enhanced usual care (EUC). Female hip fracture patients age ≥ 65 years are being recruited from clinical centers across the United States. Participants are community dwelling and enrolled within 24 weeks after surgical repair of the fracture. The EX intervention is a center-based program of progressive resistance training. The EUC group receives a home exercise program and health education. Participants receive dietary counseling, calcium and vitamin D. The primary outcome is the Six Minute Walk Distance. Secondary outcomes include physical performance measures, self-reported function and quality of life, and dual energy x-ray absorptiometry measures of body composition and bone mineral density.

RESULTS

Enrollment, interventions, and follow-up are ongoing. We describe the impact of the coronavirus disease 2019 pandemic on the trial, including modifications made to allow continuation of the interventions and outcome data collection using remote video and audio technology.

CONCLUSIONS

Results from the STEP-HI study are expected to have important clinical and public health implications for management of the growing population of hip fracture patients.

Using Treatment Fidelity Measures to Understand Walking Recovery: A Secondary Analysis From the Community Ambulation Project

OBJECTIVES

Physical therapist intervention studies can be deemed ineffective when, in fact, they may not have been delivered as intended. Measurement of treatment fidelity (TF) can address this issue. The purpose of this study was to describe TF of a home-based intervention, identify factors associated with TF, and examine whether components of TF were associated with the outcome of change in 6-minute walk distance (∆6MWD).

METHODS

This is a secondary analysis of community-dwelling hip fracture participants who completed standard therapy and were randomly assigned to the active intervention (Push). Push was 16 weeks of lower extremity strengthening, function, and endurance training. TF was defined as delivery (attendance rate, exercise duration) and receipt (progression in training load, heart rate reserve [HRR] during endurance training, and exercise position [exercise on floor]). The outcome was ∆6MWD. Independent variables included baseline (demographic and clinical) measures. Descriptive statistics were calculated; linear and logistic regressions were performed.

RESULTS

Eighty-nine participants were included in this analysis; 59 (66%) had attendance of 75% or greater. Participants walked for 20 minutes or more for 78% of sessions. The average training load increased by 22%; the mean HRR was 35%; and 61 (69%) participants exercised on the floor for at least 75% of sessions. Regression analyses showed that a higher body mass index and greater baseline 6MWD were related to components of TF; 4 out of 5 components of TF were significantly related to ∆6MWD. The strongest TF relationship showed that those who exercised on the floor improved by 62 m (95% CI = 31-93 m) more than those who did not get on the floor.

CONCLUSIONS

Measures of TF should extend beyond attendance rate. This analysis demonstrates how measures of TF, including program attendance, progression in training load, endurance duration, and exercising on the floor were significantly related to improvement in 6MWD in participants post hip fracture.

IMPACT

This careful analysis of treatment fidelity assured that the intervention was delivered and received as intended. Analysis of data from a large trial with participants after hip fracture showed that regular attendance, frequent endurance training for 20 minutes, increases in lower extremity training loads, and exercising on the floor were associated with improvements in the outcome of 6-minute-walk distance. The strongest association with improvement was exercising on the floor.

Baseline Prevalence of Polypharmacy in Older Hypertensive Study Subjects with Elevated Dementia Risk: Findings from the Risk Reduction for Alzheimer's Disease Study (rrAD)

BACKGROUND

Little is known about the prevalence of polypharmacy, the taking of five or more medications a day, in older adults with specific dementia risk factors.

OBJECTIVE

To examine the prevalence of polypharmacy in participants at baseline in a vascular risk reduction focused Alzheimer's disease (rrAD) trial targeting older patients with hypertension and elevated dementia risk.

METHODS

We conducted a detailed review of medications in a cross-sectional study of community-dwelling older adults with hypertension and elevated dementia risk. Medications were identified in a structured interview process with an onsite pharmacist or qualified designee. Polypharmacy was defined as use of five or more medications on a regular basis. Descriptive analyses were conducted on the sample as well as direct comparisons of subgroups of individuals with hypertension, diabetes, and hyperlipidemia.

RESULTS

The 514 rrAD participants, mean age 68.8 (standard deviation [sd] 6), reported taking different combinations of 472 unique medications at their baseline visit. The median number of medications taken by participants was eight [Range 0-21], with 79.2% exhibiting polypharmacy (n = 407). Sites differed in their prevalence of polypharmacy, χ2(3) = 56.0, p < 0.001. A nearly identical percentage of the 2,077 prescribed (51.8%) and over the counter (48.2%) medications were present in the overall medication profile. The presence of diabetes (87.5%), hyperlipidemia (88.2%), or both (97.7%) was associated with a higher prevalence of polypharmacy than participants who exhibited hypertension in the absence of either of these conditions (63.2%), χ2(3) = 35.8, p < 0.001.

CONCLUSION

Participants in a dementia risk study had high levels of polypharmacy, with the co-existence of diabetes or hyperlipidemia associated with a greater prevalence of polypharmacy as compared to having hypertension alone.

Application of Cut-Points for Low Muscle Strength and Lean Mass in Mobility-Limited Older Adults

BACKGROUND

The Sarcopenia Definitions and Outcomes Consortium (SDOC) is a collaborative initiative seeking to develop and evaluate cut-points for low muscle strength and lean mass that predict an increased risk for slowness (usual walking speed <.8 m/s) among older adults.

OBJECTIVES

The goal of the present study was to provide clinicians and researchers with an understanding of the diagnostic implications of using SDOC variables and cut-points in mobility-limited older adults. Using data from older individuals with specific conditions that render them at increased risk for mobility limitation, we evaluated the performance characteristics (ie, sensitivity and specificity) of five putative sarcopenia parameters and then compared these values with previously recommended diagnostic criteria for sarcopenia.

DESIGN

Retrospective analysis of six randomized controlled trials enriched in persons at risk for mobility limitation.

SETTING

National and international geriatric clinical research centers.

PARTICIPANTS

A total of 925 mobility-limited older adults (≥55 years of age; 58% women) were included in the analysis.

MEASUREMENTS

The prevalence of low muscle strength and lean mass were assessed using five candidate metrics discriminative of slowness. Analyses of sensitivity and specificity were used to compare muscle weakness criteria with published diagnostics for sarcopenia.

RESULTS

Odds ratios (ORs) supported maximal grip strength (Grip max <35.5 and 20.0 in men and women, respectively) as the most discriminative of slowness in both men and women (OR = 3.66 and 3.53, respectively). More men (58%) than women (30%) fell below sex-specific maximal grip cut-points. When applying previously recommended sarcopenia component definitions in our population, we found that fewer individuals met those criteria (range = 6%-32%).

CONCLUSION

A greater number of individuals fall below SDOC Grip max cut-points compared with previous recommendations. Clinicians and researchers working with older adults may consider these thresholds as an inclusive means to identify candidates for low-risk lifestyle promyogenic and function-promoting therapies. J Am Geriatr Soc 68:1445-1453, 2020.

Application of SDOC Cut Points for Low Muscle Strength for Recovery of Walking Speed After Hip Fracture

BACKGROUND

Sarcopenia is often conceptualized as a precursor to loss of mobility, but its effect on recovery of mobility after a hip fracture is unknown. We determined the prevalence of low muscle strength (weakness) after hip fracture using putative sarcopenia metrics (absolute grip strength, and grip strength normalized to body mass index, total body fat, arm lean mass, and weight) identified by the Sarcopenia Definitions and Outcomes Consortium (SDOC).

METHODS

We examined two well-characterized hip fracture cohorts of community-dwelling older adults from the Baltimore Hip Studies (BHS). The prevalence of muscle weakness was assessed using the SDOC cut points compared to published definitions at 2 and 6 months postfracture. We assessed associations of 2-month weakness with 6-month walking speed <0.6 m/s and calculated the sensitivity and specificity in predicting lack of meaningful change in walking speed (change < 0.1 m/s) at 6 months.

RESULTS

Two hundred and forty-six participants (192 women; 54 men) were included; mean (SD) age of 81 (8) for women and 78 (7) for men. At 2 months, 91% women and 78% men exhibited slow walking speed (< 0.6 m/s). SDOC grip strength standardized by weight (<0.34 kg women, <0.45 kg men) was the most prevalent measure of weakness in men (74%) and women (79%) and provided high sensitivity in men (86%) and women (84%) predicting lack of meaningful change in walking speed at 6 months, although specificity was poor to moderate.

CONCLUSIONS

SDOC cut points for grip strength standardized to weight provided consistent indication of poor walking speed performance post-hip fracture.

Effect of a Multicomponent Home-Based Physical Therapy Intervention on Ambulation After Hip Fracture in Older Adults: The CAP Randomized Clinical Trial

IMPORTANCE

Disability persists after hip fracture in older persons. Current rehabilitation may not be sufficient to restore ability to walk in the community.

OBJECTIVE

To compare a multicomponent home-based physical therapy intervention (training) with an active control on ability to walk in the community.

DESIGN, SETTING, AND PARTICIPANTS

Parallel, 2-group randomized clinical trial conducted at 3 US clinical centers (Arcadia University, University of Connecticut Health Center, and University of Maryland, Baltimore). Randomization began on September 16, 2013, and ended on June 20, 2017; follow-up ended on October 17, 2017. Patients aged 60 years and older were enrolled after nonpathologic, minimal trauma hip fracture, if they were living in the community and walking without human assistance before the fracture, were assessed within 26 weeks of hospitalization, and were not able to walk during daily activities at the time of enrollment. A total of 210 participants were randomized and reassessed 16 and 40 weeks later.

INTERVENTIONS

The training intervention (active treatment) (n = 105) included aerobic, strength, balance, and functional training. The active control group (n = 105) received transcutaneous electrical nerve stimulation and active range-of-motion exercises. Both groups received 2 to 3 home visits from a physical therapist weekly for 16 weeks; nutritional counseling; and daily vitamin D (2000 IU), calcium (600 mg), and multivitamins.

MAIN OUTCOMES AND MEASURES

The primary outcome (community ambulation) was defined as walking 300 m or more in 6 minutes at 16 weeks after randomization. The study was designed to test a 1-sided hypothesis of superiority of training compared with active control.

RESULTS

Among 210 randomized participants (mean age, 80.8 years; 161 women [76.7%]), 197 (93.8%) completed the trial (187 [89.0%] by completing the 6-minute walk test at 16 weeks and 10 [4.8%] by adjudication of the primary outcome). Among these, 22 of 96 training participants (22.9%) and 18 of 101 active control participants (17.8%) (difference, 5.1% [1-sided 97.5% CI, -∞ to 16.3%]; 1-sided P = .19) became community ambulators. Seventeen training participants (16.2%) and 15 control participants (14.3%) had 1 or more reportable adverse events during the intervention period. The most common reportable adverse events reported were falls (training: 6 [5.7%], control: 4 [3.8%]), femur/hip fracture (2 in each group), pneumonia (training: 2, control: 0), urinary tract infection (training: 2, control: 0), dehydration (training: 0, control: 2), and dyspnea (training: 0, control: 2).

CONCLUSIONS AND RELEVANCE

Among older adults with a hip fracture, a multicomponent home-based physical therapy intervention compared with an active control that included transcutaneous electrical nerve stimulation and active range-of-motion exercises did not result in a statistically significant improvement in the ability to walk 300 m or more in 6 minutes after 16 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01783704.

Effect of Enhanced Medical Rehabilitation on Functional Recovery in Older Adults Receiving Skilled Nursing Care After Acute Rehabilitation: A Randomized Clinical Trial

IMPORTANCE

Enhanced medical rehabilitation (EMR) is a systematic and standardized approach for physical and occupational therapists to engage patients. Higher patient engagement in therapy might lead to improved functional recovery in rehabilitation settings, such as skilled nursing facilities (SNFs).

OBJECTIVE

To determine whether EMR improves older adults' functional recovery.

DESIGN, SETTING, AND PARTICIPANTS

A double-blind, parallel-group, randomized clinical trial was conducted from July 29, 2014, to July 13, 2018, in 229 adults aged 65 years or older admitted to 2 US SNFs. Participants were randomized to receive EMR (n = 114) vs standard-of-care rehabilitation (n = 115). Intention-to-treat analysis was used.

INTERVENTIONS

The intervention group received their physical and occupational therapy from therapists trained in EMR. Based on models of motivation and behavior change, EMR is a toolkit of techniques to increase patient engagement and therapy intensity. The control group received standard-of-care rehabilitation from physical and occupational therapists not trained in EMR.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in function in activities of daily living and mobility, as assessed with the Barthel Index, which measures 10 basic activities of daily living or mobility items (scale range, 0-100), from SNF admission to discharge; secondary outcomes were gait speed for 10 m, 6-minute walk test, discharge disposition, rehospitalizations, and self-reported functional status at days 30, 60, and 90. To examine the rehabilitation process, therapists' engagement with patients and patient active time during therapy were measured for a sample of the sessions.

RESULTS

Of the 229 participants, 149 (65.1%) were women; 177 (77.3%) were white, and 51 (22.3%) were black; mean (SD) age was 79.3 (8.0) years. Participants assigned to EMR showed greater recovery of function than those assigned to standard of care (mean increase in Barthel Index score, 35 points; 95% CI, 31.6-38.3 vs 28 points; 95% CI, 25.2-31.7 points; P = .007). There was no evidence of a difference in the length of stay (mean [SD], 23.5 [13.1] days). However, there were no group by time differences in secondary outcome measures, including self-reported function after SNF discharge out to 90 days as measured on the Barthel Index (mean [SE] score: EMR, 83.65 [2.20]; standard of care, 84.67 [2.16]; P = .96). The EMR therapists used a median (interquartile range) of 24.4 (21.0-37.3) motivational messages per therapy session vs 2.3 (1.1-2.9) for nontrained therapists (P < .001), and EMR patients were active during a mean (SD) of 52.5 (6.6%) of the therapy session time vs 41.2 (6.8%) for nontrained therapists (P = .001).

CONCLUSIONS AND RELEVANCE

Enhanced medical rehabilitation modestly improved short-term functional recovery for selected older adults rehabilitating in SNFs. However, there was no evidence that the benefits persisted over the longer term. This study demonstrates the value of engaging and motivating older adults in rehabilitation therapy, but more work is needed to extend these benefits to longer-term outcomes after discharge home.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02114879.

Rationale and methods for a multicenter clinical trial assessing exercise and intensive vascular risk reduction in preventing dementia (rrAD Study)

Alzheimer's Disease (AD) is an age-related disease with modifiable risk factors such as hypertension, hypercholesterolemia, obesity, and physical inactivity influencing the onset and progression. There is however, no direct evidence that reducing these risk factors prevents or slows AD. The Risk Reduction for Alzheimer's Disease (rrAD) trial is designed to study the independent and combined effects of intensive pharmacological control of blood pressure and cholesterol and exercise training on neurocognitive function. Six hundred and forty cognitively normal older adults age 60 to 85 years with hypertension and increased risk for dementia will be enrolled. Participants are randomized into one of four intervention group for two years: usual care, Intensive Reduction of Vascular Risk factors (IRVR) with blood pressure and cholesterol reduction, exercise training (EX), and IRVR+EX. Neurocognitive function is measured at baseline, 6, 12, 18, and 24 months; brain MRIs are obtained at baseline and 24 months. We hypothesize that both IRVR and EX will improve global cognitive function, while IRVR+EX will provide a greater benefit than either IRVR or EX alone. We also hypothesize that IRVR and EX will slow brain atrophy, improve brain structural and functional connectivity, and improve brain perfusion. Finally, we will explore the mechanisms by which study interventions impact neurocognition and brain. If rrAD interventions are shown to be safe, practical, and successful, our study will have a significant impact on reducing the risks of AD in older adults. NCT Registration: NCT02913664.

AGS Report on Engagement Related to the NIH Inclusion Across the Lifespan Policy

After passage of the 21st Century Cures Act, the National Institutes of Health held a workshop in 2017 to consider expanding its inclusion policy to encompass individuals of all ages. American Geriatrics Society (AGS) leaders and members participated in the workshop and formal feedback period. AGS advocacy clearly impacted the resulting workshop report and Inclusion Across the Lifespan policy that eliminates upper-age limits for research participation unless risk justified and changes the language used to describe older adults and other vulnerable groups. AGS recommendations that were not specifically stated in the updated policy were to encourage active recruitment of older adults, add standard measures of function and/or frailty, and change review criteria to ensure the health status of a study population mirrors typical clinical populations. The updated inclusion policy ultimately offers academic geriatrics programs the opportunities to expand knowledge about health in aging and to continue to provide leadership for research and advocacy efforts on behalf of older adults. J Am Geriatr Soc 67:211-217, 2019.

Successful intervention to mitigate an acetylcholinesterase inhibitor-induced rhinorrhea prescribing cascade: a case report

WHAT IS KNOWN AND OBJECTIVE

A prescribing cascade if often treated by discontinuing both medications. We describe an intervention to mitigate a prescribing cascade while continuing a clinically necessary medication without negatively impacting the patient.

CASE SUMMARY

A 77-year-old women experienced probable acetylcholinesterase inhibitor-induced rhinorrhea and subsequently self-medicated with diphenhydramine which lead to worsening cognitive function. We reduced the dose of the acetylcholinesterase inhibitor and discontinued the diphenhydramine. The symptoms of rhinorrhea were subsequently reduced without negatively impacting cognition.

WHAT IS NEW AND CONCLUSION

This was the first published prescribing cascade intervention that did not require discontinuation of both medications, which may be emulated in future prescribing cascade cases.

Myostatin antibody (LY2495655) in older weak fallers: a proof-of-concept, randomised, phase 2 trial

BACKGROUND

Myostatin inhibits skeletal muscle growth. The humanised monoclonal antibody LY2495655 (LY) binds and neutralises myostatin. We aimed to test whether LY increases appendicular lean body mass (aLBM) and improves physical performance in older individuals who have had recent falls and low muscle strength and power.

METHODS

In this proof-of-concept, randomised, placebo-controlled, double-blind, parallel, multicentre, phase 2 study, we recruited patients aged 75 years or older who had fallen in the past year from 21 investigator sites across Argentina, Australia, France, Germany, Sweden, and the USA. Eligible patients had low performance on hand grip strength and chair rise tests, tested with the procedure described by Guralnik and colleagues. Participants were stratified by country, age, hand grip strength, and performance on the chair rise test, and were randomly assigned (1:1) by a computer-generated random sequence to receive subcutaneous injections of placebo or 315 mg LY at weeks 0 (randomisation visit), 4, 8, 12, 16, and 20, followed by 16 weeks observation. The primary outcome was change in aLBM from baseline to 24 weeks. We measured physical performance as secondary outcomes (four-step stair climbing time, usual gait speed, and time to rise five times from a chair without arms, or with arms for participants unable to do it without arms) and exploratory outcomes (12-step stair climbing test, 6-min walking distance, fast gait speed, hand grip strength, and isometric leg extension strength). Efficacy analyses included all randomly assigned patients who received at least one dose and had a baseline and at least one subsequent measure. The primary analysis and all other tests of treatment effect (except physical performance tests) were done at a two-sided alpha level of 0·05. Tests of treatment effect on physical performance tests were done at a pre-specified two-sided alpha level of 0·1. This trial is registered with ClinicalTrials.gov, number NCT01604408.

FINDINGS

Between June 19, 2012, and Dec 12, 2013, we screened 365 patients. 99 were randomly assigned to receive placebo and 102 to receive LY. Treatment was completed in 85 (86%) of patients given placebo and in 82 (80%) given LY. At 24 weeks, the least-squares mean change in aLBM was -0·123 kg (95% CI -0·287 to 0·040) in the placebo group and 0·303 kg (0·135 to 0·470) in the LY group, a difference of 0·43 kg (95% CI 0·192 to 0·660; p<0·0001). Stair climbing time (four-step and 12-step tests), chair rise with arms, and fast gait speed improved significantly from baseline to week 24 with differences between LY and placebo of respectively -0·46 s (p=0·093), -1·28 s (p=0·011), -4·15 s (p=0·054), and 0·05 m/s (p=0·088). No effect was detected for other performance-based measures. Injection site reactions were recorded in nine (9%) patients given placebo and in 31 (30%) patients given LY (p<0·0001), and were generally mild, and led to treatment discontinuation in two patients given LY.

INTERPRETATION

Our findings show LY treatment increases lean mass and might improve functional measures of muscle power. Although additional studies are needed to confirm these results, our data suggest LY should be tested for its potential ability to reduce the risk of falls or physical dependency in older weak fallers.

FUNDING

Eli Lilly and Company.

Association of functional polymorphisms from brain-derived neurotrophic factor and serotonin-related genes with depressive symptoms after a medical stressor in older adults

Depressive symptoms are common in older adults after a disabling medical event and interfere with rehabilitation and recovery from the disability. This prospective study examined the role of genetic polymorphisms implicated in synaptic integrity and stress-associated depression as predictors of depressive symptoms after hip fracture. We recruited healthy comparisons from the community and participants with hip fracture after surgical fixation from Saint Louis, Missouri hospitals. We examined the valine (Val) to methionine (Met) polymorphism in brain-derived neurotrophic factor (BDNF), serotonin 1A receptor (5HT1a-rs6295) polymorphism, and the serotonin transporter-linked polymorphic region (5HTTLPR) interaction with the rs25531 A to G single nucleotide polymorphism (5HTTLPR-rs25531) as predictors of depressive symptoms. We also examined whether depressive symptoms mediate the influence of BDNF genotype on functional recovery. Among 429 participants with hip fracture, BDNF Met/Met carriers developed significantly more depressive symptoms than Val/Val carriers during a four-week period after the fracture (p=.012). BDNF genotype also predicted functional recovery over the ensuing year, mediated by its effects on depressive symptoms (CI: 0.07-3.37). Unlike prior studies of stressful life events, the S' 5HTTLPR-rs25531 variant did not predict higher levels of depressive symptoms; instead, we report an exploratory finding of an epistatic effect between BDNF and 5HTTLPR-rs25531 whereby the compounded effects of two LA alleles and BDNF Met/Met genotype elevate risk of depressive symptoms after hip fracture (p=.006). No differences between 5HT1a genotypes were found. Our findings suggest plasticity-related genetic factors contribute to the neural mechanisms of mental and functional well-being after a disabling medical stressor.

Effects of cognitive training with and without aerobic exercise on cognitively demanding everyday activities

We investigated the potential benefits of a novel cognitive-training protocol and an aerobic exercise intervention, both individually and in concert, on older adults' performances in laboratory simulations of select real-world tasks. The cognitive training focused on a range of cognitive processes, including attentional coordination, prospective memory, and retrospective-memory retrieval, processes that are likely involved in many everyday tasks, and that decline with age. Primary outcome measures were 3 laboratory tasks that simulated everyday activities: Cooking Breakfast, Virtual Week, and Memory for Health Information. Two months of cognitive training improved older adults' performance on prospective-memory tasks embedded in Virtual Week. Cognitive training, either alone or in combination with 6 months of aerobic exercise, did not significantly improve Cooking Breakfast or Memory for Health Information. Although gains in aerobic power were comparable with previous reports, aerobic exercise did not produce improvements for the primary outcome measures. Discussion focuses on the possibility that cognitive-training programs that include explicit strategy instruction and varied practice contexts may confer gains to older adults for performance on cognitively challenging everyday tasks.

Short-term affective recovery from hip fracture prospectively predicts depression and physical functioning

OBJECTIVE

The goals of the current study were to determine the average affective experiences in the weeks and months after a hip fracture and assess how these experiences relate to physical and mental health functioning over time.

METHOD

Positive and negative affect were assessed over time in a sample of older adults recruited after surgery for hip fracture (n = 500) and a comparison sample of older adults without hip fracture (n = 102) for 1 year longitudinally.

RESULTS

For most of the individuals with a hip fracture, positive affect tended to increase over time and negative affect tended to decrease over time, suggesting that most people had at least some recovery of affect. In addition, individuals who showed a slower decrease in negative affect had higher levels of depression 1 year later, and individuals who showed a sharper increase in positive affect had superior physical function 1 year later.

CONCLUSION

The current study provides evidence that both positive and negative affect in the first 12 weeks of recovery from hip fracture are potential targets for intervention to maximize psychological and physical recovery in the ensuing year.

Patient Active Time During Therapy Sessions in Postacute Rehabilitation: Development and Validation of a New Measure

BACKGROUND AND PURPOSE

The accurate measurement of therapy intensity in postacute rehabilitation is important for research to improve outcomes in this setting. We developed and validated a measure of Patient Active Time during physical (PT) and occupational therapy (OT) sessions, as a proxy for therapy intensity.

METHODS

This measurement validity study was carried out with 26 older adults admitted to a skilled nursing facility (SNF) for postacute rehabilitation with a variety of main underlying diagnoses, including hip fracture, cardiovascular diseases, stroke, and others. They were participants in a randomized controlled trial that compared an experimental high-intensity therapy to standard-of-care therapy. Patient Active Time was observed by research raters as the total number of minutes that a patient was actively engaging in therapeutic activities during PT and OT sessions. This was compared to patient movement (actigraphy) quantified during some of the same PT/OT sessions using data from three-dimensional accelerometers worn on the patient's extremities.

RESULTS

Activity measures were collected for 136 therapy sessions. Patient Active Time had high interrater reliability in both PT (r = 0.995, p < 0.001) and OT (r = 0.95, p = 0.012). Active time was significantly correlated with actigraphy in both PT (r = 0.73, p < 0.001) and OT (r = 0.60, p < 0.001) and discriminated between a high-intensity experimental condition and standard of care rehabilitation: in PT, 47.0 ± 13.5 min versus 16.7 ± 10.1 min (p < 0.001) and in OT, 46.2 ± 15.2 versus 27.7 ± 6.6 min (p < 0.001).

CONCLUSIONS

Systematic observation of Patient Active Time provides an objective, reliable, and valid index of physical activity during PT and OT treatment sessions that has utility as a real-world alternative to the measurement of treatment intensity. This measure could be used to differentiate higher from lower therapy treatment intensity and to help determine the optimal level of active therapy time for patients in postacute and other settings.

Cardiometabolic risks during anabolic hormone supplementation in older men

OBJECTIVE

To determine the cardiometabolic risks of testosterone and growth hormone (GH) replacement therapy to youthful levels during aging.

DESIGN AND METHODS

A double-masked, partially placebo controlled study in 112 men 65-90 years-old was conducted. Transdermal testosterone (5 g vs. 10 g/day) using a Leydig Cell Clamp and subcutaneous recombinant GH (rhGH) (0 vs. 3 vs. 5 μg/kg/day) were administered for 16-weeks. Measurements included testosterone and IGF-1 levels, body composition by DEXA, and cardiometabolic risk factors (upper body fat, blood pressure, insulin sensitivity, fasting triglycerides, HDL-cholesterol, and serum adiponectin) at baseline and after 16 weeks of treatment.

RESULTS

Some cardiometabolic factors improved (total and trunk fat, triglycerides, HDL-cholesterol) and others worsened (systolic blood pressure, insulin sensitivity index [QUICKI], adiponectin). Cardiometabolic risk composite scores (CRCSs) improved (-0.69 ± 1.55, P < 0.001). In multivariate analyses, QUICKI, triglycerides, and HDL-cholesterol contributed 33%, 16%, and 14% of the variance in CRCS, respectively. Pathway analyses indicated that changes in fat and lean mass were related to individual cardiometabolic variables and CRCS in a complex manner. Changes in BMI, reflecting composite effects of changes in fat and lean mass, were more robustly associated with cardiometabolic risks than changes in fat mass or LBM individually.

CONCLUSIONS

Testosterone and rhGH administration was associated with diverse changes in individual cardiometabolic risk factors, but in aggregate appeared not to worsen cardiometabolic risk in healthy older men after 4-months. The long-term effects of these and similar anabolic therapies on cardiovascular events should be investigated in populations with greater functional limitations along with important health disabilities including upper body obesity and other cardiometabolic risks.

Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: a randomized-controlled trial

OBJECTIVES

For millions of disabled older adults each year, postacute care in skilled nursing facilities is a brief window of opportunity to regain enough function to return home and live independently. Too often this goal is not achieved, possibly because of therapy that is inadequately intense or engaging. This study tested Enhanced Medical Rehabilitation, an intervention designed to increase patient engagement in, and intensity of, daily physical and occupational therapy sessions in postacute-care rehabilitation.

DESIGN

Randomized controlled trial of Enhanced Medical Rehabilitation versus standard-of-care rehabilitation.

SETTING

Postacute care unit of a skilled nursing facility in St Louis, MO.

PARTICIPANTS

Twenty-six older adults admitted from a hospital for postacute rehabilitation.

INTERVENTION

Based on models of motivation and behavior change, Enhanced Medical Rehabilitation is a set of behavioral skills for physical and occupational therapists that increase patient engagement and intensity, with the goal of improving functional outcome, through (1) a patient-directed, interactive approach, (2) increased rehabilitation intensity, and (3) frequent feedback to patients on their effort and progress.

MEASUREMENTS

Therapy intensity: assessment of patient active time in therapy sessions. Therapy engagement: Rehabilitation Participation Scale. Functional and performance outcomes: Barthel Index, gait speed, and 6-minute walk.

RESULTS

Participants randomized to Enhanced Medical Rehabilitation had higher intensity therapy and were more engaged in their rehabilitation sessions; they had more improvement in gait speed (improving from 0.08 to 0.38 m/s versus 0.08 to 0.22 in standard of care, P = .003) and 6-minute walk (from 73 to 266 feet versus 40 to 94 feet in standard of care, P = .026), with a trend for better improvement of Barthel Index (+43 points versus 26 points in standard of care, P = .087), compared with participants randomized to standard-of-care rehabilitation.

CONCLUSION

Higher intensity and patient engagement in the postacute rehabilitation setting is achievable, with resultant better functional outcomes for older adults. Findings should be confirmed in a larger randomized controlled trial.

Durability of the effects of testosterone and growth hormone supplementation in older community-dwelling men: the HORMA Trial

OBJECTIVES

To determine the durability of anabolic effects and adverse events (AEs) after stopping testosterone and growth hormone supplementation in older men.

DESIGN

Secondary analysis of a double-masked, randomized controlled trial of testosterone gel (5 or 10 g/daily) plus rhGH (0, 3 or 5 μg/kg/day) with follow-up of outcomes 3 months later.

PARTICIPANTS

A total of 108 community-dwelling 65- to 90-year-old men.

MEASUREMENTS

Testosterone and IGF-1 levels, body composition (DEXA), 1-repetition maximum (1-RM) strength, stair-climbing power, quality-of-life (QOL) and activity questionnaires, AEs.

RESULTS

Despite improvements in body composition during treatment, residual benefits 3 months later (week 28) were variable. For participants with improvements exceeding their week-17 median changes, benefits were sustained at week 28 for lean body mass (1·45 ± 1·63 kg, 45% of week-17 values, P < 0·0001 vs baseline), appendicular skeletal muscle mass (ASMM, 0·71 ± 1·01 kg, 42%, P < 0·0001), total fat (-1·06 ± 2·18 kg, 40%, P < 0·0001) and trunk fat (-0·89 ± 1·42 kg, 50%, P < 0·0001); retention of ASMM was associated with greater week-16 protein intake (P = 0·01). For 1-RM strength, 39%-43% of week-17 improvements (P ≤ 0·05) were retained and associated with better week-17 strength (P < 0·0001), change in testosterone from week 17-to 28 (P = 0·004) and baseline PASE (P = 0·04). Framingham 10-year cardiovascular risks were low (~14%), did not worsen and improved by week 28 (P = 0·0002). The hypothalamic-pituitary-gonadal axis recovered completely.

CONCLUSIONS

Durable improvements in muscle mass, strength and fat mass were retained 3 months after discontinuing hormone supplementation in participants with greater than median body composition changes during treatment, but not in others with smaller gains. AEs largely resolved after intervention discontinuation. Additional strategies may be needed to sustain or augment muscle mass and strength gains achieved during short-term hormone therapy.

Whole-body and muscle protein metabolism are not affected by acute deviations from habitual protein intake in older men: the Hormonal Regulators of Muscle and Metabolism in Aging (HORMA) Study

BACKGROUND

Acute deviations in protein intake before the quantification of protein kinetics in older humans may explain the controversy over the effects of older age on muscle protein synthesis and proteolysis rates.

OBJECTIVE

We hypothesized that an acute decrease in protein intake from the habitual intake is associated with lower muscle protein synthesis and higher proteolysis rates, whereas an acute increase in protein intake from the habitual intake is associated with higher muscle protein synthesis and lower proteolysis rates.

DESIGN

In 112 community-dwelling healthy men aged 65-90 y, we quantified resting whole-body [1,2-(13)C(2)]leucine kinetics, muscle mixed protein fractional synthesis rates (FSRs), and muscle proteasome proteolytic enzyme activities after participants consumed for 3 d controlled research meals (0.9-1.1 g protein · kg(-1) · d(-1)) that contained more or less protein than that habitually consumed and that induced alterations in nitrogen balance.

RESULTS

Protein kinetic parameters were not significantly different between the groups, despite controlled research protein intakes that were lower (-0.2 to -0.3 g · kg(-1) · d(-1)) or higher (+0.2 g · kg(-1) · d(-1)) than habitual intakes and that induced negative (-22 to -25 mg · kg(-1) · d(-1)) or positive (22-25 mg · kg(-1) · d(-1)) nitrogen balance. Within these acutely altered protein intake and nitrogen balance boundaries, a reduction in protein intake from habitual intake and induction of negative nitrogen balance were not associated with higher proteolysis or lower muscle FSR, and an acute increase in protein intake from habitual intake and induction of positive nitrogen balance were not associated with lower proteolysis or higher muscle FSR. A higher quantitative insulin sensitivity check index was associated with lower whole-body proteolysis rates.

CONCLUSIONS

The practice of acutely controlling protein intake, even at intakes lower than habitual intakes that induce negative nitrogen balance, before quantifying human protein kinetics does not significantly reduce muscle protein synthesis or increase proteolysis. Factors other than protein intake explain lower muscle protein synthesis rates with advanced age. This trial is registered at clinicaltrials.gov as NCT00183040.

N-terminal propeptide of type III procollagen as a biomarker of anabolic response to recombinant human GH and testosterone

CONTEXT

Biomarkers that predict musculoskeletal response to anabolic therapies should expedite drug development. During collagen synthesis in soft lean tissue, N-terminal propeptide of type III procollagen (P3NP) is released into circulation. We investigated P3NP as a biomarker of lean body mass (LBM) and muscle strength gains in response to testosterone and GH.

DESIGN

Community-dwelling older men received GnRH agonist plus 5 or 10 g testosterone gel plus 0, 3, or 5 microg recombinant human GH daily. P3NP levels were measured at baseline and wk 4, 8, 12, and 16. LBM and appendicular skeletal muscle mass (ASM) were measured by dual-energy x-ray absorptiometry.

RESULTS

One hundred twelve men completed treatment; 106 underwent serum P3NP measurements. P3NP levels were higher at wk 4 than baseline (6.61 +/- 2.14 vs. 4.51 +/- 1.05, P < 0.0001) and reached plateau by wk 4 in men receiving testosterone alone. However, wk 8 P3NP levels were higher than wk 4 levels in men receiving testosterone plus recombinant human GH. Increases in P3NP from baseline to wk 4 and 16 were significantly associated with gains in LBM (r = 0.26, P = 0.007; r = 0.53, P < 0.001) and ASM (r = 0.17, P = 0.07; r = 0.40, P < 0.0001). Importantly, for participants receiving only testosterone, P3NP increases at wk 4 and 16 were related to muscle strength gains (r = 0.20, P = 0.056 and r = 0.36, P = 0.04). In stepwise regression, change in P3NP explained 28 and 30% of the change in ASM and LBM, respectively, whereas change in testosterone but not IGF-I and age provided only small improvements in the models.

CONCLUSION

Early changes in serum P3NP levels are associated with subsequent changes in LBM and ASM during testosterone and GH administration. Serum P3NP may be a useful early predictive biomarker of anabolic response to GH and testosterone.

Testosterone and growth hormone improve body composition and muscle performance in older men

CONTEXT

Impairments in the pituitary-gonadal axis with aging are associated with loss of muscle mass and function and accumulation of upper body fat.

OBJECTIVES

We tested the hypothesis that physiological supplementation with testosterone and GH together improves body composition and muscle performance in older men.

DESIGN, SETTING, AND PARTICIPANTS

One hundred twenty-two community-dwelling men 70.8 +/- 4.2 yr of age with body mass index of 27.4 +/- 3.4 kg/m2, testosterone of 550 ng/dl or less, and IGF-I in lower adult tertile (< or =167 ng/dl) were randomized to receive transdermal testosterone (5 or 10 g/d) during a Leydig cell clamp plus GH (0, 3, or 5 microg/kg . d) for 16 wk.

MAIN OUTCOME MEASURES

Body composition by dual-energy x-ray absorptiometry, muscle performance, and safety tests were conducted.

RESULTS

Total lean body mass increased (1.0 +/- 1.7 to 3.0 +/- 2.2 kg) as did appendicular lean tissue (0.4 +/- 1.4 to 1.5 +/- 1.3 kg), whereas total fat mass decreased by 0.4 +/- 0.9 to 2.3 +/- 1.7 kg as did trunk fat (0.5 +/- 0.9 to 1.5 +/- 1.0 kg) across the six treatment groups and by dose levels for each parameter (P < or = 0.0004 for linear trend). Composite maximum voluntary strength of upper and lower body muscles increased by 14 +/- 34 to 35 +/- 31% (P < 0.003 in the three highest dose groups) that correlated with changes in appendicular lean mass. Aerobic endurance increased in all six groups (average 96 +/- 137 sec longer). Systolic and diastolic blood pressure increased similarly in each group with mean increases of 12 +/- 14 and 8 +/- 8 mm Hg, respectively. Other predictable adverse events were modest and reversible.

CONCLUSIONS

Supplemental testosterone produced significant gains in total and appendicular lean mass, muscle strength, and aerobic endurance with significant reductions in whole-body and trunk fat. Outcomes appeared to be further enhanced with GH supplementation.

Hormonal regulators of muscle and metabolism in aging (HORMA): design and conduct of a complex, double masked multicenter trial

BACKGROUND

Older persons often lose muscle mass, strength, and physical function. This report describes the challenges of conducting a complex clinical investigation assessing the effects of anabolic hormones on body composition, physical function, and metabolism during aging.

METHODS

HORMA is a multicenter, randomized double masked study of 65-90-year-old community dwelling men with testosterone levels of 150-550 ng/dL and IGF-1 < 167 ng/dL. Subjects were randomized to transdermal testosterone (5 or 10 g/day) and rhGH (0, 3, or 5 microg/kg/day) for 16 weeks. Outcome measures included body composition by DEXA, MRI, and (2)H(2)O dilution; muscle performance (strength, power, and fatigability), VO2peak, measures of physical function, synthesis/breakdown of myofibrillar proteins, other measures of metabolism, and quality of life.

RESULTS

Major challenges included delay in startup caused by need for 7 institutional contracts, creating a 142-page manual of operations, orientation and training, creating a 121-page CRF; enrollment inefficiencies; scheduling 16 evaluations/ subject; overnight admissions for invasive procedures and isotope infusions; large data and image management and transfer; quality control at multiples sites; staff turnover; and replacement of a clinical testing site. Impediments were largely solved by implementation of a web-based data entry and eligibility verification; electronic scheduling for multiple study visits; availability of research team members to educate and reassure subjects; more frequent site visits to validate all source documents and reliability of data entry; and intensifying quality control in testing and imaging. The study exceeded the target goal of 108 (n = 112) completely evaluable cases. Two interim DSMB meetings confirmed the lack of excessive adverse events, lack of center effects, comparability of subjects, and that distribution of subjects and enrollment will not jeopardize outcomes or generalizability of results.

CONCLUSIONS

Flexibility and rapidly solving evolving problems is critical when conducting highly complex multicenter metabolic studies.

Falls in older adults: risk assessment, management and prevention

Falls are a common and serious problem for older adults. This article reviews practical aspects of the evaluation and management of this disorder in the ambulatory setting. Older patients should be screened for falls or changes in mobility as part of their annual health maintenance examination. Most falls are due to multiple factors, including disorders of gait, balance, strength, and vision. Polypharmacy and certain medications contribute to falls in many patients and can be a remediable factor. Many falls can be prevented through individualized multicomponent interventions. Exercise programs, rehabilitation, medication management, and treatment of vitamin D deficiency are the most effective single interventions. Referral to a geriatrician should be considered for patients with other common geriatric syndromes, such as cognitive impairment, incontinence, or depression.

Training-induced strength and functional adaptations after hip fracture

BACKGROUND AND PURPOSE

At 3 months after hip fracture, most people are discharged from physical therapy despite residual muscle weakness and overall decreased functional capabilities. The purposes of this study were: (1) to determine, in frail elderly adults after hip fracture and repair, whether a supervised 6-month exercise program would result in strength gains in the fractured limb equivalent to the level of strength in the nonfractured limb; (2) to determine whether the principle of specificity of training would apply to this population of adults; and (3) to determine the relationship between progressive resistance exercise training (PRT) intensity and changes in measures of strength and physical function.

SUBJECTS

The study participants were 31 older adults (9 men and 22 women; age [X+/-SD], 79+/-6 years) who had surgical repair of a hip fracture that was completed less than 16 weeks before study enrollment and who completed at least 30 sessions of a supervised exercise intervention.

METHODS

Participants completed 3 months of light resistance and flexibility exercises followed by 3 months of PRT. Tests of strength and function were completed at baseline, before PRT, and after PRT.

RESULTS

After PRT, the subjects increased knee extension and leg press 1-repetition maximum by 72%+/-56% and 37%+/-30%, respectively. After 3 and 6 months of training, lower-extremity peak torques all increased. Specificity of training appeared to apply only to the nonfractured limb after PRT. Strong correlations were observed between training intensity and lower-extremity strength gains as well as improvements in measures of physical function.

DISCUSSION AND CONCLUSION

Frail elderly adults after hip fracture can benefit by extending their rehabilitation in a supervised exercise setting, working at high intensities in order to optimize gains in strength and physical function.

Characteristics of Frail Older Adult Drivers

OBJECTIVES

To determine the prevalence of driving in older adults with mild to moderate physical frailty and to compare characteristics of current frail older adult drivers with those of former drivers in the sample.

DESIGN

Retrospective study of frail older adults enrolled in randomized trials of exercise and hormone replacement therapy.

SETTING

Urban, academic medical center.

PARTICIPANTS

One hundred eighty-three sedentary community-dwelling men and women aged 75 and older with mild to moderate physical frailty, as defined by two of the following three criteria: modified Physical Performance Test (PPT) score between 18 and 32, peak oxygen uptake (VO2) between 10 and 18 mL/kg per minute, and self-report of difficulty or assistance with one activity of daily living (ADL) or two instrumental ADLs. Participants were classified as current or former drivers.

MEASUREMENTS

Demographic characteristics, medical diagnoses, medication use, modified PPT score, and psychometric tests.

RESULTS

The majority (85%) of the participants were drivers. Former drivers were more likely to be older, be female, reside in congregate independent living for the elderly, have a higher incidence of arthritis and congestive heart failure, take sedating medications, have lower total ADL scores, have lower VO2 peak scores, and have more impairment on tests of cognition and physical strength, although only age, type of residence, and grip strength were independent predictors of driving cessation in the regression analysis.

CONCLUSION

Despite the presence of physical frailty, many older adults choose to continue to drive. Further studies are needed to better understand the driving behaviors of frail older adults and explore opportunities for optimizing driving abilities.

Effects of progressive resistance training on body composition in frail older adults: results of a randomized, controlled trial

BACKGROUND

Progressive resistance exercise training (PRT) has been shown to increase muscle strength and fat-free mass (FFM) in elderly persons. Limited information is available regarding the effects of PRT on lean and fat mass in frail elderly persons.

METHODS

Ninety-one community-dwelling sedentary men and women, 78 years and older with physical frailty (defined using standardized objective criteria) were enrolled in a 9-month trial of exercise training (ET). Physical frailty was defined as having 2 of the 3 following criteria: modified Physical Performance Test score between 18 and 32, peak aerobic power between 10 and 18 ml/kg/min, or self-report of difficulty or assistance with two instrumental activities of daily living or one basic activity of daily living. Participants were randomly assigned to either a control (CTL) group that performed a low intensity home exercise program or a supervised ET group that performed 3 months of low intensity exercise and 3 months of PRT.

RESULTS

After completion of PRT, ET participants had greater improvements than did CTL participants in maximal voluntary force production for knee extension (mean Delta +5.3 +/- 13 ft/lb vs +1.1 +/- 11 ft/lb, p =.05), measured using isokinetic dynamometry. Total body FFM (measured using dual energy x-ray absorptiometry) increased in the ET group, but not in the CTL group (mean Delta +0.84 +/- 1.4 kg vs +0.01 +/- 1.5 kg, p =.005). Total, trunk, intra-abdominal, and subcutaneous fat mass (measured using dual energy x-ray absorptiometry and (1)H-magnetic resonance imaging) did not change in response to PRT.

CONCLUSIONS

Three months of supervised PRT induced improvements in maximal voluntary thigh muscle strength and whole body FFM in frail, community-dwelling elderly women and men. This supervised exercise program may not be sufficient to reduce whole-body or intra-abdominal fat area in this population.

Risk of osteoporotic fracture in elderly patients taking warfarin: results from the National Registry of Atrial Fibrillation 2

BACKGROUND

Vitamin K allows for gamma-carboxylation of glutamyl residues, a conversion that activates clotting factors and bone proteins. Vitamin K antagonists such as warfarin inhibit this process. Our goal was to quantify the association between warfarin and osteoporotic fractures in patients with atrial fibrillation.

METHODS

This was a retrospective cohort study of Medicare beneficiaries with atrial fibrillation who were hospitalized between March 1998 and April 1999 in all 50 US states. The study outcome was osteoporotic fractures, identified by an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for a fracture of the hip, spine, or wrist.

RESULTS

Compared with 7587 patients who were not prescribed warfarin, the adjusted odds ratio (OR) of fracture was 1.25 (95% confidence interval [CI], 1.06-1.48) in 4461 patients prescribed long-term warfarin therapy (> or = 1 year). The association between osteoporotic fracture and long-term warfarin use was significant in men (OR, 1.63; 95% CI, 1.26-2.10) but nonsignificant in women (OR, 1.05; 95% CI, 0.88-1.26). In 1833 patients prescribed warfarin for less than a year, the risk of osteoporotic fracture was not increased significantly (OR, 1.03). Odds ratios (95% CIs) of independent predictors of osteoporotic fractures were as follows: increasing age, 1.63 (1.47-1.80) per decade; high fall risk, 1.78 (1.42-2.21); hyperthyroidism, 1.77 (1.16-2.70); neuropsychiatric disease, 1.51 (1.28-1.78); and alcoholism, 1.50 (1.01-2.24). Factors with a reduced OR (95% CI) included African American race, 0.30 (0.18-0.51); male sex, 0.54 (0.46-0.62); and use of beta-adrenergic antagonists, 0.84 (0.70-1.00).

CONCLUSIONS

Long-term use of warfarin was associated with osteoporotic fractures, at least in men with atrial fibrillation. Beta-adrenergic antagonists may protect against osteoporotic fractures.

Persistent pain in frail older adults after hip fracture repair

OBJECTIVES

To identify factors associated with persistent hip pain in elderly hip fracture patients with physical frailty.

DESIGN

Cohort study.

SETTING

Community-based study conducted at academic medical center.

PARTICIPANTS

Eighty-eight men and women (mean age+/-standard deviation 80+/-7 years) with a recent hip fracture (mean 14.5+/-4.8 weeks after hip fracture repair) and physical frailty, defined as a modified Physical Performance Test Score between 12 and 28, enrolled in an exercise intervention trial.

MEASUREMENTS

Dependent variable was self-report of moderate to severe regional hip pain in the week preceding the baseline interview. Independent variables were self-reported demographic information, health characteristics, and activity of daily living (ADL) function; Yesavage Mood Score (YMS); 36-item Short Form percentile scores; and objective measurements of lower extremity strength, range of motion, balance, and gait.

RESULTS

Forty-two percent of the sample reported moderate or severe hip pain at the baseline assessment. Moderate/severe pain was related to difficulty with ADL performance and multiple measures of quality of life. Variables independently associated with moderate/severe hip pain were frequency of pain medication use (adjusted odds ratio (AOR)=5.75, 95% confidence interval (CI)=2.23-14.82, P=.003), YMS score (AOR=2.69, 95% CI=1.18-6.12, P=.02), and knee extension at 60 degrees /s in the fractured limb (AOR=0.96, 95% CI=0.92-1.0, P=.05, model coefficient of determination=0.34).

CONCLUSION

Persistent hip pain is a frequent symptom in frail elderly community-dwelling hip fracture patients. Pain medication use, symptoms of depression, and skeletal muscle weakness of the fractured leg are independent correlates of moderate to severe hip pain in this patient population. Clinicians should assess for, and address, persistent pain in this patient population.

Does hospitalization impact survival after lower respiratory infection in nursing home residents?

BACKGROUND

Lower respiratory infection (LRI) is the leading cause of hospitalization for nursing home residents, but hospitalization is costly and may cause complications.

OBJECTIVE

We sought to compare mortality and cost between episodes of LRI initially treated in the hospital versus the nursing home after controlling for illness severity and the probability of hospitalization.

DESIGN

This was a prospective cohort study of nursing home residents with LRIs.

SUBJECTS

We identified 1406 episodes of LRI in 36 nursing homes in central Missouri and the St. Louis area between August 15, 1995, and September 30, 1998. Economic analysis was restricted to 1033 episodes identified after March 31, 1997.

MEASURES

We adjusted for the higher probability of initial hospitalization in sicker residents using measures of illness severity and a hospitalization propensity score. The propensity score was derived from a logistic regression model that included patient, physician, and facility variables. Estimated costs were attributed to initial treatment setting.

RESULTS

After controlling for the probability of hospitalization and illness severity, hospitalization was not a significant mortality predictor (odds ratio 0.89, 95% confidence interval 0.52-1.52). Mean daily cost was $138.24 for initial nursing home treatment and $419.75 for the hospital.

CONCLUSIONS

After controlling for illness severity and propensity for hospitalization, hospital treatment is not associated with either increased or decreased risk for mortality for nursing home residents with LRIs. For residents with low and medium mortality risk, nursing home treatment is likely to be safe and less costly.

Effects of extended outpatient rehabilitation after hip fracture: a randomized controlled trial

CONTEXT

Hip fractures are common in the elderly, and despite standard rehabilitation, many patients fail to regain their prefracture ambulatory or functional status.

OBJECTIVE

To determine whether extended outpatient rehabilitation that includes progressive resistance training improves physical function and reduces disability compared with low-intensity home exercise among physically frail elderly patients with hip fracture.

DESIGN, SETTING, AND PATIENTS

Randomized controlled trial conducted between August 1998 and May 2003 among 90 community-dwelling women and men aged 65 years or older who had had surgical repair of a proximal femur fracture no more than 16 weeks prior and had completed standard physical therapy.

INTERVENTION

Participants were randomly assigned to 6 months of either supervised physical therapy and exercise training (n = 46) or home exercise (control condition; n = 44).

MAIN OUTCOME MEASURES

Primary outcome measures were total scores on a modified Physical Performance Test (PPT), the Functional Status Questionnaire physical function subscale (FSQ), and activities of daily living scales. Secondary outcome measures were standardized measures of skeletal muscle strength, gait, balance, quality of life, and body composition. Participants were evaluated at baseline, 3 months, and 6 months.

RESULTS

Changes over time in the PPT and FSQ scores favored the physical therapy group (P =.003 and P =.01, respectively). Mean change (SD) in PPT score for physical therapy was +6.5 (5.5) points (95% confidence interval [CI], 4.6-8.3), and for the control condition was +2.5 (3.7) points (95% CI, 1.4-3.6 points). Mean change (SD) in FSQ score for physical therapy was +5.2 (5.4) points (95% CI, 3.5-6.9) and for the control condition was +2.9 (3.8) points (95% CI, 1.7-4.0). Physical therapy also had significantly greater improvements than the control condition in measures of muscle strength, walking speed, balance, and perceived health but not bone mineral density or fat-free mass.

CONCLUSION

In community-dwelling frail elderly patients with hip fracture, 6 months of extended outpatient rehabilitation that includes progressive resistance training can improve physical function and quality of life and reduce disability compared with low-intensity home exercise.

Effect of Do-Not-Resuscitate Orders on Hospitalization of Nursing Home Residents Evaluated for Lower Respiratory Infections

OBJECTIVES

To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs).

DESIGN

Prospective cohort.

SETTING

Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study.

PARTICIPANTS

NH residents with a LRI (n=1031).

MEASUREMENTS

Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed.

RESULTS

Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49-0.97).

CONCLUSION

DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI.

Attenuation of cardiovascular adaptations to exercise in frail octogenarians

To determine the mechanisms underlying increased aerobic power in response to exercise training in octogenarians, we studied mildly frail elderly men and women randomly assigned to an exercise group (n = 22) who participated in a training program of 6 mo of physical therapy, strength training, and walking followed by 3 mo of more intense endurance exercise at 78% of peak heart rate or a control sedentary group (n = 24). Peak O2 consumption (V(O2 peak)) increased 14% in the exercise group (P < 0.0001) but decreased slightly in controls. Training induced 14% increase (P = 0.027) in peak exercise cardiac output (Q), determined via acetylene re-breathing, and no change in arteriovenous O2 content difference. The increase in Q was mediated by increases in heart rate (P = 0.009) and probably stroke volume (P = 0.096). Left ventricular stroke work also increased significantly. In the men, the increase in V(O2 peak) was exclusively due to a large increase in peak Q (22%). In the women, the gain in V(O2 peak) was due to small increases in Q and O2 extraction from skeletal muscles. Pulse pressure normalized for stroke volume and arterial elastance during peak effort did not change with training. Controls showed no changes. The results suggest that, although frail octogenarians have a diminished capacity for improvement in aerobic power in response to exercise training, this adaptation is mediated mostly by an increase in Q during peak effort. Furthermore, Q likely plays a greater role in the adaptive increase in V(O2 peak) in old men than old women.

Exercise Training Program for Older Adults Incentives and Disincentives for Participation

The purpose of this study was to describe the incentives and disincentives for participating in an exercise training program for community-dwelling individuals 78 and older. One hundred forty-seven women and 62 men participated in this descriptive study, and ages ranged from 78 to 95 years (mean 82.7 +/- 4.1). Individuals were interviewed by phone about their decision to participate in an exercise program. Qualitative responses were analyzed using content analysis. Three main incentive themes emerged: Health Benefits, Psychological Benefits, and Positive Program Features. Disincentive themes included Competing Commitments, Doubts about Exercise, and Negative Program Features. To better tailor an exercise program to the needs of this older age group, nurses working with older adults should keep in mind the lifestyle, age-specific obligations, and set of values affecting this cohort's participation.

Effects of exercise training added to ongoing hormone replacement therapy on bone mineral density in frail elderly women

OBJECTIVES

To determine whether exercise training added to ongoing hormone replacement therapy (HRT) increases bone mineral density (BMD) in physically frail elderly women.

DESIGN

Prospective controlled trial.

SETTING

University-based research center.

PARTICIPANTS

Twenty-eight women on HRT, aged 75 and older with physical frailty.

INTERVENTIONS

Participants were assigned to 9 months of supervised (EXER) or home (HOME) exercise. The EXER program started with physical therapy and gradually incorporated resistance and endurance training. The HOME program consisted of flexibility exercises.

MEASUREMENTS

Changes in BMD and body composition.

RESULTS

There were larger increases in lumbar spine BMD in response to EXER than with HOME (3.5% vs 1.5%, P =.048), with a trend for larger increases in total body BMD (1.5% vs 0.2%, P =.058). There were no significant between-group differences in hip BMD. The EXER group had decreases in weight (-2.2 +/- 0.3 kg, P =.010) and fat mass (-2.7 +/- 0.4 kg, P =.018) and increases in muscle strength (9-30%, P <.05).

CONCLUSION

In physically frail elderly women on HRT, relatively vigorous exercise training significantly increased lumbar spine BMD. The improved BMD and strength in response to exercise could reduce fracture risk in frail women already on HRT.

Effects of trimonthly progestin administration on the endometrium in elderly postmenopausal women who receive hormone replacement therapy: a pilot study

OBJECTIVE

The purpose of this study was to determine the effect of trimonthly progestin administration on the endometrium in elderly postmenopausal women who receive hormone replacement therapy.

STUDY DESIGN

This was a prospective, randomized, double-blind, placebo-controlled study at a university teaching program. Twenty-five postmenopausal women who were >or=75 years old with an intact uterus were assigned randomly to receive conjugated equine estrogens (0.625 mg/d plus medroxyprogesterone acetate 5 mg/d for 13 days every 3 months (n = 13) or placebo (n = 12) for 9 months). At the end of the 9 months, patients in the hormone replacement therapy arm continued therapy for an additional 9 months. Statistical analysis was performed with the Student t test, the chi(2) test, and the Fisher exact test.

RESULTS

Transvaginal sonography was performed at baseline and at 9 and 18 months. Endometrial biopsy was performed if the endometrial thickness was >4 mm or as clinically indicated at 18 months. Patients in the hormone replacement therapy group demonstrated a significant increase in endometrial thickness between baseline (3.9 + 0.8 mm) and 9 months (8.0 + 4.8 mm). There were no cases of endometrial hyperplasia at the 18-month endometrial biopsy.

CONCLUSION

Trimonthly progestin administration in elderly postmenopausal women who receive hormone replacement therapy may be a reasonable alternative to the monthly administration of progestin in hormone replacement therapy.

Predictors of short-term functional decline in survivors of nursing home-acquired lower respiratory tract infection

BACKGROUND

Scant information exists about the risk of functional decline following treatment of acute illness in the nursing home (NH) setting. The aim of this study was to determine the incidence of short-term (30-day) functional decline among survivors of NH-acquired lower respiratory tract infection (LRI) and the factors that predict such decline, including the role of initial hospitalization.

METHODS

We used a prospective cohort design to study 781 episodes of LRI in 1044 NH residents in 36 NHs in central Missouri and the St. Louis metropolitan area. Functional decline was defined as a 3-point increase on the Minimum Data Set (MDS) activities of daily living (ADL) long form scale.

RESULTS

Of 781 LRI cases who survived to 30 days, the incidence of ADL decline was 28.8%. In a logistic regression model that used generalized estimating equations to adjust for clustering, variables associated with ADL decline included the following: chronic feeding tube use (AOR = 4.54, 95% confidence interval, or CI, 1.61, 12.80), decubitus ulcer (adjusted odds ratio [AOR] = 2.29, 95% CI 1.35, 3.90), shortness of breath (AOR = 2.18, 95% CI 1.44, 3.30), short-term memory problems (AOR = 2.07, 95% CI 1.33, 3.23), decline in self-performance of toilet use in the 24 hours prior to evaluation (AOR = 1.65, 95% CI 1.29, 2.12), age (AOR = 1.02, 95% CI 1.00, 1.05), and baseline ADL score. Addition of treatment variables to the model showed that initial hospitalization was also associated with ADL decline (AOR = 1.90, 95% CI 1.20, 3.00). Residents with ADL decline at 30 days were less likely to recover to their baseline ADL status at 90 days.

CONCLUSIONS

Many NH residents who survive to 30 days following LRI develop new functional limitations, and such individuals are at risk for ADL decline at 90 days. A limited number of clinical variables may predict short-term functional decline. Initial hospitalization for acute treatment of LRI may increase the risk of subsequent ADL decline among individuals who survive to 30 days.