Frailty and hormones

Weight loss of 5% or more after lobectomy for lung cancer via minimally invasive approaches is associated with poor prognosis

INTRODUCTION

We analyzed the association between postoperative weight loss (WL), preoperative body mass index (BMI), and prognosis in patients with lung cancer who underwent lobectomy using minimally invasive approaches.

METHODS

Weight change in 325 patients who underwent radical lobectomy for non-small cell lung cancer was assessed at 3, 6, and 12 months postoperatively and compared to preoperative weight. Patients were divided into three groups according to their preoperative BMI interquartile range: low BMI ≤20.3 kg/m2 , middle BMI 20.4-24.4 kg/m2 , and high BMI ≥24.5 kg/m2 . Postoperative WL ≥5% was evaluated with reference to frailty.

RESULTS

There were no significant differences in pathological findings, postoperative complications, or postoperative hospital stay among the three groups. Thirty all-cause deaths and 39 cancer recurrences occurred. Within the first year after surgery, WL of any grade was observed in 229 patients (70.5%) and WL ≥5% in 86 patients (26.5%). Postoperative WL of any grade within 1 year after surgery was not associated with OS and RFS (both p > .05). However, WL ≥5% within 1 year after surgery was associated with worse OS and RFS (p = .007 and .006, respectively). WL ≥5% within 1 year after surgery was more common in the low BMI group (p = .045). There was no difference in OS and RFS among the BMI groups in patients with WL ≥5% and those without WL ≥5% (all p > .05).

CONCLUSION

WL ≥5% was associated with poor prognosis after lobectomy via minimally invasive approaches. Weighing is a useful prognostic marker that can be easily self-checked.

Lower albumin levels are associated with frailty measures, trace elements, and an inflammation marker in a cross-sectional study in Tanushimaru

Background

There is little data on the association between the lower nutrition represented by serum albumin levels and related factors in a general population. The present study aimed to determine whether the albumin level positioned as some kind of biomarker with frailty measures, trace elements, and an inflammation marker.

Methods

In 2018, we performed an epidemiological survey in 1368 subjects who resided in Tanushimaru, Japan, in which we examined the blood chemistry including albumin, trace elements, hormone levels, and carotid ultrasonography. Albumin levels were categorized into 4 groups (G1 [3.2–3.9 mg/dL], G2 [4.0–4.3 mg/dL], G3 [4.4–4.6 mg/dL], and G4 [4.7–5.3 mg/dL]). The participants underwent measurements of handgrip strength and were tested by asking to walk 5 m. Their cognitive functions were evaluated by the mini-mental state examination (MMSE).

Results

Multiple stepwise regression analysis demonstrated that albumin levels were significantly and independently associated with age (inversely), systolic blood pressures, estimated glomerular filtration rate (eGFR), MMSE score, frailty measures (handgrip strength), an inflammation marker (high-sensitivity C-reactive protein), hormones (growth hormone (inversely) and insulin-like growth factor-1), and trace elements (calcium, magnesium, iron, and zinc), with a linear trend.

Conclusions

Lower albumin levels, even in the normal range, were found to be related factors of frailty measures, trace elements, and an inflammation marker in a general population.

Menopause and frailty: a scoping review

IMPORTANCE AND OBJECTIVE

Frailty refers to the decline in physiological reserve capacity caused by the deterioration of multiple physiological systems (brain, endocrine system, immune system, and skeletal muscle), leading to increased vulnerability and decreased stress capacity. Women have a higher prevalence of frailty than men, although the epidemiological factors underlying this phenomenon are not fully understood. Menopause and menopause-related characteristics may be among the contributing factors. Hence, the purpose of this scoping review was to explore the relationship between menopause and frailty. We attempted to summarize information such as the age that menopause occurs, years since menopause, types of menopause, and hormones and inflammatory markers of frailty among postmenopausal women.

METHODS

PubMed, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature and Web of Science, the China National Knowledge Infrastructure, the China Biomedical Literature Service System, Wanfang Database and the WeiPu (VIP) Database were searched from inception until April 3, 2019. Supplementary searches of the references, cited documents, and similar documents of the included literature were also carried out.

DISCUSSION AND CONCLUSIONS

Of 762 papers identified, 15 articles matching the criteria were included. The prevalence of frailty among postmenopausal women ranged from 5.9% to 57.3%. Existing studies suggest that menopause is associated with frailty. Early menopause, hysterectomy, low-free testosterone levels, and high C-reactive protein levels may increase the likelihood of frailty among postmenopausal women. Few original studies have explored the relationship between estrogen and frailty and the results of these studies are conflicting. Changes in hormone and inflammatory cytokine levels may mediate frailty among postmenopausal women. More in-depth research would be required to better understand the physiological and etiological mechanisms of the occurrence of frailty among postmenopausal women.

Sex Hormones and Novel Corona Virus Infectious Disease (COVID-19)

Given the rapid spread of the coronavirus disease 2019 (COVID-19) pandemic and its overwhelming effect on health care systems and the global economy, innovative therapeutic strategies are urgently needed. The proposed primary culprit of COVID-19 is the intense inflammatory response-an augmented immune response and cytokine storm-severely damaging the lung tissue and rendering some patients' conditions severe enough to require assisted ventilation. Sex differences in the response to inflammation have been documented and can be attributed, at least in part, to sex steroid hormones. Moreover, age-associated decreases in sex steroid hormones, namely, estrogen and testosterone, may mediate proinflammatory increases in older adults that could increase their risk of COVID-19 adverse outcomes. Sex hormones can mitigate the inflammation response and might provide promising therapeutic potential for patients with COVID-19. In this article, we explore the possible anti-inflammatory effects of estrogen and testosterone and the anabolic effect of testosterone, with particular attention to the potential therapeutic role of hormone replacement therapy in older men and women with COVID-19.

Surgical Menopause and Frailty Risk in Community-Dwelling Older Women: Study of Osteoporotic Fractures

OBJECTIVES

To determine whether women with surgical menopause have a higher risk of frailty than naturally menopausal women.

DESIGN

Prospective cohort study with up to 18 years of follow-up.

SETTING

Four U.S clinical centers.

PARTICIPANTS

Community-dwelling white women aged 65 and older (mean 71.2±5.2) enrolled in the Study of Osteoporotic Fractures (N=7,699).

MEASUREMENTS

Surgical menopause was based on participant self-report of having undergone bilateral oophorectomy before menopause. The outcome was incident frailty, classified as robust, prefrail, frail, or death at 4 follow-up interviews, conducted 6 to 18 years after baseline. Information on baseline serum total testosterone concentrations was available for 541 participants.

RESULTS

At baseline, 12.6% reported surgical menopause. Over the follow-up period, 22.0% died, and 10.1% were classified as frail, 39.7% as prefrail, and 28.3% as robust. Surgically menopausal women had significantly lower total serum testosterone levels (13.2 ± 7.8 ng/dL) than naturally menopausal women (21.7 ± 14.8 ng/dL) (p=0.000), although they were not at greater risk of frailty (adjusted odds ratio (aOR)=0.94, 95% confidence interval (CI)=0.72-1.22), prefrailty (aOR=0.96, 95% CI=0.80-1.10), or death (aOR=1.17, 95% CI=0.97-1.42) after adjusting for age, body mass index, and number of instrumental activity of daily living impairments. There was no evidence that oral estrogen use modified these associations.

CONCLUSION

In postmenopausal women, surgical menopause was not associated with greater risk for frailty than natural menopause, even in the absence of estrogen therapy. Future prospective studies are needed to investigate hormonal mechanisms involved in development of frailty in older postmenopausal women. J Am Geriatr Soc 66:2172-2177, 2018.

SARCOPENIA: AN ENDOCRINE DISORDER?

Sarcopenia is defined as low muscle function (walking speed or grip strength) in the presence of low muscle mass. A simple screening test-the SARC-F-is available to identify persons with sarcopenia. The major endocrine causes of sarcopenia are diabetes mellitus and male hypogonadism. Other causes are decreased physical activity, loss of motor neuron units, weight loss, inflammatory cytokines, reduced blood flow to muscles, very low 25(OH) vitamin D levels, and decreased growth hormone and insulin-like growth factor 1. Treatment for sarcopenia includes resistance and aerobic exercise, leucine-enriched essential amino acids, and vitamin D. In hypogonadal males, testosterone improves muscle mass, strength, and function. Selective androgen receptor molecules and anti-myostatin activin II receptor molecules are under development as possible treatments for sarcopenia.

ABBREVIATIONS

COPD = chronic obstructive pulmonary disease DHEA = dehydroepiandrosterone IGF-1 = insulin-like growth factor 1 GH = growth hormone mTOR = mammalian target of rapamycin SARM = selective androgen receptor molecule.

Low FT3: a possible marker of frailty in the elderly

Introduction

Frailty is associated with a functional decline of multiple physiological systems, of which they may be a cause or consequence. The objective of the study was to evaluate the prevalence of thyroid hormone modifications in elderly frail subjects and its relationship with frailty.

Study population and methods

An observational study was carried out at the University Hospital “Tor Vergata” in Rome among ambulatory and hospitalized patients. The study population consisted of 112 elderly subjects: 62 were hospitalized following hip fracture and 50 control subjects were outpatients. Participating patients received a multidimensional geriatric evaluation. The Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) was used to assess the degree of frailty. Thyroid stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4) were measured to evaluate thyroid status.

Results

FT3, but not FT4, was significantly correlated with Frailty score, both in patients with hip fracture and in patients from the control group. In the entire study population, FT3 under normal limits is effective in discriminating frail/prefrail subjects from nonfrail subjects.

Discussion

The reduction in serum concentrations of FT3 is a clear manifestation of stress associated with fractures. Numerous preexisting factors, such as the fracture patients’ nutritional status, sarcopenia, disability and comorbidities, which characterize the condition of frailty and influence its pathogenesis, are strongly correlated with FT3 values, suggesting the existence of latent nonthyroidal illness syndrome (NTIS).

Conclusion

We conclude that measuring FT3 can be a useful laboratory parameter in clinical assessment, which can play an important role in identifying vulnerable elderly subjects and in quantifying the condition of frailty.

Linking Frailty Instruments to the International Classification of Functioning, Disability, and Health: A Systematic Review

To date, the major dilemma concerning frailty is the lack of a standardized language regarding its operationalization. Considering the demographic challenge that the world is facing, standardization of frailty identification is indeed the first step in tackling the burdensome consequences of frailty. To demonstrate this diversity in frailty assessment, the available frailty instruments have been linked to the International Classification of Functioning, Disability, and Health (ICF): a standardized and hierarchically coded language developed by World Health Organization regarding health conditions and their positive (functioning) and negative (disability) consequences. A systematic review on frailty instruments was carried out in PubMed, Web of Knowledge, and PsycINFO. The items of the identified frailty instruments were then linked to the ICF codes. 79 original or adapted frailty instruments were identified and categorized into single (n = 25) and multidomain (n = 54) groups. Only 5 frailty instruments (indexes) were linked to all 5 ICF components. Whereas the ICF components Body Functions and Activities and Participation were frequently linked to the frailty instruments, Body Structures, Environmental and Personal factors were sparingly represented mainly in the multidomain frailty instruments. This review highlights the heterogeneity in frailty operationalization. Environmental and personal factors should be given more thought in future frailty assessments. Being unambiguous, structured, and neutral, the ICF language allows comparing observations made with different frailty instruments. In conclusion, this systematic overview and ICF translation can be a cornerstone for future standardization of frailty assessment.

Human Immunodeficiency Virus as a Chronic Disease: Evaluation and Management of Nonacquired Immune Deficiency Syndrome-Defining Conditions

In the modern antiretroviral therapy (ART) era, motivated people living with human immunodeficiency virus (HIV) who have access to therapy are expected to maintain viral suppression indefinitely and to receive treatment for decades. Hence, the current clinical scenario has dramatically shifted since the early 1980s, from treatment and prevention of opportunistic infections and palliative care to a new scenario in which most HIV specialists focus on HIV primary care, ie, the follow up of stable patients, surveillance of long-term toxicities, and screening and prevention of age-related conditions. The median age of HIV-infected adults on ART is progressively increasing. By 2030, 3 of every 4 patients are expected to be aged 50 years or older in many countries, more than 80% will have at least 1 age-related disease, and approximately one third will have at least 3 age-related diseases. Contemporary care of HIV-infected patients is evolving, and questions about how we might monitor and perhaps even treat HIV-infected adults have emerged. Through key published works, this review briefly describes the most prevalent comorbidities and age-associated conditions and highlights the differential features in the HIV-infected population. We also discuss the most critical aspects to be considered in the care of patients with HIV for the management and prevention of age-associated disease.

Testosterone level and the effect of levodopa and agonists in early Parkinson disease: results from the INSPECT cohort

Background

To determine if testosterone levels are influenced by dopaminergic therapy in Parkinson disease (PD) patients. Testosterone level has been reported to be low in patients with PD and other neurodegenerative diseases. In this study, we sought to determine whether dopaminergic therapy (i.e. levodopa and dopamine agonist) influenced testosterone levels. We used a cohort of consecutive male patients from the INSPECT trial--a multi-center, prospective, study that primarily investigated the effects of short-term treatment with pramipexole or levodopa on [¹²³I] B-CIT SPECT imaging in early PD.

Methods

Testosterone levels were drawn on consenting male subjects with early PD who enrolled in the INSPECT trial at three study visits (baseline, 12 weeks post-treatment, and 8–12 weeks post-washout). Subjects were randomized to: no treatment, pramipexole (up to 3 mg) or levodopa (up to 600 mg). Testosterone levels were obtained twice (prior to 10 AM) and averaged for each of three study visits.

Results

Thirty two male patients participated in this sub-study and there were no significant differences in disease characteristics in the 3 groups at baseline. Twenty-nine patients completed the follow-up visits and were suitable for analysis. There were statistically significant differences in the change in free testosterone level, increased in both the levodopa group and pramipexole group but decreased in the untreated group at 12-weeks post-treatment. There were no significant differences in the changes of UPDRS total or motor scores, although there was a strong trend toward improvement in motor scores. The testosterone level persisted in its increase only in the pramipexole group at the end of the washout period.

Conclusion

These preliminary data support the premise that dopaminergic medications do not reduce testosterone levels in early PD patients.

Electronic supplementary material

The online version of this article (doi:10.1186/2054-7072-1-8) contains supplementary material, which is available to authorized users.

Off-label use of hormones as an antiaging strategy: a review

Given demographic evolution of the population in modern societies, one of the most important health care needs is successful aging with less frailty and dependency. During the last 20 years, a multitude of anti-aging practices have appeared worldwide, aiming at retarding or even stopping and reversing the effects of aging on the human body. One of the cornerstones of anti-aging is hormone replacement. At present, women live one third of their lives in a state of sex-hormone deficiency. Men are also subject to age-related testosterone decline, but andropause remains frequently under-diagnosed and under-treated. Due to the decline of hormone production from gonads in both sexes, the importance of dehydroepiandrosterone (DHEA) in steroid hormone production increases with age. However, DHEA levels also decrease with age. Also, growth hormone age-associated decrease may be so important that insulin growth factor-1 levels found in elderly individuals are sometimes as low as those encountered in adult patients with established deficiency. Skin aging as well as decreases in lean body mass, bone mineral density, sexual desire and erectile function, intellectual activity and mood have all been related to this decrease of hormone production with age. Great disparities exist between recommendations from scientific societies and actual use of hormone supplements in aging and elderly patients. In this article, we review actual data on the effects of age related hormone decline on the aging process and age-related diseases such as sarcopenia and falls, osteoporosis, cognitive decline, mood disorders, cardiovascular health and sexual activity. We also provide information on the efficiency and safety of hormone replacement protocols in aging patients. Finally, we argue on future perspectives of such protocols as part of everyday practice.

Serum sex steroid hormones and frailty in older American men of the Third National Health and Nutrition Examination Survey (NHANES III)

OBJECTIVE

To determine whether frailty is associated with circulating total and free testosterone, total and free estradiol, and sex hormone-binding globulin (SHBG) in older men.

METHODS

With NHANES III data of 461 men aged 60 years and older, we used logistic regression to analyze the associations between serum concentrations of sex steroid hormones, SHBG and frailty. Participants meeting any three or more of the five frailty criteria were classified as "frail", all others were considered as non-frail.

RESULTS

2.5% of men were frail. Men with SHBG ≥66 nmol/L had three times the odds of frailty (OR = 2.97; 95% CI 1.28-6.86) compared to men with SHBG <66 nmol/L. Men with free testosterone levels below 243 pmol/L had an increased odds of frailty (OR = 3.92; 95% CI 1.29-11.89). None of these associations was statistically significant after additionally adjusting for body mass index, smoking and history of cardiovascular diseases (CVD). Total testosterone, and total and free estradiol serum levels were not statistically significantly associated with frailty.

CONCLUSIONS

In this US nationally representative study of older men, low free testosterone and high SHBG serum levels were associated with a significantly increased odds of frailty after adjustment for age and race/ethnicity. These associations may, however, be explained by confounding due to obesity, smoking, and the higher prevalence of CVD in frail men or by low hormones or high SHBG mediating the association between obesity, smoking, CVD and frailty.

Diabetes and frailty: an emerging issue. Part 1: Sarcopaenia and factors affecting lower limb function

Frailty and sarcopaenia are commonly used terms in the medical management of older people but their relationship to those with diabetes has not been explored in great detail. In this review, we hypothesise that diabetes and frailty are related conditions, and we attempt to explain the nature of this relationship, and consider the possibility that sarcopaenia is an intermediate step.

The frailty syndrome: a comprehensive review

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

Sex differences in the association between serum levels of testosterone and frailty in an elderly population: the Toledo Study for Healthy Aging

BACKGROUND

Age-associated decline in testosterone levels represent one of the potential mechanisms involved in the development of frailty. Although this association has been widely reported in older men, very few data are available in women. We studied the association between testosterone and frailty in women and assessed sex differences in this relationship.

METHODS

We used cross-sectional data from the Toledo Study for Healthy Aging, a population-based cohort study of Spanish elderly. Frailty was defined according to Fried's approach. Multivariate odds-ratios (OR) and 95% confidence intervals (CI) associated with total (TT) and free testosterone (FT) levels were estimated using polytomous logistic regression.

RESULTS

In women, there was a U-shaped relationship between FT levels and frailty (p for FT(2) = 0.03). In addition, very low levels of FT were observed in women with ≥ 4 frailty criteria (age-adjusted geometric means = 0.13 versus 0.37 in subjects with <4 components, p = 0.010). The association of FT with frailty appeared confined to obese women (p-value for interaction = 0.05).In men, the risk of frailty levels linearly decreased with testosterone (adjusted OR for frailty = 2.9 (95%CI, 1.6-5.1) and 1.6 (95%CI, 1.0-2.5), for 1 SD decrease in TT and FT, respectively). TT and FT showed association with most of frailty criteria. No interaction was found with BMI.

CONCLUSION

There is a relationship between circulating levels of FT and frailty in older women. This relation seems to be modulated by BMI. The relevance and the nature of the association of FT levels and frailty are sex-specific, suggesting that different biological mechanisms may be involved.

Sarcopenia and diabetes: pathogenesis and consequences

Sarcopenia, loss of muscle mass with age, is considered as a major cause of frailty and decreased independence in the elderly population. On the other hand, ageing is associated with an increase in prevalence of diabetes. In this review, we discuss the pathophysiological basis of sarcopenia and its relationship to oxidative stress and insulin resistance state, which contribute to development of glucose intolerance and type 2 diabetes. We will also discuss some ideas on the consequences and treatment of sarcopenia.

Physical frailty predicts future cognitive decline - a four-year prospective study in 2737 cognitively normal older adults

OBJECTIVE

To examine the association between baseline frailty measurements and cognitive function 4 years later.

DESIGN

Prospective observational study.

SETTING

Community.

PARTICIPANTS

Two thousand seven hundred and thirty seven cognitively normal older adults.

MEASUREMENT

The appendicular muscle mass (ASM), hand grip strength, timed chair-stand test, walking speed and step length were measured at baseline. The Mini-mental state examination (MMSE) was administered at baseline and 4 years later.

RESULTS

In men, all baseline frailty measurements, namely, being underweight, lower ASM, weaker grip strength, slower chair-stand test, shorter step length, slower timed walk were significantly associated with a lower MMSE score 4 years afterwards. After adjustment for age, years of education and baseline MMSE score, ASM and timed walk became insignificant. In women, all frailty measurements except underweight and low ASM were significantly associated with MMSE score 4 years later. Moreover, only weaker grip strength persisted to be significant after adjustment for age, years of education and baseline MMSE score.

CONCLUSION

Physical frailty, as represented by being underweight, weaker grip strength, slower chair-stand test, shorter step-length in men and weaker grip strength in women, was associated with cognitive decline over a four year period.

Testosterone but not estradiol level is positively related to muscle strength and physical performance independent of muscle mass: a cross-sectional study in 1489 older men

OBJECTIVE

To examine the relationship between different measures of testosterone and estradiol (E(2)), muscle mass, muscle strength, and physical performance; and to test whether the association of sex hormone level with muscle strength and physical performance was independent of muscle mass.

DESIGN AND METHODS

A cross-sectional survey on 1489 community-dwelling men older than 64 years of age. Serum levels of testosterone and E(2) were measured by mass spectrometry, and sex hormone-binding globulin (SHBG) levels were measured by immunoradioassay. Muscle mass was examined by dual-energy X-ray absorptiometry and physical performance was assessed by hand-grip strength, gait speed, step length and chair-stand test.

RESULTS

Appendicular skeletal mass (ASM) was positively associated with total testosterone (TT; P<0.001), free testosterone (FT; P<0.001), and total E(2) (P<0.001) but not with free E(2) (P=0.102). After adjustment for age, serum SHBG and relative ASM, both TT and FT were significantly associated with grip strength, narrow-walk speed and the composite neuromuscular score. Higher total E(2), but not free E(2) was associated with lower grip strength (P<0.05) after adjustment for age, FT, SHBG and relative ASM.

CONCLUSIONS

Testosterone level was related to both muscle mass, strength and physical performance. Total E(2) level, though related to muscle mass positively, affected muscle strength adversely in older men.

Drug discovery and development for ageing: opportunities and challenges

The prevention and treatment of late-life dysfunction are the goals of most geriatricians and should be the primary target for discovery and development of new medicines for elderly people. However, the development of new medicines for elderly people will face a number of challenges that are not seen for other patient populations. The burdens of multiple chronic diseases, low physiological reserve and polypharmacy must result in new clinical trials in frail older people with a high expectation of safety and efficacy. The etiology of functional limitations in elderly people is complex and often ascribed to conditions that escape the traditional definition of disease. While our society urgently needs new treatments that can reduce the burden of physical decline among older persons, guidelines on how these treatments should be developed and tested are currently lacking, in part because a consensus has not yet been achieved regarding the identifiable target diseases. New potential indications included sarcopaenia, anorexia of ageing, frailty, mobility disability and reduced functional capacity secondary to hospitalization. The challenges to conducting clinical trials in the elderly should not offset the great opportunity for the development of new medicines to prevent or reverse age-associated changes in body composition and poor functional capacity in the elderly.

Use of potentially inappropriate medications in the care of frail older people

Achieving safe prescribing in frail older people is difficult owing to age-related physiological changes, multiple comorbidities, multiple medication use and a higher risk of adverse drug events (ADEs). Among people aged 65 years and over, 7–25% are frail. While frailty is recognized as a major public health problem, there is a lack of consensus on the definition of frailty and validated tools that can be used to assess the effects of frailty on pharmacological response in old age. Frail individuals are at higher risk of adverse clinical outcomes, such as hospitalization, falls, disability and mortality. There is also a lack of consensus on the definition of inappropriate medications. Inappropriate medication use is a major contributor to the risk of ADEs in frail older people. Therefore, development and implementation of tools to optimize appropriate use of medications is necessary for the medical care of frail older people.

Thyroid hormone abnormalities and frailty in elderly patients with chronic kidney disease: a hypothesis

Thyroid hormones play a crucial role in the metabolic activities of adults, affecting almost every organ system. All types of thyroid diseases are encountered in the elderly. As symptoms and signs of thyroid diseases may overlap with what is considered to be "normal aging," the presence of a thyroid disorder may go undiagnosed in the elderly. This potential problem is further compounded in elderly patients with chronic kidney disease (CKD), where the presence of an underlying hormonal problem such as hypothyroidism may be erroneously attributed to multiple comorbidities, the aging process, or the kidney disease. Frailty is being recognized as a contributing factor to the poor outcomes (hospitalization and high mortality) in elderly patients with CKD. Predisposing factors leading to frailty in elderly with CKD such as increased inflammatory markers, anemia, low testosterone, sarcopenia, and depression are associated with thyroid hormonal abnormalities. These associations are remarkable and raise the question of whether routine monitoring and screening for thyroid hormone changes in elderly CKD patients might be helpful in identifying reversible causes of frailty. In this review, we will focus on the associations between thyroid hormone abnormalities and the predisposing factors of frailty in elderly patients with CKD. If a cause-effect relationship of thyroid hormone abnormalities and factors predisposing to frailty in CKD patients is established, identification and treatment of thyroid abnormalities in this population would assume increased importance.

Low free testosterone predicts frailty in older men: the health in men study

CONTEXT

The prevalence of frailty increases, whereas testosterone decreases, as men age. Low testosterone may be a risk factor for development of this syndrome.

OBJECTIVE

Our objective was to determine whether testosterone levels are associated with frailty.

DESIGN

We conducted a prospective cohort study.

SETTING AND PARTICIPANTS

Between 2001 and 2004, frailty was assessed in 3616 community-dwelling men aged 70-88 yr. Frailty was reassessed in 1586 men aged 76-93 yr in 2008-2009.

MAIN OUTCOME MEASURES

Frailty was assessed with the FRAIL scale, comprising five domains: fatigue, difficulty climbing a flight of stairs, difficulty walking more than 100 m, more than five illnesses present, or weight loss greater than 5%. Testosterone, SHBG, and LH were assayed at baseline. Free testosterone was calculated using mass action equations.

RESULTS

At baseline, 15.2% of men (n = 548) were frail (at least three deficits), increasing to 23.0% (n = 364) at follow-up. At baseline, each 1 sd decrease in total or free testosterone level was associated with increased odds of frailty [odds ratio (OR) = 1.23; 95% confidence interval (CI) = 1.11-1.38, and OR = 1.29; 95% CI = 1.15-1.44 for total and free testosterone, respectively]. Lower LH was associated with reduced odds of frailty (OR = 0.88; 95% CI = 0.81-0.95). Adjustments were made for age, body mass index, smoking, diabetes, social support, and other covariates. At follow-up, only lower free testosterone levels (OR = 1.22; 95% CI = 1.05-1.42) predicted frailty.

CONCLUSIONS

Lower free testosterone was independently associated with frailty at baseline and follow-up. Randomized trials should explore whether testosterone therapy can prevent the development of frailty.

Frailty, serum androgens, and the CAG repeat polymorphism: results from the Massachusetts Male Aging Study

CONTEXT

The CAG repeat polymorphism in the androgen receptor, denoted (CAG)n, is thought to (inversely) index androgen sensitivity. We hypothesized that (CAG)n would exhibit a modifying influence on the association between circulating total and calculated free testosterone (TT and FT) and physical frailty in aging men.

OBJECTIVE

The objective of the study was to establish the influence of (CAG)n on the relation between circulating TT, FT, LH, SHBG, and frailty.

DESIGN

This was a prospective cohort study of health and endocrine functioning in randomly selected men, with a baseline (T1: 1987-89) and two follow-up (T2: 1995-1997; T3: 2002-2004) visits.

SETTING

This was an observational study of men residing in greater Boston, MA.

PARTICIPANTS

A total of 624 subjects aged 50-86 yr were retained.

MAIN OUTCOME MEASURES

The frailty phenotype was measured at T3. Components included weight loss, exhaustion, low physical activity, weakness, and slowness. Subjects exhibiting two of these five components were considered to be in an intermediate state, and those exhibiting three or more were considered frail.

RESULTS

(CAG)n was positively associated with TT and FT. Multivariable regression analyses revealed no influence of CAG on longitudinal within-subject changes in hormone levels or cross-sectional (T3) associations between hormone concentrations and the prevalence of intermediate frailty or frailty. Models incorporating subjects' history of hormone decline produced similar negative results.

CONCLUSIONS

This population-based study does not support the hypothesis that interindividual differences in (CAG)n can account for a lack of association between circulating androgens and the frailty phenotype. Longitudinal analyses are needed to confirm these conclusions.

A review of the effects of growth hormone changes on symptoms of frailty in the elderly with chronic kidney disease

The incidence and prevalence of chronic kidney disease (CKD) is increasing worldwide, especially in the elderly. Recently, functional impairment and frailty have been recognized as factors affecting the quality of life, and outcomes in elderly patients with CKD and therapeutic interventions to improve function and reduce frailty are therefore being considered. Growth hormone (GH) levels decrease with age and GH actions are impaired in CKD patients. GH stimulates protein synthesis, bone, and glucose metabolism, and affects body composition by reducing body fat and increasing lean body mass. An increase in lean body mass may reduce frailty and thus avoid functional impairment. Thus, providing GH to elderly CKD patients could potentially improve outcomes and quality of life by lowering the risk of frailty and associated functional impairment. There are few studies assessing the long-term effects of GH administration on symptoms of frailty in elderly patients with CKD. In this review we will try to shed some light on the trials assessing the administration of GH to elderly subjects and to patients with CKD and focus on the possible role GH administration may play to improve frailty and quality of life in those patients.

Frailty: an emerging concept for general practice

Ageing of the population in western societies and the rising costs of health and social care are refocusing health policy on health promotion and disability prevention among older people. However, efforts to identify at-risk groups of older people and to alter the trajectory of avoidable problems associated with ageing by early intervention or multidisciplinary case management have been largely unsuccessful. This paper argues that this failure arises from the dominance in primary care of a managerial perspective on health care for older people, and proposes instead the adoption of a clinical paradigm based on the concept of frailty. Frailty, in its simplest definition, is vulnerability to adverse outcomes. It is a dynamic concept that is different from disability and easy to overlook, but also easy to identify using heuristics (rules of thumb) and to measure using simple scales. Conceptually, frailty fits well with the biopsychosocial model of general practice, offers practitioners useful tools for patient care, and provides commissioners of health care with a clinical focus for targeting resources at an ageing population.

Temporal trends in testosterone levels and treatment in older men

PURPOSE OF REVIEW

Longitudinal studies of testosterone concentrations have yielded sharper estimates of age-related androgen declines than their cross-sectional counterparts. A potential explanation for this phenomenon is a secular (age independent) mechanism acting to accelerate within-individual testosterone decreases with time. This article reviews the evidence in favor of such secular trends and discusses potential causes and implications.

RECENT FINDINGS

The magnitude of the proposed secular trend may be as much as 1% per calendar year in excess of per year cross-sectional trends. Current evidence suggests that body composition changes as expressed by BMI can in part account for the trend in testosterone. More speculative recent findings suggest a potential contributory role for environmental endocrine disruptors, but to date no longitudinal studies have examined this question. Symptomatic androgen deficiency as currently defined is associated with diverse downstream morbidity, but may not constitute a robust designation over longer term periods of time. Information concerning treatment patterns in the general population is limited.

SUMMARY

Existing evidence, though limited, supports the hypothesis of secular declines in serum testosterone levels in adult men. It is conceivable that these trends may influence the health of the public. Studies confirming and accounting for these trends are needed.

Influence of testosterone and a novel SARM on gene expression in whole blood of Macaca fascicularis

Anabolic hormones, including testosterone, have been suggested as a therapy for aging-related conditions, such as osteoporosis and sarcopenia. These therapies are sometimes associated with severe androgenic side effects. A promising alternative to testosterone replacement therapy are selective androgen receptor modulators (SARMs). SARMs have the potential to mimic the desirable central and peripheral androgenic anabolic effects of testosterone without having its side effects. In this study we evaluated the effects of LGD2941, in comparison to testosterone, on mRNA expression of selected target genes in whole blood in an non-human model. The regulated genes can act as potential blood biomarker candidates in future studies with AR ligands. Cynomolgus monkeys (Macaca fascicularis) were treated either with testosterone or LGD2941 for 90 days in order to compare their effects on mRNA expression in blood. Blood samples were taken before SARM application, on day 16 and on day 90 of treatment. Gene expression of 37 candidate genes was measured using quantitative real-time RT-PCR (qRT-PCR) technology. Our study shows that both testosterone and LGD2941 influence mRNA expression of 6 selected genes out of 37 in whole blood. The apoptosis regulators CD30L, Fas, TNFR1 and TNFR2 and the interleukins IL-12B and IL-15 showed significant changes in gene expression between control and the treatment groups and represent potential biomarkers for androgen receptor ligands in whole blood.

Multiple hormonal deficiencies in anabolic hormones are found in frail older women: the Women's Health and Aging studies

BACKGROUND

Alterations in anabolic hormones are theorized to contribute to aging and frailty, with most studies focusing on the relationship between individual hormones and specific age-associated diseases. We hypothesized that associations with frailty would most likely manifest in the presence of deficits in multiple anabolic hormones.

METHODS

The relationships of serum levels of total IGF-1, DHEAS, and free testosterone (T) with frailty status (nonfrail, prefrail, or frail) were analyzed in 494 women aged 70-79 years enrolled in the Women's Health and Aging Studies I or II. Using multivariate polytomous regression, we calculated the odds of frailty for deficiency in each hormone (defined as the bottom quartile of the hormone) individually, as well as for a count of the hormones.

RESULTS

For each hormone, in adjusted analyses, those with the deficiency were more likely to be frail than those without the deficiency, although this did not achieve statistical significance (IGF-1: odds ratio [OR] 1.82, confidence interval [CI] 0.81-4.08; DHEAS: OR 1.68, CI 0.77-3.69; free T: OR 2.03, CI 0.89-4.64). Compared with those with no hormonal deficiencies, those with one deficiency were not more likely to be frail (OR 1.15, CI 0.49-2.68), whereas those with two or three deficiencies had a very high likelihood of being frail (OR 2.79, CI 1.06-7.32), in adjusted models.

CONCLUSIONS

The absolute burden of anabolic hormonal deficiencies is a stronger predictor of frailty status than the type of hormonal deficiency, and the relationship is nonlinear. These analyses suggest generalized endocrine dysfunction in the frailty syndrome.

Adipose endocrine function, insulin-like growth factor-1 axis, and exceptional survival beyond 100 years of age

BACKGROUND

Observational studies have demonstrated similarities between the underpinning of frailty and biological features of centenarians, suggesting that adaptability to age-related multiple physiological decline may be a core component of successful aging. The aim of this study is to determine whether hormonal pathways potentially involved in energy homeostasis contribute to survival beyond 100 years of age.

METHODS

We assessed a total of 252 centenarians (mean [standard deviation (SD)] age, 101.5 (1.8) years, range 100-108 years) using a complete set of biomarkers of adipose endocrine function and the insulin-like growth factor-1 (IGF-1) axis. Conventional risk factors at baseline were also assessed. The participants were followed up for all-cause mortality every 12 months by telephone contact.

RESULTS

During 2253 days of follow-up, 208 centenarians (82.5%) died. The lowest tertile of leptin and the highest tertile of tumor necrosis factor-alpha were associated with higher mortality risk among centenarians after adjusting for age (per 6-month increase), sex, education, smoking, activities of daily living (ADL), cognitive function, and comorbidities (hazard ratio [HR] 1.6; 95% confidence interval [CI], 1.14-2.35; and HR 1.45; 95% CI, 1.00-2.08, respectively). The lowest tertiles of both IGF-1 and IGF binding protein 3 (IGFBP3) were also associated with increased mortality. The adipose risk score, indicating cumulative effects of adipokine dysregulation, was strongly associated with increased mortality risk; ADL; cognitive function; and levels of albumin, cholinesterase, high-density lipoprotein-cholesterol, C-reactive protein, interleukin 6, and IGF-1 at baseline.

CONCLUSIONS

The results suggested that preservation of adipose endocrine function and the IGF-1 axis may be potentially important for maintaining health and function and promoting survival at an extremely old age.

Selective androgen receptor modulators in preclinical and clinical development

Androgen receptor (AR) plays a critical role in the function of several organs including primary and accessory sexual organs, skeletal muscle, and bone, making it a desirable therapeutic target. Selective androgen receptor modulators (SARMs) bind to the AR and demonstrate osteo- and myo-anabolic activity; however, unlike testosterone and other anabolic steroids, these nonsteroidal agents produce less of a growth effect on prostate and other secondary sexual organs. SARMs provide therapeutic opportunities in a variety of diseases, including muscle wasting associated with burns, cancer, or end-stage renal disease, osteoporosis, frailty, and hypogonadism. This review summarizes the current standing of research and development of SARMs, crystallography of AR with SARMs, plausible mechanisms for their action and the potential therapeutic indications for this emerging class of drugs.

Predictors of serum testosterone and DHEAS in African-American men

There are few reported data on biochemical and functional correlates of androgen levels in African-American men. This study aimed at reporting physical and biochemical correlates of serum total testosterone (total T), bioavailable testosterone (BT) and dehydroepiandrosterone-sulphate (DHEAS) levels in community-dwelling, African-American men aged 50-65 years. Home-based physical examinations and health status questionnaires were administered to randomly sampled men. Body composition (dual-energy X-ray absorptiometry), lower limb and hand-grip muscle strength, and neuropsychological functions were assessed. Levels of serum total T, BT, DHEAS, oestradiol (E2), adiponectin, leptin, triglycerides and glucose were measured. Multiple linear regression models were constructed to identify factors independently associated with androgen levels. DHEAS levels declined from age 50 to 65 years (p < 0.0001), but total T and BT levels remained constant. Independent of other associated factors, higher total T levels were associated with lower serum triglyceride levels (beta = -0.142, p = 0.049); higher BT was associated with better performance on the trail-making tests (TMT-B:TMT-A ratio: beta = -0.118, p = 0.024) and higher DHEAS levels were associated with lower adiponectin (beta = -0.293, p = 0.047) and higher mini-mental state examination (MMSE) score (beta = 0.098, p = 0.008). Multiple regression models predicted 21, 18 and 29% of variance in total T, BT and DHEAS, respectively. Higher total T levels were associated with serum metabolic markers, particularly lower triglycerides, whereas higher BT was associated with better cognitive and muscle function and DHEAS with lower adiponectin and higher MMSE scores.

Frailty: an emerging geriatric syndrome

Frailty is a new and emerging syndrome in the field of geriatrics. The study of frailty may provide an explanation for the downward spiral of many elderly patients after an acute illness and hospitalization. The fact that frailty is not present in all elderly persons suggests that it is associated with aging but not an inevitable process of aging and may be prevented or treated. The purpose of this article is to review what is known about frailty, including the definition, epidemiology, and pathophysiology, and to examine potential areas of future research.

Testosterone, Sex Hormone–Binding Globulin, and Frailty in Older Men

OBJECTIVES

To determine whether testosterone (T) levels are associated with frailty or its components.

DESIGN

Population-based cohort study conducted in three waves (T1: 1987-1989, T2: 1995-1997, T3: 2002-2004).

SETTING

Communities in the Boston, Massachusetts, area.

PARTICIPANTS

Six hundred forty-six men aged 50 to 86 at T(3) with complete data on frailty components and hormone measurements.

MEASUREMENTS

The frailty phenotype was defined as the presence of three or more of the following: weight loss, exhaustion, low physical activity, slowness, and weakness. Men were classified as frail (> or = 3 components), intermediate (1-2 components), and nonfrail (0 components). Whether total and free T or sex hormone-binding globulin (SHBG) levels were associated cross-sectionally with frailty and with degree of frailty was determined. Potential confounders such as age, chronic disease, lifestyle factors, diet, and physical activity were considered.

RESULTS

No association was observed between total or free T and the frailty phenotype after adjusting for confounders. Conversely, a significant association was observed between SHBG and frailty phenotype with an adjusted odds ratio of 1.25 (95% confidence interval=1.06-1.46) per 10-nM increase in SHBG levels. Associations between hormones and degree of frailty were similar to those for overall frailty. Of frailty components, grip strength and physical activity, but not exhaustion, slow walking, or weight loss, were associated with total T levels, whereas SHBG was related to weight loss, exhaustion, and physical activity.

CONCLUSION

Total and free T levels were not associated with frailty phenotype, but SHBG was. Furthermore, T and SHBG levels were associated with some, but not all, components of frailty. Therefore, T trials in older men should focus on men experiencing decreases in strength.

Frailty

Frailty is a common condition in older people. It now can be objectively defined by the Fried criteria. When recognized, early intervention should begin with the institution of endurance, resistance, and balance exercises. In men with testosterone deficiency a trial of testosterone replacement should be considered. Vitamin D deficiency needs to be recognized and treated. Appropriate treatment of underlying diseases, such as anemia, diabetes mellitus, and congestive heart failure, are a key management principle. In people who have frailty aggressive health promotion and disease prevention techniques can lead to an inhibition of the downward spiral to disability.