Exercise and sarcopenia

Sarcopenia is a major component of the frailty syndrome and is also a strong predictor of disability, morbidity, and mortality in older persons. Without any available pharmacological intervention to sarcopenia, non-pharmacological interventions are the only option to prevent these poor outcomes in sarcopenic patients. Among those interventions, physical activity with or without protein supplementation has demonstrated to be effective in improving muscle mass and function and in preventing disability and frailty in older persons. Additionally, to the beneficial effect of physical activity on metabolic and cardiovascular diseases, a regular exercise program (3 times/wk) that includes resistance and endurance exercise training would have a major positive effect on sarcopenic muscle through improving muscle mass, strength, and function. In this review, we looked at the effect of exercise on sarcopenic frail older persons from the biological aspects of the response of the muscle to exercise to some practical aspects of exercise prescription in this high-risk population. We conclude that, although challenging, older persons should be encouraged to participate in this type of programs, which would improve not only their function and independence but also their quality of life

Clinical outcomes of impaired muscle and bone interactions

Muscle and bone are in constant interaction. With aging, there is a progressive decline in muscle mass, known as sarcopenia, as well as in bone mass, which is known as osteopenia/osteoporosis. Sarcopenia and osteoporosis increase the risk of suffering falls and fractures, respectively. In fact, the simultaneous occurrence of osteoporosis and sarcopenia has been observed in a subset of frailer individuals at higher risk of disability, falls and fractures. However, the particular clinical outcomes that are unique to the sarco-osteoporotic patients remain unknown. In this review, we propose a common mechanism of sarco-osteoporosis and summarize those clinical and biochemical features that are prevalent in sarco-osteoporotic subjects. We expect that by describing a set of biological, clinical and functional characteristics that are associated with sarco-osteoporosis, this information could be used to inform the design of future trials and to develop interventions for this particular syndrome

Yield and cost-effectiveness of laboratory testing to identify metabolic contributors to falls and fractures in older persons

Summary: Falls and fractures constitute a major cause of morbidity and mortality among older adults. Although falls and fractures share similar risk factors, there is no integrated approach to identifying secondary causes of both entities. We report a cost-effective approach to identify metabolic causes of falls and fractures in the clinical setting. Purpose: Falls and fractures are a major cause of morbidity and mortality among older adults. Metabolic disorders contributing to the combined risk of falls and fractures are frequent but often go undetected. The most efficient and cost-effective laboratory screening strategy to unmask these disorders remains unknown. The purpose of this study was to identify the most cost-effective laboratory tests to detect undiagnosed metabolic contributors and to decide treatment of these disorders in older persons. Methods: This is a cross-sectional study design, which included all participants attending the Falls & Fractures Clinic, Nepean Hospital (Penrith, Australia) between 2008 and 2013. Chemistry profile included 25(OH) vitamin D, parathyroid hormone (PTH), albumin, creatinine, calcium, phosphate, vitamin B-12, folate, and thyroid-stimulating hormone (TSH) for all patients, and serum testosterone in men. The number of new diagnoses identified and their cost-effectiveness (cost in US$per patient screened and cost per new diagnosis) were calculated. Results: A total of 739 participants (mean age 79, 71$190.19 per patient screened and $257.64 per diagnosis. Conclusions: The minimum cost-effective battery for occult metabolic disorders in older adults at risk of falls and fractures should include serum vitamin D, PTH, TSH, creatinine/eGFR, testosterone (in men), and calcium

Comprehensive nutritional status in sarco-osteoporotic older fallers

Objectives: In older persons, the combination of osteoporosis and sarcopenia has been proposed as a subset of frailer individuals at higher risk of falls and fractures. However, the particular nutritional status of the sarco-osteoporotic (SOP) patients remains unknown. The goal of this study was to obtain a comprehensive picture of nutritional status in SOP patients. Design: Cross-sectional study. Setting: Falls & Fractures Clinic, Nepean Hospital (Penrith, Australia). Participants: 680 subjects (mean age=79, 65% female) assessed between 2008–2013. Measurements: Assessment included medical history, mini-nutritional assessment, physical examination, bone densitometry and body composition by DXA, and blood tests for nutritional status (albumin, creatinine, hemoglobin, vitamin D, vitamin B-12, calcium, phosphate and folate). Patients were divided in 4 groups: 1) osteopenia/osteoporosis (BMD6 remained independently associated with SOP after adjustment for all variables including inflammatory conditions. Hypoalbuminemia (<35 g/L) was associated with just osteopenia/osteoporosis (OR: 2.03, 95%CI 1.08–3.81, p<0.01) and just sarcopenia (OR: 1.77, 95%CI 1.0–3.0, p<0.01) compared to normal. No differences in vitamin D, glomerular filtration rate, albumin, corrected calcium, phosphate, red blood cells folate or vitamin B12 levels were found between the subgroups. Conclusions: In approaching SOP patients, early prevention protocols directed to optimize their nutritional status would be a key strategy to prevent poor outcomes such as falls and fractures in this high risk population. Therefore, nutritional assessment and early nutritional supplementation should be essential domains in this strategy

Phenotype of sarcopenic obesity in older individuals with a history of falling

Background: Although sarcopenic obesity is associated with disability in middle-aged community-dwelling individuals, the phenotype of sarcopenic obesity in people 65 and older, especially those with a history of falls, remain unknown. To fill this knowledge gap, the goal of this study was to obtain a comprehensive phenotype of sarcopenic obesity in this high-risk population. Methods: Cross-sectional study of 680 subjects (mean age = 79 +/- 9, 65% female) assessed between 2009 and 2013 at the Falls and Fractures Clinic, Nepean Hospital (Penrith, Australia). The assessment included a comprehensive examination, posturography, gait velocity, grip strength, bone densitometry and body composition by DXA, and blood tests for biochemical status. Patients were divided into four groups based on DXA and clinical criteria: 1) sarcopenic obese; 2) non-sarcopenic obese; 3) sarcopenic and; 4) non-sarcopenic/non-obese. The difference between groups was assessed by one-way ANOVA, chi-square analysis, and multivariable linear regression. Results: Sarcopenic obese subjects were older (81.1 +/- 7.3), mostly female and more likely to have lower bone mineral density, lower grip strength, slower gait velocity, and poor balance. Sarcopenic obese individuals also showed significantly higher parathyroid hormone and lower vitamin D. Conclusions: We identified a particular set of clinical and biochemical characteristics in our subgroup of sarcopenic obese older fallers. Identification of these particular characteristics in the clinical setting is essential in order to prevent poor outcomes in this high-risk population

Vitamin D status in relation to postural stability in the elderly

Objectives: Postural instability (PI) is an important risk factor for falls, especially in the frail older population. In this study, we investigated the impact of vitamin D deficiency on PI in a sample of community dwelling older subjects. Our objective was to determine the potential association between vitamin D deficiency and PI in older fallers. Design: Cross-sectional study. Setting: Falls and Fractures Clinic, Department of Geriatric Medicine, Nepean Hospital, Penrith, Australia. Participants: One hundred and forty-five adults aged 65 years and older who have had at least one episode of a fall within the six months prior to assessment at the Falls and Fractures Clinic. Measurements: Serum 25(OH) vitamin D3 [25(OH)D3] and parathyroid hormone concentrations were determined at baseline. Subjects were separated into 3 groups based on serum 25(OH)D3 levels with the following cut-off values: 50 nmol/L (normal). Other baseline measurements included body mass index, mini-nutritional assessment, grip strength, serum calcium concentration and creatinine clearance, which were used as covariables. PI was assessed using a computerized virtual reality system (Medicaa, Uruguay). Measured parameters included limits of stability (LOS) and centre of pressure (COP) under eyes closed on foam (ECF) and visio-vestibular stimulation. The estimated swaying area, computed from the ellipse of confidence under eyes closed standing on foam (ECF), was also used as a PI parameter. Gait velocity (GV) was measured using a GaitRITE walkway system. Results: Posture was impaired in vitamin D deficiency (<30 nmol/L) as indicated by lower LOS (90 +/- 18), higher ECF (25 +/- 10) and slower GV (55 +/- 7) as compared with the insufficient and normal groups. After adjustment for demographic, biochemical and anthropometric variables, vitamin D deficiency significantly correlated with low LOS and high COP under ECF. Conclusion: Low levels of vitamin D were associated with PI. This association could also have an effect on slow GV and increased risk of falls. In conclusion, using an objective method to measure balance in older fallers we have identified a novel role of vitamin D in balance control. Prospective studies are required to confirm the effect of vitamin D on PI and elucidate the mechanisms of this association

Evaluation of a blended learning model in geriatric medicine : a successful learning experience for medical students

Despite the increasingly ageing population, teaching geriatric medicine at medical schools is a challenge due to the particularities of this subspecialty and the lack of student interest in this subject. Methods: We assessed a blended system that combines e-learning and person-to-person interaction. Our program offered the students a hands-on learning experience based on self-reflection, access to technology, interactive learning, frequent interaction with the multidisciplinary team, more exposure to patients, and regular feedback. Results: Our results indicate that the students appreciate this system as a rich and effective learning experience demonstrated by their positive feedback and by their significant improvement in knowledge assessed at the end of their rotation. Conclusion: Implementing an interactive blended system is a beneficial approach to teaching geriatric medicine in medical schools and to motivating medical students' interest in this important medical subspecialty

Effects of balance training using a virtual-reality system in older fallers

Poor balance is considered a challenging risk factor for falls in older adults. Therefore, innovative interventions for balance improvement in this population are greatly needed. The aim of this study was to evaluate the effect of a new virtual-reality system (the Balance Rehabilitation Unit [BRU]) on balance, falls, and fear of falling in a population of community-dwelling older subjects with a known history of falls. In this study, 60 community-dwelling older subjects were recruited after being diagnosed with poor balance at the Falls and Fractures Clinic, Nepean Hospital (Penrith, NSW, Australia). Subjects were randomly assigned to either the BRU-training or control groups. Both groups received the usual falls prevention care. The BRU-training group attended balance training (two sessions/week for 6 weeks) using an established protocol. Change in balance parameters was assessed in the BRU-training group at the end of their 6-week training program. Both groups were assessed 9 months after their initial assessment (month 0). Adherence to the BRU-training program was 97%. Balance parameters were significantly improved in the BRU-training group (P < 0.01). This effect was also associated with a significant reduction in falls and lower levels of fear of falling (P < 0.01). Some components of balance that were improved by BRU training showed a decline after 9 months post-training. In conclusion, BRU training is an effective and well-accepted intervention to improve balance, increase confidence, and prevent falls in the elderly

Association between circulating osteogenic progenitor cells and disability and frailty in older persons : the Nepean Osteoporosis and Frailty study

Circulating osteogenic progenitor (COP) cells are considered as surrogates of the mesenchymal repository in the body. In this study, we hypothesized that COP cells decrease with age and that lower levels of COP cells are associated with greater frailty and disability in older persons. Using well-established clinical criteria, we quantified physical performance and disability and stratified frailty in a random sample of community-dwelling individuals enrolled in the Nepean Osteoporosis and Frailty (NOF) Study (mean age 82.8; N = 77; 70% female; 27 nonfrail, 23 prefrail, and 27 frail). Percentage of COP cells was quantified by flow cytometry. Logistic regression models estimated the relationship between the percentage of COP cells and prevalent disability, poor physical performance, and frailty. We found that aging is associated with a significant decrease in COP cells (p <.001). Lower percentages of COP cells were associated with disability and poor physical performance (p <.001). Older adults with COP cells in the lower quartile were more likely to be frail (odds ratio 2.65, 95% confidence interval 2.72-3.15, p <.001). In conclusion, COP cells in the circulation decrease with age. Lower percentages of COP cells in late life are associated with prevalent frailty and disability. Further longitudinal studies are needed to understand COP cells as a risk stratifier, biomarker, or therapeutic target and to predict disability in frail older persons

Phenotype of osteosarcopenia in older individuals with a history of falling

Objectives: In older persons, the combination of osteopenia/osteoporosis and sarcopenia has been proposed as a subset of frailer individuals at higher risk of institutionalization, falls, and fractures. However, the particular clinical, biochemical, and functional characteristics of the osteosarcopenic (OS) patients remain unknown. In this study, we used a clinical definition of osteosarcopenia aiming to determine the clinical, functional, and biochemical features that are unique to these patients within a population of older people who fall. Design: Cross-sectional study. Setting: Falls and Fractures Clinic, Nepean Hospital (Penrith, NSW, Australia). Participants: A total of 680 people (mean age = 79, 65% women) assessed between 2009 and 2013. Measurements: Assessment included medical history, physical examination, bone densitometry and body composition by dual-energy X-ray absorptiometry, posturography, grip strength, gait parameters (GaitRITE), and blood tests for nutrition and secondary causes of sarcopenia and osteoporosis. Patients were divided into 4 groups: (1) osteopenic (BMD <–1.0 SD), (2) sarcopenic, (3) OS, and (4) nonsarcopenic/nonosteopenic. Difference between groups was assessed with 1-way ANOVA and χ2 analysis. Multivariable linear regression evaluated the association between the groups and measures of physical function. Multivariable logistic regression evaluated risk factors for being in the OS group. Results: Mean age of the OS patients was 80.4 ± 7.0 years. Our analyses showed that OS patients are older, mostly women, are at high risk for depression and malnutrition, have body mass index lower than 25, and showed a higher prevalence of peptic disease, inflammatory arthritis, maternal hip fracture, history of atraumatic fracture, and impaired mobility. Conclusion: We have reported a set of characteristics that are highly prevalent in OS patients. This study could be used to inform the design of future trials and to develop interventions to prevent institutionalization and poor outcomes in this particular set of high-risk patients